Matrix Health Insurance

Model

Describe the model

How is the care paid or financed when this model is used?

What is the structure behind this model? Is it a gatekeeper, open-access, or combination of both?

What are the benefits for providers who use this model?

What are the challenges for providers who use this model?

Health Maintenance Organization (HMO)

The model aims at decreasing health care costs for its subscribers (Zhu). Thus, the model is normally applicable for large organizations needing to offer insurance for their staff.

The model applies the capitation style of payment. The model receives a fixed amount of money for the services to be given per patient for a specified amount of time.

The care physician acts like a gatekeeper. He or she welcomes patients and refers them to health specialists. Patients using the model are required to access medical attention from specific facilities except for emergency cases.

The patients enjoy healthcare services at a reduce cost compared to other models. The patients do not have to pay for deductible, thus a decrease in the amount paid. In addition, the model have a fixed fee for each patient, thus the medical cost remains fixed regardless of the services accessed during the agreed period.

Patients do not have the choice for the healthcare provider. They are just referred to any specialist. In addition, the capitation mode of payment maybe expensive since subscribers has to pay for services even if they will not have to access them. Further, some physicians may subscribe cheaper drugs for the patents aiming at maximizing profits.

Preferred Provider Model

The model includes an organization contracting with other health care organizations to form a network of healthcare providers. Patients are free to choose from the list the hospital and doctor to access health care from.

The covered individuals access free medical care. In addition, the model may require patients to pay deductibles and co-pays.

The preferred provider model can be said to combine both gate keeping and open access structures. A gatekeeper structure involves the plan participant to refer patients for care access (Zhu). However, a patient can choose to go directly to a specialist without seeking approval from the gatekeepers, which constitutes the open access of the structure.

The patient is free to choose to hospital and doctor to access health care from. Again, covered individuals pay a reduced cost for treatment. In addition, subscribers receive quality health care from specialized physicians. Further, preferred providers are flexible to meet the specified needs of their subscribers.

Preferred provider models have higher premiums as they are expensive to establish. In addition, patients pay for deductibles and co-pays, which increase the cost of medical services. Further, a patient has to pay full medical cost to access care in hospitals outside the network.

Point-of-Service Model

This model combines the aspects of a health maintenance model and preferred provider model. A subscriber is free to be designated a primary care giver who will make referrals to specialists if need. Again, a subscriber may receive care from non-networked hospitals at a higher cost.

Payments are made by either the primary care physician or the policyholder. If made by the primary care physician, the cost is higher than that made by a policyholder for out-network services. However, in-network payments are lower if mage by the primary care physicians. In addition, a point of service model incorporates copayments. Deductibles are also applicable for out-network services.

The point of service model combines the gatekeeper and open access structures. Subscribers are free to seek specialty services without consulting primary care givers, or may contact the primary care givers for referrals.

Subscribers receive quality health care form the wide range of networked hospitals and doctors. In addition, networking allows subscribers to access health care at lower rate from hospitals within the network. Further, the in-networks do not charge deductibles, which makes healthcare cheaper and more affordable. Point of service model caters for subscribers who travel frequently as they offer nationwide coverage.

Out-of-network services are more expensive as subscribers have to pay for the full cost of service. Further, subscribers who do not use out-of-network services provided by the model incur higher costs that they actually do not enjoy.

Provider-Sponsored Organization

This health care organization utilizes a group of doctors and hospitals network to provide health care services for people within that coverage.

The provider-sponsored organization takes full risk to insure the coverage patient population. The provider provides treatment services and payment services. Every beneficiary to the plan pays a fixed amount of money for the healthcare services.

The provider-sponsored organization is a gatekeeper structure. The beneficiaries must consult the primary care physicians for specialty treatment.

In the provider-sponsored organization, primary care givers work with health plan administrators thus enjoy less revenue leakage. In addition, provider-sponsored organizations provide health care for its population at lower costs. Further, the model is geared towards a specified population, thus higher quality care is administered.

The success of the provider-sponsored organization is threatened by competitions from other models. Further, the model offers a narrow network, which puts the quality of health care in question. In addition, the primary care physicians may focus on internal care provisions aspiring to maximize profits, which demote the quality of health acre administered.

High Deductible Health Plans and Savings Options

The model contains higher deductible payments as compared to traditional insurance plans. This model is organized in such a way that subscribers pay for medical expenses without paying for federal taxes.

A subscriber initially pays for health care for a specified amount of time before the insurance company takes over in the payments. However, the health savings account contributes to the high deductible plan

This model is purely a gate-keeping model. The primary care physicians receive the medical needs and refer the patient to the specialists.

Premiums are lower than those of other models are. The networks are not as narrow as those with health maintenance organization. In addition, the savings options substitute for the money that would have been paid from pockets.

Chronic illnesses patients pay higher amounts of money from their pockets. In addition, for surgery, the patients deductibles are first depleted before the insurance company chips in. Deductible rates for families are so expensive.