Affordable Direct Primary Care Affordable Direct Primary Care Lee S. - PowerPoint PPT Presentation

Affordable Direct Primary Care Affordable Direct Primary Care Lee S. Gross, M.D. Founder, Epiphany Health President, Docs4PatientCare Foundation

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

Balancing the cost of care All other 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 savings Service 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 savings Service Typical Charge Your Cost Savings Nuclear Stress $1,470 $520 65% Test CT of the chest $940 $211 78% w/contrast Carotid $425 $120 72% ultrasound Colonoscopy $4,028 $1,127 71% Chest x ‐ ray $220 $22 90%

Hospital Charges Epiphany Charges Lab charges $38.14 $8.00 $70.79 Chemistry $3524.14 $15.00 Hematology $1,782.95 $4.50 Urology $231.79 $18.00 Chest x ‐ ray $490.94 $185 CT scan $10,955.13 $0 ER Level 4 $2,700.18 $278.79 TOTAL: $19,723.27

What Does It Cost? Monthly Membership $80 Individual with Spouse / Domestic $150 partner $175 Family (Dependent child 5 ‐ 27)

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 $250,000 [VALUE] Total Savings $200,000 Traditional PPO Insurance $168,340 Epiphany + HDHP* $150,000 $100,000 $51,960 $50,000 $0 1 2 3 4 5 6 7 8 9 10 * Aetna Health Network Option Value 10000 www.ehealthinsurance.com ($10K deductible, $258/mos)

Employer of 10: Ten year total projection $2,500,000 $2,203,000 Total savings $2,000,000 Traditional PPO Insurance $1,683,400 Epiphany + HDHP $1,500,000 $1,000,000 $519,600 $500,000 $0 1 2 3 4 5 6 7 8 9 10 Assumes middle aged employees with families of 4.

Saving a profession… Service Revenue Our Cost Annual patient dues $960 Labs $30 Mammogram $25 Influenza vaccine $6 Pap smear $28 25 office visits 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

Patient Business Epiphany Health Practice A Practice C Practice B Other third party contracts Patient Business