affordable direct primary care - fmma
TRANSCRIPT
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Affordable Direct Primary Care
Lee S. Gross, M.D.Founder, Epiphany Health
President, Docs4PatientCareFoundation
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What was the Epiphany?• Primary care SHOULD be affordable!• Why is basic health care so expensive?• Third party disconnect from cost makes it expensive.
• Outside factors drive cost– Hospital– Administrative costs– Pharmacy– Imaging– Labs– Specialty care– Physical Therapy
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What is Epiphany Health?• Direct Primary Care
– Membership Based Patient‐Centered Medical Home
• Includes:– Comprehensive primary care and wellness services
– Access to a local network of steeply discounted labs, imaging, specialty care, physical therapy, pharmacy and more.
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Free Market Model
Over time, new technology prices come down in a free market
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What about health care prices?
Health care is not a free market!
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Why is health “insurance” so expensive?• It’s not “insurance”, it’s health maintenance• Traditional “Insurance” is for catastrophic care,
not first dollar coverage– What would homeowners’ insurance cost?
• Light bulb replacement• Landscape maintenance• Housekeeping• Routine repairs
– Third party coverage drives up costs• “I’m paying for it, I’m going to use it.”• Administrative costs
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All other care
Balancing the cost of care
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Remove the cost drivers
All other care
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Most patients can be cared for at the primary care level
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There is a solution!
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How does it work?• Separates routine from catastrophic care• Monthly membership fee for primary care• Clearly defined package of services• Fixes the cost of routine care• Catastrophic insurance becomes a true safety net again
• Not fee for service• Total price transparency• Network of discount providers
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What’s Included?
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What’s Excluded?• There are no pre‐existing condition exclusions
• There are no co pays• There are no deductibles
• There are two exceptions…– Our doctors do not treat chronic pain– Our doctors do not prescribe chronic controlled substances
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Examples of in‐office savingsService Typical Charge Your Cost
Additional labs $50‐350 each $10 each
Joint injection (knee) $150 $0
Skin biopsy $160 $0
Drain abscess $275 $0
Laceration repair $260 $0
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Examples of network savingsService Typical Charge Your Cost Savings
Nuclear Stress Test $1,470 $520 65%
CT of the chest w/contrast $940 $211 78%
Carotid ultrasound $425 $120 72%
Colonoscopy $4,028 $1,127 71%
Chest x‐ray $220 $22 90%
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Hospital Charges
Lab charges $38.14
Chemistry $3524.14
Hematology $1,782.95
Urology $231.79
Chest x‐ray $490.94
CT scan $10,955.13
ER Level 4 $2,700.18
TOTAL: $19,723.27
Epiphany Charges
$8.00
$70.79
$15.00
$4.50
$18.00
$185
$0
$278.79
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What Does It Cost?Monthly
Membership
Individual $80
with Spouse / Domestic partner $150
Family (Dependent child 5‐27)$175
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Savings with Epiphany
Family of 4 = $ 175 per month
2013 Average PPO Insurance*
Family of 4 = $1,836 per month
Difference per year: $17,292
*http://http://www.forbes.com/sites/danmunro/2013/05/22/annual‐healthcare‐costs‐surpasses‐22000/
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10 year projection – Family of 4
$168,340
[VALUE]
$51,960
$0
$50,000
$100,000
$150,000
$200,000
$250,000
1 2 3 4 5 6 7 8 9 10
Total Savings
Traditional PPOInsuranceEpiphany + HDHP*
*Aetna Health Network Option Value 10000 www.ehealthinsurance.com ($10K deductible, $258/mos)
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Employer of 10: Ten year total projection
$1,683,400
$2,203,000
$519,600
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
1 2 3 4 5 6 7 8 9 10
Total savings
Traditional PPO Insurance
Epiphany + HDHP
Assumes middle aged employees with families of 4.
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Saving a profession…Service Revenue
Annual patient dues $960
Labs
Mammogram
Influenza vaccine
Pap smear
25 office visits
Our Cost
$30
$25
$6
$28
50% overhead
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Saving a profession…• Expenses of guaranteed services are covered
with first month’s dues
• $80 per month x 11 months = $880 net revenue per patient per year
• 500 patients x $880 = $440,000 annual revenue
• less 50% overhead = annual net $220,000
• Epiphany can be added to an existing practice
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Saving a Nation
• ACA estimates 32 million newly “insured”
• Many of the “insured” will be on Medicaid
• Estimated 26 million remain uninsured
• Current 10‐year CBO projected cost $1.8 trillion
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Saving a Nation
• If ALL 58 million uninsured were enrolled in Epiphany Health…
• Total 10 year cost = $556.8 billion
Net 10 year savings…
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Saving a Nation
$1,355,200,000,000!!!
$1.3 Trillion
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Any questions?
www.docs4patients.org
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Epiphany Health
Practice A Practice B Practice C
Patient Business
Other third party contracts
Patient Business