Hmo/ffs

[ocean11]

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Hello all.... I'm Canadian and am wondering how you feel about your American Health Care system? Could you shed some light on using HMO services vs. FFS (fee-for-service)....

how does HMO services work? is it up to an individual to choose an HMO or is it covered by employment insurance (ie: the company chooses one for you?)...

What are other options for health care

Please shed some light...

Thank you so Much

 

[Kashue]

Originally posted by ocean11
Hello all.... I'm Canadian and am wondering how you feel about your American Health Care system? Could you shed some light on using HMO services vs. FFS (fee-for-service)....

how does HMO services work? is it up to an individual to choose an HMO or is it covered by employment insurance (ie: the company chooses one for you?)...

What are other options for health care

Please shed some light...

Thank you so Much

Where I work, we were given choices. We could choose amongst several PPO's and HMO's. I chose PPO because I felt there was more freedom given to me. Also, there wasn't much of a cost difference when it came to premiums.

As to how HMO's work, you can google up or do a search for HMO topics on SDN, which I know have been discussed multiple times.

 

[snapdad]

Fee-for-service is exactly that -- you pay for service received at the time it's performed, or your insurance company, to whom you pay a premium, reimburses the service provider.

HMOs, on the other hand, attempt to control costs by having a pre-selected group of physicians, facilities, etc. who provide services under the HMO's umbrella. The HMO is centrally managed, and patients usually pay a monthly premium that covers all services rendered. The idea is that this is cheaper than a straight fee-for-service due to centralized management of all services, providers, and procedures performed. A small copayment is also usually paid by the patient at the time of the service. HMOs can take the form of either a full-on provider organization (like Kaiser Permanente) that contains its own providers and facilities (and pays its doctors on salary), or a grouping of semi-independent physicians and facilities bound by service and billing agreements.

 

[ocean11]

Thank you both so much,

I'm just wondering why Doctors complain about HMO's sometimes?!?

 

[snapdad]

A big gripe is lack of freedom to practice. By way of controlling costs, HMOs really clamp down on what procedures doctors can perform under given circumstances, what they can prescribe, and sometimes even how long they can see a given patient. By way of example, there was a "15-minute maximum" rule applied to the amount of time a doctor could spend with a given patient. Many doctors (and patients, too) felt this made the visit perfunctory and cold, and made it hard for patients and primary care docs to form a relationship. There have been similar difficulties with procedures...often docs want to perform a certain procedure or test because they feel it's necessary for the patient's health, but the HMO doesn't feel it's required so they don't approve it. This creates a "docs vs. the bean counters" culture, and a lot of anti-HMO sentiment from both doctors and patients.

There's been a backlash against this in recent years...patients are becoming more knowledgeable about their rights to quality medical care, and their expectations are increasing dramatically as a result. This is beginning to be recognized by HMOs and they're changing their management practices slightly to accommodate this. Not much, as they're still constrained by operating in an incredibly expensive system (due to salaries, technology costs, and pharmaceutical costs), but some changes are occurring.

Another gripe is that there isn't much freedom for patients to choose their physicians, which is more of a gripe on the patient's side, but does affect physicians in the sense that patients whom they have established, long-term relationships with are often suddenly forced to go elsewhere if they change jobs, insurance, etc.

 

[mamadoc]

Another gripe about HMOs: primary care docs serve as "gatekeepers," in that they must provide an approved referral for a patient to see a specialist. This is extra staff time and paperwork for the primary care doc for which s/he is not reimbursed by anyone. Patients get mad when they are told they must make an office visit in order to obtain a referral, but that is the only way the PCP [primary care provider] gets any $$ to cover the cost of generating the referral.

My own insurance is an HMO and I HATE it. But it's the only thing available through my husband's job; I can choose from this HMO or a different HMO. 😡

 

[exmike]

One thing you guys havent mentioned is the fact that HMO's and FFS is almost non-existant. FFS, or indemnity, is virtually impossible to find because it is the most expensive choice, and no insurance company is willing to give their subscribers a free for all to use all the services they want. PPO, which is currently the most popular choice, is considered discounted FFS. However, most PPOs levy a 20% copay on the user as a form of usage control. Also they negotiate a lower rate with the provider, and thats also an incentive to control usage.

HMO's are also a minor player in health care nowadays because it is usually the high cost alternative for a consumer. HMO's cost less to the patient at the clinic because the tend to include more care, and have a lower copay. As a result the monthly fee is much higher than PPOs. HMOs are also subject to intense government regulation, and because of this insurance companies dont push their HMO products as much.

These are a couple reasons why PPOs have become the dominant form of insurance. PPOs allow the patient to see a wide range of providers, addressing one cocern of HMOs. PPOs are not capitated, so it is not up to only the provider to control usage. PPOs are not as highly regulated as HMOs. And of course, PPOs are a lower cost alternatlve. Since insurance companies cannot really leverage the providers to reduce costs, newer plans place the burden of cost control on the user. These types of plans include high-deductible catastrophic coverage, Point of Service (POS) plans (which are capitated, but you can choose outside your network), and MSAs or Medical Savings Plans, where you get a fixed amount to spend per year that is tax deductible, along with catostrophic coverage.

If you walk into your interview and say "HMO's are the biggest problem in medicine today" you're going to sound uniformed, since the HMO market share is miniscule compared to PPOs

One suprising fact is that one of the few fee for service insurances left are goverment payors! Yes, medicaid is a fee for service product. Of course, the goverment gets to dictate how much the "fee" is (a pitifully low one), but in the way it is organized, it is a fee for service product. However, even medicaid is quickly moving toward becoming a managed care product.

 

[jlee9531]

Originally posted by exmike
One thing you guys havent mentioned is the fact that HMO's and FFS is almost non-existant. FFS, or indemnity, is virtually impossible to find because it is the most expensive choice, and no insurance company is willing to give their subscribers a free for all to use all the services they want. PPO, which is currently the most popular choice, is considered discounted FFS. However, most PPOs levy a 20% copay on the user as a form of usage control. Also they negotiate a lower rate with the provider, and thats also an incentive to control usage.

HMO's are also a minor player in health care nowadays because it is usually the high cost alternative for a consumer. HMO's cost less to the patient at the clinic because the tend to include more care, and have a lower copay. As a result the monthly fee is much higher than PPOs. HMOs are also subject to intense government regulation, and because of this insurance companies dont push their HMO products as much.

These are a couple reasons why PPOs have become the dominant form of insurance. PPOs allow the patient to see a wide range of providers, addressing one cocern of HMOs. PPOs are not capitated, so it is not up to only the provider to control usage. PPOs are not as highly regulated as HMOs. And of course, PPOs are a lower cost alternatlve. Since insurance companies cannot really leverage the providers to reduce costs, newer plans place the burden of cost control on the user. These types of plans include high-deductible catastrophic coverage, Point of Service (POS) plans (which are capitated, but you can choose outside your network), and MSAs or Medical Savings Plans, where you get a fixed amount to spend per year that is tax deductible, along with catostrophic coverage.

If you walk into your interview and say "HMO's are the biggest problem in medicine today" you're going to sound uniformed, since the HMO market share is miniscule compared to PPOs

One suprising fact is that one of the few fee for service insurances left are goverment payors! Yes, medicaid is a fee for service product. Of course, the goverment gets to dictate how much the "fee" is (a pitifully low one), but in the way it is organized, it is a fee for service product. However, even medicaid is quickly moving toward becoming a managed care product.

wow thanks for the info mike....i didnt realize PPOs were teh dominant form these days...i just there was a pretty similar share of HMOs and PPOs....but its good to know this.... 🙂

 

[ocean11]

thank you all so very very much for all the answers, I think I have a much 'clearer' understading of what an HMO is and a bit more about the American Health Care System.

Just one more question... would you call the American Health Care System 'Capitalistic' ? How would you define it?

Thanks so much..

 

[Zweihander]

Originally posted by ocean11
thank you all so very very much for all the answers, I think I have a much 'clearer' understading of what an HMO is and a bit more about the American Health Care System.

Just one more question... would you call the American Health Care System 'Capitalistic' ? How would you define it?

Thanks so much..

In a sense, it became "capitalistic" with the advent of managed care because the drive was providing the best care at the lowest price, and free market competition took over. One thing that anybody thinking about HMOs should understand is that it was big business that became responsible for their rise. As employers started offering health benefits, they became concerned with increasing costs of healthcare, and for about twenty years put a great deal of support behind HMOs because the businesses believed in the HMOs' ability to cut healthcare costs.

The HMO (though not managed care) is now dying off because employers no longer believe in its ability to reduce expenses. The American system still has yet to figure out a means of insurance that can check the dreaded rises in health expenditure (around 15% of our GNP), but one thing that is changing is that the patient is once again becoming the customer, because he is increasingly shouldering the costs of care. Employers are no longer interested in providing healthcare and there is no effective method of cutting costs in sight, so they are pulling out of that particular relationship.