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

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