the spectrum of concierge care: scientific, ethical, and policy issues

The Spectrum of Concierge The Spectrum of Concierge Care:Care:

Scientific, Ethical, and Policy Scientific, Ethical, and Policy IssuesIssues

Martin DonohoeMartin Donohoe

Am I Stoned?Am I Stoned?

A 1999 Utah anti-drug pamphlet A 1999 Utah anti-drug pamphlet warns:warns:

““Danger signs that your child Danger signs that your child may be smoking marijuana may be smoking marijuana include excessive preoccupation include excessive preoccupation with social causes, race with social causes, race relations, and environmental relations, and environmental issues”issues”

“All men are created equal”Declaration of Independence

“Some people are more equal than others”George Orwell

OutlineOutline

Financial problems facing Financial problems facing academic medical centersacademic medical centers

Single specialty hospitalsSingle specialty hospitals Medical tourismMedical tourism Recruitment of wealthy, non-Recruitment of wealthy, non-

U.S. citizensU.S. citizens

OutlineOutline

Other competitive strategiesOther competitive strategies Overseas clinics/hospitalsOverseas clinics/hospitals Boutique/concierge/luxury Boutique/concierge/luxury

care clinicscare clinics Erosion of scienceErosion of science Erosion of professional ethicsErosion of professional ethics

SolutionsSolutions

Academic Medical Centers Academic Medical Centers Hurting FinanciallyHurting Financially

US health care crisisUS health care crisis

Costs associated with medical Costs associated with medical trainingtraining

Disproportionate share of complex Disproportionate share of complex and/or uninsured patientsand/or uninsured patients

Academic Medical Centers Academic Medical Centers Hurting FinanciallyHurting Financially

Erosion of infrastructureErosion of infrastructureShrinking funding baseShrinking funding base Increased competition Increased competition

with more efficient private with more efficient private and community hospitalsand community hospitals

Single Specialty Single Specialty HospitalsHospitals

Over 100 nationwideOver 100 nationwide Often physician-ownedOften physician-owned

PPACA limits physician-owned PPACA limits physician-owned hospitals from starting or expandinghospitals from starting or expanding

Provision being challenged in courtsProvision being challenged in courts Boom from 2000-2010, now on Boom from 2000-2010, now on

declinedecline

Single Specialty Single Specialty HospitalsHospitals

Problems:Problems: Cherry pick healthier patients with good Cherry pick healthier patients with good

coveragecoverage No ERNo ER No need to cross-subsidize indigent care, No need to cross-subsidize indigent care,

ER, burn wards, and mental health careER, burn wards, and mental health care Incentives for overtreatmentIncentives for overtreatment >1/3 may violate Medicare’s conditions >1/3 may violate Medicare’s conditions

for participationfor participation

Medical TourismMedical Tourism

US citizens traveling abroad for careUS citizens traveling abroad for care 750,000 in 2007750,000 in 2007 1 million in 20101 million in 2010 vs. 400,000 non-Americans visiting vs. 400,000 non-Americans visiting

the U.S. annually for care)the U.S. annually for care) $54 billion industry$54 billion industry

Medical TourismMedical Tourism

Insurance plans increasingly cover (large cost Insurance plans increasingly cover (large cost savings)savings)

Mostly for cardiac, orthopedic, and cosmetic Mostly for cardiac, orthopedic, and cosmetic proceduresprocedures

Sometimes for pharmaceuticals or procedures Sometimes for pharmaceuticals or procedures unavailable or illegal US (e.g., PAS)unavailable or illegal US (e.g., PAS)

Adverse effects on health care availability in Adverse effects on health care availability in foreign countriesforeign countries

May contribute to spread of infectious May contribute to spread of infectious diseasesdiseases E.g., NDM-1 per some scientists, othersE.g., NDM-1 per some scientists, others

Reproductive TourismReproductive Tourism

20,000 to 25,000 IVF procedures on 20,000 to 25,000 IVF procedures on US citizens done abroadUS citizens done abroad

Rent-a-womb abusesRent-a-womb abuses Converse situation is “maternity Converse situation is “maternity

tourism” – undocumented tourism” – undocumented immigrants entering U.S. to give immigrants entering U.S. to give birth (to babies guaranteed birth (to babies guaranteed citizenship by the 14citizenship by the 14thth Amendment) Amendment)

Transplant TourismTransplant Tourism

Transplant Tourism:Transplant Tourism: Black market for organs (10-25% of all Black market for organs (10-25% of all

kidneys transplanted worldwide each year)kidneys transplanted worldwide each year) Spurred on by marked organ scarcity in Spurred on by marked organ scarcity in

USUS Stem cell tourism increasingStem cell tourism increasing

Many procedures highly experimental, of Many procedures highly experimental, of dubious benefit (and possibly harm)dubious benefit (and possibly harm)

Clinical and ethical issues of treating Clinical and ethical issues of treating patients post-oppatients post-op

Competitive StrategiesCompetitive Strategies

Increase alliances with Increase alliances with pharmaceutical and biotech pharmaceutical and biotech industriesindustries

Recruit wealthy, non-U.S. citizens Recruit wealthy, non-U.S. citizens as patientsas patients

Open hospitals in other countriesOpen hospitals in other countries But non-profit hospitals flourishingBut non-profit hospitals flourishing

tax breakstax breaks net income upnet income up


More aggressive billing More aggressive billing practices / charging the practices / charging the uninsured higher pricesuninsured higher pricesAverage 2.5X what most health Average 2.5X what most health

insurers pay and insurers pay and > 3 times actual > 3 times actual costscosts

Result: class action suitsResult: class action suitsPPACA outlawsPPACA outlaws


Increase cash services (botox Increase cash services (botox treatments, cosmetic surgery) treatments, cosmetic surgery) and reimbursable, covered and reimbursable, covered services (e.g., cardiac services (e.g., cardiac catheterization, bone density catheterization, bone density testing)testing)

High end maternity suitesHigh end maternity suites


Cut back on uncovered services: Cut back on uncovered services: e.g., ER staffinge.g., ER staffing

““Triaging out” – redirecting low Triaging out” – redirecting low acuity patients from ER to acuity patients from ER to “other facilities”“other facilities” University of Chicago overturned policy University of Chicago overturned policy

in response to protests (2009)in response to protests (2009) ACEP and AAEM opposes such policiesACEP and AAEM opposes such policies

Competitive StrategiesCompetitive Strategies AdvertisingAdvertising

Often promote high-paying, unproved, Often promote high-paying, unproved, or cosmetic servicesor cosmetic services

Arch Int Med 2005;165:645-51Arch Int Med 2005;165:645-51 Outsource radiology/transcription Outsource radiology/transcription

services to physicians in developing services to physicians in developing worldworld e.g., MGH and Yale X-rays e.g., MGH and Yale X-rays →→ India India

(they have since ended agreements)(they have since ended agreements) Privacy, quality concernsPrivacy, quality concerns


Pay sports teams for privilege of being Pay sports teams for privilege of being team doctors (in return for free team doctors (in return for free publicity)publicity) Methodist Hospital – Houston TexansMethodist Hospital – Houston Texans NYU Hospital for Joint Diseases – NY NYU Hospital for Joint Diseases – NY

MetsMets Develop luxury primary care clinicsDevelop luxury primary care clinics

AKA “executive health clinics”, AKA “executive health clinics”, “boutique medicine”, “concierge “boutique medicine”, “concierge care”, “VIP clinics”care”, “VIP clinics”

Recruitment of Wealthy Recruitment of Wealthy Non-US CitizensNon-US Citizens

60,000 – 85,000 patients/yr60,000 – 85,000 patients/yr Estimated 1-2% of hospitals’ Estimated 1-2% of hospitals’

revenuesrevenues Number estimated to quadruple in Number estimated to quadruple in

next few yearsnext few years Recruitment worldwideRecruitment worldwide Hospitals forming consortia to target Hospitals forming consortia to target

certain countries, including those with certain countries, including those with national health plansnational health plans


Doctors sent on overseas Doctors sent on overseas speaking and recruitment toursspeaking and recruitment tours

Patients offered rapid access to Patients offered rapid access to state-of-the-art carestate-of-the-art care


Payment at “retail rate,” well Payment at “retail rate,” well above what government and above what government and private insurance reimburseprivate insurance reimburse

Immediate access to face-to-face Immediate access to face-to-face translatorstranslators Only spottily available to Only spottily available to

uninsured, non-English uninsured, non-English speaking patientsspeaking patients


Patients have not paid taxes in support Patients have not paid taxes in support of medical education and health care of medical education and health care subsidiessubsidies The federal government spends The federal government spends

about $10 billion/yr to pay medical about $10 billion/yr to pay medical schools and teaching hospitals for schools and teaching hospitals for medical education and trainingmedical education and training

State and local governments provide State and local governments provide $2-3 billion/yr in additional subsidies$2-3 billion/yr in additional subsidies


Health needs may not be as Health needs may not be as pressing (and are usually more pressing (and are usually more costly) than the needs of those costly) than the needs of those living in poverty in their home living in poverty in their home countriescountries

Academic medical centers often Academic medical centers often refuse non-emergent care to non-US refuse non-emergent care to non-US citizen refugees and undocumented citizen refugees and undocumented aliensaliens

Overseas Clinics and Overseas Clinics and HospitalsHospitals

Academic medical centers owning Academic medical centers owning and/or operating clinics and and/or operating clinics and hospitals overseashospitals overseas

Substantially lower costs (most Substantially lower costs (most surgeries 50-90% less expensive)surgeries 50-90% less expensive)

Many hospitals accredited, staffed Many hospitals accredited, staffed by U.S.-trained physiciansby U.S.-trained physicians


AMA guidelines existAMA guidelines exist

Regulations imperfectRegulations imperfect

Risks include lack of follow-up, Risks include lack of follow-up, exposure to regional infectious exposure to regional infectious diseases, limited malpractice optionsdiseases, limited malpractice options


Examples:Examples:Cleveland Clinic: Abu Dhabi, Cleveland Clinic: Abu Dhabi,

UAEUAEDuke University: Duke-National Duke University: Duke-National

University of SingaporeUniversity of Singapore Johns Hopkins: Cancer center in Johns Hopkins: Cancer center in

Singapore International Medical Singapore International Medical CenterCenter


Examples:Examples: Mayo Clinic : DubaiMayo Clinic : Dubai Cornell-Weill Medical College: QatarCornell-Weill Medical College: Qatar University of Pittsburgh: transplant University of Pittsburgh: transplant

center in Palermo, Sicily, Italycenter in Palermo, Sicily, Italy MD Anderson Cancer Center: MD MD Anderson Cancer Center: MD

Anderson International-EspaAnderson International-España in ña in Madrid, SpainMadrid, Spain

Boutique MedicineBoutique Medicine

Retainer Fee Medical PracticeRetainer Fee Medical PracticeLarge/expensive vs. small/less Large/expensive vs. small/less expensive (sometimes for the expensive (sometimes for the uninsured)uninsured)

QlianceQliance Premier Care, Valet Care, VIP Care, Premier Care, Valet Care, VIP Care,

Gold Care, Platinum CareGold Care, Platinum Care Luxury Primary Care / Executive Luxury Primary Care / Executive

Health ClinicsHealth Clinics

Boutique MedicineBoutique Medicine

Medi-SpasMedi-Spas Cosmetic procedures, massage, Cosmetic procedures, massage,

aromatherapy, cosmeceutical salesaromatherapy, cosmeceutical sales Generate over $1 billion annually in USGenerate over $1 billion annually in US

Travel medicine clinics for exotic Travel medicine clinics for exotic destinationsdestinations

Direct sales to patients of health and Direct sales to patients of health and nutritional products, home nutritional products, home laboratory and genome testing kitslaboratory and genome testing kits

Urgent Care ClinicsUrgent Care Clinics

9,300 nationwide9,300 nationwide

3 million visits /wk3 million visits /wk

Could avert 1/5 ER visitsCould avert 1/5 ER visits

Other Specialized Other Specialized Primary Care ClinicsPrimary Care Clinics

On-site corporate clinicsOn-site corporate clinics1,200 companies host 2,200 clinics1,200 companies host 2,200 clinicsServe 4% of working AmericansServe 4% of working Americans

Telemedicine/videomedicine )advice Telemedicine/videomedicine )advice lines, cannot prescribe, increasingly lines, cannot prescribe, increasingly common overseas (take U.S. calls)common overseas (take U.S. calls)

Self-service kiosksSelf-service kiosks

Retail Outlet ClinicsRetail Outlet Clinics

Approximately 1400 in U.S.Approximately 1400 in U.S. 6 million visits (2009)6 million visits (2009) 44% of visits on nights and 44% of visits on nights and

weekendsweekends MinuteClinic (CVS Caremark); Health MinuteClinic (CVS Caremark); Health

Systems LLC (Walgreen’s); Walmart; Systems LLC (Walgreen’s); Walmart; othersothers

Major health insurers opening retail Major health insurers opening retail clinics, hoping to sell new policiesclinics, hoping to sell new policies


Quality of care good for simple Quality of care good for simple problemsproblems

Number may increase with Number may increase with PPACA (due to lack of primary PPACA (due to lack of primary care providers)care providers)Almost 2/3 of current Almost 2/3 of current

customers have no PCPcustomers have no PCP


Problems includeProblems include Fragmentation of careFragmentation of care Incomplete recordsIncomplete records Inadequate communication with PCPsInadequate communication with PCPs Lost opportunity for ongoing contact Lost opportunity for ongoing contact

with PCPwith PCP Less common in low SES and minority Less common in low SES and minority

neighborhoodsneighborhoods

Factors Which Might Factors Which Might Encourage Retainer Fee Encourage Retainer Fee

Medical PracticeMedical PracticeJ Clin Ethics 2005(Spring):72-84J Clin Ethics 2005(Spring):72-84

Tight office schedules, long Tight office schedules, long delays for appointments, short delays for appointments, short visit lengthsvisit lengths

Authorization requirements of Authorization requirements of insurance companies, HMOs, insurance companies, HMOs, and Medicareand Medicare


Medical PracticeMedical Practice Insufficient time to return phone callsInsufficient time to return phone calls

Non-reimbursableNon-reimbursable Congested ERs, with long delays for Congested ERs, with long delays for

patients with minor illnesses who are patients with minor illnesses who are unable to access PCPunable to access PCP

Patients referred to specialists for Patients referred to specialists for problems that do not necessarily require a problems that do not necessarily require a specialist’s carespecialist’s care Specialist referrals up outside luxury Specialist referrals up outside luxury

care, partly due to busy, short PCP visitscare, partly due to busy, short PCP visits


Medical PracticeMedical Practice Frequent changes in PCP, abetted by:Frequent changes in PCP, abetted by:

Hospitalist movementHospitalist movement Employers seeking cheaper plans, which Employers seeking cheaper plans, which

provide narrower range of coverageprovide narrower range of coverage Insurance company de-listing of Insurance company de-listing of

physicians based on economic criteriaphysicians based on economic criteria Physician extenders (NPs and Pas)Physician extenders (NPs and Pas) Less time for patient-care advocacyLess time for patient-care advocacy Less time for CMELess time for CME

Luxury Primary Care Luxury Primary Care ClinicsClinics

Some are solo and small group practicesSome are solo and small group practices 4,400 - 5,000 physicians (includes “direct 4,400 - 5,000 physicians (includes “direct

primary care” and “hybrid” practices)primary care” and “hybrid” practices) Direct primary careDirect primary care

E.g., Qliance ($44-$129 per month, 70-E.g., Qliance ($44-$129 per month, 70-75% already insured)75% already insured)

Some evidence shows cost reductions, Some evidence shows cost reductions, unnecessary tests averted, ER visits unnecessary tests averted, ER visits reduced, hospital stays shorterreduced, hospital stays shorter


Hybrid Practice: Physicians see both Hybrid Practice: Physicians see both concierge (80%) and regular (20%) concierge (80%) and regular (20%) patientspatients E.g., Concierge Choice Physicians, Atlas MDE.g., Concierge Choice Physicians, Atlas MD

Paying by timePaying by time E.g., DocTalker Family Medicine - $300-E.g., DocTalker Family Medicine - $300-

$400 per hour$400 per hour Cash-only practicesCash-only practices

To avoid insurance company hassles, To avoid insurance company hassles, simplifies billingsimplifies billing


Some affiliated with large corporationsSome affiliated with large corporations Executive Health RegistryExecutive Health Registry Executive Health Exams InternationalExecutive Health Exams International OneMDOneMD

MDVIP (largest concierge corporation)MDVIP (largest concierge corporation) 24 practices in 7 states, with 40 more 24 practices in 7 states, with 40 more

practices in the workspractices in the works Purchased by Procter and GamblePurchased by Procter and Gamble

Luxury Primary CareLuxury Primary Care

Professional Organization:Professional Organization:American Society of American Society of Concierge Physicians Concierge Physicians (ASCP) (ASCP) → → Society for Innovative Medical Practice Design (SIMPD)

American Academy of Private Physicians (AAPP)


University-affiliated:University-affiliated: Mayo Clinic (3000 pts/yr); Mayo Clinic (3000 pts/yr);

Cleveland Clinic (3500 pts/yr); Cleveland Clinic (3500 pts/yr); MGH (2000 pts/yr)MGH (2000 pts/yr)

Johns Hopkins, Penn, New York Johns Hopkins, Penn, New York Presbyterian, Washington Presbyterian, Washington University, UCSF, UCLA, many University, UCSF, UCLA, many othersothers


Annual exams last 1-2 daysAnnual exams last 1-2 days $2000 - $4000 per visit for $2000 - $4000 per visit for

baseline package baseline package (range $1500 (range $1500 - $20,000)- $20,000)

Additional tests extraAdditional tests extra Physicians available 24/7/365 by Physicians available 24/7/365 by

phone/pager for additional feephone/pager for additional fee


Patient/physician ratios 10-25% Patient/physician ratios 10-25% of typical managed care levelsof typical managed care levelsPhysicians cut current panel Physicians cut current panel

size, but often keep some size, but often keep some patients, including the patients, including the uninsured (“hybrid practice”)uninsured (“hybrid practice”)

Luxury Primary Care Luxury Primary Care Clinics:Clinics:

Perks and PamperingPerks and Pampering Tests, subspecialty consultations Tests, subspecialty consultations

available same dayavailable same day Patients jump the queue, Patients jump the queue,

sometimes delaying tests on sometimes delaying tests on other patients with more other patients with more appropriate and urgent needsappropriate and urgent needsSpecial shirtsSpecial shirtsGold cardsGold cards


Perks and PamperingPerks and Pampering Vaccines (in short supply Vaccines (in short supply

elsewhere) always availableelsewhere) always available Valet parkingValet parking EscortsEscorts Plush bathrobesPlush bathrobes High thread count sheetsHigh thread count sheets


Perks and PamperingPerks and Pampering Fancy decorationsFancy decorations Oak-paneled waiting rooms with Oak-paneled waiting rooms with

high-backed leather chairs and fine high-backed leather chairs and fine artart

Polished marble bathroomsPolished marble bathrooms TVs, computers, fax machinesTVs, computers, fax machines Dedicated chefsDedicated chefs Saunas and massagesSaunas and massages

Aside Regarding Amenities

Improvements in amenities cost Improvements in amenities cost hospitals more than improvements hospitals more than improvements in quality of care, but improved in quality of care, but improved amenities have a greater effect on amenities have a greater effect on hospital volumehospital volume

Unclear what effect is on patients’ Unclear what effect is on patients’ welfare and overall costs of carewelfare and overall costs of care


Capitalize on widespread Capitalize on widespread dissatisfaction with managed care dissatisfaction with managed care and too-busy physicians with and too-busy physicians with inadequate time to provide inadequate time to provide comprehensive care and counselingcomprehensive care and counseling

Appeal to patients’ desires to Appeal to patients’ desires to receive the latest high-tech receive the latest high-tech diagnostic and therapeutic diagnostic and therapeutic interventionsinterventions

Clients / PatientsClients / Patients

Predominantly healthy / asymptomaticPredominantly healthy / asymptomatic US and non-US citizensUS and non-US citizens Corporate executivesCorporate executives

Some from companies with extensive Some from companies with extensive histories of harming health through histories of harming health through environmental pollution, tobacco salesenvironmental pollution, tobacco sales

Some from insurance companies, whose Some from insurance companies, whose own policies increasingly limit the own policies increasingly limit the coverage of sick individuals, including coverage of sick individuals, including their own lower level employeestheir own lower level employees

Clients / Patients:Clients / Patients:Upper ManagementUpper Management

Disproportionately white males:Disproportionately white males: Data available from one Executive Data available from one Executive

Health ProgramHealth Program Women:Women:

46% of the workforce46% of the workforceHold Hold < 2% of senior-level < 2% of senior-level management positions in Fortune management positions in Fortune 500 Companies500 Companies

Lower SES of non-CaucasiansLower SES of non-Caucasians

Luxury Primary Care:Luxury Primary Care:MarketingMarketing

Directed at the heads of large and Directed at the heads of large and small companiessmall companies

Hospitals hope high-level managers Hospitals hope high-level managers will steer their companies’ lucrative will steer their companies’ lucrative health care contracts toward the health care contracts toward the institution and its providersinstitution and its providers

Some programs give discounted Some programs give discounted rates in exchange for a donation to rates in exchange for a donation to the hospitalthe hospital

Luxury Primary Care:Luxury Primary Care:MarketingMarketing

Promotional materials imply that Promotional materials imply that wealthy executives are busier and wealthy executives are busier and lead more hectic lives than otherslead more hectic lives than others We cater to “the busy executive” who We cater to “the busy executive” who

“demands only the best”“demands only the best” In fact, lower SES patients’ lives are In fact, lower SES patients’ lives are

often busier and their health often busier and their health outcomes worse, rendering them in outcomes worse, rendering them in greater need of efficient, greater need of efficient, comprehensive carecomprehensive care

Programs are SecretivePrograms are Secretive

Stating that I was a physician Stating that I was a physician researching the phenomenon of LPC researching the phenomenon of LPC clinics, I wrote and then called 13 LPC clinics, I wrote and then called 13 LPC clinicsclinics

Only one person at one clinic would Only one person at one clinic would answer basic questions relating to the answer basic questions relating to the # of providers, involvement of # of providers, involvement of residents, funding, cross-subsidizationresidents, funding, cross-subsidization

LPC Clinics and The LPC Clinics and The Erosion of ScienceErosion of Science

Many tests not clinically- or cost-effectiveMany tests not clinically- or cost-effective Percent body fat measurementsPercent body fat measurements Chest X rays in smokers and non-Chest X rays in smokers and non-

smokers over age 35 to screen for lung smokers over age 35 to screen for lung cancercancer

VIP Syndrome: Clinicians deviate from VIP Syndrome: Clinicians deviate from practice guidelines and thus offer lower practice guidelines and thus offer lower quality carequality care


Electron-beam CT scans and stress Electron-beam CT scans and stress echocardiograms for coronary artery echocardiograms for coronary artery diseasedisease Radiation from a full-body CT scan Radiation from a full-body CT scan

comparable to dose with increased comparable to dose with increased cancer mortality in low-dose atomic bomb cancer mortality in low-dose atomic bomb survivors (Radiology 2004;232:735-8)survivors (Radiology 2004;232:735-8)

Raise cancer riskRaise cancer risk Abdominal-pelvic ultrasounds to screen for Abdominal-pelvic ultrasounds to screen for

liver and ovarian cancerliver and ovarian cancer


Other tests controversialOther tests controversial Genetic testingGenetic testing Mammograms in women beginning Mammograms in women beginning

at age 35at age 35 False positive tests may lead to False positive tests may lead to

unnecessary investigations, higher unnecessary investigations, higher costs and needless anxietycosts and needless anxiety And increased profits to the And increased profits to the

clinic…..clinic…..

Direct Marketing of High-Direct Marketing of High-Tech Tests to PatientsTech Tests to Patients

Ameriscan:Ameriscan: Full body scans: “detect over 100 Full body scans: “detect over 100

life-threatening diseases in the life-threatening diseases in the arteries, heart, lungs, liver and arteries, heart, lungs, liver and other major vital organs – before it’s other major vital organs – before it’s too late”too late” aka “CT scams”aka “CT scams”

MRI breast screens: detect “nearly MRI breast screens: detect “nearly 100% of all breast cancers”100% of all breast cancers”

Virtual colonoscopiesVirtual colonoscopies

The Use of Clinically-The Use of Clinically-Unjustifiable TestsUnjustifiable Tests

Erodes the scientific underpinnings Erodes the scientific underpinnings of medical practiceof medical practice

Sends a mixed message to trainees Sends a mixed message to trainees about when and why to utilize about when and why to utilize diagnostic studiesdiagnostic studies

Runs counter to physicians’ ethical Runs counter to physicians’ ethical obligations to contribute to the obligations to contribute to the ethical stewardship of health care ethical stewardship of health care resourcesresources

The Use of Clinically-The Use of Clinically-Unjustifiable TestsUnjustifiable Tests

Some might argue that if a patient is Some might argue that if a patient is willing to pay for a scientifically-willing to pay for a scientifically-unsupported test that she should be unsupported test that she should be allowed to do so. However,allowed to do so. However, ““Buffet” approach to diagnosis makes a Buffet” approach to diagnosis makes a

mockery of evidence-based medical caremockery of evidence-based medical care Diverts hardware and technician time Diverts hardware and technician time

away from patients with more away from patients with more appropriate and possibly urgent appropriate and possibly urgent indications for testingindications for testing

Ethics/Justice:Ethics/Justice:Treating Patients from Treating Patients from

OverseasOverseas The greatest good for the The greatest good for the

greatest numbergreatest numberLiver transplant for wealthy Liver transplant for wealthy foreign banker vs. treating foreign banker vs. treating undocumented farm undocumented farm laborers for TB and laborers for TB and pesticide-related diseasespesticide-related diseases

Ethics/Justice:Ethics/Justice:Treating Patients OverseasTreating Patients Overseas

Deploying medical students and Deploying medical students and physicians overseas to provide physicians overseas to provide care and educate local care and educate local practitioners in the care of practitioners in the care of respiratory and water-borne respiratory and water-borne infectious diseasesinfectious diseasesKill thousands worldwide each Kill thousands worldwide each dayday

Ethics/JusticeEthics/Justice

Market forces have spurred Market forces have spurred for-profit health care for-profit health care companies to export the most companies to export the most inefficient, unjust elements of inefficient, unjust elements of American medicine to the American medicine to the developing worlddeveloping world

The Medical Brain DrainThe Medical Brain Drain

Migration of medical Migration of medical professionals from the developing professionals from the developing world, where they were trained at world, where they were trained at public expense, to the US further public expense, to the US further depletes health care resources in depletes health care resources in poor countries and contributes to poor countries and contributes to increasing inequities between increasing inequities between rich and poor nationsrich and poor nations


U.S. is largest consumer of U.S. is largest consumer of health care personnelhealth care personnel

Five times as many migrating Five times as many migrating doctors flow from developing to doctors flow from developing to developed nations than in the developed nations than in the opposite directionopposite direction Even greater imbalance for nursesEven greater imbalance for nurses


2011: WHO estimates 2011: WHO estimates developing world shortage of 4.3 developing world shortage of 4.3 million health professionalsmillion health professionalsUS: 280 physicians/100K US: 280 physicians/100K

populationpopulation India: 60/100KIndia: 60/100KSub-Saharan Africa: 18/100K Sub-Saharan Africa: 18/100K


Example of “inverse care law”:Example of “inverse care law”:Those countries that need the most Those countries that need the most

health care resources are getting health care resources are getting the leastthe least

Voluntary WHO Global Code of Voluntary WHO Global Code of Practice on the International Practice on the International Recruitment of Health Care Personnel Recruitment of Health Care Personnel (adopted 2010)(adopted 2010)U.S. working on implementingU.S. working on implementing

LPC Clinics and The LPC Clinics and The Erosion of Professional Erosion of Professional

EthicsEthics Public contributes substantially to the Public contributes substantially to the

education and training of new physicianseducation and training of new physicians May object to doctors limiting their May object to doctors limiting their

practices to the wealthy, not accepting practices to the wealthy, not accepting Medicare or Medicaid patientsMedicare or Medicaid patients Over 1/3 of physicians not accepting new Over 1/3 of physicians not accepting new

Medicaid patients; ¼ see no Medicaid Medicaid patients; ¼ see no Medicaid patientspatients

Increases health disparities between Increases health disparities between rich and poorrich and poor


EthicsEthics Alternatively, debt-ridden Alternatively, debt-ridden

physicians might justify limiting physicians might justify limiting their practices to the wealthy by their practices to the wealthy by claiming a right to freely choose claiming a right to freely choose where they practice and for where they practice and for whom they carewhom they careLimits: HIV patients, racial Limits: HIV patients, racial

prejudiceprejudice


EthicsEthics Academic medical centers’ justifications for Academic medical centers’ justifications for

LPC clinics:LPC clinics: Enhance plurality in health care deliveryEnhance plurality in health care delivery Increase choices available to health care Increase choices available to health care

consumersconsumers Cross-subsidization of training or indigent Cross-subsidization of training or indigent

care programscare programs Tufts, Virginia-MasonTufts, Virginia-Mason Otherwise, evidence lacking due to Otherwise, evidence lacking due to

secrecysecrecy Variant of “trickle down economics”Variant of “trickle down economics”


EthicsEthics AMA Guidelines:AMA Guidelines:

Physicians switching to LPC Physicians switching to LPC practices must facilitate the transfer practices must facilitate the transfer of patients who don’t pay retainers to of patients who don’t pay retainers to other physiciansother physiciansShifts un- and poorly-compensated Shifts un- and poorly-compensated patient care onto fewer providers; patient care onto fewer providers; risks domino effectrisks domino effect

Dearth of primary care providersDearth of primary care providers


EthicsEthics AMA Guidelines:AMA Guidelines:

If non-retainer care is not locally available, If non-retainer care is not locally available, physicians may be obligated to continue to care physicians may be obligated to continue to care for patients without charging them a premiumfor patients without charging them a premium

Otherwise risk charges of abandonmentOtherwise risk charges of abandonment Physicians with boutique practices are also still Physicians with boutique practices are also still

obligated to provide care to patients in needobligated to provide care to patients in need Retainer-style practices shouldn’t be marketed Retainer-style practices shouldn’t be marketed

as providing better diagnostic and therapeutic as providing better diagnostic and therapeutic servicesservices


EthicsEthics ACP Ethics Manual:

“All physicians should provide services to uninsured and underinsured persons. Physicians who choose to deny care solely on the basis of inability to pay should be aware that by thus limiting their patient populations, they risk compromising their professional obligation to care for the poor and the credibility of medicine’s commitment to serving all classes of patients who are in need of medical care.”

Legal Risks of Boutique Practices

Violations of: Medicare regulations (prohibit charging

Medicare beneficiaries additional fees for Medicare-covered services)

False Claims Act Provider agreements with insurance

companies Anti-kickback statutes and other laws

prohibiting payments to induce patient referrals

Other Limitations on Boutique Practices

Some hospitals use economic credentialing to deny hospital privileges

New Jersey prevents insurers from contracting with physicians who charge additional fees

New York prohibits concierge medicine for enrollees in HMOs

States investigating payment mechanisms


49 million uninsured patients in US49 million uninsured patients in US Millions more underinsuredMillions more underinsured

Remain in dead-end jobsRemain in dead-end jobsGo without needed prescriptions Go without needed prescriptions

due to skyrocketing drug pricesdue to skyrocketing drug prices Public and charity hospitals closingPublic and charity hospitals closing


Retail outlet clinics increasing (Wal Retail outlet clinics increasing (Wal Mart, CVS, etc.)Mart, CVS, etc.) Approximately 1400 currentlyApproximately 1400 currently Hopes for increasing stores’ profits Hopes for increasing stores’ profits

through sales of merchandise, over-priced through sales of merchandise, over-priced pharmaceuticalspharmaceuticals

Less likely to be located in underserved Less likely to be located in underserved areasareas

No guarantee of continuity of careNo guarantee of continuity of care Most not profitableMost not profitable


Study of visits for OM, pharyngitis, and Study of visits for OM, pharyngitis, and UTIUTI Ann Int Med 2009;151:321-8.Ann Int Med 2009;151:321-8.

Quality same as in physician offices Quality same as in physician offices and urgent care clinics, better than in and urgent care clinics, better than in ERER

Prescription costs similarPrescription costs similar Overall costs significantly lowerOverall costs significantly lower Convenience factorConvenience factor

Headline from Headline from The OnionThe Onion

Uninsured Man Hopes His Uninsured Man Hopes His Symptoms Diagnosed This Symptoms Diagnosed This

Week On Week On HouseHouse


US ranks near the bottom among US ranks near the bottom among westernized nations in life westernized nations in life expectancy and infant mortalityexpectancy and infant mortality

20-25% of US children live in 20-25% of US children live in povertypoverty

Gap between rich and poor wideningGap between rich and poor widening Racial inequalities in processes and Racial inequalities in processes and

outcomes of care persistoutcomes of care persist


Widening disparity between what Widening disparity between what hospitals charge uninsured and self-hospitals charge uninsured and self-pay patients compared with insured pay patients compared with insured patientspatients

Private hospitals charging more than Private hospitals charging more than public hospitals for end-of-life carepublic hospitals for end-of-life careNo effect on outcomes, quality of No effect on outcomes, quality of

life/deathlife/death

Hudson River, 2009Hudson River, 2009

Voltaire

“The comfort of the rich rests upon an abundance of the poor”

Meanwhile, Outside the Meanwhile, Outside the US…US…

1 billion people lack access to 1 billion people lack access to clean drinking waterclean drinking water

3 billion lack adequate 3 billion lack adequate sanitation servicessanitation services

Hunger kills as many individuals Hunger kills as many individuals in two days as died during the in two days as died during the atomic bombing of Hiroshimaatomic bombing of Hiroshima

Physician Physician Dissatisfaction/Cynicism/ErDissatisfaction/Cynicism/Er

osion of Professionalismosion of Professionalism

Increasing dissatisfaction and cynicism among Increasing dissatisfaction and cynicism among patients, practicing physicians and traineespatients, practicing physicians and trainees High levels of career dissatisfaction and High levels of career dissatisfaction and

physician burnoutphysician burnout Educators increasingly concerned over adequacy Educators increasingly concerned over adequacy

of trainees’ humanistic and moral developmentof trainees’ humanistic and moral development Doctors fabricating/upgrading publications on Doctors fabricating/upgrading publications on

training program applications, cheating on training program applications, cheating on board examsboard exams

Ethical DistortionsEthical Distortions

Insurance/Medicare fraudInsurance/Medicare fraud Seeding trialsSeeding trials Taking bribesTaking bribes Doctors offering varying levels Doctors offering varying levels

of testing and treatment based of testing and treatment based on patient’s ability to payon patient’s ability to pay J Gen Int Med 2001;16:412-8.J Gen Int Med 2001;16:412-8.

Doctor-Patient Doctor-Patient Communication re Out-of-Communication re Out-of-

Pocket CostsPocket Costs 15-20% of U.S. health care costs 15-20% of U.S. health care costs

paid by patients out-of-pocketpaid by patients out-of-pocket Physician-patient communication Physician-patient communication

hindered by discomfort (patients) hindered by discomfort (patients) and perceived lack of time/nihilism and perceived lack of time/nihilism (physicians)(physicians)

Relevant/importantRelevant/important


A sizeable minority of A sizeable minority of physicians admit to “gaming physicians admit to “gaming the system” by manipulating the system” by manipulating reimbursement rules so their reimbursement rules so their patients can receive care the patients can receive care the doctors perceive is necessarydoctors perceive is necessary JAMA 2000;238:1858-65JAMA 2000;238:1858-65 Arch Int Med 2002;162:1134-9Arch Int Med 2002;162:1134-9


¼ of the public sanctions ¼ of the public sanctions deception (½ of those who deception (½ of those who believe doctors have believe doctors have inadequate time to appeal inadequate time to appeal coverage decisions)coverage decisions) Ann Int Med 2003;138:472-5Ann Int Med 2003;138:472-5 Am J Bioethics 2004;4(4):1-7Am J Bioethics 2004;4(4):1-7

Conclusion:Conclusion:Erosion of ScienceErosion of Science

LPC clinics offer care based on LPC clinics offer care based on unsound science and non-evidence-unsound science and non-evidence-based medicinebased medicine

Motives:Motives: MarketabilityMarketability ProfitabilityProfitability Patient satisfaction/demandPatient satisfaction/demand

Potential for harmPotential for harm

Conclusion:Conclusion:Erosion of EthicsErosion of Ethics

The promotion of LPC clinics The promotion of LPC clinics and the recruitment of wealthy and the recruitment of wealthy foreigners by academic medical foreigners by academic medical centers erodes fundamental centers erodes fundamental ethical principles of equity and ethical principles of equity and justice and promotes an overt, justice and promotes an overt, two-tiered system of health two-tiered system of health carecare

SolutionsSolutions

Renounce the marketplace as dominant Renounce the marketplace as dominant standard or value in medicinestandard or value in medicine

Combat corporate activities antithetical Combat corporate activities antithetical to medicine and public healthto medicine and public health

Divert intellectual and financial Divert intellectual and financial resources to more equitable and just resources to more equitable and just investments in community and global investments in community and global healthhealth

Address Social Factors Address Social Factors Responsible for Illness Responsible for Illness

and Deathand Death Deaths in 2000 attributable to:Deaths in 2000 attributable to:

Low education: 245,000Low education: 245,000 Racial segregation: 176,000Racial segregation: 176,000 Low social support: 162,000Low social support: 162,000 Individual-level poverty: 133,000Individual-level poverty: 133,000 Income inequality: 119,000 (population-Income inequality: 119,000 (population-

attributable mortality – 5.1%)attributable mortality – 5.1%) Area-level poverty: 39,000 (population-Area-level poverty: 39,000 (population-

attributable mortality – 1.7%)attributable mortality – 1.7%) (AJPH (AJPH 2011;101:1456-1465)2011;101:1456-1465)

Address Social Factors Address Social Factors Responsible for Illness and Responsible for Illness and

DeathDeath Deaths in 2000 attributable to:Deaths in 2000 attributable to:

AMI – 193,000AMI – 193,000CVD – 168,000CVD – 168,000Lung CA – 156,000Lung CA – 156,000

AJPH 2011;101:1456-1465AJPH 2011;101:1456-1465

Deaths per yearDeaths per year

Tobacco = 400,000 (+ 50,000 ETS)Tobacco = 400,000 (+ 50,000 ETS) Obesity = 300,000Obesity = 300,000 Alcohol = 100,000Alcohol = 100,000 Microbial agents = 90,000Microbial agents = 90,000 Toxic agents = 60,000 (likely higher)Toxic agents = 60,000 (likely higher) Firearms = 35,000Firearms = 35,000 Sexual behaviors = 30,000Sexual behaviors = 30,000 Motor vehicles = 25,000Motor vehicles = 25,000 Illicit drug use = 20,000Illicit drug use = 20,000

Major Contributors to Major Contributors to Illness and DeathIllness and Death

40% of US mortality due to 40% of US mortality due to tobacco, poor diet, physical tobacco, poor diet, physical inactivity, and misuse of alcoholinactivity, and misuse of alcohol

Every $1 invested in programs Every $1 invested in programs covering above items saves covering above items saves $5.60 in health care costs$5.60 in health care costs

PreventionPrevention

2-4% of national health care 2-4% of national health care expendituresexpenditures

Every $1 spent on building biking Every $1 spent on building biking trails and walking paths would save trails and walking paths would save nearly $3 in medical expensesnearly $3 in medical expenses

Every $1 spent on wellness Every $1 spent on wellness programs, companies would save programs, companies would save over $3 in medical costs and almost over $3 in medical costs and almost $3 in absenteeism costs$3 in absenteeism costs

Public Health SpendingPublic Health Spending

Public health spending minimalPublic health spending minimal

Mortality rates fall 1-7% for Mortality rates fall 1-7% for every 10% increase in public every 10% increase in public health spendinghealth spending

Address Racial Disparities Address Racial Disparities in Health Carein Health Care

Equalizing the mortality rates of Equalizing the mortality rates of whites and African-Americans whites and African-Americans would have averted 686,202 deaths would have averted 686,202 deaths between 1991 and 2000between 1991 and 2000 Whereas medical advances Whereas medical advances

averted 176,633 deathsaverted 176,633 deaths

(AJPH 2004;94:2078-2081)(AJPH 2004;94:2078-2081)

SolutionsSolutions

Close some academic Close some academic medical centersmedical centers

Consolidate redundant Consolidate redundant educational and clinical educational and clinical programs in nearby teaching programs in nearby teaching hospitalshospitals

SolutionsSolutions

Reduce costs throughReduce costs through Quality improvement programsQuality improvement programs Improved governance and decision-Improved governance and decision-

makingmaking Augmenting philanthropic Augmenting philanthropic

contributionscontributions Increasing alliances with industry?Increasing alliances with industry?

Risks undue corporate influence on Risks undue corporate influence on academic institutions’ agendasacademic institutions’ agendas

SolutionsSolutions

Improved training and practice Improved training and practice of professionalism in medicineof professionalism in medicine

Heal schism between medicine Heal schism between medicine and public healthand public health

Service-oriented learning, Service-oriented learning, research-based activist courses, research-based activist courses, volunteerism, political activismvolunteerism, political activism

SolutionsSolutions

History and literatureHistory and literature

Role models/mentorsRole models/mentors

Refocus ethics trainingRefocus ethics training

SolutionsSolutions

Empathic and equal provision of Empathic and equal provision of care to all individuals, regardless of care to all individuals, regardless of insurance status, financial insurance status, financial resources, race, gender, or sexual resources, race, gender, or sexual orientationorientation

Confront and work to abolish the Confront and work to abolish the reality of rationing; promote equal reality of rationing; promote equal access and care in all spheres of access and care in all spheres of medicinemedicine

SolutionsSolutions

Educate public and Educate public and policymakers regarding the policymakers regarding the important roles they play in important roles they play in research, education and patient research, education and patient carecareParticularly in terms relevant Particularly in terms relevant to individuals and their to individuals and their familiesfamilies

SolutionsSolutions

Communicate these ideas to Communicate these ideas to business leaders, government business leaders, government representatives, and representatives, and purchasers of health carepurchasers of health careParticularly deans, hospital Particularly deans, hospital presidents and department presidents and department chairschairs

SolutionsSolutions

Society/legislators should provide Society/legislators should provide increased funding for the education increased funding for the education and training of medical students and and training of medical students and resident physicians and for the resident physicians and for the continued health of vital academic continued health of vital academic medical centers, to allow them to medical centers, to allow them to carry out their missions of education, carry out their missions of education, research, and patient care, research, and patient care, particularly for the underservedparticularly for the underserved

Primo Levi

“A country is considered the more civilized the more the wisdom and efficiency of its laws hinder a weak man from becoming too weak or a powerful one too powerful.”

ReferencesReferences Donohoe MT. “Standard vs. luxury care,” Donohoe MT. “Standard vs. luxury care,”

in in Ideological Debates in Family Ideological Debates in Family MedicineMedicine, S , S Buetow and T Kenealy, Eds. Buetow and T Kenealy, Eds. ((New York, Nova Science Publishers, Inc., New York, Nova Science Publishers, Inc., 2007). Available at 2007). Available at http://phsj.org/?page_id=22

Donohoe MT. Elements of professionalism Donohoe MT. Elements of professionalism for a physician considering the switch to a for a physician considering the switch to a retainer practice. In retainer practice. In Professionalism in Professionalism in Medicine: The Case-based Guide for Medicine: The Case-based Guide for Medical StudentsMedical Students, Editors: Spandorfer, , Editors: Spandorfer, Pohl, Rattner, and Nasca (Cambridge Pohl, Rattner, and Nasca (Cambridge University Press, 2008, in press).University Press, 2008, in press).

ReferencesReferences Donohoe MT. Luxury primary care, Donohoe MT. Luxury primary care,

academic medical centers, and the academic medical centers, and the erosion of science and professional ethics. erosion of science and professional ethics. J Gen Int Med 2004;19:90-94. Available at J Gen Int Med 2004;19:90-94. Available at http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525-1497.2004.20631.x

Donohoe MT. Retainer practice: Scientific Donohoe MT. Retainer practice: Scientific issues, social justice, and ethical issues, social justice, and ethical perspectives. American Medical perspectives. American Medical Association Virtual Mentor 2004 Association Virtual Mentor 2004 (April);6(4). Available at (April);6(4). Available at http://www.ama-assn.org/ama/pub/category/12249.html

Contact InformationContact Information

Public Health and Social Public Health and Social Justice WebsiteJustice Website

http://www.publichealthandsocialjustice.org

http://[email protected]

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