HMO model in health insurance

What is the HMO model?

HMO means Health Maintenance Organisation and is a health insurance model that is an alternative and cheaper variant to the compulsory basic insurance.

How does the HMO model work?

The HMO model works as follows:

• Choice of HMO practice: insured persons choose an HMO practice from a predefined list of HMO doctors.
• Coordination of care: The selected HMO practice coordinates all medical care and monitors the patient's health status.
• Referrals: If specialised treatments are required, the HMO practice issues a referral to ensure that the costs are covered by the insurance.
• Emergencies and certain specialised treatments: In emergencies or for specialised services, patients can go directly to specialists or hospital without needing a referral from their HMO practice.

What is the difference between the HMO model and the family doctor model?

The term "HMO model" is often used synonymously with the "family doctor model". Both models are based on the concept that insured persons must first see their family doctor. The main difference lies in the terminology; "HMO" stands for "Health Maintenance Organisation," while "GP model" focuses on the family doctor himself. In practice, however, the two models are similar.

HMO model advantages

The benefits of the HMO model are as listed below:

1. Premium discount

With the HMO model, insured persons receive a premium discount of up to 25% compared to the standard model. The premium discount depends on the health insurance company and the chosen HMO practice.

2. Faster medical care

Thanks to the organisational structure of HMO practices, numerous medical services and specialties are available under one roof. This enables the joint use of expensive diagnostic equipment such as X-ray and ultrasound machines, which means that a wide range of medical services can be offered. Close cooperation with specialists also often facilitates and speeds up referrals to these specialists.

3. Substitution in case of absence

In case of absence of the regular doctor, a substitute is always available due to the close cooperation of doctors within the HMO practice.

4. Continuity of health care

The assigned doctor in an HMO practice has a comprehensive overview of the patient's medical history, health needs and individual preferences. This contributes to the provision of effective medical care that is tailored to the individual.

HMO model disadvantages

The disadvantages of the HMO model are as listed below:

1. Limited choice of doctors.

In an HMO model, patients are usually required to first see their assigned HMO doctor when they become ill. This restriction can be problematic for some patients, especially if they already have a preferred relationship with a doctor outside the HMO network.

2. Requirement of a doctor's referral.

A referral from the HMO doctor is usually required to see a specialist. This may be perceived as an extra step and occasionally cause delays.

3. Availability of HMO practices.

For people living in rural areas or outside of urban centres, it can be challenging to find an HMO practice near them. This can limit the accessibility and convenience of medical care.

Are there alternatives to the HMO model in Switzerland?

Yes, there are alternatives to the HMO model, such as the standard model, telephone model and family doctor model. Each model has its own advantages and disadvantages and the choice depends on your needs.

How can I compare the HMO models of the health insurance companies?

You can use the health insurance premium calculator to compare the HMO models. Read the customer reviews and experiences to learn more about the quality of the HMO model of a particular health insurance company.