Merritt Personal Lines Manual: Other Managed Care Variations

There are many variations of managed care systems, including: physician hospital organizations (PHOs), practice management organizations (PMOs) and provider-owned networks. Most of these alternatives combine the mechanical controls of HMOs, the flexibility of PPOs and some kind of provider (that is, physician) ownership.

Here are details on three such variations:

1. Exclusive provider organizations (EPOs) are a type of PPO in which the insured can use a particular provider, instead of choosing from a list of preferred providers. In this situation, providers are not paid a salary but are paid on a fee-for-service basis. EPOs are characterized by a primary physician who monitors care and makes referrals to a network of providers (this is the same gatekeeper concept), strong utilization management, experience rating and simplified claims processing. EPOs can serve as an alternative to or companion to HMOs and PPOs.
2. An Open Ended HMO (also known as a "leaky HMO" and "point-of-service HMO") is a hybrid arrangement whereby the insured can use non-HMO providers at any time and receive indemnity benefits which are subject to higher deductible and co-insurance amounts. The out-of-pocket cost to the insured (and probably the insured's employer, too) is higher, but the arrangement allows the insured to remain in control in choosing a health care provider.
3. An insured might also want to consider a multiple option plan. This type of plan is an integrated health plan that includes services of an HMO, PPO, EPO and a traditional indemnity plan -- all of which are administered by a single vendor (usually a traditional insurance company)
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The goal of these alternative managed care plans is to reap the benefits of cost control while keeping doctors in on the decision-making process.

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