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. Hudson River, 2009

5. Outline • Single specialty hospitals • Medical tourism • Financial problems facing academic medical centers

6. Outline • Recruitment of wealthy, non-U.S. citizens • Overseas clinics/hospitals • Boutique/concierge/luxury care clinics • Erosion of science • Erosion of professional ethics • Solutions

7. Single Specialty Hospitals • Over 100 nationwide • Problems: • Cherry pick healthier patients with good coverage • No need to cross-subsidize indigent care, ER, burn wards, and mental health care • Incentives for over-treatment • Many violate Medicare’s conditions for participation

8. Medical Tourism • US citizens traveling abroad for care (1 million in 2010) • 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

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

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

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

12. Competitive Strategies • More aggressive billing practices / charging the uninsured higher prices • Increase cash services (botox treatments, cosmetic surgery) and reimbursable, covered services (e.g., cardiac catheterization, bone density testing)

13. Competitive Strategies Cut back on uncovered services: e.g., ER staffing “Triaging out” – redirecting low acuity patients from ER to “other facilities” Outsource radiology/transcription services to physicians in developing world

14. Competitive Strategies • Recruitment of Wealthy Non-US Citizens • 70,000 patients/yr (estimated to quadruple in next few years) • Pay sports teams for privilege of being team doctors (in return for free publicity) • NYU Hospital for Joint Diseases – NY Mets • Develop luxury primary care clinics • AKA “executive health clinics”, “boutique medicine”, “concierge care”, “VIP clinics”

15. 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

16. 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

17. Overseas Clinics and Hospitals • Academic medical centers own and/or operating clinics and hospitals overseas • Examples: • Cleveland Clinic: Abu Dhabi, UAE • Mayo Clinic : Dubai • Cornell-Weill Medical College: Qatar

18. Boutique Medicine • Medi-Spas • Cosmetic procedures, massage, aromatherapy, cosmeceutical sales • Retainer Fee Medical Practice • Qliance – lower cost • Premier Care, Valet Care, VIP Care, Gold Care, Platinum Care – much pricier • Luxury Primary Care / Executive Health Clinics

19. Factors Which Encourage Retainer Fee Medical Practice • Tight office schedules, long delays for appointments, short visit lengths • Authorization requirements of insurance companies, HMOs, and Medicare

20. Luxury Primary Care Clinics • University-affiliated (3,000-5,000 pts/yr): • Mayo Clinic; Cleveland Clinic; MGH • Johns Hopkins, Penn, New York Presbyterian, Washington University, UCSF, UCLA • Many others

21. 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

22. 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”)

23. 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

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

25. 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

26. Clients / Patients • Predominantly healthy / asymptomatic • US and non-US citizens • Corporate executives • Disproportionately white males

27. 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

28. LPC Clinics and The Erosion of Science • Many tests not clinically- or cost-effective • Percent body fat measurements • Electron-beam CT scans and stress echocardiograms for coronary artery disease • Significant radiation exposure; raises cancer risk • Abdominal-pelvic ultrasounds to screen for liver and ovarian cancer

29. LPC Clinics and The Erosion of Science • False positive tests may lead to unnecessary investigations, higher costs, and needless anxiety • And increased profits to the clinic…..

30. 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

31. 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 antithetical to evidence-based medical care • Diverts hardware and technician time away from patients with more appropriate and possibly urgent indications for testing

32. 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 • Cross-subsidization of training or indigent care programs rare • Tufts, Virginia-Mason

33. 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

34. 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

35. Headline from The Onion “Uninsured Man Hopes His Symptoms Diagnosed This Week On House”

36. 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

37. Ethical Distortions • Doctors offering varying levels of testing and treatment based on patient’s ability to pay • 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

38. Conclusion:Erosion of Ethics • The promotion of various forms of concierge care 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

39. Solutions • Renounce the marketplace as dominant standard or value in medicine • Promote equal access to scientifically-based, high quality health care

40. Solutions • Society/legislators should provide increased funding for the education and training of physicians and for the continued economic health of academic medical centers, to allow them to carry out their missions of education, research, and patient care, particularly for the underserved

41. 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.”

42. 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).

43. 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.blackwell-synergy.com/doi/pdf/10.1111/j.1525-1497.2004.20631.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.ama-assn.org/ama/pub/category/12249.html

44. Contact Information Public Health and Social Justice Website http://www.publichealthandsocialjustice.org http://www.phsj.org martindonohoe@phsj.org