Accountable Care Act

By SHEFALI LUTHRA

For Kaiser Health News

A growing number of primary-care physicians, spurred by the Accountable Care Act and frustrations with insurance requirements, are bringing a service that generally has been considered “health care for billionaires” to middle-income, Medicaid and Medicare populations.

It’s called “direct primary care,” modeled after “concierge” practices that have gained prominence in the past two decades. Those feature doctors generally bypassing insurance companies to provide personalized healthcare while charging a flat fee on a monthly or yearly basis. Patients can shell out anywhere from thousands to tens of thousands of dollars annually, getting care with an air of exclusivity.

In direct primary care, patients pay about $100 a month or less directly to the physician for comprehensive primary care, including basic medication, lab tests and follow-up visits in person, over email and by phone. The idea is that physicians, who no longer have to wade through heaps of insurance paperwork, can focus on treating patients. They spend less on overhead, driving costs down. In turn, physicians say they can give care that’s more personal and convenient than in traditional practices.

The 2010 health law, which requires that most people have insurance, identifies direct primary care as an acceptable option. Because it doesn’t cover specialists or emergencies, consumers need a high-deductible health plan as well. Still, the combined cost of the monthly fee and that plan is often still cheaper than traditional insurance.

The health law’s language was “sort of [an] ‘open-for-business’ sign,” said Jay Keese, a lobbyist who heads the Direct Primary Care Coalition. Before 2010, between six and 20 direct primary care practices existed across the country. Now, there are more than 400 group practices.

The total number of physicians participating doctors may exceed 1,300. The American Academy of Family Physicians estimates 2 percent of its 68,000 members offer direct care.

“This is a movement — I would say it’s in its early phase,” said AAFP President Wanda Filer, a doctor in Pennsylvania. “But when I go out to chapter meetings, I hear a lot more interest.”

But questions persist about feasibility. The lower fees could still be a non-starter for people earning minimum wage or on a limited budget, said Robert Berenson, a senior fellow at the Urban Institute. “Can people afford this? Or is it [still] just for well-off people?”

The American College of Physicians advises doctors to consider whether direct primary care can work within their practices, but also urges physicians to recognize how it could affect poorer patients and look for ways to keep care affordable.

Direct primary-care doctors say they see patients across incomes. Dr. Stanford Owen, of Gulfport, Miss., treats “waitresses and shrimpers, as well as doctors and lawyers.” He charges $225 for initial visits, $125 for a follow-up, if needed, and then about $50 per month after.

Owen and other physicians report positive experiences, triggering other efforts to apply direct care more broadly. Although most of these doctors eschew dealing with insurance, some have been trying the model with Medicaid and Medicare patients.

If those experiments work — and save money and improve health — they could mitigate concerns about who can afford direct primary care. Berenson pointed out that partnering with insurance or public programs is key to making direct care affordable for lower-income people.

“The idea of setting up stronger primary care services for patients is very exciting and very much needed,” said Ann Hwang, director of the Center for Consumer Engagement in Health Innovation, an outpost of the consumer advocacy group Community Catalyst. But, she added, “This is so new that I think the jury is still really out on whether this will be successful.”

In Seattle, a company called Qliance, which operates a network of primary-care physicians, has been testing how to blend direct primary care with the state’s Medicaid program. They started taking Medicaid patients in 2014. So far, about 15,000 have signed up. They get a Qliance doctor and the unlimited visits and virtual access that are hallmarks of the model.

“Medicaid patients are made to feel like they’re a burden on the system,” said Dr. Erika Bliss, Qliance’s CEO. “For them, it was a breath of fresh air to be able to get such personalized care — to be able to talk to doctors over phone and email.”

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 15  to 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.’”