Jan L. Warner & Jan Collins
If you are getting divorced and, like most, looking at your health care plan for the first time, you need to know about managed care and how it will affect you and your family.
The first managed care in the United States was in the early 1900's in the form of pre-paid group practices which were developed to provide coordinated, cost-effective health care. While World War IIaccelerated the growth of these plans, the federal HMO Act in 1973 stimulated the growth of managed care.
The theory behind managed care is the ability of combining the delivery of health care services with the financing of the care. If you enroll in a managed care plan -- for example, an HMO (Health Maintenance Organization) or PPO ( Preferred Provider Organization), in return for receiving your care from a selected group of health care providers within a network, you pay a set monthly fee for the services you receive.
Since the real value of these plans is the ability to combine financing and delivery of health care, as the cost of health care increased, employers and the public health insurance programs of Medicare and Medicaid began looking for ways in which to contain costs. By mid-1997, half of the United State population was enrolled in some type of managed care plan: 74 percent of enrollees received their health coverage through their employment; 13 percent of were beneficiaries of Medicare. In addition, a large percentage were Medicaid beneficiaries.
Over time, the types of managed care plans have increased, but the differences have become blurred. Basically, managed care plans now range from "very restrictive" -- fewest choices to consumers -- to "least restrictive" -- most choices to consumerss -- models, and all types are not available everywhere.
Group and Staff Model Health Maintenance Organizations (HMO) often have their own medical centers where primary care doctors and specialists practice in the same medical center. In this model, all medical care and services -- including laboratory, x-ray, and sometimes pharmacy services -- can be received in one central location. The most restrictive, this model requires that you choose a primary care physician or one is assigned to you. Generally, you may change your primary care physician. Generally, HMO's either pay doctors a salary or a set amount per patient which is called "capitation".
Individual Practice Associations (IPAs) are a less restrictive form of HMO. Here, physicians practice in their own offices and are under contract with a separate group which is called an IPA. The IPA, in turn, contracts with an HMO. As an enrollee, you will receive a list of those doctors who participate and you will choose you primary care doctor. Visits take place in the doctor's office, and if you need specialty care, your doctor will refer you to a specialist who belongs to the IPA or with whom the IPA has contracted. Today, the largest number of HMO enrollees have joined the IPA model. Doctors can belong to more than one HMO and can continue to see fee-for-service patients in their offices.
Point of Service Plans (POS) -- also called self-referral options or open-ended options -- allow enrollees greater choice and flexibility. Although ordinarily using doctors within the network, you have the option to go outside of plan to use non-HMO providers which will cost you more by virtue of higher coinsurance and deductibles.
Preferred Provider Organizations (PPOs) are networks of doctors, hospitals, and health care providers that have agreed to give the sponsoring organization -- such as an employer or an insurance company -- discounts from their normal and usual rates. Under this plan, you pay more out-of-pocket costs if you use physicians or hospitals outside the PPO network. Some PPOs use primary care physicians as gatekeepers, while in others, you have the right to choose your own doctors and visit specialists without getting permission from a gatekeeper. In some PPOs, you may receive such additional benefits such as immunizations so long as you use providers who are a part of the PPO network. Of all the managed care plans, PPOs offer you the greatest latitude in selecting health care providers, but premiums are somewhat higher than HMO premiums and there is less coordination of care.
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