Common models of managed health care organizations.

• Gatekeeper system: HMOs require patients to see their primary care doctor for a referral before they can see a specialist. This can delay care for patients who need to see a specialist urgently.

• Potential for financial incentives: HMOs may have financial incentives to deny or delay care, which could put patients' health at risk.

Suggestions to Strengthen the Weaknesses of HMOs:

• Expand provider networks: HMOs should expand their provider networks to give patients more choice of providers.

• Limit the use of gatekeepers: HMOs should limit the use of gatekeepers and allow patients to see specialists directly if they need to.

• Increase transparency: HMOs should be more transparent about their decision-making processes and provide patients with more information about their care.

Preferred Provider Organizations (PPOs)

Pros:

• More choice of providers: PPOs have a larger network of contracted providers than HMOs, and patients can also see out-of-network providers.

• No gatekeeper system: PPOs do not require patients to see their primary care doctor for a referral before they can see a specialist.

• Lower costs for in-network providers: PPOs typically have lower costs for in-network providers than out-of-network providers.

Cons:

• Higher costs: PPOs typically have higher premiums and out-of-pocket costs than HMOs.

• Less emphasis on preventive care: PPOs may not have as strong an emphasis on preventive care as HMOs.

• Less coordinated care: PPOs may not provide as coordinated care as HMOs.

Suggestions to Strengthen the Weaknesses of PPOs:

• Negotiate lower out-of-network rates: PPOs should negotiate lower rates with out-of-network providers to reduce costs for patients.

• Promote preventive care: PPOs should promote preventive care by offering incentives to patients who receive preventive care services.

• Improve coordination of care: PPOs should improve coordination of care by using electronic health records and other tools to share information between providers.

Exclusive Provider Organizations (EPOs)

Pros:

• Lower costs: EPOs typically have lower premiums and out-of-pocket costs than PPOs.

• Strong emphasis on preventive care: EPOs have a strong emphasis on preventive care.

• Coordinated care: EPOs provide coordinated care.

Cons:

• Limited choice of providers: EPOs have a network of contracted providers, and patients must choose from within this network. Patients cannot see out-of-network providers.

• Gatekeeper system: EPOs require patients to see their primary care doctor for a referral before they can see a specialist.

Suggestions to Strengthen the Weaknesses of EPOs:

• Expand provider networks: EPOs should expand their provider networks to give patients more choice of providers.

• Limit the use of gatekeepers: EPOs should limit the use of gatekeepers and allow patients to see specialists directly if they need to.

• Increase transparency: EPOs should be more transparent about their decision-making processes and provide patients with more information about their care.

Health Maintenance Organizations (HMOs)

Pros:

• Lower costs: HMOs typically have lower premiums and out-of-pocket costs than other types of managed care plans. This is because HMOs have a network of contracted providers who agree to provide care at discounted rates.

• Emphasis on preventive care: HMOs emphasize preventive care, which can help to reduce the need for more expensive medical care in the future.

• Coordinated care: HMOs provide coordinated care, which means that patients have a primary care doctor who coordinates their care with other specialists and providers.

Cons:

• Limited choice of providers: HMOs have a network of contracted providers, and patients must typically choose from within this network. This can limit patients' choice of providers, especially if they live in a rural area.