|2721 Capital Ave.
Sacramento, CA 95816-6004
Phone: (916) 446-5054
Message: (561) 873-8335
Fax: (916) 446-0500
|American Society of Dermatology, Inc.
A Voice for Private Dermatologists Since 1992
TYPES OF MANAGED CARE PLANS
The distinction between the myriad managed health care plans
is sometimes blurry, but it can be important in terms of
compensation, patient access to dermatologists, and
benefits to you.
Refer to the table below for a list of managed care plan types.
Types of managed care plans
|Plan Type||Structure||Impact on Dermatologists
||Carrier pays preferred providers a monthly
capitation rate or through discounted fee-
for-service contract. Primary care physicians
act as gatekeepers, referring to
dermatologists as necessary.
- Staff Model: physicians are
salaried employees of HMO
- Group Model: HMO contracts with large
multispecialty group practices, usually
on a capitation basis.
- IPA Model: see below
- Direct Contract Model: see below
|The primary care physician may treat many
skin-related conditions rather than making
referrals to dermatologists. The impact of
depends on fee arrangement between the
primary care physicians and the carrier, as
as the carrier and the specialists.
Carrier contracts with groups of health
care providers, usually under a discounted
fee-for-service arrangement. Patients can
seek treatment directly from participating
Risk for dermatologists is minimal unless
the discounted reimbursement rate is
too low. Ability to seek treatment
directly from a dermatologist helps build
A group of physicians forms an IPA and
contracts with various managed care
organizations. The IPA usually is paid on a
capitated basis and pays its physicians on a
discounted fee-for-service or capitated
basis. The IPA is responsible for
controlling/monitoring utilization of
IPA contracts can be advantageous --
dermatologists joining a large physician
group have more leverage when
contracting with. managed care
organizations. Centralized administration,
limited gatekeeper roles, and the greater
clinical autonomy are attractive factors.
A variation of HMO or PPO structure.
POSs allow patients to obtain medical
services outside of the closed network.
To do this, patients must cover larger
copays and deductibles.
Patients seeing dermatologists outside of
their plan are responsible for full fee. Risk is
minimal for nonparticipating dermatologist
in this situation.
HMOs contract with individual physicians
or groups on a capitated or discounted
Plans must be evaluated carefully in terms
of compensation, services included and
excluded, administrative procedures, and
the referral process.
Like a PPO, but patients must use
participating providers or otherwise pay for
all costs incurred. EPO physicians are usually
paid on a fee-for-service basis, and some
EPOs award bonuses if performance targets
Because patients must pay for all medical
costs for physicians out-of-plan, an EPO
dermatologist will probably have a larger
patient volume than a PPO dermatologist
Also, the financial risk is less than under a
Physician group purchases a hospital,
which then contracts with employers to
provide full health care services.
This may be a preferred option for
dermatologists in remote areas who want
to increase their patient base and keep
administrative expenses down. In
metropolitan areas, dermatologists are
more likely to be excluded from these
types of plans.
Dermatologists can also develop their
relationships with primary care physicians and other referral networks through
various hospital-based managed care plans. Because most dermatologists are
not hospital-based, these plans may not be as familiar as those mentioned
Hospital-based managed care plans
|Physicial Hospital Organizations (PHOs)
||Joint ventures are formed between hospitals and independent or in-
house medical staff, typically contracting with managed care
organizations on a capitation basis.
|Hospital Direct Contracts
||Hospitals contract directly with employers to provide specialty or
acute care services, thereby eliminating an intermediary.
||In an effort to compete with other managed care plans, hospitals
network to obtain direct contracting with employers.
Health Care Networks
Some dermatologists have decided that the best
way to participate in managed care plans and preserve the physician-patient
relationship through independent practice is to form their own health care
networks. Physician-based plans, such as Management Services
Organizations (MSOs), Physician Organizations (POs), PHOs, and IPAs, are
initiatives formed by dermatologists and other physicians to run integrated
health care delivery systems without the oversight of a hospital or third party.
Such systems give physicians more voice and quality control within a
managed care environment.
IPAs are fast becoming the structure of choice for many dermatologists.
Forming these independent practice networks requires some research,
calculations, and legal or financial counsel. But specialists are finding it's
worth the work. A crucial element to the success of these networks is
selecting physicians who are flexible, cooperative, and willing to share the
administrative and financial responsibilities.
Various types of plans are constantly being created. We do not advocate any
one solution to maintaining access to your patients. What we do know is that
while there is no single remedy to the problem of HMOs squeezing specialists
out of the market, you must keep referral sources diversified to survive. So
explore and pursue several of your "best options," perhaps joining or forming
both single-and multispecialty groups either county-, state-, or
nationwide--as they make sense for you.