Monday, March 24, 2014
Interview with Lee Gross, MD, Primary Care Physician, North Port, Florida
Gross is able to offer low prices by unbundling primary care , which he says is essentially just “brain time,” from expensive catastrophic, palliative, and chronic care. He also achieves savings by eliminating the administrative costs that come from handling insurance.
Jordan Bruneau, “Concierge Care for the Little Guy,” The Freeman, Februrary 25, 2014
Dr. Lee Gross is a 42 year old family physician in a two man group in North Port, Florida, a community of 60,000 in Southwest Florida. Since January 1, 2010, he has pioneered the idea of adding a concierge component to his traditional medical practice, thereby creating a hybrid primary care practice. Out of this experience has come a surprise. Contrary to his expectations and conventional wisdom, most patients signing up for his concierge practice have been uninsured, insured with high deductibles, or Medicaid recipients.
Dr. Gross serves on the national executive board of Doctors4PatientCare and is a delegate to the Florida Medical Association.
Q: Tell me about your practice and your experience with concierge medicine.
A: We’re a two person practice. Both of us have full traditional practices. We still see
Medicare and traditional insurance patients, and since January, we have been seeing a lot of
patients who fell through the cracks of the Affordable Care Act. We are getting many referrals
from ObamaCare navigators.
Q: Does that surprise you?
A: Yes, we met these navigators at a health fair at a nearby college. They were there to sign up
students. They had a nearby booth. They saw our sign about no insurance needed. They were
seeing a lot of patients who couldn’t afford ObamaCare exchange plans because they earned
between 100% and 138% of the poverty level, and didn’t qualify for subsidies. We talked,
they took our flyers, and we’ve been getting their referrals ever since. Ironically, ObamaCare
navigators are now a sales force for us.
The County Health Department is also sending us patients. Because of ObamaCare rules, they
are no longer federally qualified, and they had to shut down their primary care program. They
told their patients they had two places to go – a federally qualified center or us – and many are
coming to us. We are now getting people who were on federal government assistance who are
now paying their own way. In a weird way, we’re ideally suited to care for people insurers don’t
want and for people a lot of physicians don’t want.
Q: So you’re attracting Medicaid patients and the uninsured?
A: Yes. They want to get into our program.
Q: Are you a Medicaid provider?
A: No, we are not. And we do not enroll new Medicare patients or Medicare-eligible patient
into our concierge program. In Florida, Medicaid patients have a deductible to meet every
month that can run in the hundreds of dollars. Medicaid patients cannot afford that, but
they can afford our services for routine care. Paired together, Medicaid makes a perfect high
deductible safety net for catastrophic illness for these patients.
Percent in Concierge Practice
Q: What percent of patients are in your concierge practice?
A: About 5%, but concierge medicine accounts for about 30% of our revenue. The optimal
age of the people we’re signing up are between 40 and 64, old enough to have developed
conditions like hypertension or diabetes. We can provide affordable services for these folks.
Optimism about Future
Q: Are you optimistic about the future of direct pay or concierge medicine?
A: Yes, I think if a doctor wants to remain in private practice, they’ll have to add a concierge
component to their practice. Otherwise, it’s just too costly to remain in compliance with
federal regulations and 3rd parties. As more of health care gets passed off to midlevel
practitioners, there’s going to be growing demand for patients that want to actually see
Unbundling Primary Care
Q: You often speak about “unbundling care” from traditional 3rd parties. Tell me about that.
A: Unbundling primary care is where the cost savings come from. When you try to bundle
primary care into an insurance product that must also provide $100,000 for chemotherapy or
a $150,000 pacemaker insertion, you shift the expense of the high-cost service to the primary
When you carve out the primary care component, which is basically “brain time” and
inexpensive equipment and services, we can sell our services very cheaply, especially when you
don’t devote 40% to 60% of your overhead dealing with 3 rd party payers or coding.
I love the fact that my chart notes no longer have to do with billing but are for care of the
patient. When I send a patient to the ER, I sometimes get a 16 page report that meets
compliance standards but tells me little about the patient or what was done. I don’t have to do
that. I can be brief and to the point, e.g. “Patient responding well to medication. Follow-up
in 3 months.” No bullet points. No ICD-9 codes. No worry about paperwork compliance. I just
Q Do you have EHR?
A: Yes, I was an early adopter. It was fantastic. But the company who provided it was bought
and sold about 5 times. The last company terminated it. I changed to a new EHR in order to
comply with meaningful use. It isn’t nearly as good as my old one. So I switched back to my old
one that doesn’t meet meaningful use, but does what I need it to do.
Marketing Concierge Medicine
Q: Do you have a marketing plan?
A: Yes, we work with small businesses with companies with less than 50 employees. We work
through the Chamber of Commerce. We do mailings and talks. We do direct mailings to small
businesses. Our best marketing has been through news stories written about us in the paper or
Q: How large is your community?
A: 60,000. We are in Sarasota County. We have a lot of real estate and construction work. At
the height of the recession, we approached 20% unemployment. Our concierge practice was
at first slowed by the recession, by the fact that we have a large retirement community, and by
waiting to see what the impact of ObamaCare would be.
But after January 1, once people saw what ObamaCare policies offered, the phones have been ringing like mad. People found we are a much better deal.
We don’t sign up patients with insurance unless they have a high deductible plan. We haven’t
taken any new patients with traditional insurance for about 3 years. We will transition
eventually to a complete concierge practice.
The Nice Thing about Hybrid Approach
The nice thing about hybrid approach is that you do not need to shed your existing practice to
start it. You can do it at your own pace with no financial risk. When we start hitting a critical
concierge mass, we can start shedding our worst insurers. We waited until ObamaCare rollout
to see how many patients we would lose to exchanges. The exact opposite occurred. When
people saw how expensive the plans were and how high the deductibles were, our enrollment
increased. What a lot of people are doing is signing up with us and for the Bronze plan with the
Relationship with Specialists and Others
Q: How do other physicians view what you’re doing?
A: They are extremely supportive. We’ve put together a network of physicians in the
community willing to accept large discounts for cash. I have a contracts with 4 local
pharmacies, 2 physical therapy group, 2 imaging centers, 2 labs, a surgery center, an orthopedic
group, nephrologists, rheumatologists, GI specialists, among others.
We have a written price list for specialty and ancillary care under contract. When we send
patients out for specialty care, we can tell them to the penny what their services will cost. Our
policy is total price transparency in everything we do.
Q: So people who deal with you get a good deal through your partnership arrangements.
A: Absolutely. Our contracts allow us to bundle in the routine labs, mammograms, Pap tests
and flu vaccine with our primary care program. If it is medically indicated and can be done in
our office, it is done at no additional charge, such as joint injections, laceration repair, ECGs,
Holter monitors, etc. If non-routine blood work needs to be done, we offer wholesale pricing.
Imaging is a fraction of traditional costs, such as an MRI of the knee for $200, a CT of the head
for $175 or a chest x-ray for $20, including the reading. Our patients sign a contract that they
will only get contracted rates if they pay the specialist in full at the time of service.
Specialists like our plan because they don’t have to hunt down bills or deal with prior
authorizations. It’s supplemental revenue for them, as long as they are not already operating
at full capacity. The concept is similar to Priceline.com that sells otherwise vacant hotel rooms
for a steep discount in exchange for advanced payment. It’s a win win for primary care and
Q: How do you view future 5 years from now?
A: I am probably one of the few primary care physicians that remains excited about the future
of health care. Physicians are scared, frustrated, beat down. Direct primary care represents
the only remaining pure relationship between a patient and a physician. We are working
within a model of complete price transparency that is not fee-for-service, encourages the cost- conscious consumer, and reduces the cost of routine medical care to a level that is affordable
for nearly all, does not exclude for medical conditions and makes primary care a financially
viable specialty. Congress passed a 2,700 page law that couldn’t accomplish it. We did it with a
Tweet: Dr. Lee Gross of North Port, Florida, has developed a hybrid concierge-traditional
primary care practice that attracts the uninsured, insured with high deductibles, and Medicaid