A Staff Model or a Prepaid-Only Group Model HMO indicates an exclusive HMO-medical group arrangement. Which of the following statements concerning point of service is correct? Medicare physician incentive payments by prepaid health plans could lower quality of care. These physicians were generally paid on a discounted fee-for-service basis and may have been at financial risk to the extent of a withhold from their fee-for-service payments. B. 2.) I. an ongoing quality assurance program II. No examination of the performance of HMOs in their Medicare and Medicaid lines of business (often a relatively small component) has been undertaken. In earlier studies of HMO experience, IPA Model HMOs were consistently found to experience higher hospital utilization rates than did other types of HMOs (Luft and Trauner, 1981). Covered employees have financial incentives to receive treatment with in the preferred provider network. The Staff Model is characterized by HMO ownership of the delivery system facilities and the employment of physicians on salary to serve exclusively the HMO membership. Because of their financial arrangements with providers, IPA Model HMOs were found to have a higher level of data availability, overall, than were other HMOs. To the extent that Medicare and Medicaid risk contract HMOs represent a different distribution of organizational characteristics than is found in all of the United States HMOs, it is likely that public program beneficiaries in HMOs are exposed to a different mix of utilization management methods than are all HMO enrollees. True. The nature of the interaction between the medical group and physician providers and the HMO organization differs substantially by the kind of HMO model type. 3.) 2023 Open Enrollment is over, but you may still be able to enroll in 2023 health insurance through a Special Enrollment Period. When Nelson et al. Which of the following statements about vision-care benefits is correct? A solidly based assessment of the potential of managed care to constrain future growth in health care utilization and costs requires that several aspects of the current managed care environment be examined. Miller RH, Luft HS. [1]As prepaid health plans, HMOs combine financing and care delivery and thus allegedly provide an incentive to provide cost-efficient quality care. [TRUE/FALSE] An IDS may NOT operate primarily as a vehicle for negotiating termswith private payers. HMOs are the most common type of health insurance plan available in the Affordable Care Act (ACA) marketplace and Medicare Advantage. Four studies of HMO financial incentives to physicians were initiated during 1986 and 1987 in response to the OBRA 1986 directive. in the 1980's and 1990's managed care grew rapidly while traditional indemnity health insurance declined. Compensation may impact where the Sponsors appear on this website (including the order in which they appear). All of these reasons combined have led the profit status of the industry to change so that a majority of HMOs are now for-profit entities. Here are the four categories: If youre looking for affordable health insurance, an HMO may be a good option for you. National Library of Medicine Given that HMOs operate with a prepaid model and thus must make predictions about future costs and revenue, failures generally involve the HMO underestimating its incurred claims while overestimating the funds it receives. In this article, the author reviews evidence on the relationship between HMO organizational arrangements and performance, and the trends within the HMO industry toward new organizational structures. State responses to HMO failures. The term "moral hazar " refers to which of the following? 7500 Security Boulevard, Baltimore, MD 21244. C. utilization management. a. (1989) shows a somewhat different mix of utilization management techniques reported by 41 Medicare risk contracting HMOs than was reported by GHAA for all HMOs. I. they may allow experience rating of an employer's entire medical expense plans, including HMO coverage II. C. Disease management programs typically focus on a single episode of impatient care. (1989) examined the HMO-physician financial arrangements by other organizational characteristics of Medicare risk contract HMOs, they found that IPAs, chain-affiliated HMOs, and for-profit HMOs were slightly more likely to capitate physicians than were other types of HMOs, and that IPAs were much more likely to use withholds as a component of their physician incentive packages. For example, Staff Model HMOs that pay physicians on a salary basis may be expected to rely more heavily on formal utilization controls since they have limited flexibility with respect to financial incentives. Second, the nature of utilization management strategies and financial incentives to providers should be identified. Elizabeth Rivelli is a freelance writer who covers various insurance topics. Despite attempts to decrease health care costs and improve care quality in the U.S. through strategies such as HMOs, the U.S. health care system is still the most expensive of any health care system in the world, encompassing approximately 18% of U.S. gross domestic product (GDP). The organizational characteristics that were associated with a particularly low ratio of HMO hospital-use-to-market-area-hospital-use were: Group Model HMOs were found to have the lowest hospital use ratios, IPA Model HMOs had the second lowest ratios, and Staff Model HMOs had the highest utilization relative to area rates. Rapid changes in the HMO industry have occurred in response to competitive pressures and changes in the legal and regulatory environment within which HMOs are operating. Utilization management programs are most effective if they are kept independent of provider compensation methods. Unlike other health insurance plans, HMOs typically require the member choose a primary care physician (PCP), who is responsible for coordinating their care. Each of the organizations that monitors HMOs on a continuing basis uses a slightly different definition of HMO model for classifying reported HMOs. Such alignment of incentives contrasts with alternativehealth care paymentstructures such as fee-for-service designs where those providing care may have a financial incentive to do so inefficiently. 8600 Rockville Pike [11] ACOs often include features that motivate quality care, such as incentives to meet specific quality benchmarks involving factors such as disease prevention and successful management of chronically ill patients. The site is secure. [2] Network model HMOs share many similarities with group model HMOs, except that providers under contract with a network model HMO also usually treat a substantial number of patients outside of the HMO. CIOs are the commercial counterpart of ACOs, as ACOs were designed, strictly speaking, to contract with Medicare only. Only 13% of employer-sponsored plans are HMOs. B. Reinsurance and health insurance are subject to the same laws and regulations. Research on health maintenance organization (HMO) participation in public programs and on the effects of HMOs in serving public program enrollees has focused primarily on the Medicare or Medicaid experience of these HMOs. The HMO Act of 1973 (Public Law 93-222) offered financial support for the development of new HMOs and required employers who offered traditional health insurance plans to also offer an HMO alternative if a federally qualified HMO was available in the area. Course Hero is not sponsored or endorsed by any college or university. First annual report: National evaluation of Medicare competition demonstrations. 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. Such research may fail to identify factors that are not unique to the public program contract but which are important in understanding HMO behavior, overall. A number of reasons account for the conversion of nonprofit plans to for-profit status. No individual applying for health coverage through the individual marketplace will be discouraged from applying for benefits, turned down for coverage or charged more premium because of health status, medical condition, mental illness claims experience, medical history, genetic information or health disability. Mandatory second surgical opinion (44 percent). Accountable care organizations (ACOs), including the similar concept of clinically integrated organizations (CIOs), represent one such innovation in the managed care space. C. Most plans have a co-payment for each prescription. C. Managed care plans offer an unrestricted use of medical care providers. ), which permits others to distribute the work, provided that the article is not altered or used commercially. 28. This HMO variation appears similar to the preferred provider organization (PPO) arrangements that offer the enrollee a provider network at a lower out-of-pocket price, but permits the enrollee to use other providers at a higher out-of-pocket price. The trend toward greater chain affiliation of HMOs also has been documented by the HMO industry. These managed care entities differ substantially among themselves in terms of organizational structure, utilization management, and financial incentives to providers. Compared to other common health insurance plans, such as preferred provider organizations (PPOs), HMOs are generally less expensive. 4GHAA conducted a special survey of its members. HMOs arent nearly as common in the employer-sponsored health insurance market. (1985) found that among Medicare risk contract HMOs: Thus, utilization management methods vary with the organizational characteristics of the HMO. Data requirements and the MIS structure will vary, however, by type of HMO (Neal, 1986). D. utilization managemt directly intervene in referral decisions, A. The defining feature of a direct contract model is the HMO contracting directly with a hospital to provide acute services to its members. HMOs are, however, the only organizations that combine utilization management, provider selection, and financial incentives to control provider behavior. In 1980, 236 HMOs served 9 million members in the United States. A. direct access to specialists B. any-willing-provider laws C. provider gag clauses D.Point-of-service options, Which of the following statements concerning accreditation of managed care plans is incorrect? Here are some of the biggest HMO advantages and disadvantages: PPO plans, which stands for preferred provider organization, are the most common employer-sponsored health plan. TF An IDS may not operate primarily as a vehicle for negotiating terms with private payers. Choi Y. The results of the Nelson et al. 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. For this reason, the PCP is sometimes referred to as a gatekeeper as they are the first providers to evaluate patients before sending patients to specialists if necessary. Hillman AL, et al. (1989) study of 41 Medicare risk contract HMOs shows a similar pattern to those reported by ICF, Inc. and the U.S. General Accounting Office (GAO), both of which concentrated on HMOs with Medicare risk contracts: The 61 percent capitation rate for these plans is lower than the 73 percent rate of all HMOs reported by GHAA (1988) or the 78 percent rate of BC/BS HMOs reported by BC/BS (1988), but is similar to the proportion of TEFRA risk contract HMOs that capitate as reported by ICF, Inc., and by GAO.
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