A system of organizing and financing the delivery of health care services that aims to control costs and improve the quality of care provided to individuals or groups.
Key Features:
Predetermined network of health care providers
Emphasis on preventive care and wellness
Utilization of evidence-based medicine
Coordination of care through case management
Restrictions on out-of-network services
Implementation of cost-containment strategies
Integration of medical services and insurance coverage
Implementation of utilization review processes
Benefits:
Improved access to health care services
Coordinated and efficient health care delivery
Cost savings through negotiated rates
Predictable health care costs
Enhanced focus on preventive care
Drawbacks:
Restricted choice of health care providers
Potential for limited coverage for out-of-network services
Possibility of denial or delay of certain treatments
Administrative complexities
Dependence on insurance company policies and regulations