Transcript The Spectrum of Concierge Care: Scientific, Ethical, and Policy Issues Martin Donohoe.

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

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)
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
Medical 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)
Medical Tourism

Transplant Tourism:
Black market for organs (10-25% of all kidneys
transplanted worldwide each year)
 Spurred on by marked organ scarcity in US
 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

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”

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)
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



70,000 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 stateof-the-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 followup, 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
Other Specialized Primary Care
Clinics
Urgent 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
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
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
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

 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

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
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 costeffective
 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
 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

1998 UN/WHO Study: 56% of all migrating
doctors flow from developing to developed
nations, while only 11% migrate in the opposite
direction (even greater imbalance for nurses)
 2007: WHO estimates 2.4 million too few
physicians, nurses, and midwives to provide
essential health services to developing world
 U.S. largest “consumer” of health workers
from the developing world
The Medical Brain Drain

Example of “inverse care law”:
 Those countries that need the most
health care resources are getting the least
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”
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

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

Ethics/Justice

Retail outlet clinics increasing (Wal Mart, CVS,
etc.)
Approximately 1200 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
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
 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.
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

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.phsj.org
[email protected]