HMO is a Health Maintenance Organization (HMO) that provides the services related to health with an annual fee. These are the medical insurance group that offers health care plans, self-funded health care benefit plan etc. to individuals and entities. HMO covers the care plan that is rendered by the health professional and doctors and also involves emergency care under the guidelines of HMO. According to the Health Maintenance Organization Act 1973, the employers in every health entities requires 25 or more than 25 employees for the purpose of offering the federally certified HMO options. HMO requires the members to select a Primary Care Physician known as PCP. The PCP is persons such as paediatricians, family doctors, general practitioners, internists, geriatricians. Each Patient needs a referral program from the Primary Care Physician in order to see a doctor and another specialist except in the situation of a medical emergency. HMO include different products such as Open access and Point of Service (POS) and different traditional Indemnity plan.
HMO Pharmacy Process
The HMO pharmacy process helps and cares about the patients provided by Pharmacist. The five stages of the HMO pharmacy process are discussed as –
1. Collect – In order to understand the clinical status of the patient and medication history of the patient, the Pharmacist and Health maintenance organization collects the subjective and objective information of their patient. This information can be gathered by different sources such as from the health professionals, from the existing record of the patient and so on. Collecting and gathering includes –
• The latest medication history, dietary supplements and other herbal products.
• Appropriate health data including biometric test results, health information, medication history, physical assessment etc.
• Socioeconomic factors that access the medications and many other areas.
• Health and functional goals of the patient, lifestyle habits, beliefs and preference of patients.
2. Assess – After gathering the relevant information, the Pharmacist assess the information for identifying and prioritizing the problems of the patients. HMO analyzes the therapy of the patients for measuring the overall health of the patient. Assessing includes –
• Health data, health literacy, health status, risk factors and cultural factors
• Medication for effectiveness, appropriateness and safety of the patient
• Provide Preventive care and health care services when needed.
3. Plan – With the collaboration of health care professionals and patients, the Pharmacist develops a plan named Individualized patient-centred plan. The plan is always cost-effective and evidence-based makes by the Pharmacist and HMO. The process of planning includes –
• Engage the patients in a plan through self-management, education and empowerment.
• Support care which includes transitions of care and follows up.
• Optimizing the medication therapy and addresses the medication-related problems
• Setting the goals of patients’ therapy for measuring the overall health of the patients
4. Implement – After making the plan, it is implemented by the Pharmacist in collaboration with health professionals and patients. With the implementation of the plan, the Health Maintenance Organization –
• Engages in preventive care strategies and addresses the health-related problems & medication
• Modifies administers and initiates the therapy of medication where appropriated
• Enhance the education skills and self- management training to the patient
• Contribute to the transition or referral of the patient to another professional of health care
• Follow up care of the patient for the purpose to achieve the goals of therapy.
5. Follow up – The final step of the HMO process is monitoring and evaluating the information and care plan. The Pharmacist monitors the effectiveness of the care plan and then modifies the plan in collaboration with health professional and patients. The process of Follow Up includes –
• Effectiveness, safety and appropriateness of Medication with the help of health data, patients’ feedback and biometric test results.
• Health care outcomes include progress towards the goals of therapy of patients.
• Patients overall health that is contributed by the clinical endpoints.
Models of HMO
HMO operates the different types of models named Staff model, Group model and Network model.
1. Staff Model – In the staff model, the offices of Physicians are situated in HMO buildings. In this model, Physicians are the direct employees of Health Management Organizations (HMOs). This model is the best example of Closed –Panel HMO.
2. Group Model – In this model, the Health Maintenance Organization (HMO) does not employ the Physicians directly. The practices of the group model always are established by HMO and only serve the facilities to the members of the Health Maintenance Organization. HMO contracts with the multi-specialty group practices of Physician. However, Individual Physicians are employed by the group instead of HMO. HMO also contracts with independent and existing group practices which generally treat to Non – HMO patients. This model is also considered as closed panel because Doctors may participate in the group practices of HMO.
3. Network Model – In this model, HMO contracts with a combination of groups such as Individual Physicians and Independent Practice Associations.
4. Since 1990, the managed care organizations run the most of Health Maintenance Organizations (HMO) by using the network models.