HMO Model Analysis

A HMO is a plan that provides comprehensive health care services, with an emphasis on preventive care, for a fixed (capitated) payment. HMOs are the most stringent form of managed care. Participants must select a primary care physician, who acts as a “gatekeeper” for most services covered by the plan. If the patient does not channel care through the gatekeeper and obtain care at one of the HMO’s participating facilities, it is generally not covered under the plan.

There are two basic types of HMOs — the group or staff model and the independent practice association (IPA). These two models are sometimes referred to as non-network (group/staff) and network (IPA) HMOs. Under the group/staff model, the plan’s doctors share facilities and equipment. Some are employed by the HMO while others are compensated in other ways, such as a capitated rate per person. In an IPA model, physicians are organized like an HMO, but practice in their own offices. IPA doctors often have a mix of patients, some belonging to the HMO and some not. IPAs tend to have more doctors than the group/staff model and tend to be more geographically dispersed.

A PPO falls between an HMO and a traditional indemnity plan. Patients choose from a network of

The first POS plans typically included a HMO, a PPO and an indemnity plan option. Now most POS plans are simply HMO plans with an opt-out feature. POS plans are often referred to as open-ended HMOs. As in an HMO, participants select a gatekeeper from the panel of participating doctors, and that gatekeeper directs all care received. Care received in-network typically requires only a small dollar copayment per visit. Unlike true HMOs, POS plans cover care received outside of the network, but the patient will pay more. Typically, the higher cost sharing is in the form of deductibles and percentage