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The financing of America's health care system has changed the way health care services are organized and delivered, as evidenced by a movement from traditional fee-for-service systems to managed care networks. These range from structured staff model HMOS to less structured preferred provider organizations (PPOS).
A managed care organization (MCO) is responsible for the health of its enrollees, which can be administered by the MCO that serves as a health plan or contracts with a hospital, physician group, or health system.
Most managed care financing is achieved through a method called capitation, and enrollees are assigned to or select a primary care provider who serves as the patient's gatekeeper.
Federal legislation mandated that MCOS participate in quality assurance programs and other activities, including utilization management, case management, requirements for second surgical opinions, non-use of gag clauses in MCO contracts, and disclosure of any physician incentives.
Managed care is categorized according to six models: exclusive provider organizations, integrated delivery systems, health maintenance organizations, point-of-service plans, preferred provider organizations, and triple option plans.
Consumer-directed health plans (CDHPS) provide incentives for controlling health care expenses and give individuals an alternative to traditional health insurance and managed care coverage.
Accreditation organizations, such as the NCQA, evaluate MCOS according to preestablished standards.
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