How are PPOs different from HMOs?
Medicare Advantage
As with all HMOs—no matter whether a person is on Medicare or not—persons who enroll in a Medicare Advantage or other Part C HMO cannot use certain specialist physicians or out-of-network providers without prior authorization from the HMO, except in emergencies. In almost all Medicare Advantage plans—HMO or otherwise—the beneficiary must choose a primary care physician (PCP) to provide referrals and the beneficiary must confirm that the plan authorizes the visit to which the beneficiary was referred by the PCP. As with all HMOs, this can be a problem for people who want to use out-of -network specialists or who are hospitalized and are forced to use out-of-network doctors while hospitalized. Many Medicare Advantage PPO plans permit a subscriber to use any physician or hospital without prior authorization, but at a somewhat higher expense.
Paul M. Ellwood Jr.
Paul M. Ellwood Jr. (born 16 July 1926) is a prominent figure in American health care. Often referred to as the "father of the health maintenance organization," he not only coined the term, he also played a role in bringing about structural changes to the American health care system to simultaneously control cost and promote health by replacing fee-for-service with prepaid, comprehensive care. The term "HMO" was coined by Dr. Paul M. Ellwood Jr. in a January 1970 Fortune Magazine article. More recently, he has advanced an agenda for monitoring health outcomes, so that patients, providers, and payers can make health care decisions based on real information about what treatments and providers are actually effective.