Can someone explain the concepts of hmo and ppo?

[serge23]

Hey I'm just wondering if someone can better expain the roles of hmo's and ppo's or maybe you have a llink to where there is more explanation towards these topic. This something good to know, especailly for interviews.

Thanks a lot.

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[Veilside]

hmo's and ppo's are two of the major players in managed care. hmo is an organization that contracts with medical facilities, doctors, and employers to provide medical care. once an individual enrolls in an hmo plan, he/she can only visit doctors who are in that hmo network. in addition, the pcp has to refer you to a specialist before you can go see a specialist.
an individual who is enrolled in a ppo plan receive significantly more coverage if they visit health care providers who are affiliated with the ppo plan.

the main argument is that these managed care groups claim that they reduce health care costs (and they do) but it may also come at a price (i.e., hmo's and ppo's indirectly and directly controlling the amount of treatments and procedures given to patients). the major debate is how to balance the two

 

[Amy B]

I think one difference is that a doctor receives a monthly fee for patients with an HMO. If that patient needs to be seen more than what that fee would cover, than the doctor has to pick up that cost. There are more rules and committees thta review patient's cases and deceide whether that patient can get the help they need or if they are denied. Even the doctor can feel pressure not to send patients to specialists and can feel their hands are tied by the review committees.

A ppo is much better. The doctor contracts with the insurance company and agrees what he/she will charge for an visits, tests or procedures. The patient has more rights and more freedom.

I have had both and would NEVER EVER use an HMO ever again. I have a PPO and have been very satisified.

Hope this helps.

 

[Random Access]

Originally posted by Amy B
There are more rules and committees thta review patient's cases and deceide whether that patient can get the help they need or if they are denied. Even the doctor can feel pressure not to send patients to specialists and can feel their hands are tied by the review committees.

Very true. HMOs tend to have pretty hardcore policies on specialist referrals, drugs offered, etc. etc. etc..., not necessarily in the best interest of patients. They are running a business... This of course increases litigation too, for those who are willing to fight an HMO...

-RA

 

[Veilside]

Originally posted by Random Access
This of course increases litigation too, for those who are willing to fight an HMO...

-RA

can the hmo be sued in court?

 

[Amy B]

Anyone can be sued........ as to whether or not they can win... well that's another story. I remember last year there were alot of people testifying in front of congress about their HMO abuse and how they suffered from the HMO's lack of treatment for them.

A popular phrase at the free clinic where I volunteered was

HMO = managed health costs and not managed health care like most people call it. It is just all about costs.

On a personal note I have a short story... I injured my back. My HMO said they wanted to try "alternetive treatments = chiropractor, physical therapy, mind over matter", etc. The doctor accussed me of faking and being depressed, etc. I was in extreme PAIN and quit my HMO after 1 1/2 months of agonizing pain and visists over and over to the doctor who happen to be the head of the review committee on course of treatments.

I went to a new doctor under an 80/20 plan and was sent to an othropedic doctor that very day. I was IMMEDIATLY put in a back brace. I had indeed injured my back as seen in the xray, which my old doctor refused to do. The specialist was dumbfounded at the lack of treatment I had recieved. I was in the brace for 6 months. It would have been a shorter time if not for the old doctor's care of me.

I could have sued, but it would have taken years and years and lost of money. And this was back in the late 80's before people discovered how bad HMOs can be.

 

[Jet915]

The one difference I remember is that in a ppo, you do not have to wait over a month to see a specialist. You can see one immediately........obviously a ppo is more expensive.

Jetson

 

[SMW]

Welcome to SDN, serge23! Public Agenda Online has a very comprehensive look at the managed care debate (along with every other political issue). Good luck with your interviews!

 

[Sweet Tea]

Originally posted by Exene
What do the acronyms stand for? For HMO I'm guessing something like "heathcare management organization" but PPO I have no idea.

-Ex

PPO= Prefered Provider Organization

 

[SMW]

HMO = Health Maintenance Organization
PPO = Preferred Provider Organization

 

[secretstang19]

Lots of useful info here, especially as everyone is going off to interviews...

BUMP

 

[LoveDoc]

I work for a major insurance company that offers HMO and PPO.

Here are some thoughts to ponder:

One insurance company may deny coverage for treatment and receive bad press. Another company will pick up the cost of the treatment and immediately call the media to report this act.

Insurance companies, as do many companies, form PACs (political action committees) to inform their stakeholders on decisions being made by government that will directly affect the industry.

Millions of dollars are recovered yearly from people\insurance companies\hospitals\etc. who commit insurance fraud. Although HMO flaws may be evident there are career criminals in our society who seek methods to manipulate the system.

My company employs doctors, nurses, and pharmacists to determine what is appropriate treatment. Many patients receiving long-term care have nurse case managers who monitor their improvement daily.

My point is...there are positives and negatives with these institutions so make sure your opinions are well researched.

Good luck!

 

[Sweet Tea]

good info, LoveDoc. Thanks!

 

[Amy B]

Originally posted by secretstang19
Lots of useful info here, especially as everyone is going off to interviews...

BUMP

I wanted to add that I was asked during an interview....

How would you solve the problems associated with HMO's?

 

[athena21]

was there something in congress awhile back that would give HMOs immunity from lawsuits?

 

[ColumbiaMPH]

Just to clear some things up....

The idea of managed care was introduced in the 1990's to combat the uncontrollably escalating costs of health care, mainly because people get medical care that they don't need simply because they don't have to pay for it. HMOs and PPOs both fit into that category. There are differences in the two which cater to personal preferences. An HMO means that you are a member of a specific "network" and don't have coverage for services outside the network. A PPO means that you will have to pay a percentage of your visits in exchange for greater provider access (i.e., not limited to the network of an HMO). It's beneficial for someone who travels and still wants to be covered, for example. "Preferred Provider" means that if you use a PCP who has contracted with the PPO, you will receive a discount.

Both systems are used to control costs in different ways. A PPO makes you pay more out-of-pocket expense. Economics tells us that people will opt not to get unnecessary care if they have to pay more of the cost. An HMO controls costs by providing incentives to the doctors to not provide unnecessary services. The idea is efficiency.

Controversy arises in both systems. In a PPO, if a patient has to pay more money to receive care, some patients will opt to not receive necessary medical care because they can't or don't wan't to spend the money. In an HMO, there is question as to whether or not quality is sacrificed for cost.

Also, you cannot sue an insurance company. Insurance companies do not actually prevent you from getting medical care, but they can refuse to pay for it.

For interview purpose, I think that they are looking to see if you know the basics of what HMOs and PPOs are and that, though they help control costs, they aren't the ideal solution to the problems in health care.

 

[kidsmd]

Yeah, I have noticed that because of the publicity that HMOs had gotten over the years, many of the patients come under the assumption that HMOs are a preferable type of insurance to have. Weird, how bad publicity can turn into something positive once the name gets thrown around enough.

Anyways as a example of how HMOs can be so much of a business, here is something that happened to my dad who is a physician. The physicians that are networked under the HMO will usually get bonuses if it makes enough money from any costs that it cuts. Well it so happened that when the time came to hand out bonuses, many of the physicians were complaining about my dad because he had been writing too many prescriptions. They weren't complaining because he was over-medicating his patients; they were complainng because the company had to spend more money to pay for these medications, thus lowering the bonuses the physicians get. What the heck? Don't you people make enough money as it is? Anyways, my mom said that was a bad idea on their part to complain to my dad since he is the type of person who will write twice as many prescriptions in spite. Heh.

 

[blues]

Hi Everyone!

PPOs and HMOs are easier to understand from a pure financial analysis. But keep in mind that they are not purely financial... there are many other factors that HMOs/PPOs plans use as their outcome measures.

3 Levels - Indemnity, PPOs, HMOs (Healthcare Financing Products)

Indemnity - Essentially Fee-for-Service (FFS) payment. Think of going out to eat. You pay after you eat. Insurance company pays after the patient eats. Patients have free choice of where to go. They can go to any physician/hospital and the insurance company pays. Impossible to identify needs of patients.

PPOs - Indeminity plan with a twist. Pure indemnity does not provide prevention services. PPOs give the freedom of choice (at a cost to the patient), but also provides prevention services. Essentially a Indemnity/HMO hybrid.

HMOs - Insurance company controls all levels of care through gatekeepers (PCPs usually). Hence managed care. They also provide as many prevention services. It is easier to because the insurance company can analyze aggregate patient data and see what the needs are for different groups/populations (e.g. providing free glucometers to diabetics).

Hope this helps!

 

[Random Access]

[bump -- mainly because I wanted a decent thread up top instead what's being posted now]