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

This book explores the scientific, ethical, and policy issues surrounding concierge care, including financial problems facing academic medical centers, single specialty hospitals, medical tourism, and the recruitment of wealthy non-U.S. citizens. It analyzes the erosion of science and professional ethics and offers solutions to the challenges faced by academic medical centers.

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

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

  2. 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”

  3. “All men are created equal” • Declaration of Independence • “Some people are more equal than others” • George Orwell

  4. Outline • Financial problems facing academic medical centers • Single specialty hospitals • Medical tourism • Recruitment of wealthy, non-U.S. citizens

  5. Outline • Other competitive strategies • Overseas clinics/hospitals • Boutique/concierge/luxury care clinics • Erosion of science • Erosion of professional ethics • Solutions

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

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

  8. 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

  9. 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

  10. Medical Tourism • US citizens traveling abroad for care • 750,000 in 2007 • 1.4 million in 2016 • vs. 800,000 non-Americans visiting the U.S. annually for care in 2015 • Estimated $439 billion industry (2015)

  11. 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

  12. Reproductive Tourism • 20,000 to 25,000 IVF procedures on US citizens done abroad • Rent-a-womb abuses • India, 25,000 children/yr, surrogacy unregulated • Converse situation is “maternity tourism” – undocumented immigrants entering U.S. to give birth (to babies guaranteed citizenship by the 14th Amendment)

  13. 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) • Hundreds of companies operating in US (regulation weak) • Clinical and ethical issues of treating patients post-op

  14. 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; subsidized care as low as 2-3% of total expenses in many (or 1/2 of profits)

  15. 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

  16. Competitive Strategies Increase cash services (botox treatments, cosmetic surgery) and reimbursable, covered services (e.g., cardiac catheterization, bone density testing) High end maternity suites

  17. 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

  18. 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

  19. 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”

  20. Recruitment of Wealthy Non-US Citizens • Estimated 800,000 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

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

  22. 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

  23. 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 $20 billion/yr to pay medical schools and teaching hospitals for medical education and training • Nearly $1 million for typical 4 yr medical school and 3 yr residency • State and local governments provide $2-3 billion/yr in additional subsidies

  24. 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 immigrants

  25. 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

  26. Overseas Clinics and Hospitals • AMA guidelines exist • Regulations imperfect • Risks include lack of follow-up, exposure to regional infectious diseases, limited malpractice options

  27. 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

  28. Overseas Clinics and Hospitals • Examples: • Harvard, 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

  29. 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

  30. 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

  31. Urgent Care Clinics • 7,369 nationwide (2017) • 3 million visits /wk • Could avert 1/5 ER visits

  32. 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) • Numerous US organizations now offer virtual visits (costs vary) • Self-service kiosks/video visits

  33. Retail Outlet Clinics • Retail outlet clinics increasing • Majority are CVS Minute Clinics and WalGreens Take Care Clinics • WalMart and Target also involved • Some have links with other health care systems)

  34. Retail Outlet Clinics • Retail outlet clinics • Approximately 2,800 • Number may increase with PPACA (due to lack of primary care providers) • Almost 2/3 of current customers have no PCP • Hopes for increasing stores’ profits through sales of merchandise, over-priced pharmaceuticals • Most not profitable

  35. 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 (although not clear if serious diagnoses missed) • Prescription costs similar • Overall costs significantly lower • Convenience factor

  36. 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 • May increase inappropriate antibiotic prescribing • AAP says avoid retail clinics; AAFP has partnered with CVS

  37. Factors Which Might Encourage Retainer Fee Medical PracticeJ Clin Ethics 2005(Spring):72-84 • Tight office schedules, long delays for appointments, short visit lengths • Authorization requirements of insurance companies, HMOs, and Medicare • Insufficient time to return phone calls • Non-reimbursable

  38. Factors Which Might Encourage Retainer Fee Medical Practice • 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 • PCP burnout

  39. 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

  40. Luxury Primary Care Clinics • Some are solo and small group practices • “Doctrepeneurs” • 6,000 physicians (includes “direct primary care” and “hybrid” practices) • May be higher, as Medscape’s 2013 Compensation Survey of 22,000 doctors found 4% of pediatricians and 7% of internists and family physicians reported being in concierge or cash-only practices (similar percentage range for specialists)

  41. Luxury Primary Care and Other Clinics • Direct primary care • Over 400 practices (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

  42. 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

  43. Luxury Primary Care Clinics • Some affiliated with large corporations • Executive Health Registry • Executive Health Exams International • OneMD

  44. 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)

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

  46. Luxury Primary Care Clinics • University-affiliated: • Mayo Clinic; Cleveland Clinic; MGH; Johns Hopkins, Penn, New York Presbyterian, Washington University, UCSF, UCLA, many others • See thousands of outpatients/yr • Mayo Executive Health admissions (2015): 17,667

  47. Luxury Primary Care Clinics • Annual exams last 1-2 days • $2500 - $5000 per visit for baseline package (range $1500 - $20,000) • Additional tests extra • Physicians available 24/7/365 by phone/pager for additional fee

  48. 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”)

  49. 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 • Red blankets

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

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