Abstract
Insurance companies are often considered the origin of MCOs. Even though this is true regarding the revival of managed care since the mid-1970s, MCOs in the United States originated in the form of prepaid group practices (PGP) connected to the assumption of risks by service providers in the 1920s. In rural areas physician group practices offered to let residents use the services of the group practice without restrictions in return for monthly or annual payments. Services outside of the group practice were not covered.
The term health maintenance organisation (HMO) was coined by the physician Paul Ellwood at the beginning of the 1970s. In order to replace the negatively connotated term prepaid group practice. However, HMOs did not achieve their breakthrough with market successes, but rather through state regulations. The HMO law introduced by Nixon in 1973 prescribed that employers with 25 or more employees who provided their staff with healthcare as a social benefit had to offer at least one HMO product. HMOs could only become established thanks to this state stimulus, which opened doors to potential customers.
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Notes
- 1.
The subsequent section was written by Prof. Dr. Mirella Cacace.
- 2.
It should be emphasised that CDHP is only a rudimentary form of insurance with limited risk pooling. However, as for example Schreyögg (2003) argues, it is still justified to call it an insurance because the savings are also a form of risk coverage.
- 3.
This prompted Uwe E. Reinhardt from Princeton University to write an amusing (though probably fictitious) anecdote in the Economix blog of the New York Times. He describes how his wife signs him up for a coloscopy shortly before Christmas in order to use up the remaining available balance in his FSA (see U. E. Reinhardt: The Trouble with (In)flexible Spending Accounts: http://economix.blogs.nytimes.com/2009/05/29/the-trouble-with-flexible-spending-accounts/).
Literature
AHIP (America’s Health Insurance Plans). (2009). Individual health insurance 2009 – A comprehensive survey of premiums, availability, and benefits. Washington, DC. http://www.ahipresearch.org/. Accessed 19 Feb 2013.
Atchinson, B. K., & Fox, D. M. (1997). The politics of the health insurance portability and accountability act. Health Affairs, 16(3), 146–150.
Barrett, D. (1997). Health maintenance organizations. In K. Miller & E. Miller (Eds.), Making sense of managed care (Vol. 1, pp. 47–62). San Francisco: American College of Physician Executives.
Blakeney, B., Carleton, P. F., Mc Carthy, C., et al. (2009). Unlocking the power of innovation. The Online Journal of Issues in Nursing, 14(2), Manuscript 1.
Brown, L. D. (1998). The evolution of managed care in the US. PharmacoEconomics, 14(Suppl 1), 37–43.
Buntin, M. B., Haviland, A. M., McDevitt, R., & Sood, N. (2011). Healthcare spending and preventive care in high-deductible and consumer-directed health plans. The American Journal of Managed Care, 17(3), 222–230.
Bureau of Labor Statistics. (2011). http://www.bls.gov/home.htm. Accessed 24 Feb 2011.
Cacace, M. (2010). Das Gesundheitssystem der USA: Governance-Strukturen staatlicher und privater Akteure. Frankfurt am Main: Campus.
Chen, C., Garrido, T., Chock, D., et al. (2009). The Kaiser Permanente electronic health record: Transforming and streamlining modalities of care. Health Affairs, 28(2), 323–333.
Cooper, P., Simon, K., & Vistnes, J. (2006). A closer look at the managed care backlash. Medical Care, 44(5), 4–11.
Crossen, F. J., & Tollen, L. A. (2010). Partners in health, how physician and hospitals can be accountable together. San Francisco: Jossey-Bass.
DeNavas-Walt, C., Proctor, B. D., & Smith, J. C. (2010). Income, poverty, and health insurance coverage in the United States: 2009. U.S. Census Bureau, Current Population Reports (pp. 60–238). Washington, DC: U.S. Government Printing Office.
Department of the Treasury. (2012). 2012 instructions for form 8889: Health Savings Accounts (HSAs), Cat No. 37971Y. http://www.irs.gov/pub/irs-pdf/i8889.pdf. Accessed 13 Mar 2013.
Detmer, D., Bloomrosen, M., Raymond, B., et al. (2008). Integrated personal health records: Transformative tools for consumer-centric care. BMC Medical Informatics and Decision Making, 8(45), 3.
Dixon, A., Greene, J., & Hibbard, J. (2008). Do consumer-directed health plans drive change in enrolees’ health care behavior? Health Affairs, 27(4), 1120–1131.
Erdmann, Y. (1995). Managed Care. Veränderungen im Gesundheitswesen der USA in den letzten 30 Jahren. Baden-Baden: Nomos.
KFF [Kaiser Family Foundation], & HRET [The Henry J. Kaiser Family Foundation & Health Research and Education Trust]. (2010). Employer health benefits 2010, annual survey. Menlo Park/Chicago: Kaiser Foundation & HRET. http://ehbs.kff.org/pdf/2010/8085.pdf. Accessed 5 Oct 2012.
Feldman, R., Parente, S. T., & Christianson, J. B. (2007). Consumer-directed health plans: New evidence on spending and utilization. Inquiry, 44(1), 26–40.
Fox, P. D., & Kongstvedt, P. R. (2013). A history of managed care and health insurance in the United States. In P. R. Kongstvedt (Ed.), Essentials of managed health care. Burlington: Jones & Bartlett Learning.
Fuchs, B., & James, J. A. (2005). Health savings accounts: The fundamentals. Washington, DC: National Health Policy Forum (NHPF). http://www.nhpf.org/library/background-papers/BP_HSAs_04-11-05.pdf. Accessed 19 Feb 2013.
Fuchs, B., & Potetz, L. (2007). The fundamentals of health savings accounts and high-deductible health plans. Washington, DC: National Health Policy Forum (NHPF). http://www.nhpf.org/library/background-papers/BP_HSAs&HDHPs_Fundamentals_04-23-2007.pdf. Accessed 19 Feb 2013.
Garrido, T., Raymons, B., Jamieson, L., et al. (2004). Making the business case for hospital information systems – A Kaiser Permanente investment decision. Journal of Health Care Finance, 31(2), 16–25.
Hibbard, J. H., Greene, J., & Tusler, M. (2008). Does enrollment in a CDHP stimulate cost-effective utilization? Medical Care Research and Review, 65(4), 437–449.
Janus, K. (2003). Managing health care in private organizations. Transaction costs, cooperation and modes of organization in the value chain. Frankfurt am Main: Peter Lang.
Jost, T. S., & Hall, M. A. (2005). The role of state regulation in consumer-driven health care. American Journal of Law & Medicine, 31, 395–418.
Kaiser Permanente News Center. (2013). http://xnet.kp.org/newscenter/. Accessed 20 Mar 2013.
Knight, W. (1998). Managed care. What it is and how it works. Gaithersburg: Aspen.
Kongstvedt, P. R. (2009). Managed care: What it is and how it works (3rd ed.). Sudbury: Jones and Bartlett.
Liang, L., & Berwick, D. (2010). Connected for health: Transforming care delivery at Kaiser Permanente. San Francisco: Jossey-Bass.
McCarthy, D., Mueller, K., & Wrenn, J. (2009). Kaiser Permanente: Bridging the quality divide with integrated practice, group accountability, and health information technology (Case study organized health care delivery system). New York: Commonwealth Fund.
McCreary, L. (2010). Kaiser Permanente’s innovation on the front lines. Harvard Business Review. www.hbr.org. Accessed Apr 2011.
Reinhardt, U. E. (2009). The trouble with (in)flexible spending accounts. Economics Blog of the New York Times online: http://economix.blogs.nytimes.com/2009/05/29/the-trouble-with-flexible-spending-accounts/. Accessed 7 Nov 2012.
Robinson, J. C. (1999, March/April). The future of managed care organizations. Health Affairs, 18(2), 7–24.
Robinson, J. C. (2005). Managed consumerism in health care. Health Affairs, 24(6), 1478–1489.
Rosenthal, M., Hsuan, C., & Milstein, A. (2005). A report card on the freshman class of consumer-directed health plans. Health Affairs, 24(6), 1592–1600.
RWJF/HCFO (The Robert Wood Johnson Foundation/Changes in Health Care Financing & Organisation). (2011). High deductible health care coverage: Snapshot of some mixed evidence. http://www.hcfo.org/publications/high-deductible-health-care-coverage-snapshot-some-mixed-evidence. Accessed 10 Nov 2012.
Sacramento Business Journal. (2011). HMO report card rates Kaiser “excellent”, 11.03.2011
Sanofi. (2002). HMO-PPO/Medicare-Medicaid managed care digest series, Vol. 5; Bridgewater.
Sanofi. (2006). Managed care digest series – HMO-PPO Digest for 2006, Bridgewater.
Sanofi. (2010). Managed care digest series – HMO-PPO Digest 2010–11, Bridgewater.
Sanofi. (2012). Managed care digest series – HMO-PPO Digest for 2012–13, Bridgewater
Schreyögg, J. (2003). Demographic development and moral hazard: Health insurance with medical savings accounts. The Geneva Papers on Risk and Insurance, 29(4), 689–704.
Shi, L., & Singh, D. A. (2012). Delivering health care in America: A systems approach (5th ed.). Sudbury: Jones & Bartlett Learning.
Silvestre, A. L., Sue, V. M., & Allen, J. Y. (2009). If you build it, will they come? The Kaiser Permanente model of online health care. Health Affairs, 28(2), 334–344.
Wagner, E. R., & Kongstvedt, P. R. (2013). Types of health insurers, managed health care organizations, and integrated health care delivery systems. In P. R. Kongstvedt (Ed.), Essentials of managed health care. Burlington: Jones & Bartlett Learning.
Weiner, J., & De Lissovey, G. (1993). Razing a tower of Babel: A taxonomy for managed care and health insurance plans. Journal of Health Politics, Policy and Law, 18, 75–103.
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Amelung, V.E. (2013). Insurance-Based Managed Care Organisations and Products. In: Healthcare Management. Springer Texts in Business and Economics. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-38712-8_5
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