What Structure of Health Maintenance Organization (HMO)/ Managed Care Organization (MCO)

The MCO combines administration, delivery of treatment, and health insurance. Physician hospital organizations, managed service organizations, third-party administrators, and independent practice associations are among examples. An MCO is a company that contracts to deliver healthcare to participants or subscribers. The primary purpose of the MCO is to minimize the cost of health care by analyzing the general effectiveness of treatment in comparison to expenses, monitoring the type of the treatment that subscribers use, and negotiating the most favorable prices for subscribers (Ayyldz, Celmece, & ar, 2017). HMO, on the other hand, are also managed care institution that offers the best and improved medical services to the subscribers. The HMO is beneficial because the patients build a lasting relationship with the healthcare physician. The co-pays are minimal, and there are no deductibles. The cost for the prescription for the drugs remains low for members because the health maintenance organization purchase the prescription drugs in bulk.

Structure of MCO/HMO

The MCO will be certified by this organization to provide defined healthcare benefits to all the members who are enrolled. This MCO/HMO determines how the services are delivered; determines the reimbursement rates; determines the nature of service that demands referral or authorization. The HMO benefits will include well baby care, routine physical, and immunizations. All the HMO member will be allowed to select a Primary Care Physician who will be in charge of directing the service subscribers to hospitals and specialists if needed. The Primary care physician that the members select will be in charge of the member total health care.

This HMO/MCO will give all members the flexibility to choose the best way they can receive the health care services. It will control the availability, quality, and cost of medical care by enhancing the access and mainly laying more emphasis on the member’s wellness rather than the illness. The plan aims at employing the statisticians and doctors who will have enough experience and knowledge to assess all the computer generated data for instance what treatment is the most appropriate for the patients suffering from certain injuries or illness or for how long should a heart attack patient be hospitalized. The available data will form a better ground as benchmarks, guidelines, and best practice.

The MCO/HMO will be consolidated, audit, receive and monitor all the medical bills from the hospitals, specialist clinic, and the panel clinics before charging the institutions. The MCO/HMO will monitor the usage of the medical benefits to make sure that people receive the best services at the panel hospitals and clinics (Lux & Petit, 2015). The MCO/HMO dedicated professional team will be in a position to boost staff morale, reduce absents and sick leave and even improve productivity through the monthly programs that are based on the MCO/HMO report:

Sick leave use

Reports of individuals with high frequency of visits

Claims by clinics or individuals

Profiles of diagnoses by age group or gender

Expenditures by diagnoses

Disease patterns and more

The procedure for hospitalization, specialist clinical visits, the procedure for a clinical visit, dental and optical, and the details for the medical entitlement will be highlighted in the employee’s contract of employment. The performance will be the key factor in developing this MCO. The MCO should have the capacity of meeting the individual needs. The MCO should also be big enough to handle the largest employers. It will also be sophisticated to enable the organizations to recognize the favorable trends that provide opportunities improve the general worker’s performance.

Best Practices in HMO/MCO

Various states contract with the MCOs to provide the best medical packages to citizens. The states maybe license the MCO under a contract with a particular Medicaid agency. The provider has to be treated on equal basic and fairly and a proper transparency has to be incorporated in the contract that is signed between the pharmacy benefit manager and the MCO. MCO will lower the cost of medical services, and the providers will provide the best quality care possible. This will be accomplished between the contract that is signed by the hospitals and the doctors. All the healthcare providers and the doctors contracted through the MCO must undergo a depth credited process so that they receive approval as the network of care providers (Popejoy, 2017). This plan will also cover medication which means that the cost of medicines will substantially decrease. So many people at present require medical services so that they live a healthy life, most of the medication is unaffordable because they are highly priced.

The MCO/HMO has strict guidelines that demand that all the health care providers and the doctors that are contracted through the managed care plan must undergo a through accreditation before they are licensed to serve patient, this move will make sure that there is quality care in the healthcare sector. The availability of MCO implies that persons are free to visit any specialists and doctors as stipulate in their care plan.

References

Ayyıldız, Y., Celmece, N., & Şar, A. (2017). Healthcare Employees’ Attitudes toward Organizational Commitment and Overcoming Stress in the Healthcare Organization. Sanitas Magisterium, 3(1). http://dx.doi.org/10.12738/sm.2017.1.0031

Lux, G., & Petit, N. (2015). Coalitions of Actors and Managerial Innovations in the Healthcare and Social Healthcare Sector. Public Organization Review, 16(2), 251-268. http://dx.doi.org/10.1007/s11115-015-0304-4

Popejoy, M. (2017). Leading the Global Healthcare Organization. MOJ Public Health, 5(3). http://dx.doi.org/10.15406/mojph.2017.05.00127