HMO Regulation Health Maintenance Organizations, or HMO's, are a very important part of the American health care system. They involve elements such as beneficial health care programs like Medicare for seniors and Medicaid for the poor. HMO's are sometimes referred to as managed care programs, which involves participation through clinics, physicians and insurance companies. Other essential parts of HMO's include prescription drug plans, such as distribution and cost, and they are also important for information needed by emergency room residents in cases of emergencies. Although HMO's are not always seen as positive and helpful institutions, they are definitely important when it comes to medical care. Most of the criticism comes from consumers using these HMO's and the politicians implementing their procedures. Some of the major problems involved are denial of treatment by physicians. This has to do with the people they see and what people will receive as far as treatment. According to the Associated Press, "Consumers who have been denied a treatment that the HMO says is not covered, or who inadvertently fail to follow HMO guidelines in seeking treatment and are therefore denied reimbursement, will continue to have little recourse." [12] Basically not much is being solved or controlled. HMO's and managed care programs have been subjected to countless regulations and attempted reforms. HMO's are a combination of doctors and insurance companies that are formed into one organization. They provide treatment to their members at a fixed cost and decide on treatment based on the severity of the patient's ailments. HMO's main concerns are to control costs and provide the best treatment possible to their consumers using their pr... ... middle of paper ... ... Bibliography [1] Bodenheimer, Thomas. "Selective Chaos." The People-To-People Health Foundation, Inc. (July, 2000 -- August, 2000): 5 pp. Online. Lexis-Nexis. 27 September 2000. [2] Coorsh, Richard. "Medicare Legislation Recognizes Concerns About Underpayment, Overregulation." Health Insurance Association of America. October 3, 2000. 1 pp. Online. [http://www.hiaa.org/news/news-current/press-releases/release3 .html] 24 October 2000. [3] Freudenheim, Milt and Steinhauer, Jennifer. "HMO's Policy May Please Patients, but Raise Costs." New York Times. 10 November 1999, natl. ed. [4] No Author. "California HMO's To Allow Appeals." Associated Press. December 3, 1998. Online. [http://www.policy.com/docs/ap/hmo120498.html] 24 September 2000.
To guarantee that its members receive appropriate, high level quality care in a cost-effective manner, each managed care organization (MCO) tailors its networks according to the characteristics of the providers, consumers, and competitors in a specific market. Other considerations for creating the network are the managed care organization's own goals for quality, accessibility, cost savings, and member satisfaction. Strategic planning for networks is a continuing process. In addition to an initial evaluation of its markets and goals, the managed care organization must periodically reevaluate its target markets and objectives. After reviewing the markets, then the organization must modify its network strategies accordingly to remain competitive in the rapidly changing healthcare industry. Coventry Health Care, Inc and its affiliated companies recognize the importance of developing and managing an adequate network of qualified providers to serve the need of customers and enrolled members (Coventry Health Care Intranet, Creasy and Spath, http://cvtynet/ ). "A central goal of managed care is containing the costs of delivering care, but the wide variety of organizations typically lumped together under the umbrella of managed care pursue this goal using combination of numerous strategies that vary from market to market and from organization to organization" (Baker , 2000, p.2).
The current health care landscape has been characterized by large scale consolidation and vertical integration of payers and providers. This has led to a handful of dominate players with substantial influence, and an increasing overlap in responsibilities between payers and providers. Although payers and providers have traditionally been on opposing sides, battling each other about quality of care versus cost-effective care, they are shifting to working together to achieve better value.
One being the Health Maintenance Organizations (HMO), which was first proposed in the 1960s by Dr. Paul Elwood in the "Health Maintenance Strategy”. The HMO concept was created to decrease increasing health care costs and was set in law as the Health Maintenance Organization Act of 1973, after promotion from the Nixon Administration. HMO would, in exchange for a fee, allow members access to employed physicians and facilities. In return, the HMO received market access and could earn federal development funds. An HMO is a integrated delivery system that combines both the delivery and financial aspects of health care for consumers. Under the HMO, each patient is appointed to a primary care physician (PCP), who is essentially accountable for the long-term care of the members that she/he has been assigned and any specialists that a patient needs to see should be referred by their PCP. Some examples of HMOs are Kaiser Permanente and Humana. HMOs are licensed at the state level, under a license that is known as a certificate of authority. A pro of an HMO is that treatment for a patient can begin prior to their insurance being authorized; A member may benefit from this because there would be little to no treatment delays. A con of an HMO is that in order to save cost, most HMOs provide narrow provider networks; A member may not benefit if in an emergency because their “in-network” emergency room might be far or there are “quick-care” in their
The Health Insurance Portability and Accountability Act, most commonly known by its initials HIPAA, was enacted by Congress then signed by President Bill Clinton on August 21, 1996. This act was put into place in order to regulate the privacy of patient health information, and as an effort to lower the cost of health care, shape the many pieces of our complicated healthcare system. This act also protects individuals from losing their health insurance if they lose their employment or choose to switch employers. . Before HIPAA there was no standard or consistency for the enforcement of the privacy for patients and the rules and regulations varied by state and organizations. HIPAA virtually affects everybody within the healthcare field including but not limited to patients, providers, payers and intermediaries. Although there are many parts of the HIPAA act, for the purposes of this paper we are going to focus on the two main sections and the four objectives of HIPAA, a which are to improve the portability (the capability of transferring from one employee to another) of health insurance, combat fraud, abuse, and waste in health insurance, to promote the expanded use of medical savings accounts, and to simplify the administration of health insurance.
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
HMO’s are groups of doctors hired by insurance companies and are usually controlled or regulated by the hospitals who facilitate them. The majority of this limitation is due to pressure from within the organization or government pressure. The government influences hospitals into denying treatment in order to cut federal costs. These government actions generally result in a revision of private employee health care claims, and in turn certain businesses can no longer afford to provide health insurance for their employees. Consequently, approximately 50 to 60 million people go without insurance for at least one month each year. Many HMO’s constantly evaluate their services to "ensure" the best care and coverage. But in many cases, what is happening is the exact opposite.
Formed in 1998, the Managed Care Executive Group (MCEG) is a national organization of U.S. senior health executives who provide an open exchange of shared resources by discussing issues which are currently faced by health care organizations. In the fall of 2011, 61 organizations, which represented 90 responders, ranked the top ten strategic issues for 2012. Although the issues were ranked according to their priority, this report discusses the top three issues which I believe to be the most significant due to the need for competitive and inter-related products, quality care and cost containment.
In conclusion, managed care integrates the functions of financing, insurance, delivery, and payment within an organization. It also exercises formal control over utilization. Managed care is viewed as accepting the lowest competitive bid for services rendered. Today, HMOs and PPOs are the most common and widely used models for managed care. Although managed care is here to stay, it requires revision in some areas. Challenges that are to be faced include double agentry, fidelity, confidentiality, honesty, and vulnerability. With the help and guidance of health information professionals, managed care will continue to escalade and become better for all.
Managed care reimbursement models have contributed to risk avoidance by negotiating discounts, discouraging use, and denying payments for charges that appear to be false. Health care reform has increased awareness to the quality of care providers give, thus shifting the responsibility onto the provider to provide quality care or else be forced to receive reduced reimbursements (Buff & Terrell,
In sum, America needs to reevaluate the status quo surrounding medical care. It is becoming increasingly apparent that the current model only benefits a select few and causes insufferable costs for the rest of the world. If there is no reform for these issues, money will continue to be siphoned directly into the pockets of large, for-profit companies that benefit from the strife of
Our healthcare system has developed into a burden for most people and has terrible consequences for others. It consists of everyone paying for healthcare as a whole, instead of people paying for themselves. This system of healthcare has burdened the people who take care of themselves and have money, but extends the life of people who do not take care of themselves and live in poverty. This is not pleasant for the one’s who decided to go to school and make well over minimum wage. In turn, they are the individuals who end up paying for the people who decided to make bad decisions in their life that put them in the minimum wage position. Clearly, laws regulate the insurance companies but these regulations do not make any sense to many. Balko explains that, “More and m...
There is an ongoing debate on the topic of how to fix the health care system in America. Some believe that there should be a Single Payer system that ensures all health care costs are covered by the government, and the people that want a Public Option system believe that there should be no government interference with paying for individual’s health care costs. In 1993, President Bill Clinton introduced the Health Security Act. Its goal was to provide universal health care for America. There was a lot of controversy throughout the nation whether this Act was going in the right direction, and in 1994, the Act died. Since then there have been multiple other attempts to fix the health care situation, but those attempts have not succeeded. The Affordable Care Act was passed in the senate on December 24, 2009, and passed in the house on March 21, 2010. President Obama signed it into law on March 23 (Obamacare Facts). This indeed was a step forward to end the debate about health care, and began to establish the middle ground for people in America. In order for America to stay on track to rebuild the health care system, we need to keep going in the same direction and expand our horizons by keeping and adding on to the Affordable Care Act so every citizen is content.
What is the broader implication of managed care for health care services is how healthcare providers control health care cost and quality care. With all the competition to pick from and the rising cost of health care the consumers’ needs to look at all options available. The keys to manage care are the types of organizations and insurance options that include health (HMO’s) maintenance organizations, provider organizations PPO’ and POSS. The health insurance industry is big on wellness and prevention as part of managed care.
What Seems To Be The Problem? A discussion of the current problems in the U.S. healthcare system.
Health care policies are plans that intended to determine or influence decisions or actions that will help to achieve specific health care goals. Most of these policies are actions taken by the government to improve the American health care system. The purpose of this essay is to describe the process of how a topic eventually becomes a policy and tie to how the Affordable Health Care Act (ACA) policy process. This essay will include the formulation stage, legislative stage, and implementation stage of a complete policy process.