DOCTOR'S VIEWS ARCHIVE
ERISA, HMO, MCO, NCQA....Getting Through The Legalities & Alphabet Soup Of Managed Health Care
(August 2, 1998) Over the last few weeks there has been much in the news regarding various federal plans to "improve" the present Managed Health Care System in the U.S. This has been fueled in large part by the virtual explosion of Health Maintenance Organizations (HMOs) and other types of entities that now manage the health care of most of our citizenry.
The sudden impact of this "new" health industry, has also lead to much confusion among plan participants as to what and what may not be covered in their plans, and to accusations of fraud and abuse.
How does one pick a good, reliable health plan, and judge its performances in comparison to others? What are the legal recourses, if any, if the plan does not deliver proper medical care?
Only an informed individual can make reasonable judgments as to how the present debate in Congress should end, and which of the diverse fixes to the health care system should be enacted. In addition, only a well-informed individual who has done the appropriate research can decide which Managed Care Plan, if any, is right for them. And finally, only a well-informed and well-educated patient will be aware if the level of medical care they are receiving meets present standards. This last issue is extremely important given the presently debated issue regarding a patient's right to sue their Managed Care Organization (MCO).
So here are some basic facts and guides as to where you can find sources to make these decisions, just in time to bug your government representatives about these issues:
THE PRESENT HEALTH CARE LEGISLATION:
There are two proposals up before Congress - Democratic and Republican versions.
Where They Agree
Both plans agree in doing the following:
Where They Differ
The Democratic plan:
The Republican plan:
Now that you know what all the shouting is about on Capitol Hill and you realize what needs to be done to cure the nation's ills, you can sit down and try to figure out what personal health plan (if any) is best for you. To do this you should research your various options carefully.
To get you started with researching Managed Care, here are explanations of the terms referred to in the title of this article:
ERISA- Employment Retirement Income Security Act of 1974 which set up the ground rules for pension and retirement plans and in doing so, created a section that prohibited states from regulating these plans. Most Health Care plans in the US are covered by ERISA, and therefore these plans are exempt from certain regulatory practices, including the ability to be sued outside of federal court.
HMO-Health Maintenance Organization
MCO-Managed Care Organization; Managed Care Organizations (MCO) include HMO, PPO, POS, EPO, PHO, IDS, AHP, IPA, etc.
These definitions come from the Pam Pohly Associates web site (which contains an A-Z Glossary of terms used by the Managed Care Industry.
To help you research your health plan options, there is a non-profit organization called the National Committee for Quality Assurance (NCQA). NCQA "assesses and reports on the quality of managed care plans." You can obtain their Consumer Brochure at the NCQA web site.
Last Editorial Review: 8/14/1998