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By Defining Terms and Concepts
Staff Writers
Here are four important health care delivery models that should be understood by all financial advisors, their clients, patients and the public:
1. PHYSICIAN ORGANIZATION (PO)
A PO is a group of physicians banding together, usually for the purpose of contracting with managed care entities, or to represent the physician component in a Physician Hospital Organization. The PO is a managed care contracting entity owned by and composed exclusively of physicians. The PO tends to be more tightly controlled in terms of members and adherence to treatment protocols than an Independent Physician Association. POs typically share information systems, claims-processing procedures, financial data, medical records, and other technical support functions.
2. PHYSICIAN PRACTICE MANAGEMENT CORPORATION (PPMC)
A firm that purchases physicians’ practices in exchange for a percentage of the gross receivables. The PPMC leases the office back to the doctor or employs the doctor on a salaried basis. The PPMC then contracts with the areas MCOs.
3. POINT OF SERVICE PLAN (POSP)
A type of managed care plan that allows members to choose whether to seek medical care within the plan’s network or seek medical care out of network at the point of service (i.e., at the time services are rendered). It allows members to pay little or nothing, if they stay within the established HMO delivery system. But, it also permits members to choose and receive services from an outside doctor, any time, if they are willing to pay higher co-payments, deductibles and possibly monthly premiums. It is also called an “open-ended” plan.
4. PREFERRED PROVIDER ORGANIZATION (PPO)
A PPO is a select, approved panel of physicians, hospitals, and other providers who agree to accept a discounted fee schedule for patients and to follow utilization review and pre-authorization protocols for certain treatments. It is a system in which a payer negotiates lower prices with certain doctors and hospitals. Patients who go to a preferred provider get a higher benefit — for example, 90% or 100% coverage of their costs — than patients who go outside the network.
Assessment
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Filed under: "Advisors Only", Book Reviews, Career Development, Glossary Terms, Health Insurance, iMBA, Inc., Managed Care, Practice Management | Tagged: david marcinko, dictionary of health insurance and managed care, financial advisors, health maintenance organization, HMO, hope hetico, managed care organization, MCO, physician organization, physician practice management corporation, PO, point of service health plan, POS, PPMC, PPO, preferred provider organization, www.healthdictionaryseries.com |
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Here are a few other health care delivery models:
The Health Maintenance Organization, or HMO, involves a fee paid per patient to the physician(s), thus bringing the financing and delivery of healthcare into one entity.
The Physician Hospital Organization (PHO) involves an arrangement between physicians and usually one hospital.
The following website describes some new successful models for healthcare delivery: http://innovativecaremodels.com/.
For example, the Patient Centered Care model is decentralized interdisciplinary care utilizing a RN as a patient care manager. The Hospital at Home model provides traditional hospital-level care in the home setting. The Values Driven System is a family-centered model which provides comprehensive care for a large population of Alaska Natives. See this site for some additional unique ideas.
Brian Knabe; MD
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And, here are even a few more health care delivery models:
• Global Healthcare Model:
American businesses are extending their cost-cutting initiatives to include offshore employee medical benefits, and facilities like the Bumrungrad Hospital in Bangkok, Thailand (cosmetic surgery), the Apollo Hospital in New Delhi, India (cardiac and orthopedic surgery) are premier examples for surgical care. Both are internationally recognized institutions that resemble five-star hotels equipped with the latest medical technology. Countries such as Finland, England and Canada are also catering to the English-speaking crowd, while dentistry is especially popular in Mexico and Costa Rica. Although this is still considered “medical tourism,” Mercer Health and Benefits was recently retained by three Fortune 500 companies interested in contracting with offshore hospitals and JCAHO has accredited 88 foreign hospitals through a joint international commission. To be sure, when India can discount costs up to 80%, the effects on domestic hospital reimbursement and physician compensation may be assumed to increase downward compensation pressures.
• Values Based Healthcare Model:
According to Mark Fendrick, MD and Michael E. Chernew, PhD, instead of the one size fits all approach of traditional health insurance, a “clinically-sensitive” cost-sharing system that supports co-payments related to evidence-based value for targeted patients seems plausible. In this model, out-of-pocket costs are based on price and a cost/quality tradeoff in clinical circumstances: low co-payments for interventions of highest value, and higher co-payments for interventions with little proven health benefit. Smarter benefit packages are designed to combine disease management with cost sharing to address spending growth.
• Locum Tenens Practitioner Model:
Locum Tenens (LT) is an alternative to full-time employment for most specialties. Some younger physicians enjoy the travel, while mature physicians like to practice at their leisure. Employment factors to consider include: firm reputation, malpractice insurance, credentialing, travel and relocation expenses (which are negotiable). However, a LT firm typically will not cover taxes.
It seems there are many emerging models; especially during this political time of healthcare reform.
Hope Hetico; RN, MHA
http://www.CertifiedMedicalPlanner.com
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