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health maintenance organization (HMO)
Notes:
1) prepaid plan in which members receive a defined benefit package for a set monthly premium
2) HMO assumes financial risk for member's health care
3) member's care is covered completely (occasionally there is a small copayment)
4) comprehensive medical care with primary medical doctors (PMDs) serving as 'gate-keepers'
5) medical care is covered only when patients go to physicians & hospitals which are part of the HMO network
6) Kaiser Permanente is an example
Types of HMO
1) group model
a) collects premiums from members
b) contracts with a group of doctors for a negotiated fee
c) the doctor's group then pays the individual physicians as well as contracts with hospitals for patient care
2) network HMO
a) HMO contracts with physician groups to provide care to members for a negotiated rate
b) relationship is not exclusive
c) physicians usually work out of their own offices & often have other contracts in addition to the HMO contract
3) staff HMO
a) HMO directly employs its own doctors
b) HMO owns clinics/hospitals in which the physicians work
4) independent practice association (IPA)
5) mixed HMO
- HMO uses a variety of models to form relationships with physicians
a) some physician groups may have exclusive contracts with the HMO (group model)
b) other physicians may have non-exclusive contracts (network model)
Impact of HMOs on Hospitals
1) decreasing number & length of hospital stay
2) sicker patients
3) change from per diem to shared financial risk
4) integration & consolidation for economy of scale & bargaining power
a) physician-hospital organizations
1] advanced form of managed care in which physicians & hospitals team together & form direct relationships with employers & employees
2] physician-hospital organizations collect a set monthly fee & assume risk for all patient care for the employee
b) physician-run HMOs: physician groups form their own HMOs
1] physician group contract directly with patients
2] physician group is at risk for all care
c) hospital mergers
1] consolidate costs over larger organizations (economy of scale)
2] capture larger patient populations
d) academic/private mergers
1] academic centers are under great pressure to become more financially stable as government subsidies decline
2] academic centers must now compete with the private sector for patients
3] academic centers are forming alliances with each other & private hospitals
Specific
Centers for Medicare & Medicaid Services (CMS); formerly Health Care Financing Administration (HCFA)
EverCare
Gerontologic/Geriatric Association
independent practice association (IPA)
National Institute for Occupational Safety & Health (NIOSH)
General
medical organizational structure
References
- Contributions from Linda Kuribayashi MD, Dept of
Medicine, UCSF Fresno