462:(GPs). Except in medical emergency situations, patients need a referral from the PCP in order to see a specialist or other doctor, and the gatekeeper cannot authorize that referral unless the HMO guidelines deem it necessary. Some HMOs pay gatekeeper PCPs set fees for each defined medical procedure they provide to insured patients (
758:(ERISA) can be held to preempt negligence claims as well. In this case, the deciding factor is whether the harm results from the plan's administration or the provider's actions. ERISA does not preempt or insulate HMOs from breach of contract or state law claims asserted by an independent, third-party provider of medical services.
474:
HMO benefits are applied. However, the beneficiary cost sharing (e.g., co-payment or coinsurance) may be higher for specialist care. HMOs also manage care through utilization review. That means they monitor doctors to see if they are performing more services for their patients than other doctors, or fewer. HMOs often provide
684:, physicians are salaried and have offices in HMO buildings. In this case, physicians are direct employees of the HMOs. This model is an example of a closed-panel HMO, meaning that contracted physicians may only see HMO patients. Previously this type of HMO was common, although currently it is nearly inactive. In the
473:
Open-access and point-of-service (POS) products are a combination of an HMO and traditional indemnity plan. The member(s) are not required to use a gatekeeper or obtain a referral before seeing a specialist. In that case, the traditional benefits are applicable. If the member uses a gatekeeper, the
659:
This last provision, called the dual choice provision, was the most important, as it gave HMOs access to the critical employer-based market that had often been blocked in the past. The federal government was slow to issue regulations and certify plans until 1977, when HMOs began to grow rapidly. The
536:
Although businesses pursued the HMO model for its alleged cost containment benefits, some research indicates that private HMO plans do not achieve any significant cost savings over non-HMO plans. Although out-of-pocket costs are reduced for consumers, controlling for other factors, the plans do not
527:
are identified. In either case, the HMO takes a greater level of involvement in the patient's care, assigning a case manager to the patient or a group of patients to ensure that no two providers provide overlapping care, and to ensure that the patient is receiving appropriate treatment, so that the
688:, the HMO does not employ the physicians directly, but contracts with a multi-specialty physician group practice. Individual physicians are employed by the group practice, rather than by the HMO. The group practice may be established by the HMO and only serve HMO members ("captive group model").
425:
insurance, an HMO covers care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider's
753:
partially depends on the HMO's screening process. If an HMO only contracts with providers meeting certain quality criteria and advertises this to its members, a court may be more likely to find that the HMO is responsible, just as hospitals can be liable for negligence in selecting physicians.
692:
is an example of a captive group model HMO rather than a staff model HMO, as is commonly believed. An HMO may also contract with an existing, independent group practice ("independent group model"), which will generally continue to treat non-HMO patients. Group model HMOs are also considered
617:
in which farmers bought shares for $ 50 to raise the money to build a hospital. The medical community did not like this arrangement and threatened to suspend Shadid's licence. The Farmer's Union took control of the hospital and the health plan in 1934. Also in 1929, Baylor
Hospital provided
731:
HMOs in the United States are regulated at both the state and federal levels. They are licensed by the states, under a license that is known as a certificate of authority (COA) rather than under an insurance license. State and federal regulators also issue
748:
HMOs often have a negative public image due to their restrictive appearance. HMOs have been the target of lawsuits claiming that the restrictions of the HMO prevented necessary care. Whether an HMO can be held responsible for a physician's
482:
or for free, in order to keep members from developing a preventable condition that would require a great deal of medical services. When HMOs were coming into existence, indemnity plans often did not cover preventive services, such as
537:
affect total expenditures and payments by insurers. A possible reason for this failure is that consumers might increase utilization in response to less cost sharing under HMOs. Some have asserted that HMOs (especially those run
715:, an HMO will contract with any combination of groups, IPAs (Independent Practice Associations), and individual physicians. Since 1990, most HMOs run by managed care organizations with other lines of business (such as
572:
offered lumber mill owners and their employees certain medical services from its providers for a premium of $ 0.50 per member per month. This is considered by some to be the first example of an HMO. However,
499:
mental health care, are limited, and more costly forms of care, diagnosis, or treatment may not be covered. Experimental treatments and elective services that are not medically necessary (such as elective
679:
HMOs operate in a variety of forms. Most HMOs today do not fit neatly into one form; they can have multiple divisions, each operating under a different model, or blend two or more models together. In the
470:
specialists (that is, pay a set fee for each insured person's care, irrespective of which medical procedures the specialists performs to achieve that care), while others use the reverse arrangement.
250:
740:
adopted the HMO Model Act, which was intended to provide a model regulatory structure for states to use in authorizing the establishment of HMOs and in monitoring their operation.
238:
900:
708:(IPA), which in turn contracts with the HMO. This model is an example of an open-panel HMO, where a physician may maintain their own office and may see non-HMO members.
380:
839:
Joseph L. Dorsey, "The Health
Maintenance Organization Act of 1973 (P.L. 93-222) and Prepaid Group Practice Plan," Medical Care, Vol. 13, No. 1, (Jan., 1975), pp. 1–9
421:
required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. Unlike traditional
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closed-panel, because doctors must be part of the group practice to participate in the HMO - the HMO panel is closed to other physicians in the community.
232:
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226:
17:
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373:
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Though some forms of group "managed care" did exist prior to the 1970s, in the US they came about chiefly through the influence of
President
95:
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495:, or physicals. It is this inclusion of services intended to maintain a member's health that gave the HMO its name. Some services, such as
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418:
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601:), and more. By 1951, enrollment stood at 35,000 and included teachers, county and city employees. In 1982 through the merger of the
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401:) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges
366:
54:
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explained thus: "All the incentives are toward less medical care, because the less care they give them, the more money they make."
561:. In discussion in the White House on February 17, 1971, Nixon expressed his support for the essential philosophy of the HMO, which
1035:
755:
149:
901:"Transcript of taped conversation between President Richard Nixon and John D. Ehrlichman (1971) that led to the HMO act of 1973"
623:
218:
89:
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Employers with 25 or more employees were required to offer federally certified HMO options alongside indemnity upon request
626:
plans to cover physician services, as Blue Cross covered only hospital services. These prepaid plans burgeoned during the
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508:
619:
602:
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United States
District Court, N.D. Texas, Dallas Division. No. Civ.A. 3:03-CV-2084-G. Jan. 9, 2004. Memorandum Order
704:
285:
777:
716:
197:
185:
40:
999:
967:
Peter R. Kongstvedt, "The
Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001, p. 1322
101:
594:
568:
The earliest form of HMOs can be seen in a number of "prepaid health plans". In 1910, the
Western Clinic in
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167:
131:
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developed and became the director of the United States' first federal HMO program. He was recruited by
577:, established in 1929, is considered to be the first HMO in the United States; it was headquartered in
345:
305:
120:
125:
950:
Peter R. Kongstvedt, "The
Managed Health Care Handbook," 4th edition, Aspen Publishers, Inc., 2001,
925:
795:
323:
72:
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467:
410:
736:, requirements for health maintenance organizations to provide particular products. In 1972 the
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137:
80:
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employees. 200 DWP employees enrolled at a cost of $ 1.50 each per month. Within a year, the
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60:
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Certain state-imposed restrictions on HMOs were removed if the HMOs were federally certified
605:(INA) founded in 1792 and Connecticut General (CG) founded in 1865 came together to become
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414:
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31:
8:
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634:
542:
637:, often called the "father" of the HMO, began having discussions with what is today the
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to direct access to medical services but this is not always the case. PCPs are usually
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451:
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Health
Affairs Study Finds," 2000. Physicians for a National Health Program.
27:
Medical insurance group that provides health services for a fixed annual fee
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402:
338:
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benefit plans, individuals, and other entities, acting as a liaison with
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approximately 1,500 teachers with prepaid care. This was the origin of
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439:
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671:, the secretary of the Department of Health, Education and Welfare.
1000:
Baylor
University Medical Center v. Arkansas Blue Cross Blue Shield
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295:
66:
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However, an HMO is often insulated from malpractice lawsuits. The
251:
Health
Information Technology for Economic and Clinical Health Act
630:
as a method for providers to ensure constant and steady revenue.
84:
649:
Grants and loans were provided to plan, start, or expand an HMO
524:
520:
511:, in which patients with catastrophic cases are identified, or
239:
Medicare Prescription Drug, Improvement, and Modernization Act
788:
606:
279:
887:"Claim That HMO's Save Money Is Little More Than "Folklore"
875:"Do HMO Plans Reduce Expenditure in the Private Sector?"
816:"BBC News - G-I - Health Maintenance Organization / HMO"
633:
In 1970, the number of HMOs declined to fewer than 40.
515:, in which patients with certain chronic diseases like
597:, then the Southern California Telephone Company (now
417:(hospitals, doctors, etc.) on a prepaid basis. The US
528:
condition does not worsen beyond what can be helped.
988:
Organizational aspects of prepaid health plans-HMO's
926:"Staff-Model HMOs: Don't Blink or You'll Miss Them!"
233:
Health Insurance Portability and Accountability Act
69:/ State Health Insurance Assistance Program (SHIP)
853:(Fourth ed.). Aspen Publishers. p. 40.
1022:
227:Emergency Medical Treatment and Active Labor Act
738:National Association of Insurance Commissioners
622:. Around 1939, state medical societies created
792:, a Michael Moore documentary criticizing HMOs
374:
96:Program of All-Inclusive Care for the Elderly
639:U.S. Department of Health and Human Services
545:and tend to cherry-pick healthier patients.
643:Health Maintenance Organization Act of 1973
419:Health Maintenance Organization Act of 1973
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381:
367:
257:Patient Protection and Affordable Care Act
245:Patient Safety and Quality Improvement Act
30:"HMO" redirects here. For other uses, see
743:
583:Los Angeles Department of Water and Power
55:Federal Employees Health Benefits Program
756:Employee Retirement Income Security Act
660:dual choice provision expired in 1995.
434:HMOs often require members to select a
14:
1023:
723:and indemnity) use the network model.
645:. This act had three main provisions:
1016:Health Maintenance Organization (HMO)
163:Health insurance in the United States
581:and initially provided services for
507:Other choices for managing care are
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90:Children's Health Insurance Program
24:
702:, physicians may contract with an
603:Insurance Company of North America
25:
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1009:
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641:that led to the enactment of the
1031:Health maintenance organizations
851:The Managed Health Care Handbook
705:independent practice association
286:Massachusetts health care reform
18:Health maintenance organizations
1036:Healthcare in the United States
993:
977:
778:Preferred provider organization
395:health maintenance organization
198:Preferred provider organization
192:Health maintenance organization
186:Exclusive provider organization
41:Healthcare in the United States
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438:(PCP), a doctor who acts as a
157:Private Fee-For-Service (PFFS)
102:Veterans Health Administration
77:Prescription Assistance (SPAP)
13:
1:
877:, Economic Inquiry, Jan 2007.
849:Kongstvedt, Peter R. (2001).
801:
726:
595:Los Angeles Police Department
168:Health insurance marketplaces
504:) are almost never covered.
429:
132:Health reimbursement account
7:
783:Publicly funded health care
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591:Los Angeles Fire Department
144:High-deductible health plan
10:
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773:Exclusive provider network
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346:Fair Share Health Care Act
306:Vermont health care reform
121:Consumer-driven healthcare
49:Government health programs
29:
873:Jaeun Shin, Sangho Moon,
696:If not already part of a
613:created a health plan in
318:Municipal health coverage
126:Flexible spending account
796:Single-payer health care
674:
393:In the United States, a
324:Healthcare in California
768:Capitated reimbursement
575:Ross-Loos Medical Group
411:self-funded health care
150:Medical savings account
115:Private health coverage
744:Legal responsibilities
699:group medical practice
436:primary care physician
354:(Howard Co., Maryland)
138:Health savings account
81:Military Health System
460:general practitioners
415:health care providers
329:Healthy San Francisco
61:Indian Health Service
593:signed up, then the
543:administrative costs
541:) actually increase
206:Medical underwriting
32:HMO (disambiguation)
635:Paul M. Ellwood Jr.
609:. Also in 1929 Dr.
523:, or some forms of
426:contracted status.
930:managedcaremag.com
615:Elk City, Oklahoma
587:Los Angeles County
570:Tacoma, Washington
513:disease management
489:well-baby checkups
291:Oregon Health Plan
270:State level reform
219:Health care reform
173:Premium tax credit
984:O'Rourke, Paul F.
690:Kaiser Permanente
669:Elliot Richardson
665:Gordon K. MacLeod
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403:managed care
398:
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339:My Health LA
191:
180:Managed care
958:, pp. 35–26
686:group model
682:staff model
624:Blue Shield
579:Los Angeles
466:) and then
300:Connecticut
1025:Categories
905:Wikisource
802:References
751:negligence
727:Regulation
620:Blue Cross
585:(DWP) and
539:for profit
497:outpatient
493:mammograms
444:internists
440:gatekeeper
348:(Maryland)
663:In 1971,
480:copayment
430:Operation
423:indemnity
986:(1974).
936:22 March
825:22 March
762:See also
734:mandates
517:diabetes
468:capitate
296:SustiNet
83:(MHS) /
73:Medicare
67:Medicaid
910:7 April
711:In the
549:History
85:Tricare
57:(FEHBP)
971:
954:
857:
525:cancer
521:asthma
259:(2010)
253:(2009)
247:(2005)
241:(2003)
235:(1996)
229:(1986)
182:(CCP)
146:(HDHP)
140:(HSA)
98:(PACE)
92:(CHIP)
789:Sicko
675:Types
607:CIGNA
458:, or
280:Maine
200:(PPO)
194:(HMO)
188:(EPO)
152:(MSA)
134:(HRA)
128:(FSA)
104:(VHA)
63:(IHS)
969:ISBN
952:ISBN
938:2018
912:2018
855:ISBN
827:2018
405:for
721:POS
717:PPO
399:HMO
221:law
1027::
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818:.
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