Managed Care

.. gether on managed care issues, including utilization management and quality improvement PHOs may also offer advantages to some managed care organizations: PHOs can provide a means of rapidly establishing a panel of participating physicians and hospitals PHOs can provide a means of reducing operating costs The lack of success of PHOs are: PHOs offer little or no benefit for enrolling large panels of participating physicians and hospitals PHOs, as of right now, dont assume financial risk for delivering health services by accepting capitation-based payments HMO MODELS The five commonly recognized models of HMOs are: 1) Staff 2) Group 3) Network 4) IPA 5) Direct contact The major differences among these models pertain to the relationship between the JHMO and its participating physicians Many HMOs cannot easily be classified as a single model type, although such plans are occasionally referred to as mixed models Staff Models In a staff model HMO, the physicians who serve the HMOs covered beneficiaries are employed by the HMO Physicians are usually paid on a salary basis and may also receive bonus or incentive payments that are based on their performance and productivity Staff model HMOs must employ physicians in all the common specialties to provide for the health care needs of their members Staff model HMOs are also known as closed panel HMOs because most participating physicians are employees of the HMO, and community physicians are unable to participate Physicians in staff model HMOs usually practice in one or more centralized ambulatory care facilities Staff model HMOs usually contract with hospitals or inpatient facilities in the community to provide non-physician services for their members They have a greater degree of control over their practice patterns of their physicians Also offer the convenience of one-stop shopping for their members because the HMOs facilities tend to be full service Disadvantages of the staff model: More costly to develop and implement because of the small membership and the large fixed salary expenses that the HMO must incur for staff physicians and support staff Provide a limited choice of participating physicians for potential HMO members Productivity problems with their staff physicians raising costs for providing care Expensive to expand services into new areas Group Model The HMO contracts with a multi-specialty physician group practice to provide all physician services to the HMOs members. Physicians in the group practice are employees by the group practice (not by the HMO) Physicians in a group practice share facilities, equipment, medical record, and support staff Captive Group The physician group practice exists solely to provide services to the HMOs beneficiaries I.e. Kaiser Foundation Health Plan Independent Group The HMO contracts with an existing, independent, multi-specialty physician services to its members I.e. Geisinger Health Plan Continues to provide services to non-HMO patients while is participates in the HMO Common Features of Group Models Advantages Both types of group model HMOs are also referred to as closed-panel HMOs because physicians must be members of the group practice to participate in the HMO Group practice HMOs may have lower capital needs than staff model HMOs Disadvantages Limited choice of participating physicians from which potential HMO members can select Limited number of office locations for the participating medical groups Restricts the geographic accessibility of physician for the HMOs members Certain group practices may be perceived by some potential HMO members as offering an undesirable clinic setting Network Model In network model HMOs, the HMO contracts with more than one group practice to provide physician services to the HMOs members The HMO compensates groups on an all-inclusive physician capitation basis The group is responsible for providing all physician services to the HMOs members assigned to the group and may refer to other physicians as necessary Network modeled may be either closed- or open-panel Closed-panel plan: Only contracts with a limiter number of existing group practices Open-panel: Participation in the group practices will be open to any physician who meets the HMOs and groups credentials criteria Broader physician participation thats usually identified with network model HMOs helps overcome the marketing disadvantage associated with the closed panel staff and group model plans This model usually have more limited physician participation than either IPA model or direct contract model plans IPA Model (Individual Practice Association) IPA model HMOs contract with an association of physicians the IPA to provide physician services to their members IPA physicians continue to see their non-member HMO patients and maintain their own offices, medical records, and support staff IPA model HMOs are open-panel plans because participation is open to all community physicians who meet the HMOs and IPAs selection criteria Broad physician participation can help make the IPA model HMO more attractive to potential HMO members Methods IPA model HMO establishes relationships with their IPAs: HMO contracts with IPA that has been independently established by community physicians These types of IPAs often have contracts with more than one HMO on a nonexclusive basis The HMO works with community physicians to create an IPA and to recruit physicians to participate in it The HMO contract is usually on an exclusive basis because of the HMOs leading role in forming IPA Most HMOs compensate their IPAs on an all-inclusive physician capitation basis to provide services to the HMOs members The IPA then compensates its participation physicians on either a fee-for-service basis or a combination of fee-for-service and primary care capitation IPA model HMOs overcome all the disadvantages associated with staff, group, and network model HMOs They require less capital to establish and operate Provide a broad choice of participating physicians who practice in their private offices Two major disadvantages from an HMOs perspective: 1) The development of an IPA creates an organized forum for physicians to negotiate and contract directly with managed care plans a.

Individual members of an IPA retain their ability to negotiate and contract directly with managed care plans b. IPA are immune from antitrust restrictions on group activities 2) The process of utilization management is more difficult in an IPA model HMO than it is in staff and group model plans a. Because physicians remain individual practitioners with little sense of being a part of the HMO Direct Contact Model Direct contact model HMOs contract daily with individual physicians to provide physician services to their members I.e. U.S. Healthcare and its subsidiary HMOs Attempt to recruit broad panels of community physicians to provide physician services as participating providers A.K.A. gatekeeper systems Compensate their physicians on either a fee-for-service basis or a primary care capitation basis Direct model HMOs eliminate the potential of a physician bargaining unit by contracting directly with individual physicians Disadvantages HMO may assume additional financial risk for physician services relative to an IPA model HMO This is expensive Difficult and time consuming for a direct contract model HMO to recruit physicians because it lack the physician leadership inherent in an IP Health and Beauty Essays.