Qliance has a contract with Centene, an insurance company in the state’s Medicaid program. That Medicaid coverage pays for the monthly fee, which covers primary and preventive care, and for other specialty and emergency services. If patients need a specialist, they’ll get referred to one who accepts Medicaid. Advocates in other states — such as North Carolina, Idaho and Texas — are watching the outcomes and costs while considering rolling out similar programs.
There’s little data so far. Bliss estimated participants will cost Washington state between 15 and 20 percent less than traditional Medicaid. Before launching the Medicaid pilot, Qliance contracted with some companies that provide insurance to their employees — in those cases, employees who opted for Qliance cost about 20 percent less than employees in traditional health insurance. Because patients get better care upfront, the theory goes, they’re less likely to develop expensive chronic illnesses.
Still, expanding this approach is tricky. The number of participating physicians is low. There’s already a nationwide shortage of primary care doctors. In this model, physicians see fewer patients, potentially exacerbating that shortage’s impact. Also, Medicaid negotiates the monthly payment rate, which could be less than what doctors might set independently.
In New Jersey, a pilot program using direct primary care is launching in 2016 for state employees, like firefighters and teachers. It’s a hybrid: When consumers pick a primary doctor, they can choose a direct primary care-style practice, which gives around-the-clock access to preventive and primary care services. The monthly fee is undetermined.
Participants will get benefits such as same-day appointments for non-emergency visits. But when they pick this plan — which will be administered by Aetna and Horizon — they will have access to specialists that participate in the insurers’ plan networks.
In New Jersey, about 800,000 people will be eligible to enroll in the direct primary care program. The state’s hoping to attract and accommodate at least 10,000 in the first year.
That’s appealing, said Mark Blum, executive director of America’s Agenda, an advocacy group that helped develop the project. He cited interest in California, Texas, Pennsylvania and Nebraska. “There are a lot of eyes on New Jersey right now.”
Meanwhile, direct primary care is finding traction with Medicare Advantage, the private health plan alternatives to traditional Medicare. Iora Health, a direct primary care system that contracts with unions and employers, a year ago launched clinics in Washington and Arizona catering to Medicare Advantage patients.
Iora’s setting up similar clinics in Colorado and Massachusetts.
Despite its potential, the direct care model faces the challenges of integration into existing payment systems and attracting more participating doctors. And navigating Medicare and Medicaid rules can deter physicians.
“It’s not for the faint of heart,” said Dr. Rushika Fernandopulle, Iora’s CEO.
How it evolves from here will vary across the country, said Filer, the AAFP president.
“There are some parts of the country where it is working very well,” she said. “But there are other reasons a physician might decide, ‘This is not for my patient base.'”
By Shefali Luthra, Kaiser Health News
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.