Health Maintenance Organization

Health Maintenance Organization (HMO) is a private special form of a specific health insurance and care model that has developed in the United States since around 1910 . HMOs are funded and legally sponsored by the federal government under the Health Maintenance Organization Act of 1973. They are the prototype of a Managed Care Organization (MCO) , but other managed care concepts such as Preferred Provider Organizations (PPO) or Provider Sponsored Organizations (PSO) are also widespread in the USA. The basic idea of this model is on the one hand that service providers in the health sector(Doctors, physiotherapy / psycho / occupational therapy, speech therapy, nutritional counseling, etc.) are paid not for the illness , but for the health of their clientele, and on the other hand, that a service provider does not receive any financial reward for excessive diagnostic and therapeutic measures.

This is implemented in such a way that a community of clients and service providers (which can be doctors, trade unions or consumer cooperatives as sponsors) has a certain fixed overall budget from which all medical measures are paid for. The service provider has an incentive to save because he receives part of the unused remainder of the budget in addition to his wages.

(In contrast, in the traditional health insurance system, the income of the service provider increases the more he provides, i.e. the more costs he incurs).

Development and current situation in the USA

HMOs were originally developed in the United States . The United States health system does not have universal health coverage (aside from Medicaid for the needy and Medicare for the 64+ and disabled), but often insurance solutions between establishments , their employees, and a group of care providers. The idea of providing service providers with a fixed budget for the treatment of all employees in a company is relatively easy to implement. In large companies in particular, staff are offered the choice between different HMOs (usually three). Employees also still have the option of going to another doctor if they are dissatisfied with the system, but they then have to pay for it themselves.

A health maintenance organization is contractually obliged to provide its voluntary members with outpatient, inpatient and, in some cases, dental services and to provide insurance cover for them. The monthly contribution is fixed and independent of the use of the services. There is only an excess of the costs in exceptional cases.

In 2005, 69.2 million people in the USA were members of a private HMO (2004: 66.1 million, 2003: 71.8 million). Most HMO members live in the state of California (17.6 million), followed by New York (4.6), Florida (4.5) and Pennsylvania (3.7 million). In California, 49.1% of the population were HMO members. There are a total of 414 Health Maintenance Organizations in the United States.

The largest HMO is Kaiser Permanente , which has 8.4 million HMO members, 134,000 employees, 12,000 doctors, 30 medical centers and 431 regional and local offices in nine American states and the District of Columbia. Of the 8.4 million members, 6.3 million live in California. Annual sales are $ 34.4 billion (2006).

No objectively measurable differences in the quality of care between HMO's and traditional medical practices could be shown in the USA. On the other hand, there are studies that show that older people in particular feel subjectively less well cared for by doctors in HMOs than those with individual conventional health insurance. The cost savings through HMOs, on the other hand, are beyond question.

A Gallup poll in June 2007 looked at how much trust Americans have in the HMOs: 7% a lot, 8% a lot, 39% a lot, 38% some trust; 4% no trust, 4% no opinion. The corresponding values for confidence in the US Congress: 4% very much, 10% a lot, 46% quite a lot, 36% some trust; 3% no trust, 1% no opinion. The military, SMEs, the police, the churches, the banks, the federal court and the public schools enjoy the highest trust. (Gallup Poll June 11-14, 2007 among 1007 adults)

Existing models in Switzerland

HMO practices have existed in Switzerland since 1990 . Since Switzerland also has a privately organized health system, but on the other hand has a general health insurance obligation with strict regulations, HMOs are more complex structures here than in the USA. Various health insurance companies offer HMO models, none of them in all of Switzerland . At the center there is an HMO center, which brings together doctors from various disciplines and therapists under one roof. HMO insured persons are obliged to be treated primarily at the HMO center. Exceptions are emergencies, illnesses outside the geographical area of activity of the HMO and often gynecology and ophthalmology.

In return, those who opt for such an HMO variant receive a health insurance premium reduction . If an insured person does not follow the rules of the game and goes to an external doctor, for example, the insurance company can refuse to cover the costs of this treatment in whole or in part.

Organization of the HMO centers

The HMO centers are either owned by the insurance company or have contracts with one or more health insurers. Doctors and therapists are employees or shareholders of the HMO centers with fixed wages and / or profit and loss sharing. The budget that the HMO center receives has to be renegotiated every year and depends on the number and age structure of the insured at this center. All costs for the insured must be covered by the budget, for example also bills from external doctors, therapists or hospitals. One goal of an HMO center is therefore to offer the most comprehensive possible care with important disciplines in the HMO itself in order to keep the number of necessary external services as small as possible. This in turn meets the needs of patients who receive holistic treatment "under one roof".

However, for these reasons, an HMO center can only function if there is a certain minimum number of affiliated insured persons. HMOs are therefore restricted to metropolitan areas.

Aspects of the HMO concept

Restriction of the free choice of doctor: The HMO insured person undertakes to be treated normally only by doctors of his HMO or by external (specialist) doctors, to whom he was referred by the HMO. The HMO doctor is a “gatekeeper” with regard to other doctors, hospital stays, etc. This means that he knows his patients well and can overlook, manage and monitor the entire treatment chain.

Group practice: In addition to certain disadvantages (e.g. less personal treatment and more cumbersome organization), group practice (also outside of an HMO) has considerable advantages: opening times, holiday replacement, internal training, internal quality control by colleagues, better utilization of expensive equipment, employment of specialist staff ( such as physiotherapist, psychologist, health nurse , nutritionist, diabetes advisor , practice manager , IT specialist ), prevention courses, stronger negotiating position, etc.

Structure of the insured: The HMO insurance model is predominantly chosen by younger and healthy people. From the point of view of the HMO centers, this is positive (since this clientele causes little costs), but from the point of view of the health insurance company, it is unfavorable. You miss premiums because they are lower in the HMO system, but it does not save any costs (since these insured persons rarely receive medical services anyway and therefore hardly offer any savings potential). Older and sick people who need more benefits tend to stick to the traditional insurance model. This lacks the premium contributions of the healthy, which in turn makes it more expensive. HMO is thus a model that undermines the solidarity idea of the health insurance system and leads to a creeping desolidarization.

Quality of care: Since the HMO centers make more profit the less services they provide, there is an inherent temptation to "save" services that are actually required. More or less complex control and quality assurance measures are necessary, which make the system more bureaucratic and expensive. Since the quality of a single medical measure is difficult to measure objectively, it is also not always possible to prove that the expensive quality assurance measures are of any use. There are now approaches to independent quality certification (e.g. Equam), the value and effectiveness of which cannot yet be assessed because of the short duration of their existence.

Time horizon: The HMO system is based, among other things, on the idea that the HMO centers promote preventive measures and thus improve the health of their clientele (since they benefit from having their insured stay healthy). The success of preventive health measures often only shows itself after years and decades ( smoking cessation , healthy eating , exercise , blood pressure control , etc.), while the budget of the HMO center has to be in line with each other in the short term and from year to year. Individual preventive measures are therefore not worthwhile in the short term and are therefore only subsidized if they do not worsen the balance sheet, i.e. cost nothing, or if they contribute to the good image of the HMO and thus to more HMO insured persons (or if the operating health insurance company has one has sufficient staying power to tolerate deficits in the HMO centers for several decades).

High risks: Even a few patients with diseases that cost a lot of money to treat could mean financial ruin for an HMO. This is why protective measures are necessary for such incalculable risks. For example, compensation funds between different HMO centers or insurance companies, for example with the HMO carrier, are common. The calculation of such a protection is anything but trivial and has to be rebalanced regularly. For smaller HMO centers, “expensive” diseases remain a financial risk that is difficult to calculate.

Balance sheet

Even after 17 years of HMO in Switzerland, it is not possible to draw a clear balance. The inherent weaknesses of the concept outlined above and the relatively low level of acceptance among the population mean that greater success in the next few years seems unlikely. On the other hand, the health insurance premiums continue to rise, making joining a cheaper HMO more attractive. Efforts by various political forces also contribute to this, which insurance models with budget responsibility of the service providers (and thus also HMOs) would like to promote changes in the law.

On January 1, 2005, 119,000 people in Switzerland were insured in HMOs (January 1, 2000 = 100,000). They were treated by 121 HMO doctors (January 1, 2000 = 80).

Related concepts

Gatekeeping: Patients are obliged to always go to a specific office first in the event of illness, which will then refer them to others if necessary. This idea found various implementations ( family doctor models , ambulance models , tri-stations , telephone hotline , etc.) and seems to meet with more acceptance than the pure HMO models.

HMOs with budget responsibility.

Budget responsibility in the family doctor association: The association concludes special contracts with the health insurance companies, which include a share in the profit and loss of the patient collective included. This takes over part of the HMO idea.

Preferred Provider Organizations (PPO). An alternative type with a growing market share are the Preferred Provider Organizations (PPO), which allow patients to go to doctors who are not part of the network.

literature

Daniel Finsterwald: Managed Care - Pioneer Country Switzerland / Managed Care - La Suisse pionnière. Publishing house Switzerland. Society for Health Policy SGGP, Zurich, 2004, 267 pages, ISBN 978-3-8366-1313-2 .