HMO Regulation Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives. 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. HMO's can and do conduct their business quite ruthlessly. Patients are continuously unable to receive the necessary treatment due to the insufficient HMO coverage. Many HMO's actually make more money if their doctors see or treat fewer patients. 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.” (2) Many people must drive for hours, generally sick or injured, simply to receive treatment from a doctor that will be covered by their HMO. Another downfall to HMO coverage is selective-contracting. This is a process where hospitals deny treatment to patients because their... ... middle of paper ... ...ts to cover their mistakes. This is the exact opposite of what the country needs. Why should costs go up because of denied treatment? The big concern is whether or not government really understands the great difficulty in trying to control HMO’s and other health care programs without a nationalized program. Since there are some 6 million people using Medicare in HMO’s something needs to be done to ensure these patients the treatment that they need. In conclusion, there still needs to be a lot of work done to health care in the United States. Other nations provide universal health care to their citizens, but this would cause dilemmas in balancing two often conflicting policy goals: providing the public with equitable access to needed pharmaceuticals while controlling the costs. Universal health care probably would not work in the U.S. because our nation is so diverse and our economy is so complex. The system we have now obviously has its problems, and there is a lot of rom for improvement. HMO’s will still create problems for people and their medical bills, but they definitely should be monitored to see that their patients are receiving just treatment.
While most countries around the world have some form of universal national health care system, the United States, one of the wealthiest countries in the world, does not. There are much more benefits to the U.S. adopting a dorm of national health care system than to keep its current system, which has proved to be unnecessarily expensive, complicated, and overall inefficient.
Health Maintenance Organization (HMO) is a group of individual health plans that are intended to provide services for costumers’ that purchase insurance policies and for those that cannot afford health insurance. Many of these organization are led by physicians, and other professionals that network together to make health care affordable for patients. In the HMO category there are five separate managed care plan models. First, the Group Model (HMO), is a group that has a number of physicians that mainly agree to provide care to a defined group of patients in return for a fix rate capita payment for discounted fees from insurance companies (Henderson, 2012 p.212).
For ease of review in discussing the developmental theorists and their theories of human development I have subdivided each theorist into their respective schools of psychology. These schools include the psychoanalytic school, behavioral school, humanistic school, cognitive school, and the individual schools of psychology. Each developmental theorist holds their own unique ideas and theories about various components of human development. I will be discussing the contributions of each of these theorists.
Out of all the industrialized countries in the world, the United States is the only one that doesn’t have a universal health care plan (Yamin 1157). The current health care system in the United States relies on employer-sponsored insurance programs or purchase of individual insurance plans. Employer-sponsored coverage has dropped from roughly 80 percent in 1982 to a little over 60 percent in 2006 (Kinney 809). The government does provide...
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...
Although many people refuse to see it, the foundation of universal healthcare is built upon socialistic ideas. In an industry where talent and intellect is required, value will no longer be placed on the expertise or skill of a doctor. There will be no profit incentive for medical providers if they are compensated the same regardless of the quality of treatment they administer. The two government-run health insurance programs, Medicare and Medicaid, are a perfect example of this. Medicare determines which doctor the patient sees, and what treatments are appropriate. It also determines the duration of the treatment, and compensation of the doctor. Financially speaking, these programs are bankrupting our government. According to the Objective Standard, “These two federal insurance programs compose nearly 20 percent of the federal budget, and the percentage keeps rising.” (Zinser, “Moral Healthcare vs. Universal Healthcare”). Doctors are paid far less from treating Medicare patients because of the insufficient funding of the program, and therefore have to turn away a lot of new Medicare patients. This is an example of what public healthcare will look like if this was prov...
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.
Health insurance companies are experts in setting traps for consumers to entice them into handing over a vast amount of money and not receive a single valuable service. After all there isn’t an entity available to regulate them.
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
As described in the Health Care in the United States textbook and notes, managed care services are delivered through organizations, better known as MCO (Managed Care Organizations). MCO’s are a category of insurance company – main way health insurance is delivered – that guarantees a member’s health care will be provided. The key functions of insurance, such as funding, distribution/delivery, and payments are taken over and overseen by MCO’s. This means MCO’s control quantity and reimbursement, resulting in cutting costs. One specific way managed care attempts to control costs is by gatekeeping. Gatekeeping is fundamentally a patient needs a referral from his primary physician to see any other specialist inside their network. Making referrals necessary helps cut the cost immensely. For example, a patient cannot make an appointment to see a
Employees want affordable premiums and access to care, employers want to spend the least amount to insure their employees, and insurance companies want a low-risk pool and charge substantially more for outliers, which under the ACA, translates into higher premiums for everyone. The Commonwealth Fund (2013) conducted a survey that targeted these inequalities and found more than one-third of adults went without recommended or needed care or failed to fill a prescription because of costs. Additionally, one-quarter of the respondents reported having problems paying their premiums, had difficulties paying medical bills, or were unable to pay them at all. Certainly, the altruistic ideas of reform are still possible; however, the competing interests of the three demographics are not in harmony and will never be as long as the insurance companies continue to write the narrative and control the costs of healthcare premiums and obtaining
Health maintenance organizations (HMO) are organizations that provide or organize health insurance, self-funded health care benefits plans, individuals, and other entities for the United States as a liaison with health providers or hospitals on a prepaid basis. In this simulation a virtual organization Castor Collins Health Plans presented three HMO options to two organizations. I will review one of the company’s demographics, discuss the HMO choices, explain the differences in the choices presented, and why I chose the plan I chose.
Managed care puts providers in a tough position to deliver the necessary care. If the medical provider was free to perform any procedure he thought is necessary under fee-for-service payment, he may get penalized for doing that under managed care guidelines. Managed care doesn’t allow the medical providers to recommend expensive procedures, but instead in encourages cheaper alternatives. The patients that use to pay-for-service system feel that they don’t get the best care that they deserve. Managed care places restrictions on certain services and discourages the overuse of medical care, which was encouraged by the pay-for-service system. Henderson mentions that “Managed care is unpopular among health care providers, and that managed care challenges their clinical independence and income. When providers are not happy with a plan their patients will mimic the
The healthcare industry is very complex and is contentiously changing. There are many key elements that affect healthcare policy. One of those key elements is cost. When the price of a gallon of gas or a pound of hamburger rises, consumers can anticipate how the increase will affect what they have left to spend on other goods. It is far less obvious to consumers how increases in health care costs hit their pocket book. In the past several years, medical spending has risen faster than inflation and the economy as a whole. The reason for this is due to high deductible health plans, providers rising operating and regulatory costs, employers desire to offer a health benefit while managing their own costs, and the opaque pricing and payment
As indicated by McLaughlin and McLaughlin (2008), governments must respond to the concerns of healthcare providers having a conflict of interest as it relates to patients and for others. In the 1990s, the United States saw the emergence of many physician-owned hospitals specializing in certain high-dollar procedures such as cardiac care and orthopedics. They had many reasons for their development. First of all, physicians sought to funnel the private insured patients to facilities in which they had a financial stake. Additionally, they were able to pick and choose patients who might have a better outcome. Moreover, the doctor had more control over the patient's care and length of stay in a facility in which he had ownership. This created problems