This is a reference on the terminology of HMO's, PPO's, IPA's, PHO's, MSO's & some questions to ask.

Traditionally, medical services have been paid for on a fee-for-service basis. In this system , the fee is paid either by a third party administrator - typically an insurance company, Medicare or a combination of the above. Alternatives to the fee-for-service system are now available for employers and individual patients to consider.

If you are considering an alternative system this information will help you make an educated decision. It briefly reviews important features of these alternative health care systems, and how they operate.

HMO's

A Health Maintenance Organization consists of an association of health care professionals and facilities that provides a specified package of health care for a fixed sum of money paid in advance for a specified period of time. The HMO contracts with health care professionals and facilities to provide the specified care. Generally a patient cannot seek care outside of the health care providers and or hospitals under contract with HMO.

Primary care physicians in an HMO are called "gatekeepers" because they determine whether a specialist is needed. Thus patients are not guaranteed the right to see a specialist unless the gatekeeper approves or requests the consultation.

PPO's

A Prefered Provider Organization is a group of health care professionals and/or hospitals, who contract with an employer, insurance company or third party payer, to provide medical care to a specified group of potential patients. The services offered are not prepaid or fixed. There is typically more choice in a PPO than in an HMO, and thus it is more costly. Patients usually have the right to obtain services outside of those provided by the PPO, but they are then obligated to pay a greater percentage of the fee for services rendered.

IPA's

An Individual Practice Association provides both insurance coverage and medical services . Physicians practicing in their own offices participate in the prepaid health care plan, charge patients agreed upon rates, and bill the IPA on a fee-for-services basis.

PHO's & MSO's

A Physician Hospital Organization is established to permit a hospital and members of its medical staff to enter into joint managed care contracts. PHO's vary in terms of structure, governance, credentials, administration, and managed care contracting. Most commonly, the impetus to form the PHO comes from the hospital, which incorporates a not-for-profit organization with hospital and physician board members.

The hospital may also form a Management Services Organization (MSO) to provide enhanced medical practice management and physician recruiting systems, establish consistent information, billing, collection and quality monitoring systems, and to provide other services.

Considering Joining?

Shop around. The "educated shopper" is likely to get the fairest "deal". Below we have listed some questions that you should ask a representative of any managed care plan you consider. They can be used as a guide to sorting out the differences, pluses, and minuses among the many plans offered today. Whenever possible, answers to these questions should be documented in writing. Alternatives to traditional fee-for-service are available. They may or may not satisfy your specific health needs and personal preference.

Carefully study the plans before you choose one.

1.Will I be allowed the freedom to be seen and treated by my current personal physician, or must I accept a designated physician?

2.If you I assigned a physician, will I be allowed the freedom to change physicians if I don't like the one selected for me?

3.Will I be seen and treated each time by the same physician who knows and understands my condition?

4.How many doctors who were affiliated with the HMO, IPA or PPO a year ago are no longer there? How many doctors are now

affiliated with each plan?

5.Will I always see a physician, or will routine care be handled by nurse practitioners, physicians assistants or other physician extenders?

6.What is the policy if I want to be seen by a physician only, rather than by a physician extender?

7.What about physicians credentials? What proportion of the physicians are bored certified or board eligible?

8.How many routine medical care locations does each plan have in my community and where are they located? How convenient are they

and will I have a choice of locations? Plan members usually must go to assigned locations to receive care. If your access to

transportation is limited, determine whether the travel will create a burden for you, your family and friends.

9.Can I see a physician immediately ? How long must I wait for an appointment? How many patients does the plan have in my

community? Compare the number of offices in the area to the total number of patients each must serve. If for instance, a few locations

are responsible for seeing and treating several thousand patients, you may have long waits for routine care.

10.What proportion of the plan's patients voluntarily dropped out during the past year?

11.Where do I go for care if I have a serious or chronic health problem requiring the attention of a specialist?

12.What provision for insurance coverage is made if the plan is not affiliated with the particular specialist I may need?

13.If I want a second opinion from a physician outside the plan, will the plan pay for it?

14.Is there any limit to the number and type of visits per year, the number and type of diagnostic procedures or hospitalization?

15.What hospitals and nursing facilities may I go to and still have the expenses covered by the plan? Consider whether these facilities are

convenient for your family and friends to visit, and whether it is a facility you would want to use.

16.If I need to be hospitalized, are there any limitations to my coverage under the plan?

17.Is 24-hour emergency care available, and if so, where must I go to receive emergency care?

18.Does the plan pay the bill if, in an emergency, I am taken to the nearest hospital and require extended treatment?

19.What do I do when the plan's offices are closed and I need to see a physician?

20.What costs am I responsible for under the plan?