affordable direct primary care - fmma

Affordable Direct Primary Care

Lee S. Gross, M.D.Founder, Epiphany Health

President, Docs4PatientCareFoundation

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

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.

Free Market Model

Over time, new technology prices come down in a free market

What about health care prices?

Health care is not a free market!

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

All other care

Balancing the cost of care

Remove the cost drivers

All other care

Most patients can be cared for at the primary care level

There is a solution!

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

What’s Included?

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

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

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%

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

What Does It Cost?Monthly 

Membership

Individual $80

with Spouse / Domestic partner $150

Family (Dependent child 5‐27)$175

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/

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)

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.

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

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

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

Saving a Nation

• If ALL 58 million uninsured were enrolled in Epiphany Health…

• Total 10 year cost = $556.8 billion

Net 10 year savings…

Saving a Nation

$1,355,200,000,000!!!

$1.3 Trillion

Any questions?

www.docs4patients.org

Epiphany Health

Practice A Practice B Practice C

Patient Business

Other third party contracts

Patient Business