To choose between HMO and PPO, rate them on the comparison parameters by entering scores (+ve or -ve) in the comparison tool.
The total points are automatically shown in the top row. This should help you decide.
Restrictions are laid down by the HMOs’ for range and scope of treatment. Specialists can be seen only after a referral from a PCP.
Less restrictive. Referrals are not required to see specialists in the network.
Cost:
Lower premiums
Premiums are higher than HMOs since it offers more flexibility.
Doctor/Medical Practitioner Incentive:
Doctors typically have a work-pay relation i.e. they get paid per visit
Doctors work on a retainer fees (capitation) per year hence no incentive to prolong treatment of patients
Network Doctors:
Members can only go to the specified network doctors after taking prescription from the Primary physician
Members can go to non-network doctors as well without any prescription.
Payment mode:
Patients pay the provider through a card without having to fill forms
Patients have to bear a part of the cost if they go to a non-network (non-preferred) provider.
Clientele:
Large corporate clientele since companies offer HMO insurance to most of their employees
Large retail clientele
Organisations Offering such services:
Kaiser Permanente, Aetna
Beech Street PPO, Blue Cross Blue Shield PPO
What does it stand for?:
Health Maintenance Organizations
Preferred Provider Organization
Medical problems covered:
Mostly Basic Medical care and Preventive care such as office visits, immunizations, well-baby checkups, and physicals.
Specialist treatment included as well
Emergency treatment:
HMO’s are not well suited for this since they have a defined procedure for emergency treatment outside its coverage area.
Emergency treatments are also covered.
Flexibility in choosing Doctors/Hospitals:
Limited. The patient has to choose a Primary physician (PCP) within a network and that physician takes care of all medical needs of the patient, including referrals to specialists.
High. Members have an option to choose from a number of doctors/specialists that are in the “network” of the insurer. Benefits are either curtailed or unavailable if the member sees a doctor outside the network.
A health maintenance organization (HMO) is a type of managed care organization (MCO) that provides a form of health insurance coverage in the United States that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract. Under this model, providers contract with an HMO to receive more patients and in return usually agree to provide services at a discount. This arrangement allows the HMO to charge a lower monthly premium, which is an advantage over indemnity insurance, provided that its members are willing to abide by the additional restrictions
PPO means Preferred Provider Organization, a health care plan that provides covered services at a discounted cost for subscribers who use network health care providers. PPOs also provide coverage for services rendered by health care providers who are not part of the PPO network; the subscriber generally pays a greater portion of the cost for such services. Usually, a PPO will pay a greater percentage of the cost for a preferred provider, and less for a non-preferred provider.
The earliest form of HMOs can be seen in a number of prepaid health plans. In 1910, the Western Clinic in Tacoma, Washington offered lumber mill owners and their employees certain medical services from its providers for a premium of $0.50 per member per month. Ross-Loos Medical Group, established in 1929, is considered to be the first HMO in the United States; it was headquartered in Los Angeles and approximately 500 members enrolled at a cost of $1.50 each per month. By 1970’s, the number of HMOs in US had declined to less than 40. The big boost for HMO’s came after the enactment of the Health Maintenance Organization Act of 1973 which made it obligatory for Employers with 25 or more employees to offer federally certified HMO options alongside indemnity upon request
Preferred Provider Organizations began to appear in the late 1970s and early 1980s, as an alternative to HMOs, and are a way in which employers could manage their escalating health care costs. In a PPO, there is a panel of providers who have signed contracts with the PPO, agreeing to accept a reduced payment for services rendered in return for having patients directed to their offices by way of a Provider Directory given to employees and their dependents.
HMOs provide basic medical care and preventive care such as office visits, immunizations, well-baby checkups, and physicals. HMOs are not very well suited for any emergencies since they have a defined procedure for emergency treatment outside its coverage area.
PPOs provide all the above listed services and specialist treatment as well. PPO's are well equipped to manage all emergency treatments.
A PPO plan offers a member higher flexibility in choosing physicians, hospitals, and other health care providers that are part of a preselected network. PPOs also allow you to use a doctor or hospital outside of the PPO network in return for a small fee called a co-payment from you. PPOs usually let patients see medical specialists without getting permission first from a primary care doctor. HMO’s, on the other hand, require you to member to choose a Primary Physician and all medical inquiries are routed through the Primary Physician only.
For HMOs, large corporate clientele is the core area since companies offer HMO insurance to most of their employees. For PPOs the main clientele includes large retail customers.
The major advantage of HMOs is the cost. HMOs are cheaper for the consumer than other plans. PPOs cost more than HMOs, but many people choose them because they are less restrictive. Members have more control over their healthcare decisions in a PPO than than they would have under an HMO.
Staff model: 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.
Group model: The HMO does not pay the physicians directly, but pays a physician group. The group then decides how to distribute the money to the individual physicians. This model is also closed-panel.
Physicians may contract with an independent practice association (IPA), which in turn contracts with the HMO. This model is an example of an open-panel HMO, where a physician may maintain his own office and may see non-HMO members
In the network model, an HMO will contract with any combination of groups, IPAs, and individual physicians. Since 1990, most HMOs run by managed care organizations with other lines of business (such as PPO, POS and indemnity) use the network model.
Non-gatekeeper PPO: Gives employees a provider directory that includes the names of specialists, since patients may go directly to them for medical care, without a referral form from a primary care physician.
Gatekeeper PPO: Requires that the patient seek medical care first from a primary care physician. If the patient seeks medical care directly from a specialist, without a referral from a primary care physician, he or she may have to pay the specialist’s charges in full, with no assistance from the insurance company.
