As you probably know all to well, the cost of healthcare and health insurance premiums continue to increase at levels substantially above the general inflation rate. The reasons given for these extraordinary cost increases are numerous and include: technological advancements in the medical field, increased demand for medical services and prescription drugs, the aging of the population, cost shifting caused by the uninsured and governmental reimbursement rates, state and federal mandates, and costs associated with medical related lawsuits.

As individual consumers, we have very little control over some of the factors contributing to the cost of healthcare. However, all of us have control over lifestyle related health insurance claims. A simple formula of eating a balanced diet, getting the appropriate amount of daily exercise, participating in annual physicals and other recommended routine care, limiting alcohol consumption, and eliminating the use of tobacco products will no doubt reduce our personal healthcare costs. In addition to reducing medical costs, the other benefits of following such a formula include more energy, self confidence, less stress, and increased productivity. If you are not doing so already, I encourage you to consider practical ways to promote a healthy lifestyle for you and your family. For example, one of the individual health insurance companies my organization works with has an option that will offset 25% of the annual cost of a health club membership. Simple things such as taking a walk, bike ride, or going swimming promote both a healthy body and mind. If you have a sweet tooth, consider limiting yourself to eating desert once a week. You will enjoy it more and your body will thank you.

Health insurance premiums will continue to increase as long as the cost of healthcare continues to go up. The best way to reduce the overall cost of healthcare is to decrease our need for healthcare. Healthy lifestyle choices and prudent use of the healthcare system are the best and easiest ways to get a handle on our healthcare expenditures. Perhaps the greatest benefit of a healthy lifestyle is our ability to enjoy our precious time here on earth to the fullest.

Health insurance plans have been forced to take action to contain costs of quality health care delivery as health care costs have skyrocketed. Health insurance premiums, deductibles and co-pays have steadily increased, and health insurance companies have implemented certain strategies for reducing health care costs. “Managed care” describes a group of stratgies aimed at reducing the costs of health care for health insurance companies.

There are two basic types of managed care plans; health maintenance organizations, or HMOs, and preferred provider organizations, or PPOs. So which health plan is best? How do you choose what type of health insurance best suits the health care needs of you and your family?

Both HMOs and PPOs contain costs by contracting with health providers for reduced rate on health care services for its’ members, often as much as 60%. One important difference between HMOs and PPOs is that PPOs often will cover the costs of care when the provider is out of their network, but usually at a reduced rate. On the other hand, most HMOs offer no coverage for health care services for out-of-network providers.

Both HMO and PPOs also control health care costs by use of a gateway, or primary care provider (PCP). Health insurance plan members are assigned (or select) a primary care practitioner (physician, physician assistant, or nurse practitioner). usually a family practitioner or internal medicine doctor for adult members or a pediatrician or family care practitioner for childern. The primary care provider is responsible for coordianting health delivery for plan members. Care by specialist physicians require referral from the primary care provider. This cost containment strategy is intended to avoid duplication of services (for example, the cardiologist ordering tests that have already been done by the PCP, or a sprained ankle being referred to an orthopedic) and avoid unnecessary specialist referrals, tests and/or procedures.

HMO and PPO plans also contain costs by requiring prior approval, prior authorization, or pre-certification for many elective hospital admissions, surgeries, costly tests and imaging procedures, durable medical equipment and prescription drugs. When such services are required, the provider must submit a request to the health insurance plan review department, along with medical records that justify the service. The request is reviewed by the health insurance company to determine whether the services are justified as “medically necessary” according to the health plan policy and guidelines. Review is usually performed by licensed nurses, and, if the reviewer agrees that the service is necessary, approval is given and the service will be covered by the health insurance plan.

As health care costs continue to rise, many indemnity health insurance plans, or “fee for service” plans are being forced to adopt some managed care strategies in order to provide quality health care and keep health insurance premiums affordable. And as long as health care costs continue to rise, the distinctions among PPO, HMO, FFS and other health insurance plans will become blurred. Rest assured, however, that managed health care is here to stay