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How HMOs structure primary care delivery.

S Felt-Lisk1

  • 1Mathematica Policy Research, Inc., Washington, DC, USA.

Managed Care Quarterly
|March 3, 1997
PubMed
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Health Maintenance Organizations (HMOs) show diverse primary care staffing and referral strategies. Gatekeeping, use of nurse practitioners (NPs) and physician assistants (PAs), and scope of practice vary significantly across organizations.

Area of Science:

  • Health Services Research
  • Primary Care Delivery
  • Healthcare Management

Background:

  • Health Maintenance Organizations (HMOs) play a crucial role in primary care delivery.
  • Understanding variations in primary care models is essential for healthcare policy and practice.
  • Previous research has not fully elucidated the diverse staffing and operational strategies within HMOs.

Purpose of the Study:

  • To describe and compare primary care staffing strategies across 23 Health Maintenance Organizations (HMOs).
  • To analyze the roles of gatekeepers, nurse practitioners (NPs), and physician assistants (PAs) in HMO primary care.
  • To examine referral policies and anticipated changes in the scope of primary care practice within HMOs.

Main Methods:

  • Qualitative study based on on-site interviews with senior personnel from 23 HMOs.

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  • Data collection focused on gatekeeping roles, utilization of NPs and PAs, referral patterns, and future scope of practice perceptions.
  • Analysis of strategies across different HMO models, including network/IPA plans.

    • Main Results:

    • Significant variations observed in primary care delivery strategies, ranging from open access to strict gatekeeping.
    • HMOs differ in their use of NPs and PAs, and in their referral policies.
    • In network/IPA models, provider groups and IPAs, rather than the HMO itself, often dictate primary care provision.

    Conclusions:

    • HMO primary care models exhibit considerable heterogeneity in staffing, gatekeeping, and referral practices.
    • The findings highlight the need for tailored approaches to understanding and managing primary care within diverse HMO structures.
    • Future changes in the scope of primary care practice are anticipated, with implications for workforce planning and patient access.