The Ten Most-Asked Questions About Managed Care
More and more Americans are being asked to choose between managed care and traditional fee-for-service health plans. Many people have little knowledge about how to decide between these two choices. Unified Medical Group Association, a national organization of medical groups that provides care to HMO enrollees offers answers to a few of the most-asked questions.
1. What is managed care?
Managed care is a broad term that is used to describe healthcare delivery systems that attempt to manage both the quality and cost of healthcare. Managed care most often refers to prepaid healthcare plans, which charge a fixed monthly premium per patient per month to provide all covered healthcare services to HMO members. The only additional charge is a small copayment at the time of each visit to a provider.
2. What is an HMO?
An HMO (health maintenance organization) is an organization that arranges for the provision of specified health services to its members in exchange for a prepaid monthly fee or premium. Healthcare services are provided by participating medical groups, contracting physicians or, in some cases, staff physicians. HMOs often compensate their providers on a prepaid, per-patient-per-month basis (called capitation). Since federally-qualified HMOs are required to incorporate wellness programs, they usually provide routine examinations and other preventive care that some indemnity plans don't cover.
3. How can an HMO cost less and still cover routine expenses?
Because they cover all of a member's medical needs, HMOs and their participating providers have a financial incentive to keep patients well. They provide regular health screenings and examinations, as well as preventive and education services that can help reduce the need for costly treatment later.
4. Will a prepaid plan provide all the healthcare services a patient needs?
Most prepaid health plans provide all medically necessary healthcare services. However, health plans vary and are often tailored to a specific employer's needs. With any health plan, it is important to read the contract thoroughly and know exactly what is covered.
5. Can patients choose their own doctors in an HMO?
Patients can choose their own provider groups and their own primary care physician from within that group. It's a good idea for patients to choose their medical group, or their preferred doctor from within that medical group, before deciding on a health plan. Most HMOs contract with many provider groups. Nearly all provider groups contract with more than one HMO. As a result, patients will probably be able to keep the same doctor even if their employer changes health plans.
6. What if a specialist is needed?
An HMO member's primary care physician manages that patient's total care and will refer the patient to a specialist when one is needed. By carefully coordinating the use of specialists, the primary care physician retains full knowledge and control of the case, reducing the chance of conflicting medication or duplication of services. The HMO will usually not pay if a member sees a specialist without a referral from the primary care physician, except in a clear-cut emergency situation.
7. Do patients who disagree with their primary care physicians have any recourse?
All HMOs and/or their providers have a utilization management process in place that ensures a review of cases by a team of physicians. This process can raise the quality of care by ensuring a consensus among physicians on the course of treatment recommended for a patient. The process is the equivalent of getting several "second opinions." All HMO providers must also have a formal appeal/grievance process.
8. Are HMOs available to people who are eligible for Medicare?
Yes. Many seniors are moving to prepaid plans because they cover all of their medically necessary expenses and require no deductibles. These plans also eliminate the burden of paperwork required in making traditional Medicare claims. These plans frequently offer many no-cost or low-cost health assessment and education programs to help seniors stay healthier.
9. What should an individual look for when choosing an HMO?
A patient should look carefully at the available HMO plans and evaluate the quality and convenience of their participating medical groups and hospitals. Read the contract and understand what is covered and not covered. Ask about copayments and prescription charges. Check with other members about the quality of patient services.
10. How can a patient evaluate a participating medical group?
There are many considerations in choosing a medical group, including convenience and its reputation for quality. Consumers should visit the group and ask questions about its facilities, its staff, and its emergency capabilities.
Source: The above information was provided by James O. Hillman, Executive Director of the Unified Medical Group Association, a national organization of medical groups and Independent Physician Associations (IPAs) who provide health care to enrollees in prepaid health plans.
