What Free Market Health Care Would Actually Look Like
Reason magazine|July 2021
Dr. Lee Gross’ direct primary care practice takes the complexity and unaffordability out of health care.
By John Osterhoudt

If you have health insurance but no primary care physician, the process for getting physical can be a bit complicated. Whether or not you get your health insurance through an employer, you’ll probably have to find a practice in your area that is in your network. Then you’ll have to find out if it’s accepting new patients. You may have to wait months until the office will let you come in for a physical. You’ll have to figure out if you’re responsible for a co-pay. Even after the visit, you may need to cover the additional cost of any blood work or other tests, and you probably can’t figure out how much you’ll be billed for that ahead of time. At some point, you’ll also have to decide whether it’s worth the trouble to set up a tax-advantaged account to cover the unpredictable costs of this visit or any future ones.

Or you could just find a direct primary care doctor who’s accepting new patients and pay a flat monthly fee that covers all your in-office services and tests. If you need an out-of-office test or a prescription, the practice may also give you access to steep discounts compared to what it would cost with insurance.

There are currently more than 1,400 direct primary care practices operating in 49 states. Among them are doctors Lee Gross and William Crouch at Epiphany Health Direct Primary Care in North Port, Florida. They charge just $75 a month for an adult, $30 per month for one child, and $15 a month for each additional child. After that, nothing more is owed for services provided in the office—no health insurance necessary. In January, Reason’s John Osterhoudt visited Epiphany and spoke with Gross about what free-market health care should, and can, look like.

Reason: What is primary care at a fundamental level?

Gross: Primary care in its most fundamental level is the most basic aspect of health care delivery in the world. It is where most people interact with the health care delivery system. It’s where you do your preventative maintenance, where you go for respiratory infections, where you manage your high blood pressure, your diabetes. About 85 percent of all health care delivery in the country can be managed at a primary care level, so that is really the bulk of health care delivery in our country.

What is it that you and Dr. Crouch do at Epiphany, and how is it different from the traditional fee-for-service, insurance-based model?

When I was in the fee-for-service system, I felt like I was playing a game of Whac-A-Mole with Medicare. We had to find ways of doing as much stuff to as many people as possible to generate as much revenue just to pay for the computer systems that I needed to bill Medicare so that I could get paid. So I’d have to get more people and I’d have to hire more staff, and then I’d have to see more patients to pay more staff, and it was a snowball. Every time I found a way to generate revenue and prop up this monstrosity that we were required to build, Medicare would knock the knees out from under us and take away that revenue source. Eventually, we just said, “No more.”

The name of our practice is Epiphany Health, and that’s a very strange name for a health care company. But we did have an epiphany, and the epiphany was “Why are we inserting so many people at the primary care level between the doctor and the patient? Why are we insuring primary care?” The more people that you insert between the doctor and patient, the more expensive it gets, the more cumbersome it gets, the more impersonal it gets. We had our epiphany about 11 years ago: Let’s kick the middlemen out of this relationship. Let’s have a direct relationship between the doctor and the patient, and at that point, we created one of the first direct primary care practices in the country.

Now, at the time we were doing this, there were many other practices simultaneously working on this model. It has since come to be known nationally as “direct primary care,” but essentially it’s a membership-based primary care program. Instead of a fee for service, instead of a charge for every time the doctor touches the patient, you have a flat subscription fee, much like Netflix. Once you pay that membership fee to your primary care physician, all the services that are provided in the doctor’s office are done so at no additional charge. If I see you 10 times in a month to manage a complex condition, it doesn’t cost you any more, and I don’t bill your insurance for every one of those interactions.

When we opened our practice in 2011, the first thing we saw was uninsured patients coming to our practice from all over Florida. We’re in Southwest Florida, this is not the Mayo Clinic or the Cleveland Clinic, but patients were driving hours to access care because they could afford it. They couldn’t afford an insurance policy, but they certainly could afford health care in the manner that we were providing it.

What can you do in the office? Can you give me a range of what is included in that $75-a-month fee?

Once a patient is a member of our practice, anything that we can do within the four walls of our office is included at no additional charge. That would include things like electrocardiograms (EKGs); 24-hour heart monitors or Holter monitors; minor procedures like taking off a small skin cancer. I can do biopsies and joint injections, we can remove moles and sew up lacerations. I can splint uncomplicated fractures. Most tests that we do within our office, like a strep test, urine test, or pregnancy test, are all things that we do at no additional charge.

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