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YOUR PLAN: PEOPLE WITH SPECIAL HEALTH NEEDS General Information about Managed Care Care Physician Treatment Centers INDEX |
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GENERAL INFORMATION ABOUT MANAGED CARE Over the last ten years, there has been a significant change in the way that the health care system is financed and delivered. Managed care has slowly gained support as a possible way to contain costs without sacrificing quality of care. Managed care is a generic term that applies to different types of health care arrangements. Managed care systems typically combine the financing and delivery of health services. They do this by covering some or all of the costs of health care services (financing), while encouraging enrollees to obtain services from the organization’s network of providers (delivery system). There are three primary types of managed care arrangements: Health Maintenance Organizations (HMO), Point-of-Service plans (POS), and preferred provider Organizations (PPO). • HMOs have exclusive provider networks and often use primary care providers as "gatekeepers." Gatekeepers are responsible for arranging the patient’s referral to a specialist or admission to a hospital. enrollees usually can not obtain care from providers that are outside the HMO’s network of providers. • POS plans are HMOs that give the patient the opportunity to see providers outside of the network. Patients who use the HMO network of providers pay less than patients who see providers outside the network. The HMO may still require the use of a gatekeeper to authorize in-network services, but no referral is needed for out-of-network services. • PPOs manage medical costs by creating a network of providers who are willing to accept lower reimbursement rates. In addition, PPOs usually use other methods, such as utilization review, to control unnecessary utilization. Patients can choose any health care provider. But they will have to pay additional money if they use a provider who is not part of the PPO network. PPOs are usually associated with traditional insurance companies, not HMOs. Today, managed care has become the dominant mode of health care delivery and financing in the private sector, and is quickly moving into Medicaid and Medicare. As managed care continues to grow, it becomes increasingly important for persons with disabilities and chronic illnesses to understand the advantages and disadvantages of this system so that they are able to make educated decisions about their care. REMEMBER, you are your best advocate: be an educated consumer! |