Health maintenance organization is a kind of managed health insurance or healthcare whereby the insured individuals only doctors, physicians and specialists who are part of a network. This paper seeks to focus issues that arise because of managing health maintenance organizations (Ehealthinsurance.com, 2014). The need to read this paper is to have a clearer idea of what the program concerns. Health maintenance organizations have participated in a major role of maintaining a higher standard of healthy living for the society. We will embark on their benefits and demerits, the challenges associated, and their recommendations.
- Benefits of Health Maintenance Organizations:
- Healthcare is easy and affordable to everybody.
- This health insurance covers, treatment, medication and hospital admissions.
- The terms of the monthly premium, health insurance costs much less, than it would cost treatment without insurance cover.
- It is deductible and it does not require any copayment from the members
- Individuals get to choose a primary care physician within their network who will provide most of the care and any medical issues (Advantage Health Solutions, 2013).
- If the physician leaves, the particular network that you are in, they assign another one to you.
- There are special cases that you cannot see your physician and they will need to refer an individual to a more qualified physician.
- It is easier to create stronger physician – patient relationships from this perspective of choosing your own physician.
- Disadvantages of Health Maintenance Organizations:
- Seeing a doctor outside the network means an individual has to cover the cost from their own pockets.
- Emergencies vary from network to network and it depends on the HMO. An HMO’s list of emergencies is usually less extensive.
- If a doctor drops out of the network, the patient is in a dilemma between keeping the relationship with a doctor at the expense of extra costs or letting go and taking another difficult experience working up a new relationship with another doctor (Goodwin, et al 1983).
- Challenges that face the management of HMO’s include:
- There is little cost sharing on behalf of the recipients of this program. This has seen an increase in the spending of Medicaid for instance with expenditures escalating by the year.
- If a doctor drops out of a network, the patient is torn between keeping the relationship with the doctor at the expense of extra costs or letting go and taking another difficult experience working up a new relationship with another doctor (Birch & David Associates, 2002).
- Recommended solutions to the challenges:
- On their own, HMO’s can take up initiatives by building partnerships with their state Medicaid Agencies that will provide voluntary coverage (Brown, 2004). This gives them the opportunity to have some input into the plan.
- Formation of new partnerships with other managed care organizations like hospitals (Fallon et al., 2013)
- Utilization of the Solutions
- Ensuring that population and finances are properly planned.
- Ensuring that the data the state is using is credible.
- Validating the projection assumptions the state used to get from the experience in the past to the projected period.
Health Maintenance organizations are complex programs that require different kinds of management. This includes different kinds of actuarial techniques. There is huge market potential for HMOs and when properly done, it can be a profitable program and highly beneficial to all parties involved.
References
ADVANTAGE Health Solutions. (2013). Health Maintenance Organization (HMO) - ADVANTAGE Health Solutions. [Online] Retrieved from: http://www.advantageplan.com/maplans14/member/medicare-offerings/hmo/ [Accessed: 3 Apr 2014].
Birch & Davis Associates. (2002). Claims liability management in health maintenance organizations. Rockville, Md: U.S. Dept. of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health, Office of Health Maintenance Organizations, Division of Development.
Brown, M. (2004). Managed care: Strategies, networks, and management. Gaithersburg, Md: Aspen Publishers.
Ehealthinsurance.com. (2014). HMO Health Insurance Plans - Health Maintenance Organizations. [Online] Retrieved from: http://www.ehealthinsurance.com/health plans/hmo/ [Accessed: 3 Apr 2014].
Fallon, L. F., Begun, J. W., & Riley, W. J. (2013). Managing health organizations for quality and performance. Burlington, Mass: Jones & Bartlett Learning.
Goodwin, S., Sweet, R. N., Baldwin, J. M., Wisconsin. & Wisconsin. (1983). Health maintenance organizations and preferred provider organizations. Madison: Wisconsin Legislative Council. Bottom of Form
