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HEALTH CARE SERVICES: HEALTH MAINTENANCE ORGANIZATIONS (HMOs)
HMOs provide a wide range of covered health benefits (such as checkups, surgery, doctor visits, lab tests) for a fixed amount prepaid by you, the employer, Medicaid, or Medicare. Usually, HMO premiums are the least expensive (saving between 10 and 40 percent more than other plans), but HMOs are the most restrictive type of managed care. These premiums are 8 to 10 percent lower than traditional plans, there are low or no deductibles or coinsurance payments, and copayments are 5 to 10 dollars per office visit. HMOs contract with providers to supply health services for enrollees through various systems, such as:
- The staff model. You receive care from salaried staff doctors at the HMO\'s only facility.
- The group network model. The HMO contracts with one or several groups of doctors who provide care for a fixed amount per plan member. Groups often practice in one facility.
- The independent practice association (IPA). Doctors in private practice form an association that contracts with HMOs. The physicians generally work in their own offices.
The downside of these plans is the typical requirement to use the plan\'s doctors and hospitals and to get approval from a \"gatekeeper\" or primary care physician for treatment and referrals. Although more and more people are opting for HMOs, some people continue to be skeptical about them. Concerns leveled against HMOs include issues such as these:
- Do high-paid administrators and stockholders ration care, providing only for the upper end of the paying and health continuums?
- Does the huge administrative structure imposed by the HMO make it virtually impossible for patients to sue in the event of clear violations?
- Are patients denied costly diagnostic tests because such tests cut into bottom-line profits? Are some tests given too late because of concerns over costs?
- Are HMOs really focused on prevention or intervention? Evidence exists that the fee structure of many HMOs actually discourages basic preventive services, such as immunizations.
- Are doctors allowed to treat patients using their best judgment and skills, or do policies and profit-motivated concerns interfere with the doctors\' roles as advocates for their patients?
- Are the obstacles imposed by HMOs too daunting for patients in need of urgent care?
- Do HMO cost-saving policies force patients out of hospitals and treatment centers too early?
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GENERAL HEALTH
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