Transcript Boutique Medicine Health Care for the 1%: Science, Ethics, and Policy Martin Donohoe.

Boutique Medicine
Health Care for the 1%:
Science, Ethics, and Policy
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”
Outline





Financial problems facing academic medical
centers
Competitive strategies
Boutique/concierge/luxury care clinics
 Erosion of science
 Erosion of professional ethics
Relevance to Social Justice
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
Competitive Strategies

Increase alliances with pharmaceutical and
biotech industries

Recruit wealthy, non-U.S. citizens as
patients

Open hospitals in other countries
Competitive Strategies

More aggressive billing practices / charging
the uninsured higher prices

Increase cash services (botox treatments,
cosmetic surgery) and reimbursable,
covered services (e.g., cardiac
catheterization, bone density testing)
Competitive Strategies
Advertising
 Often promote high-paying, unproved,
or cosmetic services
 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
 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
Competitive Strategies

Develop luxury primary care clinics
 VIP clinics
 Executive health clinics
 Boutique medicine
 Concierge care
Luxury Primary Care Clinics

Some are solo and small group practices

6,000 physicians (and increasing)


“Doctrepeneurs”
Includes “direct primary care” and
“hybrid” practices
Luxury Primary Care and Other
Clinics


Direct primary care
 E.g., Qliance ($44-$129 per month, 70-75% already
insured)
 Some evidence shows cost reductions, unnecessary
tests averted, ER visits reduced, hospital stays
shorter
Hybrid Practice: Physicians see both concierge (80%)
and regular (20%) patients
 E.g., Concierge Choice Physicians, Atlas MD
Luxury Primary Care and Other
Clinics




Paying by time
 E.g., DocTalker Family Medicine - $300-$400 per
hour
Online medical auctions for care (Medibid)
High deductible, “faith-based plans” for those opposed
to Obamacare
Cash-only practices
 To avoid insurance company hassles, simplifies
billing
Luxury Primary Care Clinics

Some affiliated with large corporations
 Executive Health Registry
 Executive Health Exams International
 OneMD
Luxury Primary Care Clinics

MDVIP (largest concierge corporation)
 800
affiliated physicians in 41 states
 Purchased by Procter and Gamble
 $1,500 annual fee
 First firm to be held liable in a malpractice
case for the care provided by its contracted
doctors

$8.5 million judgment (2015)
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

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
 High thread count sheets

Luxury Primary Care Clinics:
Perks and Pampering






Fancy decorations
Oak-paneled waiting rooms with high-backed
leather chairs and fine art
Polished marble bathrooms
TVs, computers, fax machines
Dedicated chefs
Saunas and massages, aromatherapy,
manipulation
Luxury Primary Care Clinics
Capitalize on widespread dissatisfaction
with managed care and too-busy physicians
with inadequate time to provide
comprehensive care and counseling
 Appeal to patients’ desires to receive the
latest high-tech diagnostic and therapeutic
interventions

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
Some programs give discounted rates in
exchange for a donation to the hospital
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 nonsmokers 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
 Unnecessary radiation raises cancer risk
 Abdominal and pelvic ultrasounds to screen
for liver and ovarian cancer
Other tests controversial
 Genetic testing
 Mammograms in women beginning at age 35
LPC Clinics and The Erosion of
Science
VIP Syndrome: Clinicians deviate from
practice guidelines and thus offer lower
quality care
 False positive tests may lead to unnecessary
investigations, higher costs and needless
anxiety
 And increased profits to the clinic…..

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 pesticiderelated diseases
Ethics/Justice:
Treating Patients Overseas
 Deploying
medical students and
physicians overseas to provide care
and educate local practitioners in the
care of respiratory and water-borne
infectious diseases
 Kill thousands worldwide each day
Ethics/Justice
 Market
forces have spurred for-profit
health care companies to export the
most inefficient, unjust elements of
American medicine to the developing
world
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
inequalities between rich and poor nations
The Medical Brain Drain

U.S. is largest consumer of health care
personnel

Five times as many migrating doctors flow
from developing to developed nations than
in the opposite direction
 Even
greater imbalance for nurses
The Medical Brain Drain

2011: WHO estimates developing world
shortage of 4.3 million health professionals
 Europe: 330 physicians/100K
population
 US: 280/100K
 India: 60/100K
 Sub-Saharan Africa: 20/100K
The Medical Brain Drain
Example of “inverse care law”:
 Those countries that need the most
health care resources are getting the least
 Voluntary WHO Global Code of Practice
on the International Recruitment of Health
Care Personnel (adopted 2010)
 U.S. working on implementing

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
 Over
1/3 of physicians not accepting new
Medicaid patients; ¼ see no Medicaid patients
 Increases
poor
health disparities between rich and
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, UCLA
 Otherwise, evidence lacking due to secrecy
 Variant of “trickle down economics”
LPC Clinics and The Erosion of
Professional Ethics

AMA Guidelines:
 Physicians switching to LPC practices must
facilitate the transfer of patients who don’t
pay retainers to other physicians
 Shifts un- and poorly-compensated patient
care onto fewer providers; risks domino
effect
 Dearth of primary care providers
LPC Clinics and The Erosion of
Professional Ethics

AMA Guidelines:
 If non-retainer care is not locally available,
physicians may be obligated to continue to care for
patients without charging them a premium

Otherwise risk charges of abandonment
Physicians with boutique practices are also still
obligated to provide care to patients in need
 Retainer-style practices shouldn’t be marketed as
providing better diagnostic and therapeutic services

LPC Clinics and The Erosion of
Professional Ethics

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

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


Before PPACA: 42 million uninsured patients in
US
 Leading to 45,000 excess deaths/yr
 Now 36 million uninsured (11%)
Millions more underinsured
 Remain in dead-end jobs
 Go without needed prescriptions due to
skyrocketing drug prices
Ethics/Justice

Public and charity hospitals closing

Hospitals provide very little charitable care
(<1% when adjusted for Medicare charges;
includes bad debt)
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

Declaration of Independence
“All men are created equal.”
George Orwell
“Some people are more equal
than others”
Hudson River, 2009
Physician
Dissatisfaction/Cynicism/Erosion of
Professionalism



Increasing dissatisfaction and cynicism among patients,
practicing physicians and trainees
 High levels of career dissatisfaction and physician
burnout
Educators increasingly concerned over adequacy of
trainees’ humanistic and moral development
Doctors fabricating/upgrading publications on training
program applications, cheating on board exams
Ethical Distortions
 Insurance/Medicare
fraud
 Seeding
trials
 Taking bribes
 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 often 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
Address social factors responsible for
illness and death
 Promote a more egalitarian society
 Confront racial disparities
 Improve the status of women worldwide

Maldistribution of Wealth is
Deadly
 880,000
deaths/yr in U.S. would be
averted if the country had an income
gap like Western European nations,
with their stronger social safety nets

BMJ 2009;339:b4471
Address Racial Disparities in Health
Care

Equalizing the mortality rates of whites
and African-Americans would have averted
686,202 deaths between 1991 and 2000
 Whereas medical advances averted
176,633 deaths
(AJPH 2004;94:2078-2081)
Improve Education
Medical advances averted a maximum of
178,000 deaths between 1996 and 2002
 Correcting disparities in educationassociated mortality would have save 1.3
million lives during the same period
 AJPH 2007;97:679-83

Status of Women



Worldwide, women do 2/3 of the world’s paid
and unpaid work (1/3 paid, 2/3 unpaid)
 receive 10% of global income
 hold less than 10% of legislative seats
 own 1% of global property
Women face educational, legal, political, and
social marginalization
Limited access to reproductive health services
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

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.”
Contact Information
Public Health and Social Justice Website
http://www.publichealthandsocialjustice.org
http://www.phsj.org
[email protected]