The Role of Health Maintenance Organizations in Improving Health Care

Introduction

Health maintenance organizations (HMOs) can be regarded as rather complex systems that include physicians, healthcare facilities or hospitals, and insurance companies. In the United States, these systems develop in the context of managed care practices, and individuals pay monthly fees in order to receive healthcare services (Toseef, Jensen, & Tarraf, 2019). On the one hand, HMOs combine the advantages of the insurance system and high-quality care, leading to the improvement of the public’s health.

On the other hand, HMOs are viewed as rather restrictive and unable to address rare conditions in patients (Healey & Evans, 2015). The purpose of this paper is to analyze the current debate on the effectiveness of HMOs and support a certain position on the problem. Although HMOs have some disadvantages, specific features and tools they use to promote services contribute to improving health care in the US in a wider context, making medical assistance more accessible.

Tools and Specific Features HMOs Use to Influence Health Care

Some features and instruments associated with HMOs’ activities lead to improving health care for not only individuals paying the fees but also communities. The reason is that it is more beneficial for HMOs to focus on predicting diseases and promoting patients’ well-being than on treating their conditions (Akinbode, Sokefun, & Aremu, 2019). For example, when individuals choose HMOs, they need to select a Primary Care Physician who will be the key healthcare provider for a person (Healey & Evans, 2015).

It is important to note that healthcare providers operating in the context of HMOs are oriented toward using tools associated with preventive medicine, such as patient education. Physicians working with HMOs are interested in keeping clients healthy as they receive payments in spite of patients’ health status. In this case, the rate of hospitalizations decreases, as well as costs connected with treating patients’ diseases.

From this perspective, providing clients with a specific insurance plan and stable access to care, HMOs also invest in patient education and promotion of a healthy lifestyle in order to keep clients strong. Therefore, HMOs do not provide restrictions regarding the number of visits associated with primary care (Edelman, Mandle, & Kudzma, 2017). As a result, the examples of tools and techniques demonstrate that the approach followed by HMOs contributes to reducing medical costs and the involvement of healthcare providers in comparison to traditional health care.

Effectiveness of HMOs in Improving Health Care

The literature on the topic indicates that the focus of HMOs on preventive and ambulatory care services plays a critical role in improving the well-being of a wide group of patients. Additionally, users of HMO services pay lower fees in comparison to other insurance plans, which makes many Americans choose this managed care plan among alternatives. As a result, individuals have an opportunity to receive complex care any time they need it while paying comparably low fees and accessing high-quality specialists (Akinbode et al., 2019; Bolzetta et al., 2018).

In cases when people need to choose between insurance plans because of their socioeconomic status, HMO can be regarded as an efficient choice. Moreover, the promotion of preventive care in the context of HMO activities is discussed in the literature as one of the main benefits of the system (Akinbode et al., 2019). Those people who use the advantages of preventive medicine require emergency medical services rarer, which also contributes to increasing the public health status.

Furthermore, the network of physicians working with HMOs is usually very wide, and this aspect helps individuals choose specialists they want to interact with. Therefore, in many cases, individuals can be referred to specialists within a network, and they do not need to cover costs associated with visiting healthcare providers who do not belong to the network. The improvement of health care, in general, is realized through the control of Primary Care Physicians over individuals’ immunization plans, regimens, and the treatment of chronic diseases (Healey & Evans, 2015). From this perspective, spending limited resources, individuals receive complex care and services to support their health.

Opponents’ Views on HMOs’ Role in Health Care

Despite the obvious advantages of HMOs for the state of the national health care and the overall system, researchers and experts also pay attention to certain disadvantages of this managed care approach. The problem is that those individuals who have selected HMOs to receive limited opportunities to choose a healthcare provider (Bolzetta et al., 2018). It is possible to select Primary Care Physicians only from an assigned list.

Additionally, people can visit specialists only after the referral is signed by their Primary Care Physicians. Furthermore, if the required specialist is not present in the network, the costs of consulting the outside professional are covered by the patient (Edelman et al., 2017). Therefore, there are risks that, if an individual is diagnosed with a rare or severe condition, he or she may face the necessity of covering high medical expenses by oneself.

Nevertheless, researchers report that those people who suffer from severe diseases usually select alternative plans. In most cases, the needs of the population are effectively addressed by HMOs, and related fees are significantly lower (Toseef et al., 2019). In addition, networks of professionals are rather expanded, and patients can find practitioners they prefer among specialists listed in the context of HMOs.

Some opponents state that the dependence on referrals to visit specialists also limits individuals in their possibility to receive high-quality care. However, following a traditional process observed in most healthcare facilities, it is possible to argue that the use of Primary Care Physicians’ referrals is a typical practice (Healey & Evans, 2015). The focus is on organizing the primary assessment of a person and consultation in order to provide a diagnosis and refer an individual to a professional specializing in his or her condition.

Conclusion

In spite of the fact that HMOs have some disadvantages in comparison to other plans related to managed care, it is still possible to support the idea that this system contributes to improving health care. First, the focus is on decreasing costs associated with medical services and on providing specialized care only when it is necessary. Second, preserving individuals’ wellness, healthcare providers working in the context of HMOs apply the principles of preventive medicine and decrease the rate of emergency cases requiring costly decisions.

As a result, clients receive only that assistance they need to remain healthy and active. Regular health care becomes not only improved but also more accessible because of low monthly premiums. All these aspects contribute to supporting the view that the tradition of selecting HMOs followed in the United States during many years is beneficial for citizens and the healthcare system in most cases.

References

Akinbode, J. O., Sokefun, E. A., & Aremu, M. O. (2019). Appraisal of health maintenance organisations’ performance in the Nigerian healthcare service sector. Journal of Healthcare Engineering, 2019, 1-6. Web.

Bolzetta, F., Wetle, T., Besdine, R., Noale, M., Cester, A., Crepaldi, G.,… Veronese, N. (2018). The relationship between different settings of medical service and incident frailty. Experimental Gerontology, 108, 209-214. Web.

Edelman, C. L., Mandle, C. L., & Kudzma, E. C. (2017). Health promotion throughout the life span (9th ed.). New York, NY: Elsevier Health Sciences.

Healey, B. J., & Evans, T. M. (2015). Introduction to health care services: Foundations and challenges. San Francisco, CA: John Wiley & Sons.

Toseef, M. U., Jensen, G. A., & Tarraf, W. (2019). Is enrollment in a Medicaid health maintenance organization associated with less preventable hospitalizations? Preventive Medicine Reports, 16, 100964. Web.