What is a suggested model for a direct hospital to patient insurance plan?

Patient-Centered Medical Home (PCMH) Model as the Optimal Direct Hospital-to-Patient Insurance Plan

The Patient-Centered Medical Home (PCMH) model represents the most effective framework for a direct hospital-to-patient insurance plan, as it improves physician and patient satisfaction, enhances health outcomes, increases accessibility, reduces costs, and decreases healthcare disparities when supported by appropriate payment structures. 1

Core Components of an Effective Direct Hospital-to-Patient Insurance Model

Risk-Adjusted Care Management Structure

• Implement risk-adjusted care management fees that provide additional revenue to support patient-centered care without creating financial barriers for lower-income patients 1
• Incorporate opportunities for shared savings and performance-based payments to incentivize quality care and cost control 1, 2
• Develop practice support mechanisms that allow physicians to accept insurance while sustaining and improving their practices 1

Value-Based Payment Structure

• Design payment models that reward high-value care rather than high-volume care to improve outcomes per dollar spent 3
• Include bundled payments and accountable care organization structures to incentivize high-value care and discourage low-value services 4
• Balance quality metrics with cost considerations to avoid unintended consequences like those seen in the Hospital Readmissions Reduction Program 1

Financial Accessibility Mechanisms

• Create sliding scale fee structures that discount charges for lower-income patients 1
• Waive requirements for payment at time of service for lower-income patients to reduce barriers to care 1
• Provide preventive services required by the Affordable Care Act at no additional out-of-pocket cost to patients 1

Insurance Processing Support

• Assist patients with insurance submission by completing all CPT and ICD coding 1
• Offer the option of submitting insurance claims for payment on patients' behalf, even when requiring cash payment at time of service 1
• Develop systems to reduce administrative burden while maintaining appropriate insurance documentation 1

Benefits of the PCMH-Based Direct Insurance Model

Improved Health Outcomes

• Studies demonstrate that PCMH models result in increased physician, staff, and patient satisfaction 1
• The model creates better health outcomes and potentially lower costs through coordinated care 1
• Reduces healthcare disparities through accessible, high-quality care for all socioeconomic groups 1

Financial Protection for Patients

• Provides financial protection against unexpected high healthcare expenses 1
• Reduces out-of-pocket spending while improving medication adherence through value-based insurance design elements 5
• Addresses the issue that patients without health insurance coverage are at greater risk for preventable deaths and injuries 1

Physician Practice Sustainability

• Helps improve physician satisfaction and reduce burnout through better practice support 1
• Creates an alternative way for physicians to accept insurance while sustaining their practices 1
• Addresses factors that undermine the patient-physician relationship and contribute to professional burnout 1

Implementation Considerations and Pitfalls

Avoiding Discriminatory Effects

• Be aware that not accepting health insurance may create barriers to care for lower-income and vulnerable patients 1
• Ensure the model doesn't disproportionately benefit higher-income patients at the expense of those with fewer resources 1
• Implement risk adjustment for socioeconomic status to avoid creating disincentives for hospitals to care for high-risk individuals 1

Quality Measurement Challenges

• Balance quality metrics with cost considerations to prevent unintended consequences 1
• Maintain transparency by reporting raw hospitalization and mortality rates among other patient-centered outcomes 1
• Develop robust qualitative and implementation research regarding structures and processes of care 1

Research Gaps to Address

• Conduct research on the impact of direct contracting models on access to care for underserved populations 1
• Study the effect on healthcare workforce, especially the supply of and access to primary care 1
• Evaluate patients' out-of-pocket costs, overall health system costs, and quality of care outcomes 1

Future Directions

• Develop innovations in health information technology that distinguish and incentivize high-value care in a patient-specific manner 6
• Create structured approaches to successfully assume downside risk in value-based arrangements 2
• Implement essential structural elements including quality performance reporting, risk adjustment, utilization management, care management, network integrity, and technology 2