Managed care mysteries are complex, and that’s why we want to help you understand the various models members select from when purchasing.
In the previous piece on managed care mysteries: staff models, we explored a more singular entity almost like a clinic where many services are offered under one roof. If you’re responsible for your own health insurance, I encourage you to understand these differences so you make the best choice for you and your family.
Today, we’re addressing another aspect of managed care, called group models.
Managed Care Mysteries — Group Models
This term refers to a managed care arrangement, usually an HMO, where the entity contracts with a group of doctors who have a broad range of specialties to provide all healthcare needs of the members. The doctors are not employees of the managed care entity. Sometimes, they are allowed to treat non-HMO members. The doctors share facilities, equipment, and medical records.
There are several variants of the group model, including:
- Captive: This is an arrangement where the medical group is created to serve the members of the managed care organization only. An example is the Kaiser Foundation Health Plan which is the licensed HMO. The Permanente Medical Groups have an exclusive contract with the Kaiser Foundation to provide medical services to the members of the health plan.
- Independent: In the independent group model HMO, the HMO contracts with an existing, independent, multispecialty physician group to provide physician services to its members. In some cases, the independent physician group is the sponsor or owner of the HMO. Often, the physician group continues to provide services to non-HMO patients while it participates in the HMO. Although the group may have an exclusive relationship with the HMO, the relationship usually does not prevent the group from having other patients.
- Network: In a network model HMO, several large group practices are used to provide services of all types to members. Alternatively, the HMO might contract with some small practices. In either event, the group(s) is/are responsible for providing comprehensive services to the HMO members. It is usually authorized to refer to outside physicians as needed but is financially liable for payment to those outside doctors.
- IPA: This format contract with an association of physicians, the IPA (Independent Practice Association), to provide physician services to the members. The physicians are members of the IPA, which is a separate legal entity, but they remain individual practitioners and retain their own practices, staff, and medical records. IPA models are generally open to participation by all community providers who meet the criteria established by the HMO and the IPA. Therefore, it is (more) likely) the case that a member will be able to retain his/her former physicians within the community, especially a smaller one.
If health insurance is provided through your employment, it will likely be a managed care arrangement of some sort. Although the terminology discussed may not be used, this should arm you with explanations of the major organizational structures. While you may not have any say over what you are offered, you are better equipped to ask the right questions about group models or staff models and know how the health plan works.
If you are self-employed or are otherwise shopping for your own health coverage, you need to know what’s out there for sale. There are lots of choices at lots of price points. Determine your needs and those of your family to the best of your ability. Buy. Don’t be Sold. And always, always, always, do business only with an insurer that is licensed to transact insurance in your state, and with an agent who is also licensed in your state. There are lots of scams; don’t be a victim. If you have any question, call your Department of Insurance. If you need more, I’ll help.