Imagine having to wait for a referral if you needed lifesaving treatment. That's the problem with HMO's. To quote a Survivor of two primary breast cancers: "The disadvantage of an HMO is that the patients give up control of their own health care to medical groups that vary in quality and abilities and whose primary concern is their profit rather than the patient’s health. Many HMOs do a satisfactory job withintheir organization on routine medical care. If the patient could get better care with a specialist outside of that HMO, the HMO may or may not refer the patient to a place where the patient can get better care."
Or the experience of another ex-HMO member: "HMO’s are a nightmare! If you need to see a specialist you always need to see the primary docbros first to get a referral. The primary doctors want to make money off of you so (in my experience) make you go for excessive unnecessary tests before they will write the referral for you. Also, that is 2 doctors' appointments, 2 copays and twice as much time wasted. Go with a PPO, so much less aggravation and you don’t even need a primary doctor!!"
Even doctors warn patients about HMO's. A physician with 40+ years general practice published this: "For years the HMO was less money per month. Not always that way now. People love to think they got something free. They don’t do their homework and don’t realize that they are surrendering freedom of choice for their care by taking the HMO. The monetary cost may be less but that is the price one pays."
The last example: In my network of friends we are all hoping and praying for a friend:
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FAQs
In an HMO there are some disadvantages. The premium that is paid is just enough to cover the costs of doctors in the network. The members are “stuck” to a primary care physician and if managed care plans change, then the member may not be able to continue with the same PCP.
What are the disadvantages of having an HMO for healthcare? ›
Disadvantages
- If you need specialized care, you will need a referral from your primary care physician to an in-network provider.
- Must see in-network providers for care-less flexibility than a PPO plan.
Cons Explained
No specialist visits without a referral: You'll need referrals for any specialists if you want your HMO to pay for those visits. If you need to visit a rheumatologist or a dermatologist, for example, your PCP must make a referral before you can see one for the plan to pay for your visit.
Why do HMOs have such a bad reputation? ›
Sadly, many HMOs are run by either incompetent or corrupt bureaucracies, thereby compromising necessary patient care in lieu of their bottom-line. That said, some HMOs are better than others, and both patients and doctors must do their due diligence to determine whether or not to participate.
Why would a person choose PPO over an HMO? ›
PPOs Usually Win on Choice and Flexibility
If flexibility and choice are important to you, a PPO plan could be the better choice. Unlike most HMO health plans, you won't likely need to select a primary care physician, and you won't usually need a referral from that physician to see a specialist.
Why should I get PPO instead of HMO? ›
A PPO plan provides more flexibility in choosing your health care providers, but it may cost more than an HMO. Key areas to remember: Your maximum copay or coinsurance is less when you stay in network for services. You can see a specialist and access many types of services without a referral.
What is not an advantage of an HMO plan? ›
The Primary Disadvantage of an HMO Plan
HMO plans do not give you the flexibility of the PPO plans that many people have become accustomed to using. You are limited to a smaller (typically local) network of providers – usually a particular hospital system.
Where do most Americans get their health insurance? ›
While the majority of people in the United States have private health insurance, primarily through an employer, others obtain coverage through programs offered by the government.
How to tell if insurance is PPO or HMO? ›
However, if you've already got a health plan and don't know which plan type you have, you can check your insurance card or contact your insurance provider directly. If you have an online account through your provider that allows you to access plan details, you can also start there.
Why did HMOs fail? ›
Feeling coerced by market forces, doctors complained to their patients. Dissatisfaction was strongest among people not in HMOs by choice. As for patients, many of them were forced into HMOs by their employers, who gave them no choice, little explanation, and none of the financial benefit.
Final answer: HMOs provide services, financing, and patient care with a fixed payment per enrollee, unlike the fee-for-service system that reimburses healthcare providers per service. Thus, the answer to which of the following is not provided by an HMO is D. Reimbursem*nt.
What is the downside to a PPO plan? ›
PPO plans are typically more expensive than other plan types. Not only will your plan premium be higher, but you'll also have to meet your annual deductible before your insurance company kicks in its share.
Why do doctors not like HMO? ›
HMO plans might involve more bureaucracy and can limit doctors' ability to practice medicine as they see fit due to stricter guidelines on treatment protocols. So just as with patients, providers who prefer a greater degree of flexibility tend to prefer PPO plans.
What is a disadvantage of an HMO quizlet? ›
One disadvantage is that HMO's require you to see HMO- affiliated healthcare providers. Fee stays the same regardless of amount of health care use.
What is an example of an HMO? ›
There are many examples of HMOs, both in the public and private sectors. Popular HMO plans can be found in State Health Insurance Assistance Program, Kaiser Permanente, Humana, Medicare, Federal Employees Health Benefits Program, and Aetna.
What's the most likely reason a patient's HMO won't pay? ›
Except in cases of emergency, out-of-network care is typically not covered. Furthermore, the HMO has the right to refuse payment if the requested service or treatment. If the procedure is considered experimental, cosmetic, or not on the approved list of covered procedures, it may be denied.
Why are PPOS so popular? ›
Freedom of choice
One of the biggest advantages of PPO policies is their flexibility. Given that PPO plans offer a larger network of doctors and hospitals, you have a lot of say in where and from whom you get your care.
What are the disadvantages of managed care? ›
Managed care plans often focuses on cost control, which can sometimes lead to cost-shifting from insurance companies to healthcare providers or patients. Reduced reimbursem*nt rates for providers might affect the availability and quality of care, and patients may face unexpected out-of-pocket costs.
