Health Insurance Options

Another difference between traditional insurance and managed care is that members typically have less freedom to choose their health care providers and have less control over the quality and delivery of care in a managed system. Members of managed care plans usually must select a "primary care physician" from a list of doctors provided by the plan sponsor.

Managed care plans can take many forms. The most popular plans are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Other services that mimic these two plans include point-of-service plans (POSs) and competitive medical organizations. In addition to these established plans, many employers and organizations offer hybrid plans that combine various elements of fee-for-service and managed care options.

The most popular plan, the basic HMO, is the purest form of the managed care concept. HMOs are differentiated by four organizational models that define the relationship between plan sponsors, physicians, and subscribers. Under the first model, called individual practice associations (IPAs), HMO sponsors contract with independent physicians who agree to deliver services to enrollees for a fee. Under this plan, the sponsor pays the provider on a per-capita, or fee-for-service, basis each time it treats a plan member. Under the second model, the group plan, HMOs contract with groups of physicians to deliver client services. The sponsor then compensates the medical group on a negotiated per-capita rate. The physicians determine how they will compensate each member of their group.

A third model, the network model, is similar to the group model but the HMO contracts with various groups of physicians based on the specialty that a particular group of doctors practices. Enrollees then obtain their service from a network of providers based on their specialized needs. Under the fourth model, the staff arrangement, doctors are actually employed by the managed care plan sponsor. The HMO owns the facility and pays salaries to the doctors on its staff. This type of arrangement allows the greatest control over costs but also entails the highest start-up costs.

A PPO is a variation of the basic HMO. It combines features of both indemnity insurance and HMO plans. A PPO is typically organized by a large insurer or a group of doctors or hospitals. Under this arrangement, networks of health care providers contract with large organizations to offer their services at reduced rates. The major difference from the HMO is that PPO enrollees retain the option of seeking care outside of the network with a doctor or hospital of their choice. They are usually charged a penalty for doing so, however. Doctors and hospitals are drawn to PPOs because they provide prompt payment for services as well as access to a large client base.

Other Options

Various other health insurance options exist for small businesses and self-employed individuals. One possibility is self-insurance, which requires a company to absorb most of the financial risk of its own health care coverage. An outside administrator may handle the paperwork, but the company pays its own claims. Self-insurance can provide a company with greater control over its health care costs and improved cash flow, but it can also be prohibitively expensive in cases of severe illness or injury. As a result, some companies choose to limit their liability by purchasing stop-loss insurance, which covers expenses after they reach a certain limit.

Finally, a company may chose to make health savings accounts (HSAs) available for employees to use in paying for their own health insurance. HSAs were established under federal law with the signing of the Medicare Prescription Drug Improvement and Modernization Act of 2003. HSAs are the successors to the Medical Savings Accounts of the 1990s. In essence, HSAs are personal accounts into which employees may set aside pre-tax dollars that can be used later to pay for health care expenditures. Disbursements from these accounts are tax-free as long as they are used for approved medical expenses. HSAs may be used as the sole form of health insurance vehicle provided by a company or they may be offered as a means of supplementing a more employer-funded type of insurance policy. In most cases, the HSA option is coupled with a high-deductible insurance policy and HSA funds are used to pay for the deductible and other out-of-pocket expenditures that an employee may have.

The patchwork pattern that is health care in the United States makes it a challenge for small businesses and sole proprietorships to acquire and maintain health insurance. Large firms too struggle with the high costs of healthcare, and with what are often referred to as legacy costs associated with providing health care insurance to retirees. For small businesses, there is the promise of new legislation that may help in the struggle to provide health care benefits to their employees. However, barring the implementation of a national health care system, which appears very unlikely for now, businesses will have to continue to weigh their options and search for the best possible coverage with what resources they have available.

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