[13][14] Multiple managed care options exist in addition to HMOs, such as PPOs, point of service (POS) plans, and the previously discussed ACOs, each with different nuances and features designed to contain health care costs while also meeting the preferences of different groups of patients. To examine the association of specific organizational characteristics and use of hospital services by Medicare beneficiaries, the ratio of HMO hospital days per 1,000 Medicare beneficiaries and market area hospital days per 1,000 Medicare beneficiaries was constructed for each HMO. From a patients perspective, HMOs represent a potential option for health insurance. HMOs are the most common type of plan in the health insurance marketplace and Medicare Advantage, but arent nearly as common in the employer-sponsored market. ICF, Inc., (1988) surveyed 215 HMOs (145 TEFRA risk contract plans and 70 non-Medicare HMOs) and reported that 59 percent capitate physicians, 21 percent pay on a fee-for-service basis, and 20 percent employ physicians on salary. All of the following are reasons an employee might elect medical expense coverage under managed care plan EXCEPT: A. the employee is required to do so by the employer. HMOs are Increasingly Recognized as a Key Component of Infant Health Human milk is the gold standard for early life nutrition, and human milk oligosaccharides (HMOs) are the third largest solid component of human milk. Managed care: Whoever has the data wins the game. D. Benefits are usually provided on the basis of benefit schedule. Bethesda, MD 20894, Web Policies Many health insurance providers offer multiple HMO plans and some are more flexible than others. It would then be possible to compare the utilization approach in successful HMOs with the approach used by less successful HMOs. In addition to the rapid growth in the number of HMOs and of enrollees, the organizational characteristics of HMOs have changed substantially over this period. TF The defining feature of a direct contract model HMO is the HMO contracting directly with a. hospital to provide acute services to its members. Managed care: practice, pitfalls, and potential. The Medicare risk HMOs were less likely to report using primary care gatekeepers (81 percent versus 93 percent of GHAA respondents) and retrospective inpatient review (56 percent versus 89 percent of GHAA respondents) and were more likely to report using physician practice profiles as a management tool (59 percent versus 44 percent of GHAA respondents). Within the HMO industry, the direction is clearly toward improving data reporting capabilities in order to better manage health care delivery. Cerne and Traska (1988) report that HMO data capabilities are becoming extremely sophisticated and, as a result, HMOs may be in stronger negotiating positions with hospitals over capitation arrangements and per diem contract agreements. Chain-affiliated HMOs were more likely than were independent HMOs to use each of the utilization control methods. HMOs are increasingly being recognized for their importance for infant health and development. 26 percent were IPA Model HMOs compared with 51 percent of all HMOs. Primary care physician practice profiles (44 percent). Changes in tonsillectomy rates associated with feedback and review. By charging patients per provider visit, cost-sharing strategies seek to disincentivize the overuse of medical services that might occur if patients were not responsible for any per-visit costs. However, it is unclear whether the association with profitability is caused by chain affiliation or by other correlated organizational characteristics. Hillman AL, et al. State responses to HMO failures. Morrison EM, Luft HS. Another restriction to HMOs is that they usually require referrals to see specialists. Which of the following statements is true? The GHAA results incorporate the BC/BS HMO data. HMOs are typically cheaper than PPOs, but they also come with more limitations. FOIA For example, by 1987, over 29 million Americans (12%) received care through HMOs. Her areas of expertise are life insurance, car insurance, property insurance and health insurance. In the early 1970s, HMOs were classified into three types: Staff, Group, and IPA. Additionally, some providers sell high-deductible HMO plans, which have an even lower premium but more out-of-pocket costs when you need care. An HMO is going to be the lowest-cost plan available in the marketplace because it provides in-network benefits only and often requires a referral to see a specialist, says Decker. true. Which of the following are reasons why a managed care plan might be selected? 21. The average employer-sponsored HMO plan costs $1,212 per year or $101 per month, based on Kaiser Family Foundation (KFF) data. Under this variation, an HMO enrollee is permitted to use providers (usually physicians) who are outside the HMO provider network. This is of particular concern as the Health Care Financing Administration considers the further expansion of managed care options available to Medicare and Medicaid beneficiaries. Typically, a Mixed Model HMO involves an HMO that adds an IPA component to its HMO-owned Staff or Group Model facilities. However, the decline in funding for HMO start-up loans from the Federal Government and the competitive disadvantage of community rating and mandatory benefit packages have caused Federal qualification to be perceived as less desirable over time. 2.) http://creativecommons.org/licenses/by-nc-nd/4.0/. 9. 65 percent were federally qualified compared with 57 percent of all HMOs. Patients with an HMO must have a primary care provider (PCP). In addition, PPOs recruit and offer a network of preferred providers who are selected on the basis of practice style and willingness to follow the utilization management and review requirements of PPOs. Copayment is a money that a member must pay before - Course Hero Find out if you qualify for a Special Enrollment Period. -Your family gets a lump-sum amount in the case of your death. TF IPAs are intermediaries between a payer such as an HMO, and its network physicians. (1989) use data from a survey of 283 HMOs to examine the relationship between financial incentives and hospitalization rates of HMO members and other measures of HMO performance.
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