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Managed Care
During this time of skyrocketing health care costs, it's thought that managing or controlling this whole process might be a good idea. So "managed care plans" have been set up to deliver health care less expensively by overseeing the use of the care, the quality of the care, and the cost of the care.
The Different Plans
Pros & Cons
Important Terms & Definitions
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Managed Care The Different Plans

Health Maintenance Organization (HMO)

Most controlled type of health care plan.
You must use the HMO's doctors and facilities.
Medical care outside the system is not covered.
No deductible or Plan Limit.

Less "freedom of choice"
Lower out-of-pocket costs.
Less paperwork.

One set monthly premium --
no matter how much care you need --
Emphasis on preventive services.

Point-of-Service Plan (POS)
A lot like an HMO.
You choose the doctor or hospital .
 
Lower costs within POS "network"
You pay difference for Dr. outside the network

Select a primary care physician "gatekeeper"
This doctor will refer you to specialists, if needed.

Preferred Provider Organization (PPO)
Network of doctors and hospitals
Discounted fee for their services from the plan.
Choose from list of "preferred providers"
Deductibles and plan limits.
Freedom to choose your own doctor and hospital.
You pay some of the costs.

Independent Practice Association (IPA)

This is a loosely organized network of doctors.
IPA usually only for groups.
Small co-payment for each visit.
Success of plan based on efficiency, affordability, etc.
Participating doctors share profits/losses.
 
Be careful: many managed care plans will notpay for medical care unless is provided or authorized by your primary care physician.
Most plans now require that you or your doctor get advance
approval for any non-emergency hospital admission.
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Pros & Cons

  • Managed Care restricts access to the more expensive procedures. Instead, emphasis is placed on preventative medicine.

  • Patients generally have less choice of doctors & treatment options.

  • Doctors are under pressure to keep costs low. In return, the doctors secure business from the Managed Care group.

  • Provides universal coverage.

  • Tendency to provide lower quality care to avoid excessive cost.

  • Physicians compromised for fear of being "dropped" from the network.

"There are quite a few more hurdles to pass in a managed Medicaid program than there are in a commercial program, just in terms of the forms and rules that are required"
(See "Autonomy")

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Terms & Definitions

  • Conversation: The ability to change your medical coverage from a group plan to an individual plan, if you should leave your present job.
  • Co-payment: The portion of the covered medical expenses that you must pay out of your own pocket.
  • Deductible: The amount you must pay (either per person or per family) before your plan starts to pay its share of benefits.
  • Fee-for-Service: A system where the doctor receives payment only after he or she has treated the patient, and has billed the insurance company. (Fees may be prenegotiated.)
  • "Gatekeeper" or Primary Care Physician: This is usually a family practitioner, an internist, or a pediatrician who provides your care, arranges for tests or hospitalization, and who refers you to a specialist.
  • Preadmission Certification: This is the verification by your insurance plan that a hospital admission is medically necessary.
  • Preauthorization: This is the prior approval of certain health care services (e.g. surgery) by the insurance plan.
  • Pre-existing Condition: This refers to a medical problem or disease that was diagnosed before the medical plan benefits took effect.
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