The Spectrum of Concierge Care: Scientific, Ethical, and Policy Issues Martin Donohoe.
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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 PPACA limits physician-owned hospitals from starting or expanding Provision being challenged in courts Boom from 2000-2010, now on decline Single Specialty Hospitals 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 vs. 400,000 non-Americans visiting the U.S. annually for care) $54 billion industry Medical Tourism 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 May contribute to spread of infectious diseases E.g., NDM-1 per some scientists, others Reproductive Tourism 20,000 to 25,000 IVF procedures on US citizens done abroad Rent-a-womb abuses Converse situation is “maternity tourism” – undocumented immigrants entering U.S. to give birth (to babies guaranteed citizenship by the 14th Amendment) Transplant Tourism Transplant Tourism: Black market for organs (10-25% of all kidneys transplanted worldwide each year) Spurred on by marked organ scarcity in US Stem cell tourism increasing Many procedures highly experimental, of dubious benefit (and possibly harm) Clinical and ethical issues of treating patients post-op Competitive Strategies Increase alliances with pharmaceutical and biotech industries Recruit wealthy, non-U.S. citizens as patients Open hospitals in other countries But non-profit hospitals flourishing tax breaks net income up Competitive Strategies More aggressive billing practices / charging the uninsured higher prices Average 2.5X what most health insurers pay and > 3 times actual costs Result: class action suits PPACA outlaws Competitive Strategies Increase cash services (botox treatments, cosmetic surgery) and reimbursable, covered services (e.g., cardiac catheterization, bone density testing) High end maternity suites Competitive Strategies Cut back on uncovered services: e.g., ER staffing “Triaging out” – redirecting low acuity patients from ER to “other facilities” University of Chicago overturned policy in response to protests (2009) ACEP and AAEM opposes such policies Competitive Strategies Advertising Often promote high-paying, unproved, or cosmetic services Arch Int Med 2005;165:645-51 Outsource radiology/transcription services to physicians in developing world e.g., MGH and Yale X-rays → India (they have since ended agreements) Privacy, quality concerns Competitive Strategies 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 Develop luxury primary care clinics AKA “executive health clinics”, “boutique medicine”, “concierge care”, “VIP clinics” Recruitment of Wealthy Non-US Citizens 60,000 – 85,000 patients/yr Estimated 1-2% of hospitals’ revenues Number estimated to quadruple in next few years Recruitment worldwide Hospitals forming consortia to target certain countries, including those with national health plans Recruitment of Wealthy Non-US Citizens Doctors sent on overseas speaking and recruitment tours Patients offered rapid access to state-ofthe-art care Recruitment of Wealthy Non-US Citizens Payment at “retail rate,” well above what government and private insurance reimburse Immediate access to face-to-face translators Only spottily available to uninsured, non-English speaking patients Recruitment of Wealthy Non-US Citizens Patients have not paid taxes in support of medical education and health care subsidies The 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 Substantially lower costs (most surgeries 50-90% less expensive) Many hospitals accredited, staffed by U.S.trained physicians Overseas Clinics and Hospitals AMA guidelines exist Regulations imperfect Risks include lack of follow-up, exposure to regional infectious diseases, limited malpractice options Overseas Clinics and Hospitals 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 Boutique Medicine Medi-Spas Cosmetic procedures, massage, aromatherapy, cosmeceutical sales Generate over $1 billion annually in US Travel medicine clinics for exotic destinations Direct sales to patients of health and nutritional products, home laboratory and genome testing kits Urgent Care Clinics 9,300 nationwide 3 million visits /wk Could avert 1/5 ER visits Other Specialized Primary Care Clinics On-site corporate clinics 1,200 companies host 2,200 clinics Serve 4% of working Americans Telemedicine/videomedicine )advice lines, cannot prescribe, increasingly common overseas (take U.S. calls) Self-service kiosks Retail Outlet Clinics Approximately 1400 in U.S. 6 million visits (2009) 44% of visits on nights and weekends MinuteClinic (CVS Caremark); Health Systems LLC (Walgreen’s); Walmart; others Major health insurers opening retail clinics, hoping to sell new policies Retail Outlet Clinics Quality of care good for simple problems Number may increase with PPACA (due to lack of primary care providers) Almost 2/3 of current customers have no PCP Retail Outlet Clinics Problems include Fragmentation of care Incomplete records Inadequate communication with PCPs Lost opportunity for ongoing contact with PCP Less common in low SES and minority neighborhoods 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 Non-reimbursable 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 Specialist referrals up outside luxury care, partly due to busy, short PCP visits Factors Which Might Encourage Retainer Fee Medical Practice Frequent changes in PCP, abetted by: Hospitalist movement Employers seeking cheaper plans, which provide narrower range of coverage Insurance company de-listing of physicians based on economic criteria Physician extenders (NPs and Pas) Less time for patient-care advocacy Less time for CME Luxury Primary Care Clinics Some are solo and small group practices 4,400 - 5,000 physicians (includes “direct primary care” and “hybrid” practices) 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 Luxury Primary Care Clinics Hybrid Practice: Physicians see both concierge (80%) and regular (20%) patients Paying by time E.g., Concierge Choice Physicians, Atlas MD E.g., DocTalker Family Medicine - $300-$400 per hour 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 MDVIP (largest concierge corporation) 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) American Academy of Private Physicians (AAPP) 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 Aside Regarding Amenities Improvements in amenities cost hospitals more than improvements in quality of care, but improved amenities have a greater effect on hospital volume Unclear what effect is on patients’ welfare and overall costs of care 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 companies with extensive histories of harming health through environmental pollution, tobacco sales 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 Programs are Secretive Stating that I was a physician researching the phenomenon of LPC clinics, I wrote and then called 13 LPC clinics Only one person at one clinic would answer basic questions relating to the # of providers, involvement of residents, funding, crosssubsidization 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 VIP Syndrome: Clinicians deviate from practice guidelines and thus offer lower quality care 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 lowdose 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 lifethreatening diseases in the arteries, heart, lungs, liver and other major vital organs – before it’s too late” aka MRI “CT scams” breast screens: detect “nearly 100% of all breast cancers” Virtual colonoscopies 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 inequities 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 US: 280 physicians/100K population India: 60/100K Sub-Saharan Africa: 18/100K 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 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 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 49 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 Ethics/Justice Retail outlet clinics increasing (Wal Mart, CVS, etc.) Approximately 1400 currently Hopes for increasing stores’ profits through sales of merchandise, over-priced pharmaceuticals Less likely to be located in underserved areas No guarantee of continuity of care Most not profitable Retail Outlet Clinics Study of visits for OM, pharyngitis, and UTI Ann Int Med 2009;151:321-8. Quality same as in physician offices and urgent care clinics, better than in ER Prescription costs similar Overall costs significantly lower Convenience factor 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 Ethics/Justice Widening disparity between what hospitals charge uninsured and self-pay patients compared with insured patients Private hospitals charging more than public hospitals for end-of-life care No effect on outcomes, quality of life/death Hudson River, 2009 Voltaire “The comfort of the rich rests upon an abundance of the poor” 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 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. Doctor-Patient Communication re Out-of-Pocket Costs 15-20% of U.S. health care costs paid by patients out-of-pocket Physician-patient communication hindered by discomfort (patients) and perceived lack of time/nihilism (physicians) Relevant/important 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 Address Social Factors Responsible for Illness and Death Deaths in 2000 attributable to: Low education: 245,000 Racial segregation: 176,000 Low social support: 162,000 Individual-level poverty: 133,000 Income inequality: 119,000 (population-attributable mortality – 5.1%) Area-level poverty: 39,000 (population-attributable mortality – 1.7%) (AJPH 2011;101:1456-1465) Address Social Factors Responsible for Illness and Death Deaths in 2000 attributable to: AMI – 193,000 CVD – 168,000 Lung CA – 156,000 AJPH 2011;101:1456-1465 Deaths per year Tobacco = 400,000 (+ 50,000 ETS) Obesity = 300,000 Alcohol = 100,000 Microbial agents = 90,000 Toxic agents = 60,000 (likely higher) Firearms = 35,000 Sexual behaviors = 30,000 Motor vehicles = 25,000 Illicit drug use = 20,000 Major Contributors to Illness and Death 40% of US mortality due to tobacco, poor diet, physical inactivity, and misuse of alcohol Every $1 invested in programs covering above items saves $5.60 in health care costs Prevention 2-4% of national health care expenditures Every $1 spent on building biking trails and walking paths would save nearly $3 in medical expenses Every $1 spent on wellness programs, companies would save over $3 in medical costs and almost $3 in absenteeism costs Public Health Spending Public health spending minimal Mortality rates fall 1-7% for every 10% increase in public health spending 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) 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 History Role and literature models/mentors Refocus ethics training 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.blackwellsynergy.com/doi/pdf/10.1111/j.15251497.2004.20631.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.amaassn.org/ama/pub/category/12249.html Contact Information Public Health and Social Justice Website http://www.publichealthandsocialjustice.org http://www.phsj.org [email protected]