Application to Help Consumers How to Choose the Right Healthcare Provider

U.S. Health Care Delivery System
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U.S. Health Care Delivery System
Introduction
The Health Maintenance Act of 1973 paved the way for the establishment of managed care organization iterations with diverse policies related to health care delivery, including provider networks, restrictions, payment, and risk-sharing formula, as well as out-of-pocket costs. This essay will differentiate between MCOs, HMOs, PPOs, POSs, and ACOs. It will also design an application to help consumers choose between the various consumer plans.
Part 1
Plan Type

Providers

Network Coverage & Restrictions

Referrals

Cost

MCO

Providers are paid through capitation and discounted fees. There is risk-sharing between providers and insurers.

Patients are limited to a network of providers and physicians. The plan does not pay for out-of-network care. Patients must also name a primary care physician to coordinate their care.

Patients require a referral from their designated primary care physician.

Out-of-pocket costs are generally low given the limited access to the health care system

HMO

Providers are typically paid under capitation, although there is some fee for service (Shi & Singh, 2017). Risk is also shared between providers and insurers.

Patients choose from a select group of network providers (physicians and institutions). The network is usually smaller than that provided by the PPO plan. The HMO plan does not allow patients to seek care outside the specified network. If they do, they have to pay for their own care. During emergency care, the only exception is when the facility (but not always the provider) may bill as in-network. Patients must also name a primary care physician to coordinate their care (Aetna, 2020).

Patients require a referral from their designated primary care physician for specialist care.

Because of the smaller network coverage and restrictive access to the health care system, patients pay lower premiums than other plans.

PPO

Providers are paid according to discounted fee schedules. There is no risk-sharing between providers and insurers.

Patients choose from an extensive network of providers and professionals. It is also possible for one to seek care from providers outside the network, but they will be charged higher. There is more flexibility in regards to seeking specialist care and going out of the network, but this comes at the cost of paying higher premiums (Heaton & Tadi, 2020). There is usually a lot of paperwork during billing and when seeking care out of the network.

Patients do not require a referral to seek specialist health care services.

While patients have unhindered access to the health care system, the PPO plan is relatively expensive compared to other plan options. There is higher cost-sharing, and patients are required to make higher monthly premiums than other plans. Besides, the patient must make an average annual deductible before the insurer can begin picking up its share of the coinsurance.

POS

Providers are paid under capitation and fee for service. There is some risk-sharing between providers and insurers.

POS plans are across between PPO and HMOs: patients can choose between HMO and PPO services every time they see a health care provider. Just like HMOs, patients are required to choose from a select group of in-network physicians and facilities. They must also specify their primary care physician. However, one can seek care in an out-of-network institution for a higher fee, just like in the PPO plan (Aetna, 2020). Similarly, there is usually a lot of paperwork during billing and when seeking care out of the network.

Patients require a referral from their designated primary care physician for specialist care.

The premiums are generally lower than those for the PPO plan if the patient chooses the HMO plan when seeking care. However, out-of-pocket fees are generally higher if one wants more flexible access to the health care system. On the whole, the POS plan is the most flexible since the patient is allowed to choose between two plans. It is suitable for those who want to k...