by: Kay Lowe
Health insurance plans have been forced to take action to contain costs of
quality health care delivery as health care costs have skyrocketed. Health
insurance premiums, deductibles and co-pays have steadily increased, and
health insurance companies have implemented certain strategies for
reducing health care costs. "Managed care" describes a group of stratgies
aimed at reducing the costs of health care for health insurance companies.
There are two basic types of managed care plans; health maintenance
organizations, or HMOs, and preferred provider organizations, or PPOs. So
which health plan is best? How do you choose what type of health insurance
best suits the health care needs of you and your family?
Both HMOs and PPOs contain costs by contracting with health providers for
reduced rate on health care services for its' members, often as much as
60%. One important difference between HMOs and PPOs is that PPOs often
will cover the costs of care when the provider is out of their network,
but usually at a reduced rate. On the other hand, most HMOs offer no
coverage for health care services for out-of-network providers.
Both HMO and PPOs also control health care costs by use of a gateway, or
primary care provider (PCP). Health insurance plan members are assigned
(or select) a primary care practitioner (physician, physician assistant,
or nurse practitioner). usually a family practitioner or internal medicine
doctor for adult members or a pediatrician or family care practitioner for
childern. The primary care provider is responsible for coordianting health
delivery for plan members. Care by specialist physicians require referral
from the primary care provider. This cost containment strategy is intended
to avoid duplication of services (for example, the cardiologist ordering
tests that have already been done by the PCP, or a sprained ankle being
referred to an orthopedic) and avoid unnecessary specialist referrals,
tests and/or procedures.
HMO and PPO plans also contain costs by requiring prior approval, prior
authorization, or pre-certification for many elective hospital admissions,
surgeries, costly tests and imaging procedures, durable medical equipment
and prescription drugs. When such services are required, the provider must
submit a request to the health insurance plan review department, along
with medical records that justify the service. The request is reviewed by
the health insurance company to determine whether the services are
justified as "medically necessary" according to the health plan policy and
guidelines. Review is usually performed by licensed nurses, and, if the
reviewer agrees that the service is necessary, approval is given and the
service will be covered by the health insurance plan.
As health care costs continue to rise, many indemnity health insurance
plans, or "fee for service" plans are being forced to adopt some managed
care strategies in order to provide quality health care and keep health
insurance premiums affordable. And as long as health care costs continue
to rise, the distinctions among PPO, HMO, FFS and other health insurance
plans will become blurred. Rest assured, however, that managed health care
is here to stay.
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