Health maintenance Organization (HMO) designates a certain health insurance and supplying model. Philosophy of this model is on the one hand that Leistungserbringer in the health service (lady doctors, Physio /Psycho /Ergotherapien, nourishing consultation etc.) are paid not for the illness, but for the health of their clientele, and on the other hand that a Leistungserbringer does not receive financial reward for ausufernde diagnostic and therapys measure.

This will in the first beginning so realized that a community from clients and Leistungserbringern has a certain fixed total budget, from which all medical measures are paid. The Leistungserbringer has by the fact a savings incentive that it has the not used remainder of the budget as income, while its income sinks if it causes higher costs.

(In contrast to it the income of the Leistungserbringers rises all the more, the more achievements it furnishes in the traditional health insurance company system, therefore the more costs it causes).

Development and current situation of the USA

HMOs were originally developed in the USA. There there is no general health insurance (apart from Medicaid for arms and Medicare for the old persons and obstructed), but often insurance solutions between enterprises, their employees and a group of Leistungserbringern. The idea to put to the Leistungserbringern a firm budget for the treatment of all employees of an enterprise at the disposal is so relatively simply interspersable. Particularly at large companies also the choice between different HMOs (mostly three) is offered to the personnel. In addition the employees have still the possibility of going with discontent with the system to another physician it must then however even pay.

In July 2004 were in the USA 66.1 million inhabitant member of a HMO (2003: 71,8 millions). To most HMO members California (17.2 million) had, followed from New York (5,2), Florida (4,1) and Pennsylvania (4 millions). In California 47.8% of the population were HMO member. Altogether there are 414 HMOs in the USA.

The largest HMO is the emperors permanent one, who cover in nine American Federal States and in the District OF Columbia 8.3 million HMO members, 134 ' 000 employees, 11 ' 000 physicians, 30 medical centers and 431 regional and restaurant places. The annual turnover amounts to 22.5 billion $.

No objectively measurable differences of the supplying quality between HMO's and traditional medical practices could be shown in the USA. On the other hand there are investigations, which show that particularly older humans feel subjectively medically more badly cared for in HMOs than such with an individual conventional health insurance. The cost saving by HMOs is against it out of question.

Existing models (Switzerland)

In Switzerland exist since 1990 HMO practices. Since Switzerland has likewise an private-economically organized health system, but on the other hand a general health insurance obligation with strict regimentation knows, is HMOs here more complex things than in the USA. Different health insurance companies offer HMO models, none of it in whole Switzerland. In the center is located in each case a HMO center, which meets physicians of different fields and therapists under a roof. Are obligated to HMO Versicherte to be able primary to be treated in the HMO center. Exceptions are often emergencies, illnesses outside of the geographical field of activity of the HMO as well as and eye medicine.

In response those, which decide for such a HMO variant, receive a health insurance company premium reduction. If an insuring adheres not to the rules and goes for example to an external physician, the insurance can refuse the assumption of the costs of this treatment totally or partly.

Organization of the HMO centers

The HMO centers are either property of the insurance or contracts with one or more health insurers locked. Physicians and therapists are employees or shareholders of the HMO centers with fixed wages and/or profit and loss participation. The budget, which receives the HMO center, must again be negotiated each year, and depends on the number and the age structure of the insured ones of this center. All costs of the insured ones, thus for example also calculations of external physicians, therapists or of hospitals must be denied by the budget. A goal of a HMO center must be it of offering as comprehensive a support with all important fields as possible in order to keep the number of necessary external achievements as small as possible. This comes to meet again the need of the patients, who receive an holistic treatment "under a roof".

However a HMO center can function only starting from a certain minimum number of attached insured one for these reasons. HMOs are therefore limited to population centres.

Aspects of the HMO concept

• Restriction of the free choice of doctor: The HMO Versicherte is obligated to let be treated under normal conditions only by physicians of his HMO or by external (specialized) physicians, to whom he was further-referred however of the HMO. The HMO physician is such a "Gatekeeper" concerning further physicians, hospitalizations etc. thereby knows it its patients well and can the whole treatment chain ignore, steer and control.

• Team practice: Apart from certain disadvantages (e.g. more impersonal treatment and more ponderous organization) a team practice (also outside of a HMO) has substantial advantages: Opening times, holidays agency, internal advanced training, internal quality control by colleague, better extent of utilization of expensive devices, employment of technical personnel (like Physiotherapeutin, psychologist, health sister, nourishing, Diabetesberaterin, practice manager, computer science specialist), prevention courses, stronger negotiating position etc.

• Insuring structure: The HMO Versicherungsmodell is predominantly selected by younger and healthy humans. This is unfavorable from view of the HMO centers pleasing (there this clientele few costs caused), from view of the health insurance company however. You escape premium, because this in the HMO system lower are, it save however no costs (there these insured ones anyway rarely medical achievements refer and therefore hardly saving potential offer). Older and krankeren humans, who need more achievements, remain against it rather in the traditional insurance model. The premium contributions are missing to this to that recovering, whereby it becomes for his part more expensive. HMO is with the fact a model that the solidarizing idea of the health insurance company system occurs and leads to a creeping Desolidarisierung.

• Supplying quality: Since the HMO centers all the more make profit, the fewer furnish achievements them, an inherent temptation exists "to save" actually necessary achievements. There is necessary more or less control and quality assurance measures, which raise the price of the system and. Since the quality of an individual medical measure is to be measured only with difficulty objectively, is it to prove in addition also not at all always possible that the expensive quality assurance measures bring anything at all. There are in the meantime beginnings to independent quality certification (e.g. Equam), whose value and effectiveness are not to be measured so far because of the too short duration of its existence yet.

• Time horizon: The HMO system is based among other things also on the idea the fact that the HMO centers promote preventive measures and improves there so the health of their clientele (they of it profit, if its insured ones remain healthy). Unfortunately the success of health care measures points itself often only to years and decades (smoker curing, healthy nutrition, movement promotion, blood pressure attitude etc.), while the budget of the HMO center must be at short notice and from year to year in the plumb bob. Individual prevention measures are not worthwhile themselves to cost thus evenly nevertheless and therefore tendentious only then promoted, if they do not worsen the balance, thus nothing at short notice or if to the good image of the HMO and thus to more HMO insuring contribute them (to tolerate or if the operating health insurance company has a sufficiently long breath, around deficits of the HMO centers some decades long).

• High risks: Already few patients with illnesses, whose treatment costs very much money, could mean the financial fall for a HMO. Therefore security measures are necessary for such uncalculable risks. Usual for example equalization funds between different HMO centers or insurance are for example with the carrier of the HMO. The calculation of such a security is however everything else as trivial and must regularly again be counterbalanced. For smaller HMO centers "expensive" illnesses remain a with difficulty calculable financial risk.

Balance

Also after 15 years HMO in Switzerland one cannot draw a clear balance. The inherent weaknesses of the concept outlined above and the relatively small acceptance in the population let a larger success appear improbable in the next years rather. On the other hand the health insurance company premiums continue to rise, so that the entry to a cheaper HMO becomes more attractive. In addition also efforts of different political forces contribute, which insurance models with Budgetveranwortung of the Leistungserbringer (and concomitantly HMOs) with law changes would like to promote.

On 1 January 2005 119,000 humans were ill-insured in Switzerland in HMOs (1 January 2000 = 100,000). They were treated by 121 HMO lady doctors and physicians (1 January 2000 = 80).

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