Luxury Primary Care, Academic Medical Centers, and the Erosion of Science and Professional Ethics

1. Luxury Primary Care,Academic Medical Centers, and the Erosion of Science and Professional Ethics Martin Donohoe, MD, FACP

2. Luxury Primary Care • Introduction • Sources • Research

3. Academic Medical Centers Hurting Financially • US health care crisis • Costs associated with medical training • Disproportionate share of complex and/or uninsured patients

4. Academic Medical Centers Hurting Financially • Erosion of infrastructure • Shrinking funding base • Increased competition with more efficient private and community hospitals

5. Single Specialty Hospitals • Over 100 nationwide • Often physician-owned • Problems: • Cherry pick healthier patients with good coverage • No ER • Academic and community hospitals depleted of income stream used to cross-subsidize indigent care, ER, trauma, burn wards, and mental health care • Incentives for overtreatment • >1/3 may violate Medicare’s conditions for participation

6. Medical Tourism • US citizens traveling abroad for care (750,000 in 2007, estimated 1 million in 2010) • Insurance plans increasingly cover (large cost savings) • Mostly for cardiac, orthopedic, and cosmetic procedures • Sometimes for procedures unavailable or illegal US (e.g., pharmaceuticals, PAS) • Adverse effects on health care availability in foreign countries

7. Medical Tourism • 20,000 to 25,000 IVF procedures on US citizens done abroad • Transplant Tourism: • Black market for organs (10-25% of all kidneys transplanted worldwide each year) • Spurred on by marked organ scarcity in US • Clinical and ethical issues of treating patients post-op • Various legal approaches being considered in US to prosecute

8. Competitive Strategies • Increase alliances with pharmaceutical and biotech industries • Recruit wealthy, non-U.S. citizens as patients • Open hospitals in other countries

9. Competitive Strategies • More aggressive billing practices / charging the uninsured higher prices • Result: class action suits • Increase cash services (botox treatments, cosmetic surgery) and re-imburseable, covered services (e.g., cardiac catheterization, bone density testing)

10. Competitive Strategies • Cut back on uncovered services: e.g., ER staffing • “Triaging out” – redirecting low acuity patients to ER to “other facilities” • University of Chicago overturned policy in response to protests (2009) • ACEP and AAEM opposes such policies

11. 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)

12. 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”

13. 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

14. Recruitment of Wealthy Non-US Citizens • Doctors sent on overseas speaking and recruitment tours • Patients offered rapid access to state-of-the-art care

15. 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

16. 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

17. 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

18. Recruitment of Wealthy Non-US Citizens • Academic medical centers often refuse non-emergent care to non-US citizen refugees and undocumented aliens • Reason: Fear of depletion of financial resources • Costs of care itself • Development of informal referral base

19. Overseas Clinics and Hospitals • Academic medical centers owning and/or operating clinics and hospitals overseas • Examples: • Cleveland Clinic: Abu Dhabi, UAE • Duke University: Duke-National University of Singapore • Johns Hopkins: Cancer center in Singapore International Medical Center

20. 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

21. Boutique Medicine • Retainer Fee Medical Practice • Large/expensive vs. small/less expensive (sometimes for the uninsured; not the focus of this talk) • Premier Care, Valet Care, VIP Care, Gold Care, Platinum Care • Luxury Primary Care / Executive Health Clinics

22. 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

23. 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

24. Factors Which Might Encourage Retainer Fee Medical PracticeJ Clin Ethics 2005(Spring):72-84 • Tight office schedules, long delays for appointments, shorter visit lengths • Authorization requirements of insurance companies, HMOs, and Medicare

25. 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

26. 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

27. Luxury Primary Care Clinics • Some are solo and small group practices • 5,000 physicians (includes “hybrid” and “direct primary care” practices) • Some affiliated with large corporations • Executive Health Registry • Executive Health Exams International • OneMD

28. Luxury Primary Care Clinics • MDVIP • Mission: “Assist doctors in transitioning from traditional to retainer-style practices” • Phenomenal growth rate • 24 practices in 7 states, with 40 more practices in the works • Purchased by Procter and Gamble

29. Luxury Primary Care • Professional Organization: • American Society of Concierge Physicians (ASCP) → • Society for Innovative Medical Practice Design (SIMPD)

30. Luxury Primary Care Clinics • University-affiliated: • Mayo Clinic (3000/yr); Cleveland Clinic (3500/yr); MGH (1950/yr) • Johns Hopkins, Penn, New York Presbyterian, Washington University, UCSF, UCLA, many others

31. Luxury Primary Care Clinics • Annual exams last 1-2 days • Average baseline cost $2000 - $4000 per visit for baseline package • Additional tests extra • (range $1500 - $20,000) • Physicians available 24/7/365 by phone/pager for additional fee

32. Luxury Primary Care Clinics • Some physicians take no insurance, only direct payments (“direct primary care”) • Patient/physician ratios 10-25% of typical managed care levels • Physicians cut current panel size, but often keep some patients, including the uninsured (“hybrid practice”)

33. 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

34. Luxury Primary Care Clinics:Perks and Pampering • Vaccines (in short supply elsewhere) always available • Valet parking • Escorts • Plush bathrobes

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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, cross-subsidization

42. 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

43. LPC Clinics and The Erosion of Science • Electron-beam CT scans and stress echocardiograms for coronary artery disease • Radiation from a full-body CT scan comparable to dose with increased cancer mortality in low-dose atomic bomb survivors (Radiology 2004;232:735-8) • Raise cancer risk • Abdominal-pelvic ultrasounds to screen for liver and ovarian cancer

44. 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…..

45. Direct Marketing of High-Tech Tests to Patients • Ameriscan: • Full body scans: “detect over 100 life-threatening diseases in the arteries, heart, lungs, liver and other major vital organs – before it’s too late” • MRI breastscreens: detect “nearly 100% of all breast cancers” • Virtual colonoscopies

46. 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

47. 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

48. Ethics/Justice:Treating Patients from Overseas • The greatest good for the greatest number • Liver transplant for wealthy foreign banker vs. treating undocumented farm laborers for TB and pesticide-related diseases

49. 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

50. 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