Final Paper Submission, How HMO's Threaten Quality of Care

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Module 1 – Overview of Managed Care 9

Module 1 – Overview of Managed Care

Jamie Raines

Rasmussen College

H310/HSA3109 Section 01 Foundation of Managed Care

Sandi Moore-Foggey

May 24th, 2020

What is a Myth?

A myth is defined as “A generic term for popular beliefs in medicine which have proven over time to be invalid, which are maintained in medical culture because of inertia” (Myth, n.d.).

Myth: HMOs threaten quality of care

The most comprehensive analysis of comparisons on quality “found that HMOs provide care that is generally better than or equal to fee-for-service care. However, HMOs are leading long-overdue efforts to measure quality of care, so that it can be brought up to standard” (Major Myths of Healthcare, n.d.).

Introduction of HMO accountability for the quality of services, the investor-controlled market was not really free. Good companies were not rewarded for delivering high-quality services, and bad companies were not punished for withholding it. Because employers, who are often more concerned about cost than quality, typically pick health plans and pay premiums, patients have been unable to vote with their feet. Mismanagement has not been penalized

What is an HMO

“An HMO is a managed care organization (MCO) that provides health care services for those on connected insurance plans. HMO-like services began appearing in the early part of the 20th century and they started becoming popular after the Health Maintenance Organization Act of 1973. The new legislation required employers with more than 25 workers to offer HMO plans with federal certification. With an HMO, those covered must choose a primary care physician (PCP) to manage their health care” (PPO vs HMO, n.d.).

The PCP has primary responsibility for the patient and serves as the personal physician. The PCP also arranges assistance from other health care providers when needed. The PCP typically, is a general physician although it is possible to pick a doctor with more specialized skills.

Generally, when patients need specialized care, the PCP will provide referrals. Doctors and other health care providers may work directly for an HMO, or they may be part of a network of HMOs. In the latter case, the same doctor may provide services for people with different HMO plans. The idea behind the HMO is to provide consumers with cost savings and structure.

“Key Facts with HMO” ( HMO 101: Definition and Key Facts, n.d.)

· With an HMO, you choose a primary care physician, or PCP, from a network of providers.

· The PCP you choose will refer you to any specialists you need to see, also chosen from a list of in-network providers.

· Instead of paying a deductible, HMO plans require you to pay copays for medical services. Different types of services will have different copay amounts.

HMO’s and Treatments

If I’m rushed into surgery today because my appendix is about to rupture, my HMO will pay 100 percent for surgical services and hospital- covered expenses. However, if a person would experience another major depressive episode, the HMO will pay 50 percent up to no more than $1,000 per year for psychiatric.

The HMO recognizes that a ruptured appendix can lead to peritonitis, which can lead to death. So, what does it think that acute unipolar depression leads to? A bad hair day?

Conclusion

Well some people may enjoy an HMO and a PCP provider, personally I like to have the open network policy where I can go where ever I want and not have to be concerned with weather or not where I am at is Out of Network or In Network. However, I do feel today more and more health insurance plans are acquiring more hospitals, clinics, surgery centers, and independent medical buildings to be with in their network to pick from. I feel that HMO’s will not be around for too long except for people on Medicare and Medicaid who have to choose a PCP because it is controlled by the government.

References

Major Myths of Healthcare. (n.d.). Retrieved May 24, 2020, from https://www.bizjournals.com/boston/stories/1998/07/27/editorial2.html?page=all

Myth. (n.d.). Retrieved May 20, 2020, from https://medical-dictionary.thefreedictionary.com/myth