Copyright
Beaver Medical Group.
All rights reserved.
Revised
August 20, 1997
The 10 Most-Asked Questions About Managed Care
- What is
Managed Care?
- What is an
HMO?
-
How can my premium cost less
and still cover my healthcare needs?
- Will a prepaid health plan provide all my
healthcare services?
-
Can I choose my own doctor
when I join an HMO?
- What if I need to see a
specialist?
- Do I have any recourse
if I disagree with my physician
about treatment?
- Are HMOs available to
people who are eligible for Medicare?
-
What should I look for
when choosing an HMO?
- How can I
evaluate
a participating medical group?
-
Managed care is a term that is used to generally describe healthcare
delivery systems (like an HMO) that attempt to manage
both the quality and cost of healthcare. This term usually
refers to a prepaid type of healthcare plan, which charges a
fixed monthly premium per patient to provide
all covered healthcare services (benefits) to the HMO
member. The only additional charge that the member might
be responsible for would be a small copayment at the time
of each visit to the provider. Some plans may also
require larger copayments for special types of benefits
(like eyewear benefits).
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What is an HMO?-
An HMO, or Health Maintenance Organization, is an organization
(like an insurance company) that arranges for the
delivery of health services to its members. The member's
employer pays a monthly premium for these health care
services (the employer may/may not ask the member to pay
a portion of this premium). These services are provided
by a participating medical group or physicians that have
a contract with the HMO. The HMOs often compensate their
contracted providers on a prepaid, per-patient-per-month
basis (this is called capitation). Since federally
qualified HMOs are required to offer wellness programs,
they usually provide routine examinations and other
preventative care that some traditional insurance
programs don't cover (like a PPO plan).
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How can my premium cost less and still cover my healthcare needs?-
Because the HMO covers all of the member's medical needs,
HMOs and their participating providers (physicians) have
a financial incentive to keep their patients well. They
provide regular health screenings and examinations as
well as preventative and educational classes and services
that can help reduce the need for costly treatment later.
This becomes an win/win situation as the physician and
patient work together as a healthcare team to accomplish
the goal of keeping the patient in the best possible physical
health.
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Will a prepaid health plan provide all my healthcare services?-
Most prepaid health plans provide all basic medically necessary
healthcare services. However, health plans do vary in the
benefits they provide and are often tailored to a specific
employer's needs. With any health plan, it is important
to read your benefit plan thoroughly and know exactly what
is covered. Become an informed consumer.
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Can I choose my own doctor when I join an HMO?-
Patients first choose the medical group (provider)
that they would like to belong to, then the patient
chooses his/her own primary care physician from that
group of physicians. If the employer gives the employee
several choices for health plans it is a good idea to
choose the medical group or preferred doctor within
that group before deciding on the health plan. Most HMOs contract
with many provider groups and nearly all provider groups
contract with more than one HMO. That means it is
possible that patients will be able to keep the same
doctor even if their employer changes health plans.
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What if I need to see a specialist?-
Before scheduling an appointment with a specialist, it
is important that you first obtain a referral from your primary care
physician. Your primary care physician works closely with
the specialist thereby reducing the chance of conflicting
medication or duplication of services. Because all of
your medical needs are arranged through your primary care provider
you must get authorization to receive care from a
specialty provider or physician who is not connected with
your medical group. Always refer to your benefit handbook or
contact your HMO representative for additional information
about the authorization/referral process which your
insurance coverage will require.
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Do I have any recourse if I disagree with my physician about treatment?-
First, you should always discuss the problem with your physician.
A partnership based on open and honest communication is
very important to the doctor/patient relationship. Also,
all HMOs and/or their providers have a process in place
that ensures a review of cases by a team of physicians.
This process can raise the quality of care by ensuring a consensus
among physicians on the course of treatment recommended
for a patient. It is the equivalent of having several
"second opinions". You also have the option of changing
physicians within the medical group if you feel that you
do not have the kind of doctor/patient relationship you
are looking for. Lastly, all HMO providers must have a
formal appeal/grievance process.
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Are HMOs available to people who are eligible for Medicare?-
Yes, more senior citizens are attracted to senior plan HMOs
because they cover all of their medically necessary expenses
and require no deductibles. They also eliminate the burden
of paperwork required in making traditional Medicare
claims and filing claims with their supplemental insurance
plans. These senior plan HMOs (also known as Medicare
Risk Plans) frequently offer many no-cost or low-cost
health assessments and education programs to help seniors
stay healthier. Many of these plans also have additional
benefits that Medicare will not cover which makes them
attractive to the senior consumer.
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What should I look for when choosing an HMO?-
A patient should look carefully at the available HMO plans
offered and evaluate the quality, reputation and convenience
of the participating medical groups and hospitals that
contract with the HMO. Carefully review the benefits
package and make sure you understand what is covered and
not covered. Ask about copayments and prescription charges.
Check with other members about the quality of patient
services and the programs offered by the HMO.
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How can I evaluate a participating medical group?-
Be an informed consumer! Ask friends, neighbors, co-workers
and pharmacists what the reputation of the physicians
group is. Visit the facilities. Does the staff seem friendly?
Do they have a facility nearby your work or home? Would
you be satisfied with the choices of primary care
physicians and specialists involved with the medical group?
Where would you go in an emergency? Does the medical
group have accreditation with a national organization,
such as The Medical Quality Commission?
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