The introduction of the health maintenance organization was seen by many as the first real attempt at managed health care. An HMO differs from traditional approaches to health care in that it stresses wellness and preventive care. The HMO's intent is to maintain the participant's health, and therefore its orientation is toward health maintenance rather than toward treatment of illness only. Accordingly, HMOs provide richer preventive benefits, such as wellness programs, health screenings, and immunizations. Also, the financial incentives and cost controls are structured differently. Whereas comprehensive and major medical programs have up-front cost sharing to discourage "excess" medical utilization, HMOs usually have no up-front costs or charge only modest copayments for routine physician visits. Theoretically, HMOs control plan costs by maintaining health, managing care more cost-effectively, and controlling specialist referral. Most HMOs assign a primary care physician (PCP) to the plan participant. This PCP is charged with providing routine medical care to the subscriber and serves as a "gatekeeper," steering the subscriber to appropriate and cost-effective care should referral to specialists be required.
HMOs can take a variety of forms. The individual practice association model (IPA) is one in which an HMO contracts with individual physicians or associations of individual physicians to provide services to the health plan's subscribers. A group model is one where the HMO purchases services from an independent multispecialty group of physicians. A network model HMO is similar to the group model, but more than one multispecialty group practice provides services to members. Yet another variation in organizational design and service delivery is the staff model HMO. Here, rather than the HMO contracting with independent physicians or multispecialty groups, the physicians are full-time, bona fide employees of the HMO that pays their salaries. As many HMOs have grown, the clear distinction between individual practice model, group model, network model, and staff model has been somewhat blurred. The dramatic and ongoing growth of various health systems has meant the aggregation and merging of these disparate models.
As mentioned earlier, most managed care providers offer broader health care coverage especially in the areas of wellness and preventive care. Often a fundamental difference is the manner in which one accesses the delivery of care. At the time of initial enrollment in the plan, the subscriber and his or her dependents select a PCP who is responsible as the primary caregiver for most routine medical care. This PCP is the person to make referrals and provide authorization for specialty care when needed. Different managed care organizations have different approaches to the process by which specialty care referrals can occur. For instance, some managed care companies publish a listing of specialists in the network and leave a referral to the discretion of the PCP. Other companies have this function centralized and require the assignment of specialty authorizations to a centralized unit that ensures steer-age to the most cost-effective specialty providers. This centralized approach to specialty care can be beneficial in ensuring that serious illnesses are directed to a "center of excellence," a provider known to have unique procedures or competence in treating certain types of injury or illnesses.
Wellness and preventive care benefits are key coverages that HMOs (and other managed care plans) provide that traditional plans have not provided. Expenses for these services historically have not been covered in the traditional fee-for-service type of plan. They include:
§ Routine physical exams.
§ Preventive screenings and diagnostic tests for early detection of certain diseases.
§ Prenatal and well-baby care.
§ Immunizations for prevention of diseases (particularly for children).
§ Vision and dental checkups.
§ Allowances for health club memberships.
Because of the growing understanding of the benefits of preventive care, some states have enacted legislation requiring all health plans to offer certain benefits such as childhood immunizations and screenings for diseases that clearly would benefit from early detection. Hence, some of the distinctions between plan models in terms of benefits offered have been blurred as preventive measures have been added to the traditional insurance plans.
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