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

The Spectrum of Concierge Care:Scientific, Ethical, and Policy Issues

Martin Donohoe

Am I Stoned?

A 1999 Utah anti-drug pamphlet warns:“Danger signs that your child may be smoking marijuana include excessive preoccupation with social causes, race relations, and environmental issues”

•“All men are created equal”–Declaration of Independence

•“Some people are more equal than others”–George Orwell

Outline

• Financial problems facing academic medical centers

• Single specialty hospitals• Medical tourism• Recruitment of wealthy, non-U.S.

citizens

Outline

• Other competitive strategies• Overseas clinics/hospitals• Boutique/concierge/luxury care

clinics–Erosion of science–Erosion of professional ethics

• Solutions

Academic Medical Centers Hurting Financially

• US health care crisis

• Costs associated with medical training

• Disproportionate share of complex and/or uninsured patients

Academic Medical Centers Hurting Financially

• Erosion of infrastructure• Shrinking funding base• Increased competition with more

efficient private and community hospitals

Single Specialty Hospitals

• Over 100 nationwide• Often physician-owned• Problems:

– Cherry pick healthier patients with good coverage– No ER– No need to cross-subsidize indigent care, ER, burn wards,

and mental health care– Incentives for overtreatment– >1/3 may violate Medicare’s conditions for participation

Medical Tourism

• US citizens traveling abroad for care (750,000 in 2007, 1 million in 2010)– Insurance plans increasingly cover (large cost

savings)– Mostly for cardiac, orthopedic, and cosmetic

procedures– Sometimes for pharmaceuticals or procedures

unavailable or illegal US (e.g., PAS)– Adverse effects on health care availability in

foreign countries

Medical Tourism

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

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

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

Competitive Strategies

• Increase alliances with pharmaceutical and biotech industries

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

Competitive Strategies

• More aggressive billing practices / charging the uninsured higher prices– Result: class action suits

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

Competitive Strategies

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

• “Triaging out” – redirecting low acuity patients from ER to “other facilities”

Competitive Strategies

• Outsource radiology/transcription services to physicians in developing world–e.g., MGH and Yale X-rays → India

(they have since ended agreements)• Pay sports teams for privilege of being

team doctors (in return for free publicity)– Methodist Hospital – Houston Texans– NYU Hospital for Joint Diseases – NY Mets

Recruitment of Wealthy Non-US Citizens

• 70,000 patients/yr–Estimated 1-2% of hospitals’

revenues–Number estimated to quadruple in

next few years

Recruitment of Wealthy Non-US Citizens

• Doctors sent on overseas speaking and recruitment tours

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

Recruitment of Wealthy Non-US Citizens

• Patients have not paid taxes in support of medical education and health care subsidies– Federal government spends about $10

billion/yr to pay medical schools and teaching hospitals for medical education and training

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

Recruitment of Wealthy Non-US Citizens

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

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

Overseas Clinics and Hospitals

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

• Examples:– Cleveland Clinic: Abu Dhabi, UAE– Duke University: Duke-National University of

Singapore– Johns Hopkins: Cancer center in Singapore

International Medical Center

Overseas Clinics and Hospitals

• Examples:– Mayo Clinic : Dubai– Cornell-Weill Medical College: Qatar– University of Pittsburgh: transplant center in

Palermo, Sicily, Italy– MD Anderson Cancer Center: MD Anderson

International-España in Madrid, Spain

Boutique Medicine

• Retainer Fee Medical Practice• Large/expensive vs. small/less expensive

(sometimes for the uninsured)• Qliance• Premier Care, Valet Care, VIP Care, Gold Care,

Platinum Care• Luxury Primary Care / Executive Health Clinics

Other Specialized Primary Care Clinics

• Retail outlet clinics

• On-site corporate clinics–1,200 companies host 2,200 clinics–Serve 4% of working Americans

Factors Which Might Encourage Retainer Fee Medical Practice

J Clin Ethics 2005(Spring):72-84

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

• Authorization requirements of insurance companies, HMOs, and Medicare

Factors Which Might Encourage Retainer Fee Medical Practice

• Insufficient time to return phone calls

• Congested ERs, with long delays for patients with minor illnesses who are unable to access PCP

• Patients referred to specialists for problems that do not necessarily require a specialist’s care

Luxury Primary Care Clinics

• Some affiliated with large corporations–Executive Health Registry–Executive Health Exams International–OneMD

• MDVIP– 24 practices in 7 states, with 40 more

practices in the works– Purchased by Procter and Gamble

Luxury Primary Care

• Professional Organization:–American Society of Concierge

Physicians (ASCP) → Society for Innovative Medical Practice Design (SIMPD)

Luxury Primary Care Clinics

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

Clinic (3500 pts/yr); MGH (2000 pts/yr)–Johns Hopkins, Penn, New York

Presbyterian, Washington University, UCSF, UCLA, many others

Luxury Primary Care Clinics

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

package (range $1500 - $20,000)• Additional tests extra• Physicians available 24/7/365 by

phone/pager for additional fee

Luxury Primary Care Clinics

• Some physicians take no insurance, only direct payments (“direct primary care”)

• Patient/physician ratios 10-25% of typical managed care levels–Physicians cut current panel size, but

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

Luxury Primary Care Clinics:Perks and Pampering

• Tests, subspecialty consultations available same day–Patients jump the queue, sometimes

delaying tests on other patients with more appropriate and urgent needs• Special shirts• Gold cards

Luxury Primary Care Clinics:Perks and Pampering

• Vaccines (in short supply elsewhere) always available

• Valet parking

• Escorts

• Plush bathrobes

Luxury Primary Care Clinics:Perks and Pampering

• Oak-paneled waiting rooms with high-backed leather chairs and fine art

• TVs, computers, fax machines

• Buffet meals, herb teas

• Saunas and massages

Clients / Patients

• Predominantly healthy / asymptomatic• US and non-US citizens• Corporate executives

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

Clients / Patients:Upper Management

• Disproportionately white males:– Data available from one Executive Health

Program– Women:

• 46% of the workforce• Hold < 2% of senior-level management

positions in Fortune 500 Companies– Lower SES of non-Caucasians

Luxury Primary Care:Marketing

• Directed at the heads of large and small companies

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

Luxury Primary Care:Marketing

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

only the best”• In fact, lower SES patients’ lives are often

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

LPC Clinics and The Erosion of Science

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

smokers over age 35 to screen for lung cancer

LPC Clinics and The Erosion of Science

– Electron-beam CT scans and stress echocardiograms for coronary artery disease• Radiation from a full-body CT scan comparable

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

• Raise cancer risk– Abdominal-pelvic ultrasounds to screen for liver

and ovarian cancer

LPC Clinics and The Erosion of Science

• Other tests controversial– Genetic testing– Mammograms in women beginning at age

35• False positive tests may lead to unnecessary

investigations, higher costs and needless anxiety– And increased profits to the clinic…..

Direct Marketing of High-Tech Tests to Patients

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

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

The Use of Clinically-Unjustifiable Tests

• Erodes the scientific underpinnings of medical practice

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

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

The Use of Clinically-Unjustifiable Tests

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

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

from patients with more appropriate and possibly urgent indications for testing

Ethics/Justice:Treating Patients from Overseas

• The greatest good for the greatest number–Liver transplant for wealthy foreign

banker vs. treating undocumented farm laborers for TB and pesticide-related diseases

The Medical Brain Drain

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

• U.S. largest “consumer” of health workers from the developing world

LPC Clinics and The Erosion of Professional Ethics

• Public contributes substantially to the education and training of new physicians–May object to doctors limiting their

practices to the wealthy, not accepting Medicare or Medicaid patients

–Increases health disparities between rich and poor

LPC Clinics and The Erosion of Professional Ethics

• Alternatively, debt-ridden physicians might justify limiting their practices to the wealthy by claiming a right to freely choose where they practice and for whom they care–Limits: HIV patients, racial prejudice

LPC Clinics and The Erosion of Professional Ethics

• Academic medical centers’ justifications for LPC clinics:– Enhance plurality in health care delivery– Increase choices available to health care

consumers– Cross-subsidization of training or indigent care

programs• Tufts, Virginia-Mason• Otherwise, evidence lacking due to secrecy• Variant of “trickle down economics”

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

Ethics/Justice

• 51 million uninsured patients in US• Millions more underinsured

–Remain in dead-end jobs–Go without needed prescriptions due

to skyrocketing drug prices• Public and charity hospitals closing

Headline from The Onion

Uninsured Man Hopes His Symptoms Diagnosed This Week On House

Ethics/Justice

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

• 20-25% of US children live in poverty• Gap between rich and poor widening• Racial inequalities in processes and

outcomes of care persist

Meanwhile, Outside the US…

• 1 billion people lack access to clean drinking water

• 3 billion lack adequate sanitation services

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

Voltaire

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

Hudson River, 2009

Physician Dissatisfaction/Cynicism/Erosion of Professionalism

• Increasing dissatisfaction and cynicism among patients, practicing physicians and trainees

• Educators increasingly concerned over adequacy of trainees’ humanistic and moral development

Ethical Distortions

• Doctors offering varying levels of testing and treatment based on patient’s ability to pay– J Gen Int Med 2001;16:412-8.

Ethical Distortions

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

Ethical Distortions

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

Conclusion:Erosion of Science

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

• Motives:– Marketability– Profitability– Patient satisfaction/demand

• Potential for harm

Conclusion:Erosion of Ethics

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

Solutions

• Renounce the marketplace as dominant standard or value in medicine

• Combat corporate activities antithetical to medicine and public health

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

Solutions

• Close some academic medical centers

• Consolidate redundant educational and clinical programs in nearby teaching hospitals

Solutions

• Reduce costs through– Quality improvement programs– Improved governance and decision-making– Augmenting philanthropic contributions– Increasing alliances with industry?

• Risks undue corporate influence on academic institutions’ agendas

Solutions

• Improved training and practice of professionalism in medicine

• Heal schism between medicine and public health

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

• Increase numbers of primary care physicians

Solutions

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

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

Solutions

• Educate public and policymakers regarding the important roles they play in research, education and patient care–Particularly in terms relevant to

individuals and their families

Solutions

• Communicate these ideas to business leaders, government representatives, and purchasers of health care–Particularly deans, hospital

presidents and department chairs

Solutions

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

References• Donohoe MT. “Standard vs. luxury care,” in

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

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

References• Donohoe MT. Luxury primary care, academic medical

centers, and the erosion of science and professional ethics. 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 issues, social justice, and ethical perspectives. American Medical Association Virtual Mentor 2004 (April);6(4). Available at http://www.ama-assn.org/ama/pub/category/12249.html

Contact Information

Public Health and Social Justice Website

http://www.phsj.orgmartindonohoe@phsj.org