Pros And Cons Of Hmo

Pros And Cons Of Hmo
Key information about HMO,PPO, and MCO These are all different types of organizations that are
different forms of a health maintenance programs.it's important to know the differences between all
these programs and know the benefits so you the patient knows what works for you. HMO An HMO
is where you pay a certain premium every month and in return your HMO will help take care of
your doctor visits, hospital stays, emergency care, surgery, lab test, X–ray, and therapy. Pros –fixed
low of pocket monthly cost –are encourage to seek medical help early before it transcends into
something worse –no limits on lifetime benefits Cons –are unable to see a specialist before seeing
your primary care physician first –are required to see treatment from HMO
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Hmo In Healthcare
The management of health care insurance market is complex and it takes time to understand how it
works. Choosing the right insurer for the right person in mind with the right price takes lot of effort
and explanation especially from experts who know what to do. HMO refer to as Health Maintenance
Organization. The organization has their specific network of hospital doctors and other healthcare
providers who have agreed to accept payment at a definite level for any services they provide. The
plan permit HMO to retain costs in check for its members. The organization (HMO) is one of the
most popular forms of managed care networks. It is important to know that HMO enrolled 89
million according to American Association of Health plans. One advantage

Hmo
HMOs: The Health Care of the Beast Many people are concerned about rising health care costs. In
reaction to this, some individuals and companies are gravitating toward the assumed lower prices of
Health Maintenance Organization (HMO) health plans. HMOs spend billions of dollars each year
advertising their low cost services. While these savings look good on paper, there are many pages of
small print. The explanation after the asterisk indicates that not only do the HMOs lack lower costs,
but they also short–change the patient in quality care. Much of the money spent on premiums goes
directly into the pockets of stockholders and less is then available for patient care. In addition, the
main clinical decisions are made not by doctors, ... Show more content on Helpwriting.net ...
HMOs are not the only answers to cost control. Most physicians practicing in the United States
consider their profession to be very much a form of art (Kleinke). The definition of art infers that
within its sphere there are many variations and preferences. After all, one should not ask Picasso to
carve like Michelangelo. Physicians too differ in their methods of treating patients. However when
needless tests and procedures are done the treatment will cost more. This is waste. Many suggest
that cutting waste will lead to a cut in quality. This is not necessarily true. Consider the following:
an otherwise healthy forty–year–old male comes to a clinic complaining of a sore throat. This is a
good nonspecific symptom, so naturally some tests are done. Some blood is drawn, a culture taken,
and an electrocardiogram performed. An EKG in this case is not medically necessary, but many
physicians still do not hesitate to order one. By eliminating useless procedures, lower cost can be
maintained. To determine which procedures are useless, scientists would need to perform ongoing
studies of patients that fall under their investigative categories. For instance, every year about 80,00
Americans get a carotid endarterectomy, a

Case Study: HMO Standss For Health Maintenance Organization
HMO stands for health maintenance organization , with this health plan you can select your primary
care physician who will be responsible for your basic healthcare needs. If you need a referral to see
a specialist your PCP has to send a referral over. Note the referral of the specialist must be within
the HMO network. If you would like to see a doctor that is considered outside of the network or
without a referral, you will brunt the cost, you will be responsible for all out of pocket cost, unless it
a medical emergency and you have no other choice.
PPO stands for preferred provider organization. With this health plan can go to any primary care
physician (PCP) and you do not have to have a referral in order to see a specialist. If you

Essay on Hmos: Making A Killing
FACT: Currently 46 million Americans live without any health care insurance whatsoever.
FACT: The United States is the only industrialized nation in the world that does not provide health
care insurance for all of its citizens.
FACT: The United States spends more money per person on health care than any other nation in the
world.
FACT: The World Health Care Organization has ranked the United States 37th in the world
regarding the health care a country provides for its people.
FACT: No country in the history of the earth has provided universal health care coverage for all its
citizens under a private health care insurance system.
The facts stated above are not only embarrassing and frightening; they are simply unacceptable.
How our ... Show more content on Helpwriting.net ...
One example of a single–payer health care proposal that is already out is entitled "Physician's
Proposal" and was first published in New England Journal of Medicine in 1989 and then later in the
Journal of the American Medical Association in 1991. Under this plan every citizen would be
covered for all necessary medical procedures including rehabilitative, long–term care, mental health
care, dental care, prescription drugs, and medical supplies. Under the plan, every person would have
access to local personalized care from the doctor of his or her choice. Physicians would still operate
in the private sector; the whole scheme would provide for different payment structures for health
care providers, this would be to minimize the disruption of the existing system. The scheme would
be designed to prevent profit motives from affecting doctor's decisions. Gone would be the
incentives that HMOs give their doctors for NOT recommending treatment for patients.
The largest obstacle between you and me, the American citizen, and universal health care insurance
is corporate greed. Jamie Court and Francis Smith have authored an intelligent and well–researched
study entitled "Making A Killing: HMOs and the Threat to Your Health". In it they state that
American medicine is currently in

Hmo Influence On Health Care
Running head: INFLUENCE OF HMO 'S
HMO's
University of Phoenix
Abstract
The term Health Maintenance Organization (HMO) was developed in 1970 as part of the Nixon
Administration to promote the growth of prepaid plans as a way to improve the nation's health
system. The Health Maintenance Organization has an appearance on the outside of being very
appealing to those with little money to spend on insurance because it has a very low premium cost,
but the truth be known that sometimes cheaper is not always better. In this paper I will discuss how
HMO's have influenced current healthcare systems.
Influence of HMO's
HMO stands for Health Maintenance Organization and was designed by Congress to eliminate
individual health insurance. ... Show more content on Helpwriting.net ...
This was a great thing and to be honest the fees were only 25 more dollars than what I am paying
for a HMO now. I became ill and was rushed to one of the best hospitals in the U.S. Tests were run
and because I had a PPO there were no questions as to who my primary care doctor was. There were
no questions as to what my insurance would pay for on the expensive tests. Now back home in the
North I currently have an HMO which as I stated is only a few dollars cheaper than my PPO. I
recently broke my back and was rushed to the local hospital because of the emergency situation.
While in the E.R. the doctors had to notify my primary doctor and get permission from the
insurance company to run tests and for me to even be allowed to stay in that hospitals E.R. My
primary care doctor was over an hour away in another state. I was cleared to go to another bigger
hospital for emergency surgery but it took a lot of time to get the clearance. I currently am suffering
through bills because through an HMO it is a courtesy for any hospital to call any insurance. If I still
had PPO I would not have been questioned as to cost and the hospital would have been paid because
I could through a PPO go to any hospital without permission. In summary, the time has come for
Congress to make decisions regarding appropriate health care and to understand that at times
cheaper is not always better.
Bibliography
Safran, D. W.

Staff Model Hmo vs. Group Model Hmo
Ashley Rassbach LP2: Staff Model vs. Group Model HMOs HMOs provide several benefits to both
physicians and patients alike; however, both Staff Model HMOs and Group Model HMOs offer
different types of benefits for both. Group Model HMOs are centered around multi–specialty
medical groups that focus on the performance of the group as a whole; they tend to be a bit less
structured than the Staff Model HMOs. Many Group Model HMOs have ties to hospitals in the
areas in which they practice, but are legally independent of those hospitals. New physicians to group
practices must sign a Non–Compete Clause to prevent stealing of patients and often face an entry
barrier due to the reverence given to senior members of the HMO. Staff Model ... Show more
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New physicians would be able to focus more on the quality of their practice as opposed to
productivity due to being paid on a salary–basis in a large organization that is better–equipped to
train incoming physicians. Staff Model HMOs provide care in extensive health systems; therefore,
there are abundant resources available to physicians, both physical resources and the resource of
additional physicians' minds and expertise. Each patient is unique and has different values;
therefore, each patient would be attracted to various HMOs for different reasons. Patients would be
attracted to the Group Model HMO because it is likely to be a bit more personalized because of a
smaller practice and a more laid–back atmosphere. The younger physicians in the practice would be
more motivated to succeed; as a patient, that motivation is priceless. In addition, the ability of
Group Model HMOs to associate with local hospitals and other local healthcare facilities would be
beneficial so that if, as a patient, you required some sort of specialty care that your Group practice
was unable to provide, you would be able to receive the necessary referral. Patients could be
attracted to Staff Model HMOs for a variety of reasons as well; because Staff Model HMOs are
practiced in comprehensive medical facilities, all necessary resources are located in one place.
Unlike the Group Model, new physicians would be salaried and would therefore not feel the
pressure to "push," patients

HMO Health Insurance
As a direct participant in my health insurance policy, I am insured by Humana. Furthermore,
Humana is a Health Maintenance Organization. Therefore, this particular health insurance is ran by
a particular choice of a Primary Care Physician from a web of local health care providers. When
applicable, you will be referred to in–network specialists and hospitals. However, unless there is a
serious or detrimental emergency occurring, HMO plans usually does not have coverage over out–
of–network care ("What Is An HMO," n.d.). When carrying an HMO type of insurance, there is less
hassle involved; this is because HMO health insurance does not require any claim forms to see a
doctor. In contrast, the member of the HMO health insurance only needs to display a card that
shows proof of insurance at a ... Show more content on Helpwriting.net ...
Overall, my HMO health insurance has enabled me to become a more productive employee and
more comfortable around my staff. If I was to change something about my health insurance, I would
preferably want my health insurance to cover medical expenses outside of my plan (5 Reasons an
HMO Plan Might Be Right for Your Company, 2017, p. 1). Each month, I pay minimal copayments
after each medical service and an out–of–pocket maximum for coverage of all my medical services
for the year. Before these payments, I have to pay a deductible fee to cover my health services
before my insurance company pays for anything. Regarding my research on health insurance, I will
make sure to wait until I graduate from college, relieve most of my debt, and have a family to take
care of before I invest a large amount of money with little diversification. With this intention, I
would not invest in a health insurance plan to early because of the high–risk possibilities along with
stacked

Statistical Thinking in Health Care-Hmo. Essay
Statistical Thinking in Health Care
Case Study 1 Week 4 Mat 510– Business Statistics
November 1, 2015
With information from the case we will attempt to address some explanations to the issue of
medication errors being dispensed at HMO pharmacy. A dispensing error is a discrepancy between a
prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on
the basis of this prescription, including the dispensing of a medicine with inferior pharmaceutical or
informational quality shows the categories of dispensing errors. If dispensing errors are considered
from the perspective that the quality of all pharmacy care activities should be assured by the
pharmacist, this list can be extended by ... Show more content on Helpwriting.net ...
(Gara, Steven, 2013) SIPOC
–––––––––––––––––––––––––––––––––––––––––––––––––
Supplier Inputs Process Outputs Customers
Patient Prescription Medication Patient
Doctor Telephone Dosage Computer Advice Printer Bill Drug Directory Causes of dispensing errors
can be traced by root–cause analysis or by inquiring with practicing pharmacists by means of a
survey. Root–cause analysis comes closer to reality, because a survey measures on the perceptions
and opinions of pharmacists. An example of the former type was a study in a UK hospital in which
the researchers used semi structured interviews of pharmacy staff about self–reported dispensing
errors (Anacleto, T.A., Perini, Rosa, Cesar, 2007) The complex interactions of variations in
materials, tools, machines, operators, and the environment are not easily understood. Variation due
to any of these individual sources appears at random; individual sources cannot be identified or
explained. However, their combined effect is stable and can usually be predicted statistically. These
common causes of variation are factors that are present as a natural part of a process. The remaining
variation in a process is the result of special causes which arise from external sources that are not
inherent in the process. (Hisson, Amy) Although rates of dispensing errors are generally low,

Hmo Vs Hmco
The HMOs' claims and benefits administration department, on the other hand, is responsible for
ensuring that all providers are paid for their services and that health care benefits that members are
entitled to are honored by the organization (Kongstvedt, 2009; Anderson & Gray, 2013).
Finance and budget
In terms of finance and budget administration, the MSO manages inventory; prepare budgets and
financial statements; manage overhead and revenue; manage accounting and auditing; payroll and
benefits; inventory management for their providers. Likewise,the HMOs' finance department
manages and trace their organizations' money throughout their operational systems and the
budgeting department is responsible for their medical expense and operating expense budget.
However, the health insurance companies are not involved in either the operational finances or
budgeting of their contracted physicians ("Welcome to HealthSmart MSO," 2015).
Marketing and Sales
The MSOs is responsible for business development and marketing, sales for their providers while
the HMO's are responsible for the development of their organizational marketing strategies and
sales of their own products.
Credentialing and relations In addition to assisting providers with accreditation; negotiating,
monitoring, managing ... Show more content on Helpwriting.net ...
Conversely,the managed care, HMOs and PPOs' fundamentals principles are rooted in their ability
to reduce the costs of hospitals and physicians by providing a set of incentives and disincentives for
physicians to limit their use of unnecessary medical

Hereditary Multiple Osteochondromas (HMO)
"Hereditary Multiple Osteochondromas (HMO) is a genetic condition in which people develop
multiple benign (noncancerous) bone tumors that are covered by cartilage (called
osteochondromas)" (2). HMO is estimated to affect 1 in 50,000 individuals (1). The tumors
"typically form at the end of long bones and on flat bones" (1). The number, size, and location of the
tumors vary between individuals (1). The tumors are not present at birth and about 96% of
individuals with HMO develop multiple by the time they are 12 years old (1). Once an individual
has reached skeletal maturity, the growth of tumors and the development of new tumors tends to
stop (2). "These tumors can cause pain, limit joint movement, and exert pressure on nerves, blood
vessels, and surround tissues" (2). Multiple tumors can also "disrupt bone growth and can cause
disturbances of the arms, hands, and legs, leading to ... Show more content on Helpwriting.net ...
These genes are responsible for coding for the proteins exostosin–1 and exostosin–2. These two
proteins bind together and form a complex in the Golgi apparatus, which is a structure in cells (1).
"The exostosin–1 and exostosin–2 complex modifies a protein called heparan sulfate so it can be
used by the cell" (1). When there is a mutation in the EXT1 or EXT2 gene, the heparan sulfate can
not be processed correctly and becomes nonfunctional (1). "Although heparan sulfate is involved in
many bodily processes, it is unclear how the lack of this protein contributes to the development of
osteochondromas" (1). Individuals who have a mutation in the EXT1 gene have HMO type 1 and
those who have a mutation in the EXT2 gene have HMO type 2. It is estimated that a mutation in
the EXT1 gene is likely to cause about "55 to 75 percent of all cases of HMO" (1). It is also
estimated that about 15% of individuals with HMO do not have a mutation in the EXT1 or EXT2
gene and it is unknown why these individuals develop osteochondromas

Health Care Plan Summary
Payers impact California Pacific Medical Center marketing for health plans, which is located at the
St. Luke's Hospital. Not all Sutter Health network of providers participate in all of the health plans
networks or products. A patient should contact his or her health plan if they have questions about
benefits, a particular product, or a provider network. Sutter Health, on behalf of St. Luke's network
of providers, is currently in agreements with several health plans to renew their contracts for 2017
(California Pacific Medical Center, 2015). Renewed health plans include Blue Shield, Care1st,
Chinese Community Health Plan, Cigna and Health Net. The organizations plan to successfully
complete these renewals by the end of 2016, so that any interruptions ... Show more content on
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Chinese Community Health Plan: Amber Plan, Bronze 60 HMO (including Covered CA for
Individual & Families), Bronze 60 HMO (including Covered CA for Small Group), Gold 80 HMO
(including Covered CA for Individual & Families), Gold 80 HMO (including Covered CA for Small
Group), Jade Plan, with minimum Coverage HMO (including Covered CA for Individual &
Families) and other approved by physician HMO's (California Pacific Medical Center,

HMO Regulation Essay
HMO Regulation Health Maintenance Organizations, or HMO's, are a very important part of the
American health care system. They involve elements such as beneficial health care programs like
Medicare for seniors and Medicaid for the poor. HMO's are sometimes referred to as managed care
programs, which involves participation through clinics, physicians and insurance companies. Other
essential parts of HMO's include prescription drug plans, such as distribution and cost, and they are
also important for information needed by emergency room residents in cases of emergencies.
Although HMO's are not always seen as positive and helpful institutions, they are definitely
important when it comes to medical care. Most of the criticism comes ... Show more content on
Helpwriting.net ...
They provide the best possible treatment to their patients to get more people enrolled and to
maintain current premiums paid by consumers using their HMO's. Most HMO's are groups of
doctors hired by insurance companies and are controlled or regulated by the hospitals who facilitate
them. They also limit what kind of care they receive. Most pressure comes from the government and
its ability to influence hospitals to deny treatment. These regulations are expensive and result in
revision of private employee health care claims. This type of behavior results in increased spending
by the public and more people become uninsured, approximately 50 to 60 million people go without
insurance for at least one month each year. Particular HMO's face many additional problems due to
attempted government control through regulations. One such institution is the United Health Group
in New York. The United Health Group said, "that it returns decision–making power over patient
care to physicians on issues like admitting health plan members to hospitals or providing other
treatments." [4] This kind of decision is made to eliminate frustrating features of most doctors'
work: like getting insurance companies to approve medical decisions that the doctors think they
should make. This is a problem because most hospitals are influenced by government officials and
make their decisions

Types Of Health Maintenance Organization Plans
Two types of health maintenance organization plans that are readily available are the Staff Model
HMO and Group Model HMO, and these plans are often called closed–panel plans (Kongstvedt,
2016, p. 63). These HMO plans are considered closed because either the HMO employs the
physician, or the physician belongs to the HMO group, thus creating a smaller network for the
patient to be seen (Farnham, n.d., Chapter 3). Each HMO plan has its benefits and disadvantages for
the physician and patient. Consequently, depending on what the patient needs to meet their medical
needs the Staff Model HMO plan or Group Model HMO plan would benefit them. Furthermore,
depending on the particular type of freedom the physician is looking for is what would influence the
type of plan they would join.
During a Staff Model HMO the physician is employed by HMO network, thus they are salaried
employees. Therefore, the physician is paid whether he sees an HMO patient or not. On the other
hand, the physician could be very busy and still get the same salary. Sometimes the HMO offers
incentives for quality control, so that the physician does not use expensive medical testing
(Kongstvedt, 2016, p. 65). Besides the HMO paying the salary of the physicians, the HMO actually
owns the medical facilities, equipment, and supplies used by the HMO physician and in some cases
the hospital. Hence, the physician employed by the HMO could be financially beneficial to them.
Additionally, because of the size of the

Preferred Provider Organization (HMO)
Health Maintenance Organization (HMO)
An HMO delivers all health services through a network of healthcare providers and facilities. A
primary care doctor to manage the care and refer to specialists when we need one so the care is
covered by the health plan; most HMOs will require a referral before we can see a specialist. The
plan may require us to pay the amount of a deductible before it covers care beyond our essential
benefits. There are no claim forms to fill out.
Preferred Provider Organization (PPO)
We do not have to get a referral from a primary care doctor to see a specialist. Higher out of pocket
costs if we see out of network doctors vs. in network providers. More paperwork than with other
plans if we see out of network providers.

Health Care Plan For Healthcare Care
Managed care plans are the most common form of health care coverage offered in the United States
today. One of the reasons that managed care plans have become so popular is because employers are
the ones footing the bills for most medical coverage. Managed Care plans work off the basic
premise that health care costs can be better controlled by controlling access to health treatments and
services. The three main categories of managed care plans is HMO, PPO, and IPA. Health
Maintance Organization
Health Maintance Organization (HMO) is a type of managed care organization system, according to
it provides a wide range of health insurance services through a network of hospitals, physicians, and
other health care providers having a ... Show more content on Helpwriting.net ...
In this case they should be ready to deal with referrals and pay more a substantial deductible, co–
payment, or coinsurance for the use non –panel providers. According to Mark & Mueller, (1996)
"HMO members will pay premiums which is through an employer, which will be deducted from
their paycheck, some employers may pay the premium costs for you". Copayments in the other hand
are received to cover medical services like emergency expenses or specialized care. Deductibles is
the amount you pay out of pocket before the HMO starts while maximum out of pocket expenses is
the maximum amount you have to pay for covered services during a certain period of time. HMO
pays benefits only if you use physicians and hospitals within the plan's network. HMO members
normally do not have to file claims and wait for reimbursements.
Preferred Providers Organization
The preferred provider organization (PPO) is a combination of traditional fee–for–service and an
HMO. Like an HMO, there are a limited number of doctors and hospitals to choose from, according
to Muino, (1992) "a preferred provider organization (PPO) is a health plan that has contracts with a
network of preferred providers from which you can choose". In a PPO plan you do not need to
select a PCP and you do not need a referral to see other providers in the network. If you receive care
from a doctor in the preferred network you will be responsible for

HMO Vs. NHS, Directed By Michael Moore
HMO vs. NHS HMO (Health Maintenance Organization) and NHS (National Healthcare Service)
have been a controversial topic for many years. I watched a movie entitled, "Sicko." It is a
documentary that was written and directed by Michael Moore. The Documentary investigates the
American health system and compares it to the National Healthcare Service in many other parts of
the world. One of the countries that have socialized medical care sits directly above the United
States. It is Canada. The horror stories I heard about the HMO has made me think twice about our
health care system. Can we honestly say that we are doing everything we can to ensure all
Americans (from the bottom of the totem pole to the very top) get the quality medical ... Show more
When and if she did deny 10% or more to save the medical insurance company money. She would
be promoted and quickly moved up the corrupted corporal ladder. When she began to have a
conscience and feel that what she was doing is wrong; the HMO came back with this statement, "We
are not denying care, we are simply denying payment." What a crock of horse manure. Hillary
Clinton was the only one who believed Americans should have the right to socialized medical care.
Or least she was the only individual in office who had the "balls" to stand up to the oligopoly of the
HMO cartel. Of course the HMO spent over 100 million dollars defeating Hillary Clinton's health
care plan. For the next 7 years Hillary Clinton was forbidden to bring up the idea of Americans
having socialized medical care. For Hillary's silence she quickly went from the HMO's worst enemy
to a devil's advocate. HMO paid Hillary Clinton $854,462 in the 2005–2006 year as an obvious
reward or incentive to remain quiet. There is four times more health care lobbyist than there is
congress. That is an interesting fact. Drug companies quickly followed behind the HMO cartel.
Drug companies were buying off the congress including the President of the United States, George
W. Bush; he was making an astonishing 891,208 a year from the drug companies. In 2003 George
W. Bush set what he referred to as "historic piece of legislation" into

Features of Private Payer and Consumer-Driven Health Plans
Features of Private Payer and Consumer–Driven Health Plans
The following reading is to familiarize the reader with private payer plans and types of consumer–
driven health plan (CDHP) accounts. Private payer plans such as PPOs, HMOs, and Group HMOs
are the most popular but there are also others to consider when making decisions on health
coverage, which are IPAs, POSs, and Indemnity plans. The CDHP accounts are made "for the
consumer" and therefore consumers (patients) have a say in what kind of plan they wish to have and
sometimes consumers can build their own health plan according to their financial situations with
savings account options. After reading this information, the reader will have a clearer idea of the
options available through ... Show more content on Helpwriting.net ...
The features of this type of plan are the same as a HMO except all members under this plan have no
choice but to visit their specific HMO providers and hospitals. The HMO pays the IPA for services,
and then based on pre–arranged capitated rates or fees; the IPA pays the providers under this plan
(Valerius, et al 2008).
Point–of–service (POS) plans involve both HMO and PPO networks. Members have the choice of
either a primary or a secondary network. Primary networks are like HMOs, and secondary networks
are like PPOs. In a POS plan, annual premiums and copayments are required from the members.
Although monthly premiums are higher, visits to non–network providers in the specialty fields are
an added benefit to the member with some coverage being provided by the POS plan. Structured as
a tiered plan, the POS might pay different rates for specially designated providers, regular
participating providers, and out–of–network providers according to the plans guidelines (Valerius, et
al 2008).
With Indemnity plans, all members are required to pay a premium, deductible, and coinsurance
payments. This type of plan usually pays 70% to 80% of the costs once the member's deductible has
been met for the year. In some cases, deductibles are very high so that the member's premium is
more affordable. Many indemnity plans have managed care features as well as a way for payers to
compete for employers' contracts and try to control costs (Valerius, et

Health Insurance Research Papers
The American lawyer Elizabeth Edwards once said, "Successful health reform must not just make
health insurance affordable, affordable health insurance has to make health care affordable." There
has been debate for years over health insurance. Who should get it? How much should it be to be
deemed affordable? Who gets to decide what is fair and what is not? The health care reform has
been going on for decades and will continue to go on for decades because of the vast spectrum of
issues it has. Everyone wants healthcare insurance that is affordable, but also gives them the most
healthcare possible. It is hard to make everyone happy, but health insurance companies try to do
what they can.
There are 3 types of managed care health insurance plans ... Show more content on Helpwriting.net
...
They have their own methods and stories of success. One of the main differences between the two is
their network size. Aetna is called a nationwide company and actually lives up to its name. Their
business layout is set up in a way that they have a nationwide network of health professionals and
hospitals. On the other hand, Blue Cross Blue Shield is not actually nationwide. Yes, there is a Blue
Cross Blue Shield in Florida, but this can be completely different from the Blue Cross Blue Shield
in Texas and any other state. These separate Blue Cross Blue Shields are small and independent
health insurance companies that want to use the name of the large and well–known company.
Because of this, they pay a licensing fee and get to use the trademark of Blue Cross Blue Shield.
Each state has their own licenses and therefore the company is technically not nationwide. This
makes Aetna the winner in nationwide

Essay on The Problems with HMOs
The Problems with HMOs
It was no surprise when I interviewed my English class about HMOs, that out of 13 students, seven
currently having HMO coverage, 77% felt HMO healthcare inferior to traditional insurance. This
group closely represents the U.S. population, as HMOs have become practically synonymous with
health care and the idea that Americans are no longer receiving the quality care they received from
unmanaged plans. Managed care plans have succeeded in dramatically cutting the rate at which
medical spending in the United States has been growing. Does it matter that 100 years after Lincoln
freed the slaves that we have found another way to trade lives for money? HMOs have introduced
an innovative way to provide health services: ... Show more content on Helpwriting.net ...
At the beginning of the 1990s, there were nearly 600 HMOs across America and they were regarded
as a practical alternative to escalating medical costs. By 1998, it was clear that HMOs were out of
control, leaving a trail of angry and neglected patients in their path. Physicians have also begun
speaking out against HMOs in increasing numbers. According to Dr. Daniel J. Esposito, the main
problem with HMOs is that, "there are no economic incentives to take care of people. The incentive
is not to do anything" ("More Trouble With Managed Care" PG).
What happened? How could something, which started out so promising, have gone so terribly
wrong? In a survey conducted by Harvard University in conjunction with the Kaiser Family
foundation, it was revealed that 51 percent of Americans polled believe that HMOs are responsible
for the deteriorating quality of their health care. Fifty–five percent expressed concern that HMOs
were more preoccupied with cost–cutting measures than with providing the best possible medical
care for the patients they serve ("The HMOs Image Problem; Public Distrust Can be Cured By
Ensuring Patient Rights" 8). This certainly does not sound like the all–purpose solution to quality
and affordable medical care the government was looking for when it began

Successful Patient Centered Medical Homes And Hmos
Successful Patient Centered Medical Homes and HMOs
Richard Jenkins
Trident University Abstract There are various models designed to enhance the quality of health care
provided in today's society. Within the health care system the objective is to provide quality care to
the patient is the primary goal, however, over time due to such a strong concentration on this
objective expenses have been forgotten. Medical care has now grown to a ridiculous expense.
Congress, medical professionals, administrators, and many others are now devising various plans
and models to attempt to conquer and eliminate such expenses. The patient centered medical home,
managed care plans, and accountable care organizations are just some of the ideas ... Show more
Within the health care system the objective is to provide quality care to the patient is the primary
goal, however, over time due to such a strong concentration on this objective expenses have been
forgotten. Medical care has now grown to a ridiculous expense. Congress, medical professionals,
administrators, and many others are now devising various plans and models to attempt to conquer
and eliminate such expenses. The patient centered medical home, managed care plans, and
accountable care organizations are just some of the ideas devised. The patient centered medical
home was developed to improve the quality of care provided within the health care system. This
ideal focuses around exactly as it sounds, the patient. The primary goals of the patient centered
medical home model is to enhance primary care through means of better access, coordination of
care, prevention, quality, and safety (Smith, 2013). There are various methods used, but the most
recognized is multiple care specialties operating under one physician. Many various medical
professionals and services form the patient care team within this system. The team is led by the
patient's primary care physician. The physician and care team will

Hmos: Summary And Analysis
Chapter 1271 of the Texas Insurance Code governs HMOs. Section D of Chapter 1271 is titled
"Certain Benefits Required," and sets forth the basic benefits that a health care plan offered by an
HMO must contain. Included under Section D is Section 1271.155, which is titled "Emergency
Care" and sets forth the required coverage for emergency care. Section 1217.155(a) states that "[a]
health maintenance organization shall pay for emergency care performed by non–network
physicians or providers at the usual and customary rate or at an agreed rate." Chapter 3 to Title 28 of
the Texas Administrative Code governs PPOs. Section 3.3725 provides regulations for the payment
of certain out–of–network claims. Section 3.3725(a) states that "[i]f an

Managed Care Vs Hmo Plan
HMO Plans requirements are that beneficiaries must see their health–care providers, doctors, and
hospitals within the chosen plans network. With the expectations of urgent care and emergency care
situations. With an HMO plan the participants are required to have a primary care physician upon
enrolling on the plan. With these conditions; only a physicians can refer the plan holder out to see a
specialist. But unlike a yearly check up that I have recently had or my mammograms doesn't require
me to be referred out. And most all of my medications are covered under the HMO plan.
On the other hand PPO plan has a managed care option for beneficiaries who decided to have a
greater provider flexibility, with my PPO coverage portion kicks in. Also

Cost Control in Health Maintenance Organizations Essay
An HMO is an organized health care delivery system, which provides health care to its members
through networks of doctors and hospitals. Rather than traditional health plans, HMO's cost less.
Two ways HMO's control costs are: controlling hospital admission and length of stay, and by
providing incentives to physicians. These two cost control methods are further examined by an
article published by The National Bureau of Economic Research (2002). The article examines the
incentives to physician strategy for reducing utilization cost. The Physician Guide to Managed Care
(1994) describes HMOs the case management procedures used to control cost through hospital
length of stay and admissions.
Much of the focus regarding HMO controlling cost is ... Show more content on Helpwriting.net ...
Bonus levels are determined on the basis of performance, as performance improves the bonuses
gradually become higher. HMO's rely on rates and member satisfaction survey results to measure
provider performance. By keeping a certain level of member satisfaction, more revenue can be
brought in through new enrollees.
Financial incentives are generally more influential when it comes to physicians improving quality of
care. According to the National Research Council (2001), research regarding payment and quality
improvement efforts of health care administrators was presented at an Institute of Medicine
Workshop in April of 2004. The research showed ,with the use of physician incentives the total
direct savings in health care cost which include reduce visits and hospital episodes was an estimated
net savings of about 2,000 per patient. For more than 13,000 diabetic patients managed by a
physician group it was projected that the savings had the potential to generate over $10 million in
net saving per year. Aligning financial incentives with physician's networks provides the
achievement of better patient outcomes, but generally provides the HMO cost control over their
equity.
HMO's utilize the process of controlling hospital admission and length of stay as another form of
cost control. According to Nash (1994), in order to minimize hospital length of stay, the HMO
arranges in advance for care to

What's The Difference Between A Hmo
The difference between a HMO and a PPO. A HMO is an insurance plan that that is more to
accommodate your finical needs but there are restrictions on which doctors that you can see and you
also pay a fixed monthly fee, but unlike the PPO you are not required to file a claim with your
insurance provider. A PPO is a little bit more flexible, fewer restrictions, and that also comes with a
higher cost. You would also be covered under the PPO if you go outside of your insurance network
plan and unlike the HMO the PPO requires that you file a claim with your insurance provider. I
would chose to go with the HMO insurance plan simply because not everybody is the richest person
in the world and we all know that money does not simply grow on trees, some

Hmo 103 Individual Health Insurance Case
I am writing in response to an inquiry received in our office on June 22, 2016. In your inquiry to the
Texas Department of Insurance you expressed concerns over the termination of your health
insurance applications. Our records show you applied for coverage under the Blue Advantage Silver
HMO 103 Individual Health insurance policy with a requested effective date of February 1, 2016.
The policy was never effectuated due to non–payment of full premiums. After a review of the
concerns presented in your inquiry to the Texas Department of Insurance, we have determined that
Blue Cross and Blue Shield of Texas (BCBSTX) properly terminated your Blue Advantage Silver
HMO 103 Individual Health insurance policy based on non–payment of full premiums. BCBSTX ...
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Box 660044 Dallas, TX 75266–0044 Enclosed for your review is a copy of Texas HMO Complaint
Appeal Process. Please note that after we receive your written request for a complaint appeal, a final
decision will be made within 30 calendar days of the receipt of your written appeal. Also, your
decision whether or not to submit an appeal of the complaint resolution will have no effect on your
rights to any other benefits under the plan. Page Three Hollis If you decide to pursue filing a claim
in court, Texas HMO agrees not to assert a defense of "failure to exhaust available administrative
remedies" against a Claimant who chooses not to make use of the Texas HMO complaint appeal
process first. In addition, Texas HMO agrees if you pursue the complaint appeal process, the time
involved for this process will be excluded from any statute of limitations timing requirements. In
addition, we are providing you with the address and phone number of the Texas Department of
Insurance: Texas Department of Insurance Consumer Protection (111–1A) P.O. Box 149091 Austin,
Texas 78714–9091 (800) 252–3439 Fax # (512) 475–1771 Should you have any further questions,
we encourage you to contact our office directly at (888)

HMO Model Paper
Evaluate the various HMO models (staff, group, and network) and identify the model that would
probably be best suited for the region. Justify your answer. There are four models of HMOs: Staff
Model –The Health Maintenance Organization employs the physician, and care is usually provided
in a facility owned by the HMO. Group Model is structured around a multi–specialty medical group
that may include internists, obstetricians, gynecologists, cardiac and oncology specialists and
surgeons contracting exclusively with the HMO to provide services. Network Model is an HMO
that contracts with many IPAs and other provider groups to form a "physician network." Mixed
Model is a combination of delivery systems. (Patient Advocate, 2015) The mixed model would be
the best model for my region. It offers the widest variety of choices and the broadest geographic
coverage to its members. Patients will often have choices of clinics, labs, pharmacies, and hospitals
as their providers of care. Research and comment on the importance and applicability of the various
levels of emergency department trauma care. Investigate the exemptions afforded to a critical care
rural hospital with respect to Medicare reimbursement and accreditation. The different levels of the
trauma center include ... Show more content on Helpwriting.net ...
Generally the installment is determined on a per member/per month (PMPM) basis. The rates are
generally calculated form projections of the services and costs of the provider's patient population,
based on historic costs. The payments fluctuate to mirror the total number of patient for a supplier
and the demographic and acuity factors of the patient population. In some cases, co–payments may
also be collected from embers for certain services. Under global capitation all care is covered under
the fee including primary care, hospitalizations, specialist care and ancillary

Preferred Provider Organization Case Study
There are currently have two main insurance options available for consumers, Health Maintenance
Organization (HMO) and Preferred Provider Organization (PPO). Both health insurance plans are
great, but we will be focusing on the plan with lower costs in general which is Health Maintenance
Insurance, or HMO. HMO is an organized system of health care that offers medical services to its
members on a prepaid foundation. It combines health insurance and delivery functions in an effort
to keep low costs and maximize the quality care provided. There are several types of HMOs that are
available: staff model, group model, network model and individual practice association, or IPA. For
the staff model, physicians are salaried and have offices in HMO

Hmo ( Health Management Organization ) Is A Preferred...
Chasity Garrison
9/12/2014
Insurance Project
MA 215
HMO (Health Management Organization) is a preferred provider organization. Their focus is to
reduce the cost of the preventative care as well as implementing utilization management controls as
part of their goal. Being part of a HMO, you can choose the primary physician for medical purposes.
One of the advantages are the low cost out of pocket costs for the patient's insurance. Each time you
seek medical care you are only obligated to pay a percentage of the bill. Members of HMO are at a
fixed cost for the monthly fees. HMO tries to encourage the patients to stay on top of their health,
and not let their illnesses get to out of hand by letting it get worse. Another advantage, is that being
part of the HMO, your offered education classes and discounted club memberships for your health.
The disadvantages of the HMO consist of some strict controls. An example of an advantage would
be if you decided you wanted to receive care from another doctor or specialist, it must be consulted.
Although by doing the consultation, which helps lower the cost for the HMO and the member, it can
also cause problems if your physician doesn't provide you with the referral. When you receive care
from a provider that's not part of a HMO, the organization will not pay for services that are non–
emergency from the physician. (Medical Billing, n.d.) PPO (Preferred Provider Organization) is
considered the group of physicians and hospitals that

Sunnyside HMO: Servicing Ethical Dilemmas
Introduction Southside HMO serves 495,000 members throughout the eastern region of the United
States. Servicing this amount of members means that the company is providing quality health care.
Given this amount of volume it is understandable that there will be concerns at times raised from
both our providers and the membership. It is essential that all issues and concerns be addressed in a
professional, ethical and timely fashion while maintaining the standard of care that our company has
built its reputation on.
It has been brought my attention that some of our Sunnyside Hospital affiliated members have filed
complaints that their primary care physician issued referrals to designated specialists are not being
approved. There are also complaints ... Show more content on Helpwriting.net ...
This educational plan will also be shared with our members and providers by the use of mailers,
posters, and inserts.
It is my recommendation that performance measures be instituted as a means to know how to better
service both the members and providers. These measures will maintain and ensure the following
(Kongstvedt, 2013): Transparency and accountability Quality improvement Education and
engagement of consumers Patient safety Research
Summary
With the implementation of the above guidelines, initiatives and protocols we will continue to
provide quality health care for our members and assist our providers with the tools needed to give
their patients the care required. Our company will continue to be in compliance with all quality
management initiatives. Ultimately, our members and providers need to feel our company is not
about the bottom line but the people it serves by providing quality

Independent Healht Insurance Company: BlueCross and...
Introduction
BlueCross BlueShield Association (BCBSA) is an independent health insurance association which
is founded in 1929. It is made up by 37 different health insurance organizations and companies in
the United States. They directly or indirectly provide health insurance to over 100 million
Americans. Under the Association, it has two famous products. One is Health Maintenance
Organizations (HMOs), and the other is Preferred Provider Organization (PPOs). Most American
who has health insurance from their employer are enrolled either an HMO or PPO. All of these
managed care plans go through the health plan's network, which contract with doctors, health care
providers, clinics, and hospital.
Body part
Health Maintenance Organizations (HMOs)
HMO is an organization that provides or arranges managed care for health insurance, individual and
other entities in the United States. It existed prior to the 1970s, which required employer who has 25
or more employee to offer HMO healthcare. In most of HMO plans, it required the insurers to select
a primary care physician (PCP) who is responsible for all their healthcare services. If they need care
from a physician specialist in the network, their primary care physician will have to provide them
with a referral. If they don't get the referral or they select to go to see a doctor outside of your
HMO's network, they will most likely have to pay all or most of the cost.
Preferred Provider Organizations (PPOs)
In health insurance, a

Case Study : The Ppo Model And The Open- Panel Hmo Model
The BCBS IL has been able to use its experience to catapult itself to the forefront of many MCO in
the health care market, today the organization offers dual health insurance model to their
beneficiaries; the PPO model and the open– panel HMO model. The Medical Of Structure: BCBSIL
As has been denoted by the history of the BCBSIL above, the medical structure of BCBSIL is
composed of providers that may, or may not have a contract with the BCBSIL. The contract with the
providers or the modality of payment to providers for services rendered to their beneficiaries is
dependent on the BCBSIL's health care plan. Therefore, providers that decide to accept BCBSIL's
PPO patient are reimbursement based on fee–for–service in accordance with the Blue Choice PPO
Schedule of Maximum Allowances (SMA). However, the providers that opt to accept the BCBSIL
HMO patients do not contract directly with BCBSIL for their HMO products. Instead ,providers that
wish to participate in the BCBSIL HMO network must contact a BCBSIL contracting HMO
Medical Group or IPA in their area of practice ("Contracting", 2016). Worth noting is that the
activities of providers, meaning the type of health care they deliver to BCBSIL beneficiaries and the
providers confidentiality process are constantly being monitored by various committees within the
organization ("Contracting", 2016). According to the BCBSIL's webpage (2009), BCBSIL's
Managed Care Quality Improvement Committee (MCQIC), for example, has the

Health Maintenance Organization Case Study
Health Maintenance Organization (HMO) was enacted in 1973 it is a prepaid group practice that is
operated by the government. The Government helps HMO meet federal standards and provides
loans and grants to organizations. Employers having more than twenty five employees offer HMO
as an alternative health treatment plan for employees. The federal government reimburses the
HMOs on a per capita basis, this means HMOs are paid on a fixed per capita amount. In order for an
employer to qualify for HMO they must provide proof they can provide comprehensive health care
and show performance reports such as medical records to the offices of department of Health and
Human Services (DHHS). HMO plans have a primary care physician also known as (PCP) ... Show
more content on Helpwriting.net ...
HSA accounts are tax free saving accounts in which an employee deposits money from their
paycheck into a savings account that can roll over year after year. An HRA account is only given to
employees with high deductible. The employer owns the account, limits covered expenses and
determines if money can be rolled over. HFSA accounts allows certain amount of wages to be put
aside for medical and child care. HFSA accounts cannot be rolled over from year to year, only cost
of drugs is deducted from this

Chesapeake Health Plans : Hmo Financial Performance
Background Chesapeake Health Plans is one of Virginia's largest managed care organizations
(MCOs) operating. The hospital group is the state's largest not–for–profit organization and boasts an
impressive performance plan, serving the healthcare needs of approximately 8 million citizens in
Virginia. Moreover, Chesapeake Health Plans was the first organization to successfully attempt to
request and obtain the highest level of accreditation from the National Committee of Quality
Assurance (NCQA). Furthermore, Chesapeake health plans are structured to provide medical plans
that cover services under the HMO's, PPO's, POS, and Medicare HMO's. Chesapeake health plans
attributes a considerable portion of their net service revenue generated to their effective HMO health
plans, which realized a 46% of total revenue, while their Medicare HMO produced an impressive
39% of total revenue. Furthermore, their Preferred Provider Plan (PPO) generated 10%, and the
Point of Service Plan (POS) saw a 5% figure. This case study financial analysis will effectively
assess Chesapeake Health Plans: HMO financial performance, focusing on a competitive analysis, a
cash flow analysis, clear profitability ratios, liquidity ratios, debt management ratios, asset
management ratios, operating indicator analysis, a comprehensive financial assessment of
Chesapeake's financial state, as well as effective fiscal recommendations for their organization.
Competitive Analysis Presently,

Why Did Hmo Come From Case Study
Where Did HMO's Come From?
In 1973 Congressional Republicans and Democrats agreed that American patients should gently but
firmly be forced into managed care. That patients do not know this fact is evidenced by public
outrage directed at health maintenance organizations (HMOs) instead of Congress. But when the
House of Representatives refused to concur, it was left to the 93rd Congress to pass the HMO Act in
1973.
Just before a voice vote passed the bill in the House, U.S. Representative Harley O. Staggers, Sr., of
West Virginia said,"I rise in support of the conference report which will stimulate development of
health maintenance organizations. . .
I think that this new system will be successful and give us exciting and

Health Care System Evolution Paper
Health Care System Evolution Paper
This paper will discuss how HMOs have influenced current health care systems. HMOs have been
able to reduce health care cost in many ways and have also faced many difficulties along the way.
Many Americans years ago did not have health coverage and we are still seeing this today because
of the cost of these plans.
HMOs or Health Maintenance Organizations are health care plans that reduce health care cost.
Members of an HMO are usually required to make a co–payment when seeing a physician. A lot of
time members have a deductible they will have to pay before they are able to see their physician too.
These are just some of the ways HMOs try to keep health care cost down.
There are some 75 million ... Show more content on Helpwriting.net ...
With a POS plan, members can use doctors who are within the network or those who are not in
order to receive their care. If member do choose doctors outside their networks they will have to pay
more to have those services performed. With the POS plan members must have a primary care
physician. With a PPO plan members have more options over who they can see. Members do not
need a primary care physician with this type of plan (What is an HMO? 2009).
HMOs have been running strong for years but to remain viable they are going to have to make some
changes. Considerable evidence points to physician and consumer dissatisfaction with HMO's.
Consumers are not satisfied with primary care physicians as gatekeepers, limited provider choice,
physician profiling, requirement of prior approval and constraints on covered treatments (Fang, Liu,
& Rizzo, 2009). Studies have shown a slight decline of the insured population covered by HMOs. In
2000–2001, 55 percent of the insured population was covered and in 2003 it dropped to 51 percent
(Fang, Liu, & Rizzo, 2009).
President Obama signed into law a new health care plan that will help many Americans. With the
way things were going, many people were not able to carry health insurance and those companies
that were carrying insurance had to drop coverage for many of their employees. Many doctors and
big HMO companies have made a killing over the years, and want to keep doing so. That is why
many did not want to

Health Care History
One of the most important issues we have in America is the ability to have and receive health care,
in our society, human health is one of the most important values. This helps explain why the US
spends 17% of its GDP on health care. The majority of Americans are vitally concerned about their
health, to the extent that people believe that health care institutions and finance mechanisms affect
their personal health, they are vitally concerned with these institutions and mechanisms. Many of us
are also concerned about the provision and finance of health care for our fellow Americans, and we
believe that the health care system reflects the values and merit of our society. Unfortunately, many
Americans have no health insurance and must either pay ... Show more content on Helpwriting.net
...
Then in 1970 there were 37 HMOs in 14 states with an enrollment of 3 million people. The HMO
movement had achieved national significance, and with that in the late 1960s and early 1970s
political conservatives embraced the HMO concept as an alternative to socialized medicine. With
support from a broad coalition in Congress, President Nixon secured the passage of the HMO Act of
1973. The Act enabled individual HMOs to receive qualifications from the federal government, and
it required all employers to offer coverage from at least one federally qualified HMO to all
employees. The Act facilitate growth in HMO enrollment by helping to create several successful
HMOs around the country, and it legitimized the HMO

Differences Between PPO And HMO
The relationship of an HMO and its physician member is to help provide a wider range health care
for its patients and a wide area of services available for its physician members. A patient must
choose a primary care physician from a list of providers. The relationship with the physician
provided from the HMO is in a contract that is to deliver services to their patients for a fee. There
can also be a group plan which is a HMOs contract with a group of physicians to deliver services.
The HMO organization compared to PPOs, a PPO is a variation of an HMO, and it features
traditional insurance and managed care.
The PPO gives discounts, with its doctors and hospitals that participation, and then pays a fee for
services given. Patients have a list that they can pick from for a primary physician. The patient pays
a set fee per office visit and the insurance provider pays the rest. It's basically a co–payment which
depends on what type of plan they have. However, like an HMO, the PPO has to choose a physician
in that network, if they don't they may be charged a penalty. ... Show more content on
Helpwriting.net ...
The principle of direct liability is an individual or business established on negligence or any results
in harming or damaging to another individual or their property. Hospitals or providers are liable for
the conduct and treatments provided by their physician members. Any damage or treatment a
physician's provides is covered by the hospital. Enterprise liability is a legal matter that a related
corporations or people can be held responsible for any actions, damage or wrong

Comparing Universal Healthcare System with the United...
An American Healthcare Crisis Debate: Comparing Universal Healthcare System (a Canadian
System) with the United States' HMO (with emphasis on cost.)
Every single life on the surface of this earth has an equal right to existence. The life of an affluent
American should not be worthier in the right to existence than that of a poor American. Neither
should is the life of a bishop be more important than that of a Muslim child. Every life is sacred and
equal. Without a healthy citizenry, no nation of people could fight enough to either demand for their
freedom nor maintain the freedom that has been already gained. It is within that context that I
declare that the right to an affordable healthcare is as sacrosanct as the right to be ... Show more
Long before the 1990s when Ms. Clinton fought for a Universal Healthcare system in America, the
issue of America's healthcare had been a political quandary. The enactment of the Republican
administration's Health Management Organization Act of 1973 was a weapon meant to address that
crisis, yet, it did little to fix the problem. While the liberal Democrats are fighting for Universal
Healthcare coverage for all Americans, the conservative Republicans are fighting to maintain the
current private health insurance, however, with some revamping of the system, which preserves the
capitalistic element of the status quo. The reason for the two opposing views stems from their
differences in political ideologies, which theoretically is like pitting socialism against capitalism.
While the liberal Democrats' endorsement of Universal Healthcare system is socialistic in practice,
the conservative Republicans' fight to retain the private or market based plan is unarguably in
support of their pro–capitalism stance. The truth, however, is that, though almost every American
believes in capitalism, yet, almost none would vote to disband the Medicare and the Medicaid
programs, both of which are socialistic. In that light, the argument of a pro–capitalist nation is
negated, as we do already have a socialized healthcare program for the seniors and the poor.
Extending that concept to include

Pros And Cons Of Hmo

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