Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:Introduction to Health Care and Public Health in the U.S.
Unit:Delivering Health Care - Part 1
Lecture:Structure and Function of Health Care Facilities and Hospital Units
Slide content:Managed Health Care HMO Prepaid health plan Physicians are paid per patient Patient pays co-payments for service, obtains referrals for specialty care PPO Physicians are independent Patient pays fees but does not need referrals Point-of-Service Plan Works as a combination of HMO and PPO 6
Slide notes:Managed care began in the late 1970s in an attempt to improve health care while controlling costs. An HMO is a prepaid health plan that provides health care for members and their families. The HMO contracts with physicians and hospitals, which are called the provider network. The HMO pays the physician a certain amount for each patient, and the patient pays a small fee, or co-payment, at each visit. Patients must use providers in the network and obtain a referral before accessing specialty care. A PPO is similar to an HMO, except that the physicians operate independently. The PPO network may be organized by an insurance company, an employer, or by the physicians themselves. Plan members pay a deductible and a co-payment. Members do not need a referral to see a specialist, but fees may be lower if they do obtain a referral. Point-of-service plans are essentially a combination of HMOs and PPOs. Patients can use physicians in the provider network, as in an HMO, but they can also go out of network without a referral, as in a PPO. The catch is that out-of-pocket costs are higher for using the PPO option. 6