Managed Health Care Question

[Examinator]

Can anyone adequately distinguish an HMO from an EPO. What about a PPO from a POS? I'm reading the text and the All 10, and they seem the same. The difference from an HMO and an EPO looks to be that some (emergency) care is covered from non-PCPs where nothing out-of-network is covered under an EPO. As for the descriptions of the PPO and POS, they look very similar.

[great3981]

Here is my take on it:

HMO and POS plans seem to have a built in network, as if the doctors are employed by a larger organization. PPOs and EPOs contract with specific medical providers, but the health care providers are not otherwise associated with eachother.

Therefore you can split up the four organizations by two characteristics:

HMO - Part of organization, no outside doctors allowed
POS - Part of organization, outside doctors allowed
EPO - Contract based, no outside doctors allowed
PPO - Contract based, outside doctors allowed

[Examinator]

Excellent, someone else who's studying near a computer on this last Saturday.

So, at the risk of sounding stupid, what exactly is the difference between a provider being part of an organization and contracting? With the contract, you're just not necessarily (or at all) associated with other providers?

[great3981]

Consider a close parallel with another part of the syllabus. It isn't exact, but it is another way to remember it.

PPO = Independent agent
EPO = Exclusive agent

POS and HMO are more like your direct writers and direct response, where they are actually employees of the company.




I'll be here all day at least today and tomorrow so keep 'em coming:)

[Examinator]

I keep rereading this section, the associated section in the All 10, and here's what I come up with. See if this makes any sense.

HMO: You have a PCP. S/He can refer you to other in-network (IN) providers. Care from out-of-network (OUT) providers is not covered.

PPO: There is no PCP. Both IN and OUT care is covered. IN care is cheaper, with respect to coinsurance/deductibles/etc.

EPO: There is no PCP. OUT care is not covered.

POS: You have a PCP. Both IN and OUT care is covered. IN care is cheaper, with respect to coinsurance/deductibles/etc.

[great3981]

I see where Weining mentions PCP in the HMO section but I don't see where he draws a connection between a PCP and the type of organization. PCPs are not mentioned at all in the other three descriptions.

While I think that you may be correct (and fine if you are looking into differences between the types), I would also consider your distinctions beyond the scope of the reading.

[Examinator]

2001 #21 asks to differentiate HMOs, PPOs, and POSs. The suggested response does include PCPs with the POSs. I still don't think their answer is all that great.

[Estrella]

First, on the topic of PCP, primary care physician is actually a general term referring to your family doctor, usually an internalist, generalist, family practioner, or Ob/Gyn. They are the first doctor you go see when you don't feel well. They might refer to you a specialist if you find that you developed cancer, severed your finger, etc. Many people associate PCPs with HMOs because HMOs require you to have a PCP so that they can monitor and limit the more expensive specialist usage, but they are not limited to HMOs.

To really understand the difference between contract-based PPO & EPO from "organizationn-based" HMO & POS, it's easier (I think) to see it from the doctor's point of view. Let's say that you just finished your MD program and requisite internships and about to be on your own. You have two job offers, one from Kaiser Permanente (HMO) and one from a small private doctors office comprising of two other doctors of your specialty, say Pediatrics.

If you decide to work for Kaiser, you'll work in one of their healthcare facilities with other Kaiser employees. Everyone you work with in your facility such as the nurses, X-ray techs, blood lab techs, and other specialists all work for Kaiser. It's usually a huge complex containing everything you need as far as healthcare is concerned like a hospital (such as operating room, doctors offices, labs, Radiology section containing X-ray, MRI, CAT scan)... Moreover, all of your patients will be Kaiser members and Kaiser members only.

If you join the two doctors in their partnership, on the other hand, your work life will be totally different. You will be much more independent since you'll not be limited to treat only HMO group members and work with other HMO employees. You can send your X-ray orders or test samples to any lab you choose (but they may be far away). You can seek anyone as your patients although any HMO members won't be interested since they will not get reimbursed for healthcare if they see you. Instead you (and your partner doctors) seek to become a preferred provider of several important PPO groups in your area. You review, negotiate, and sign the contracts with PPO groups so that you can attract their members as your potential patients. You're free to work with as many PPOs as you wish and you have the freedom to terminate the contract if they don't appeal to you anymore. You are thankful because if you had chosen Kaiser, the only way for you to break out of the restriction is to quit your job. The price that comes with this freedom is that you have to go out and seek your own customers (patients). HMO doctors automatically have a group of patients, HMO members, but you don't. At HMO, you'd also automatically get referrals from other HMO doctors, but outside HMO, you have to build your own network by meeting other doctors and building a good reputation.

This is just a longer, more illustrative way of saying what great3981 already said earlier. I hope it helps.

[Examinator]

This was a very comprehensive, helpful explanation. Thanks. Once again, let me see if I have it straight.

HMO: Organization providing a network of healthcare providers. If an HMO member seeks outside care, it is not covered by the HMO organization.

POS: Organization providing a newtwork of healthcare providers. If a POS member seeks outside care, it is covered to a lesser degree by the POS organization.

EPO: Contracted healthcare provider(s). If someone under an EPO seeks outside care, it is not covered by the EPO.

PPO: Contracted healthcare provider(s). If a someone under a PPO seeks outside coverage, it is covered to a lesser degree by the PPO.

[J.T.]

You are correct.