Merritt Personal Lines Manual: Three HMO Models
HMOs provide service through one or more of three "models" of operation.
The Group Practice Model (GPM), also known as the Medical Group Model, is composed of a group of physicians of varying specializations practicing in one facility. It is similar to a clinic-type operation. Under the group practice model, the HMO contracts with a medical group to provide the insured with health care services.
If the medical group provides services to HMO members only it is called a closed panel medical group. Under a closed panel HMO, physicians are usually salaried employees of the HMO and work at a clinic owned by the HMO. If the medical group provides services to HMO members in addition to other, nonmember patients, it is called an open panel medical group. Under an open panel, doctors are not salaried and treat HMO subscribers in their own offices. Generally, the insured would not need to go farther than the medical group for the health care, unless of course hospitalization is needed.
The medical group refers the insured internally, within the medical group, to physicians of differing specializations as needed (i.e. pediatrician, surgeon etc.). Special arrangements can be made if a specialist of a particular type of medicine is needed and not a part of the medical group. The insured's HMO also contracts with hospitals in the area to provide the insured with services that are not available through the medical group or if the insured requires surgery, etc.
The Staff Model health care delivery system is actually owned, operated, staffed etc., by the HMO. The HMO controls the physician group and the physicians and other health care professionals are employees of the HMO. The HMO could also build a medical group facility and hire physicians to staff it and provide health care services to members.
The key element of a Staff Model is that the HMO's own employees and facilities are being used to provide health care services to the HMO's members.
An Independent Practice Association Model (IPA) is a network of individually practicing physicians who contract with the HMO to provide the insured with health care services. Unlike the Group Practice Model, an IPA's physicians are located throughout a geographic area and are operated independently of each other.
If the insured selects an IPA, the insured would receive a list of physicians of varying specializations to choose from. Initially, the insured would choose the insured's own primary care physician (usually a general practitioner or if for a child oftentimes a pediatrician) and visit this physician for treatment.
However, if the insured's primary care physician cannot render treatment, then he or she will refer the insured to the appropriate specialist within the IPA network. Like the Group Practice Model, the physicians of an IPA may utilize hospitals affiliated (that is, contracted) with the HMO to render services not available at their independent practices.
Physicians who are part of an IPA treat patients on an open panel (HMO members and nonmembers) or closed panel (HMO members only) basis, depending on their contract with the HMO.
