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