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In the 1980's and early 1900's, the
number of HMOs grew substantially, providing coverage
to more and more Americans. Many health care experts predict
that by the end of this decade, half of the U.S. population
will be enrolled in HMOs or some similar form of managed
care. |
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HMO
Models
The various models of HMOs
The U.S. Department of Health and Human Services, which
is responsible for the provisions of the HMO Act of
1973, defined an HMO as "a managed health care
plan that provides or arranges for the delivery of comprehensive,
coordinated medical services to voluntarily enrolled
members on a prepaid basis."
While health plans vary and many organizations now
consider themselves to be HMOs, all still basically
adhere to the principles set forth in this original
definition. Their differences have more to do with structural,
financial and managerial organization than with the
quality of medical care. HMOs, in general, can be classified
according to the following four models: |
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Staff Model: In a staff-based
HMO, members receive all their care in one or more centralized
locations. Physicians are almost exclusively salaried
employees of the HMO, which serves as a complete medical
center, handling all health services as well as administrative
and financial operations. Each HMO member selects a primary
care physician (PCP) who coordinates all patient care,
including hospitalization and referrals to specialists
within the HMO. |
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Independent
Physician Model (IPA): IPAs are the fastest-growing
and most prevalent form of HMO nationwide.In this arrangement,
the HMO contracts with physicians in private practice
who form an association and are compensated for their
medical services on a per capita, flat retainer, or fee-for-service
basis. Members have the freedom to select their own primary
care physician within the IPA and, when necessary, are
referred to other specialists who also belong to the association.
Physicians see patients in their own offices, where they
may also continue to maintain their private practice. |
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Group Model: In a group
model, the HMO contracts with one physician group - generally
a multispecialty group, but sometimes a single-specialty
group - that forms its own partnership, professional corporation
or other association that agrees to provide medical services
to the HMO members. The physicians are typically compensated
at a negotiated per capita rate. Some large group models
own their own hospitals, while others contract with local
hospitals for inpatient care. |
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Network Model:
A network model HMO is essentially the same as a group
model except that the HMO contracts with several single-
or multispecialty physician groups. Patients may use any
doctor within the network. Physicians see patients in
their own offices, where they generally also see non-HMO
patients. Because of their size, network HMOs typically
do not run their own hospitals but rather contract with
local hospitals for inpatient services.
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HMO vs. Traditional
Indemnity Insurance
The difference between HMO and traditional indemnity
insurance coverage
HMOs accept members on a prepaid basis and, in return,
provide health care coverage and protection against
the high costs of health care. Because the membership
fee is fixed, it is to the HMO's advantage to keep its
members healthy.
General characteristics of HMOs:
- Members must use physicians and hospitals that are
affiliated with the HMO, except for emergency and
out-of-area urgent care.
- The HMO assumes responsibility for providing and
paying for necessary health care services. Members
have little or no paperwork.
- On monthly premium covers all health benefit services,
with no charge or a nominal charge for each office
visit or prescription
- Coverage includes preventive health care, including
most immunizations and physical examinations at regular
intervals.
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Health plan products and services are offered
by PacifiCare of California and PacifiCare Behavioral Health
of California, Inc. |
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Indemnity insurance products (including PPO
products) offered in California are underwritten by PacifiCare
Life and Health Insurance Company. |
| Other products and services are offered by PacifiCare
Health Plan Administrators, Inc., RxSolutions, Inc., and PacifiCare
Behavioral Health, Inc. |
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PacifiCare® is a federally registered
trademark of PacifiCare Life and Health Insurance Company. |
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