More Managed Care Mysteries: Staff Models

There are many managed care mysteries among managed care organizations (MCOs) especially among structures. It’s a challenge to understand all of them.

Whether you are still working and faced with health insurance choices through the human resources department or have your own business and need to obtain health insurance to comply with the law, you will have to deal with the complexities of managed care. Managed care is the direction in which health insurance has gone. Many people like managed care, many people don’t, but the reality is that it is here to stay. So, you’d better understand it.

The Insurance Problem Solver wants to help, and we provide some basics right here.

In this article, we will discuss the main organizational formats MCOs, mostly Health Maintenance Organizations (HMOs), take. Although they differ in some important respects, they share the goal of attempting to manage the delivery of healthcare services to members in a cost-efficient way consistent with providing quality care.

Managed Care Mysteries — Staff Models

Among the main differences is the relationship between the managed care entity and the physician. That relationship can have a bearing on the patient (member) on the freedom to select physicians, controlling his/her own care, and cost.

Staff Models

One might consider the staff model of managed care as the customary formats that were encountered when managed care and particularly, HMOs were new. Staff models are often called closed-panel HMOs. If you were or are, a member of this kind of HMO the entire entity may be housed in a single building, although the staff model HMO may have several locations. They often look like outpatient clinics.

Among the features of the staff model HMO is that usually only basic medical services are furnished on site. But, because all kinds of medical specialties could be needed by members, the staff model would probably contract with select specialists in the area for infrequently needed services. Although they usually have radiology and laboratory capabilities, they typically contract for outpatient services such as hospitals and convalescent care.

Staff models offer the advantage of one-stop shopping for the basic health care needs of members. This model can also better control health care expenditures because they have greater control over the ways in which the employed physicians practice. The staff model is about the most restrictive when it comes to the member choosing the direction of care. The counterbalance is economy for the member (because there is less choice) and an emphasis on preventative care.

If health insurance is provided through your employment, it will likely be a managed care arrangement of some sort. Although the precise terminology that we have 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, this will permit you to ask the right questions and know how the health plan works.

If you are self-employed or are otherwise shopping for your own health coverage, you need to dissect managed care mysteries and 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.