Professional Documents
Culture Documents
CHD
Not CHD
60
70
Probability
1/20
19/20
HEALTH INSURANCE
Ill
W-C
Payoff if insured
W-R
W-R
Probability
(1-p)
20,000 (W)
15,000(W-C); 20,000-5,000=
Insurance
R= .05x 5000= 250
W-R= if not sick ; 20,000-250= 19750
If sick : w-r= ; 20,000-250= 19750; 5000;
4750+250= 5000
5,000;
1,000,000 iph x 250= 250,000,000
250,000,000- 5,000= 249,995,000
50,000 iph x 5,000 = 250,000, 000
250 M, invest on real estate ; revenues , eraning
10 years after
5,000 15,000, more than 50 % iph ; nursing tf
= 20,000 30,0000; 40k
Develops CHD
20,000
15,000
Probability
19/20
1/20
P x C = Fair Premium
Adverse Selection
Moral Hazard
Non Price Competition
Affordability of Health Insurance
Related Concepts
International
Organizations :
Aetna
CIGNA
Kaiser Permanente
Humana
Health Net
Universal American
Wellpoint
Types of HMOs
HMOs operate in a variety of forms. Most HMOs today do not fit neatly into one
form; they can have multiple divisions, each operating under a different model, or
blend two or more models together.
Staff Model, physicians are salaried and have offices in HMO buildings. In
this case, physicians are direct employees of the HMOs. This model is an
example of a closed-panel HMO, meaning that contracted physicians may
only see HMO patients.
Group Model, the HMO does not employ the physicians directly, but
contracts with a multi-specialty physician group practice. Individual
physicians are employed by the group practice, rather than by the HMO.
The group practice may be established by the HMO and only serve HMO
members ("captive group model"). Example : Kaiser Permanente
Network Model, an HMO will contract with any combination of groups,
IPAs, and individual physicians. Since 1990, most HMOs run by managed
care organizations with other lines of business (such as PPO, POS and
indemnity) use the network model.
Services and medications for general/spinal anaesthesia or other forms of anaesthesia deemed necessary for a surgical
procedure.
Administered medicines
Dressings, plaster casts, sutures and other items directly related to the medical management of the patient
ICU confinements, Chemotherapy, Radiotherapy, and Dialysis are covered subject to maximum limits and pre-existing conditions
coverage
Modern therapeutic modalities and interventional surgical procedures such as, but not limited to laparoscopic surgery and
lithotripsy, are covered up to P20,000 each per years subject to the pre-existing conditions coverage
CT Scan, MRI and ultrasound are covered up to P50,000 each per member per year subject to the pre-existing conditions
coverage (inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the
procedure):
ADVANTAGES
Less Paperwork
Fewer Expenses
Broader Coverage
DISADVANTAGES
Limited Choice
Affiliation Period
Is it affordable? How do the premiums and copayments compare to other HMOs offering similar benefits?
Do the benefits match your needs? Are any services you need not covered?
How does the plan treat preexisting medical conditions? (For example, even though an HMO can't exclude a
preexisting condition, it can require a higher copayment.)
Are the HMO providers familiar to you? Are they conveniently located? Is there a wide choice of physicians,
specialists and hospitals?
Are the HMO providers accepting new patients?
Is your current doctor or specialist with the HMO? If so, is he or she satisfied with the HMO and planning to
continue with the HMO?
Is it easy to change Primary Care Physicians?