HMO health insurance is a subset of prepaid medical services where members can obtain medical services from a select group of doctors and facilities. Members must select a primary care physician who arranges all medical services. HMO aims to provide affordable medical services and eliminate spurious treatments. HMO providers operate within two models: group and staff. HMO has been the subject of controversy due to limited physician availability affecting the quality of medical care. However, HMO remains a viable alternative to traditional health insurance.
HMO health insurance is health coverage offered by a health maintenance organization or HMO. This type of health insurance is considered a subset of prepaid medical services where members of the organization can obtain medical services from a select group of doctors and health care facilities. The structure of most HMO health insurance options is different from other medical insurance options in that coverage is valid only when the member uses the services of doctors and facilities that have a contractual agreement with the organization.
While there are some differences in operating structure, most HMO health insurance plans require each member to select a primary care physician. This doctor serves as the conduit through which all medical services provided under the plan must be arranged. For example, if a member feels the need to see a specialist of any kind, she must first receive a referral from the GP before the HMO will compensate the specialist for services rendered. Outside of a medical emergency, the member should always talk to their primary care physician before seeking any type of medical treatment covered by another healthcare professional, even if this professional is also part of the HMO network.
The goal of HMO care overall is to provide affordable and competent medical services to as many people as possible. At the same time, the HMO health insurance structure is also designed to eliminate spurious treatments, tests, and other factors that often drive up the cost of medical care. These two primary goals helped boost the attractiveness of HMO health insurance in the United States during the 1970s, prompting a number of companies to switch from more traditional health insurance options to an HMO plan.
HMO health insurance providers typically operate within one of two models. With the group model, the organization contracts with physicians in a certain geographic area to provide services to members who reside within the region. Physicians are paid a monthly fee for each HMO member in their care, provided they provide a specified minimum of basic services. With this independent group model, doctors are still free to accept patients who are not associated with the HMO and who are covered by other insurance plans.
There is also a group model known as a captive group. In this scenario, the group practice is created by the HMO with the express purpose of serving the HMO patients. Physicians associated with the practice do not accept non-HMO patients and receive their compensation in the form of monthly payments for each HMO member assigned to their care.
In addition to the two group models, there is also a staff model. With this approach, physicians are based in an HMO-owned and operated facility and are full-time employees of the organization. Instead of the monthly salary based on the number of patients assigned to the doctor, each healthcare worker receives a salary.
Over the years, HMO health insurance has been the subject of controversy. Proponents of this type of medical coverage note that the structure of most HMO organizations has led to a reduction in the performance of unnecessary procedures and treatments in some cases. Furthermore, the provisions for an annual review as a safeguard are also touted as a sign of the proactive approach most HMO organizations take towards the medical well-being of members.
Detractors of HMO health insurance plans note that many plans provide a fixed monthly payment for each member assigned to a specific primary care physician. If there are very few HMO-affiliated physicians in any given location, this can lead to a single general practitioner being inundated with huge numbers of patients. As a result, the amount of time the physician can spend with each patient may be limited and thus affect the quality of medical care provided.
While some of the initial enthusiasm for HMO health insurance has cooled somewhat in the United States, this approach to health care remains a viable alternative. Several HMO health insurance companies remain in operation, most of which have refined the original 1970s model so that some of the operational problems of years gone by are no longer present.
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