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Public HealtH ScienceS ` PUBLIC HEALTH SCIENCES—HEALTHCARE dELIVERy Public HealtH ScienceS ` PUBLIC HEALTH SCIENCES—HEALTHCARE dELIVERy SectiOn ii 271

Major medical insurance plans
PLAN PRoVIdERS PAymENTS SPECIALIST CARE
Exclusive provider Restricted to limited panel No referral required
organization (except emergencies)
Health maintenance Restricted to limited panel Denied for any service that Requires referral from
organization (except emergencies) does not meet established, primary care provider
evidence-based guidelines
Point of service Patient can see providers Higher copays and Requires referral from
outside network deductibles for out-of- primary care provider
network services
Preferred provider Patient can see providers Higher copays and No referral required
organization outside network deductibles for all services
Accountable care Providers voluntarily enroll Medicare Specialists voluntarily enroll
organization

Healthcare payment models
Bundled payment Healthcare organization receives a set amount per service, regardless of ultimate cost, to be divided
among all providers and facilities involved.
Capitation Physicians receive a set amount per patient assigned to them per period of time, regardless of how
much the patient uses the healthcare system. Used by some HMOs.
Discounted fee-for- Patient pays for each individual service at a discounted rate predetermined by providers and payers
service (eg, PPOs).
Fee-for-service Patient pays for each individual service.
Global payment Patient pays for all expenses associated with a single incident of care with a single payment. Most
commonly used during elective surgeries, as it covers the cost of surgery as well as the necessary
pre- and postoperative visits.

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