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Nowadays, most American people receive health insurance from private health insurance companies. According to the Census Bureau, government insurance plans have 38% of Americans in comparison to 67% of people who get private health insurance services (Berchick et al., 2018). Nevertheless, managed care models and primary types of insurance businesses provide a variety of services for citizens to choose from. Thus, they have differences and similarities, and specific impacts on stakeholders that should be further investigated.
There are several managed care models, namely Health Maintenance Organizations (HMOs), Physician Provider Organization (PPOs), and Point-of-Service Plans (POS). HMOs are the most restrictive managed care models, PPOs are less stringent, and PPOs are the least restrictive because they present a mix of HMOs and PPOs (Namburi & Tadi, 2020). HMOs include preventive medical care services, capitation, and prepaid premiums and require insurance members to choose a professional and hospital from the in-network and pay for the in-network services only. PPOs are the most popular managed care models and entities that contract with a network of participating providers, who are therefore considered preferred (Wagner & Kongsvedt, 2013, p. 28). Similar to HMOs, PPOs have a limited panel of primary care physicians (PCP) and hospitals. However, in contrast to HMOs, Physician Provider Organizations offer the opportunity to choose physicians from out-of-network but with associated high-cost sharing in comparison to HMOs lower premiums.
Point of Service (POS) provide peoples with a mix of HMO-like features with indemnity coverage (Wagner & Kongsvedt, 2013, p. 30). In contrast to HMOs and PPOs, in a POS plan, members must select PCP but can go to an out-of-network medical professional and choose care and physicians outside. Similarly, PPOs and POS both provide different benefits coverage levels for in-network and out-of-network services (Wagner & Kongsvedt, 2013, p. 30). However, they are not entirely the same; for instance, POS plans are deductible before any coverage for in-network, facility-based services in comparison to PPOs plans that are usually not deductible (Wagner & Kongsvedt, 2013).
Three primary types of businesses, including Medicare, Medicaid, and Commercial health insurance, received their full attention in 2010 when Patient Protection and Affordable Care Act (referred to as ACA) was enacted (Namburi & Tadi, 2020). The development of managed care plans was driven by consumers and the necessity to make MCOs accountable for their members. Medicare is a federal program that provides health insurance to all people eligible for social security who are 65 years old and over, to those who obtain social security because of a disability, and those having end-stage renal disease (ESRD) (Digital Communications Division, 2015).
Medicaid, similar to Medicare, is a state and federal program, however, it covers those who are poor and who are in need of health care services to be able to grow safely or meet special health care needs. The program includes specific eligible low-income people, such as children, pregnant women, disabled adults, federal Supplemental Security Income (SSI) recipients, and those who need medical help (Digital Communications Division, 2015). Commercial health insurance is different from federal programs significantly because it is a private-based insurance system established for-profit and may cover any individual to minimize risks and exclude those who are sick or likely to become sick (Ridic et al., 2012).
Medicare impacts the eligible consumers, providing them with services, such as home health, hospice services incurring the high costs by the Medicare fee-for-service (FFS) program; Medicare+Choice program, or with the help of cost-based health maintenance organizations that are influenced. Medicaid provides services for specific groups of people who are impacted with the assistance of private health care providers, managed care plans, and community health centers to ensure the service delivery services that have to manage beneficiaries (Tikkanen et al., 2020). Commercial health insurance mostly impacts private providers, managed care companies, and payers that should deliver medical services to private consumers and incur commercial insurance costs among stakeholders.
Historically, I have had a PPO model of health insurance provided by Aetna for two years. The provider network included primary care, doctors, hospital, and facilities in and out of network with no referrals with an opportunity to choose a PCP. However, staying only in-network costs less than having an out-of-network visit. The plan provides generally provided coverage for medical expenses for the treatment of illness or injury. Hospital benefits included services provided by a hospital during the stay, such as room and board, ambulance and laboratory tests services, physicians and surgeons services, intensive care facilities; however, hospital admissions required precertification from Aetna.
Emergency services included the use of emergency room facilities and physicians services; hospital nursing staff services; radiologists and x-ray scans and pathologists services. CT, MRI, PET scans were covered only under diagnostic and preoperative testing of illness or injury. Behavioral health benefits (counseling) were limited to specific areas; dental services were provided if injury or accident occurred; vision and hearing were limited to routine exams once in a year; pharmacy covered drugs only for injury or illness treatment and family planning service. DME was covered if long-term care was planned; case management was free of charge; telehealth was not included, co-payments for preventive health services were not provided.
I had not experienced any specific problems related to the insurance model. However, the one issue that I saw regarding the provided model was expenditures for services that were significantly higher for out-of-network options and were included in the plan that did not consider per case payments that were also indicated by analysts (Pollitz et al., 2019). In my opinion, the issue arose due to a variety of services, locations, and doctors the model had to cover. To address the problem, I would propose establishing better health care costs control and flexible utilization review systems to manage the charges more precisely and allocate them to necessary services provision.
References
Berchick, E., Hood, E., & Barnett, J. (2018). Health insurance coverage in the United States: 2017. Census Bureau. Web.
Digital Communications Division. (2015). What is the difference between Medicare and Medicaid? U.S. Department of Health & Human Services. Web.
Namburi, N. & Tadi, P. (2020). Managed care economics. StatPearls Publishing. Web.
Pollitz, K., Neuman, T., Tolbert, J., Rudowitz, R., Cox, C., Claxton, G., & Levitt, L. (2019). Whats the role of private health insurance today and under Medicare-for-all and other public option proposals? Kaiser Family Foundation. Web.
Ridic, G., Gleason, S., & Ridic, O. (2012). Comparisons of health care systems in the United States, Germany and Canada. Materia socio-medica, 24(2), 112120. Web.
Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., & Wharton, G. (2020). International health care system profiles: United States. The Commonwealth Fund. Web.
Wagner, E. & Kongsvedt, P. (2013). Essentials of managed health care. Jones & Bartlett Publishers. Web.
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