Health Maintenance Organizations (HMOs)

Distinguishing factors of HMO’s: Relationship exclusivity Risk bearing (by the physician) Financial relationship Doctors must be cost conscious Network of providers HMO = no out of network services (providers) are covered Staff model Think Kaiser Doctors are employees of the HMO Group model Plan contracts exclusively with one group of providers Network model Nonexclusive Many … Continue reading

Influencing Behaviors Through Managed Care

Examples of health promotion initiatives: ¬† gym membership discounts, healthy meals plans, employee newsletters, smoking cessation programs Utilization Review (UR)- ¬†review of the services delivered by a health care provider to evaluate the appropriateness, need, and quality of the prescribed services. Guards against unacceptable variation (not necessarily creative methods) in medical or pharmacy practice and … Continue reading

Insurance Overview

3 methods of cost sharing used by insurers Co-pay (patient pays a $ amount for each service) Deductible- patient pays full copay until a certain amount is reached Co-insurance (patient pays a % amount for each service) 3 functions of cost sharing Decreases drug benefit cost to the sponsor Helps control utilization Channels patients toward … Continue reading