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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