What is an HMO?

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An HMO, Health Maintenance Organization, is a specific type of health care plan found in the United States. Unlike traditional health coverage, an HMO sets out guidelines under which doctors can operate. On average, health care coverage through the use of an HMO costs less than comparable traditional health insurance, with a trade-off of limitations on the range of treatments available.

The HMO has its roots sometime in the early part of the 20th century. Many businesses began offering their employees prepaid medical programs, under which their care was looked after so long as it fell within the scope of allowed procedures. The HMO did well throughout the mid-part of the century as well, until its use began to decline drastically in the late 1960s and early 1970s. In 1973, the U.S. Department of Health and Human Services passed the HMO Act, which helped cement the HMO as a part of the American medical universe.

The ways in which an HMO is able to offer cheaper health care are twofold. First, by contracting with specific providers of health care and dealing with large quantities of patients, the HMO is able to negotiate for more affordable health care than the patients would otherwise receive. Secondly, by eliminating treatments that the HMO views as unnecessary, and by focusing on preventative health care with an eye toward the long-term health of their members, the HMO reduces costs.

When one joins an HMO, one is usually asked to choose a primary care physician. This doctor then acts in part as the HMO's agent in determining what treatments the patient does and does not need. When the primary care physician determines that the patient needs care they cannot offer, they give a referral to a specialist that can address the patient's concerns. Emergency visits are exempt from this referral limitation, of course, and in many cases women are able to choose an OB/GYN as well.

Some well-known HMOs include Blue Cross and Blue Shield, and Kaiser Permanente, which was founded in 1945 and is widely claimed to be the largest non-profit organization in the United States. The long-term benefits of the HMO structure are a subject of much debate. Proponents point out that they offer low-cost health care to those who otherwise might be without, while critics say that restrictions placed by the HMO, and a general atmosphere encouraging practitioners to avoid referring patients when possible, results in many serious illnesses and medical conditions going untreated.

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14
HMO's are a covered benefit which pays for all your medical 100 percent. Some HMO's now are making subscriber pay a portion. That is not what an HMO is.
- anon49536
13
what is the definition of an exclusio?
- anon42669
12
Why is there no mention that HMOs receive large monthly payments that vary by county from Medicare for each person in the HMO? Any one should realize that their health care cannot be covered by the small monthly premium that they pay to the HMO.
- anon42159
11
HMO are health misery organizations who make large profits and ration care.
- anon41294
10
Hmo's have diluted the delivery of health care. The physicians are usully second rate physciains who could not make it on their own or have other problems. They are encouraged and sometimes rewarded for keeping people out of the hospital and not doing the appropriate tests to evaluate patients. Many HMO physicians are forced to see a certain number of patients in a very limited time which means they spend as little time as they have to with each patient. HMO medicine is a second level of medicine and patients need to be aware of that. Many people are forced into HMO's because of cost. You get what you pay for. --Drydoc
- anon38129
9
i dont understand what an HMO is. Can someone please "dumb" it down for me? whats the positives and negatives of HMO's? can someone simply list them without their opinion? please?
- anon37926
7
Do we foresee HMO accepting and recognizing Medical Tourism as it brings down their cost?
- anon31415
6
HMO, as far as I understand it, is a company that maintains organization for the health care providers. They are not providers themselves.
- anon30229
5
An HMO is a provider of health care services. As with any health care provider, its expenses are those of providing health care - medical and administrative. As it is a member organization, it's income is derived from member payments. You will find no literature that states payments to an HMO are premiums. Effectively, an HMO is a prepaid medical plan. I suspect that many HMOs purchase insurance to cover annual expenses that significantly exceed their expected expenses. By purchasing insurance, it doesn't make them insurance companies. Just because an organization operates using a mechanism that mirrors the insurance mechanism, that doesn't make it an insurance company unless it is incorporated as one.

In regard to the comment by anon21056 about the Supreme Court, that court can no more make an HMO an insurance company than it can make a cucumber an apple. Functioning like an insurer does not create insurance. I think that jicama tastes like fresh sugar snap peas, that doesn't mean it is sugar snap peas. The court did not state HMOs are insurers or insurance companies.

- co840
4
How does it impact on finance?
- anon23359
3
co840-

While you may think there is a "significant difference" between health insurance and health care providers, the United States Supreme Court disagrees. According to the Court in Rush v. Moran, an HMO "provides health care, and does so as an insurer." An HMO functions like an insurer because it underwrites and spreads risk among participants. Also, in most states, HMOs are regulated by their department of insurance.

- anon21056
2
An HMO is not necessarily insurance. Only Insurance Companies can sell insurance. HMOs are health care providers. If they are not incorporated as insurance companies they may not sell their product as insurance. Kaiser is the largest HMO, and it does not offer health insurance. It offers membership in a health care plan. There is a significant difference. Many complaints about smaller HMOs are directed at the insurance industry, when the insurance industry has nothing to do with them. Many PPOs are likewise, not insurance plans. Ignorance is not an excuse, it is ignorance.
- co840
1
how does the HMO earn its revenues and what are its expenses, basically how does this company earn its profits?
- anon7989

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Written by Brendan McGuigan
Last Modified: 21 October 2009

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