focus on providing preventative and wellness care.

PLEASE RESPOND TO EACH 6 DISCUSSIONS SEPERATELLY Peer Response must be substantive by bringing information to the discussion or further enhance the discussion. Each Peer Response must have a minimum of ONE reference with citations (the best is a peer-reviewed article). Word count is greater than 75 words or at least 5 sentences in length. Participation #1 Managed care plans have three main categories. HMOs, PPOs and POS. HMO stands for Health Maintenance Organizations. In as much these plans focus on providing preventative and wellness care. While it provides medical care during illness, it also offers a variety of services to help people maintain their health—hence the name “health maintenance organization.”
PPOs or Preferred Provider Organizations allow patients to choose the provider they want to see, however they are afforded a negotiated fee based on the providers partnership within a network of providers. Should the patient choose to see a provider outside of this network, they are free to do so, however will pay a higher “out of network” fee.
POS or Point of Service plans are a hybrid of the two previously defined plans. Some POS plans are offered by HMOs to give members an optional plan that allows utilization of out-of-network providers.
Participation #2Managed health care was initially brought about to control the growth in health care spending by limiting both the quantity of health care delivered and the amount of reimbursement given to providers. It is an organization that provides health care services that manage all in one the financing, insurance, delivery, and payment. (Shi & Singh, 2019). The three types of managed health care plans are HMS, PPO, and POS. The first of the three to be established was the HMO which focuses on wellness plans. The HMO plan emphasizes preventative and screening services through going to routine checkups and tests which can save costs in health care long term. Generally, the HMO health care plan has no deductibles and lower copays. HMOs, cater to those who use in-network providers. The PPO is a plan that permits the use of in-network and out-of-network providers but at the cost of higher copays and deductibles to deter the use of out-of-network providers. The POS health care plan is more so of a combination of the two and allows out-of-network providers but has high out-of-pocket costs.
Participation #3 Three types of managed care plans are health management organizations (HMOs), preferred provider organizations (PPOs), and point of service (POS) plans (Medline Plus, 2019). An HMO plan pays for the health services only within that network. The patient chooses a doctor within that network to care for most of the services. A PPO plan will pay more of services are chosen within a certain network. It will cost more if services are chosen outside of this network. A POS plan lets the patient choose between an HMO and PPO depending on the care. An HMO is best for a patient who is on a budget or do not plan on seeing a wide range of different doctors (Kaiser Permanente, 2022). A PPO is better for patients who need more flexibility in doctors. A POS is best for patients alternating between the two.
Participation #4Gatekeeping has to do with healthcare insurance. It keeps limited access to certain things, for an example a patient cannot just go see a specialist or go have surgery anywhere without that patient being referred to by their primary care physician. It is a critical aspect of managed care because gatekeeping helps reduce unnecessary treatments. When patients do see doctors outside of their primary care physician, the prices are different for the medical equipment or medical test they run, so if the insurance has gatekeeping it will reduce any of that from happening, keeping the cost low or affordable.
Participation #5
Gatekeeping is mostly used in HMOs. Gatekeeping is where the PCP is required to coordinate the services needed by the patients. They use in network provider contracts and control the access to costly medical services. They are making sure to do preventative and routine care for the patient and the Gatekeeper will have to a referral for secondary services like diagnostics, any admission to the hospital and if any specialists are seen.
Participation #6I had never really thought of it as gatekeeping, especially because I work in military healthcare, it was interesting to me that this wasn’t something that all providers do. It is an amazing tool to control healthcare costs which is why HMOs use it. The whole point of managed care plans is to control cost. Which makes perfect sense why the military would use it. We have been talking about the importance of primary care and how it has been growing. So if I go to the doctor’s and get seen for joint pain. But my primary care provider can treat it instead of me going to orthopedics. Gatekeeping allows the primary care provider to see what is really going on before we refer you to a specialist. They can also choice which provider in that specialty you will see, which if that specialist has a contract with your managed care plan then it is saving even more money. That is why it is so critical, people don’t always know how bad their issue is. So if they always self-refer themselves then their care plan would be paying more money then if they managed all of their enrollees care beforehand.

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