Health care is very important to everyone. It should be available for every person in the world no matter what their status are. Providing health care should be one of the main concern of every country. There are people who are so unfortunate that they can not afford obtaining medical treatments. This should not be the case, as a lot of budget is being allotted to make health care available to everyone. Nevertheless, this can not be assured due to many political reasons. This is where health insurances come in.
Health maintenance organizations are the ones who see to it how health care is delivered (Medicare). They are different from normal health insurances because they provide guidelines that physicians need to follow. They also cost less than normal health insurances but there are limitations on the services provided. Health maintenance organizations believe in early diagnosis. This is the reason why it is a low-cost prepaid service. Because it is available to everyone, there is no reason that treatments can not be obtained.
And when a person can get medical service any time he or she would like, diseases can be detected early and prevention can be done even before an illness becomes worse. There are a lot of health maintenance organizations available today including Blue Cross, Blue Shield, Kaiser Permanente, Aetna, Inc, and Presbyterian Health Plan (America’s Health Insurance Plans, 2004). There have been a lot of issues with regard to the advantages and disadvantages of health maintenance organizations.
Some people prefer to have one, and others do not find it that benefiting. It is advisable that an individual try to research first before applying to become a member of a certain health maintenance organization in that way, he or she can learn what is best for him or her. It also better to inquire if an individual’s family doctor belongs to a certain network in that way he or she would not have problems obtaining a new primary care physician. Others do not have to think about this because their companies have their own health maintenance organization plan.
One of the advantages of having a health maintenance organization plan is not requiring claim forms for office visits or hospital stays (Small Business Solutions); therefore, there is less paperwork to do. When there is less paperwork to do, it would not be as time consuming and patients can be given the proper attention they need. As well, there will be less waiting time for everyone because of less paperwork. Because health maintenance organizations are prepaid health insurance service, the member only pays for a fixed amount every month no matter how much medical care he or she receives.
This is better than having to pay for medical expenses every time a patient receives medical care. The member pays minimal amount from his or her pocket as compared to normal health insurances. Because there are some services that health maintenance organizations can not cover, the member has to pay for it right out from his or her own money but this only happens rarely since health maintenance organization plans cover almost all of patients needs.
The biggest advantage that a health maintenance organization have to offer is that in cases of emergency, the member does not have to worry about paying bills or service charges. The member only has to present his or her health maintenance organization card to clinics or hospitals and they can receive medical treatment without having to worry about the payment. As well, because health maintenance organizations offer different plans and members can choose what kind of hospital service they can get, patients do not have to worry about getting a hospital lodging that they do not prefer.
They can receive treatment the way they like in a comfortable manner. Health maintenance organizations have their own network of providers, which can include almost all kinds of health care. As a result, the member does not have to worry when he or she needs to avail of medical treatment. And because the number of health maintenance organizations are increasing these days, they make sure that they can cover almost all health care providers and offer the best plans so that members do not have to look anywhere else.
Another advantage is when a person receives a health maintenance organization plan through his or her employment. In this situation, the member does not pay anything (unless he or she applies for a dependent) because it is already been taken care of by his or her company. A patient will also most likely avail of the prescribed treatments when he or she has a health maintenance organization plan because he or she do not have to think about the cost. Therefore, the patient has more chances of feeling and getting better and diagnoses can be made early.
Also, health maintenance organizations can assign a case manager for a patient in order to follow the patient’s status and treatments. This can be of benefit to both parties for better communication. The patient will not have problems whenever he or she has questions with regard to his or her health care. Health maintenance organizations can also be a good thing for medical practitioners and health establishments. It can make sure doctors and hospitals will have constant influx of patients, which can mean better business.
Because of this, health care providers agree to giving medical care at a lower cost. It should also be noted that when health maintenance organizations fail to pay the network clinicians, these providers are not allowed to bill their patients for the services. It is the responsibility of the organization to pay their dues to the health care providers and as such, the payment are only between the organization and physicians. The member’s responsibility is only to pay for the assigned cost of his or her chosen plan, as well as the minimum out-of-pocket payment for uninsured services.
While there health maintenance organizations have numerous advantages, it also has its downside. The disadvantages of having a health maintenance organization plan are basically the specific guidelines that providers have to follow, as well as the non-coverage of those providers that are not member of that particular health maintenance organization. If the member decides to go to a health care provider that is not on the health maintenance organization network, the member will have to pay a certain amount or the full cost of the service rendered (Dalton, 2007).
Otherwise, a referral can be made by a physician (usually the member’s primary care doctor) from the network for the member to be able to see the provider not included in the network. This is also the case for referrals to specialists. This can be a lot of work and may cause problems with regard to the referral. Another disadvantage of being in a health maintenance organization plan is when the member’s primary care physician decides to get out of the network. It is important for a patient or member to have a primary care doctor who can monitor his or her health regularly.
As well, building a relationship with doctors are very important because of trust issues. When the member’s primary care doctor goes out of the network for some reason, the member will have problems finding another physician whom he or she can be comfortable with again. One more disadvantage that a health maintenance organization can have is when it goes out of business, which can leave members without any health care. This would be an alarming situation, as many people rely on their health maintenance organization plans for medical services.
Also noted is that most surgeries, like plastic or elective, are not covered by health maintenance organization plans. Health maintenance organizations also require utilization reviews for certain services or prescriptions. This is done to know if the prescribed treatment is necessary for the patient, with consideration for his or her medical and personal history, and present status. When deemed unnecessary, the coverage will be denied and will cause problems to the provider and patient. At times, it will cause delay in the patient’s health care.
It will also make the provider to ask for second opinions and generate another utilization review, which will cost more. Utilization reviews are usually done by health practitioners including doctors or nurses. It is indicated that a lot of health maintenance organization plans give the most consistent, predictable costs, in contrast to other health care plans (BAA Health Insurance Services). It is effective in that it does not have hidden charges and whenever there are charges that has to be paid out of the member’s pocket, the member can always be sure that it will only be minimal.
Its effectiveness can also be seen in less hospital patients and more clinic patients because people prefer going to clinics for check ups rather than waiting in line at hospitals. Because of this, preventive medicine is being practiced. This is important because early detection and diagnosis can contribute a lot to a person’s health. Many people prefer health maintenance organization because of its availability. Because it has more advantages than disadvantages, it is better to obtain a health maintenance organization plan.
Solutions for the disadvantages can be made, like having the member suggest to his or her preferred physician to become a member of the network. With all of these things accounted for, it will still be the discretion of a person if he or she wants to avail the benefits of a health maintenance organization. It is admitted that health maintenance organizations have been a great contribution in health care. It has made medical treatments within reach to everyone. Although disadvantages can be seen, they can be considered as very minimal compared to what health maintenance organizations have to offer.
An individual does not have an excuse for not obtaining medical treatment when there are numerous health maintenance organizations for him or her to become a member of. Medical care should also not be as complicated as it seems. This is what a health maintenance organization can offer its members. Services are organized and are therefore less time-consuming. A person’s health should always be taken seriously. Health care should not be as expensive as others want them to be. It should be available to everyone without consideration for age, gender, race, or status.
Anyone should not be refused medical service. Although that is the case, a problem will still arise if a patient does not have any means to pay his or her medical bills. That is why it is always a good idea to be sure of one’s health, and this is what health maintenance organizations are for. Although it is made for everybody, health maintenance organizations are perfect for those people who do not need specialized medical care that can only be obtained through an out-of-network provider. There are other health insurance plans out there that one can choose from.
When a person has the option to choose what health care organization he or she can avail, it is advisable to research about all the health maintenance organization plans available in his or her area. The person should weigh out his or her options, as well as think of the best plan that his or health status suits best. One should also review the benefits that a certain health maintenance organization plan has to offer, the health care providers and medical facilities it covers, how easy or hard it is to get referrals, number complaints that the health maintenance organization has had, and most especially the quality of its service.
Whatever a person decides to choose is actually better than not having any health insurance. It should be remembered that our health should be one of our main priorities. It should never be disregarded just because of monetary issues or even any other issue.
References America’s Health Insurance Plan. (2004, July 21). Health Plan Links. Retreieved February 22, 2008, from http://www. aahp. org/Content/NavigationMenu/About_AAHP/Who_We_Are/Health_Plan_M ember_Links/Health_Plan_Member_Links. htm BAA Health Insurance Services. HMO 100% Provides Most Effective Coverage.
Retrieved February 21, 2008, from http://www. baahealth. com/hmo_100%25_provides_most_effective_coverage. asp Dalton, James. (2007, September 22). The Advantages and Disadvantages of PPO’s and HMO’s. Retrieved February 21, 2008, from http://www. freearticlesarchive. com/article/The_Advantages_and_Disadvantages_of_PPOs_an d_HMOs/31764/0/ Medicare. What is a Medicare HMO? Retrieved February 21, 2008, from http://www. medicarehmo. com/mchmwhat. htm Small Business Solution. HMO Advantages Disadvantages. Retrieved February 21, 2008, from http://www. residual-rewards. com/hmo-advantages-disadvantages. html.