Boutique Medicine Health Care for the 1%: Science, Ethics, and Policy

1. Boutique MedicineHealth Care for the 1%:Science, Ethics, and Policy 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. Outline • Financial problems facing academic medical centers • Competitive strategies • Boutique/concierge/luxury care clinics • Erosion of science • Erosion of professional ethics • Relevance to Social Justice • Solutions

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

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

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

7. 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)

8. Competitive Strategies • Advertising • Often promote high-paying, unproved, or cosmetic services • Cut back on uncovered services: e.g., ER staffing • “Triaging out” – redirecting low acuity patients from ER to “other facilities”

9. Competitive Strategies • Outsource radiology/transcription services to physicians in developing world • 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

10. Competitive Strategies • Develop luxury primary care clinics • VIP clinics • Executive health clinics • Boutique medicine • Concierge care

11. Luxury Primary Care Clinics • Some are solo and small group practices • 4,400 - 5,000 physicians (may be many more) • “Doctrepeneurs” • Includes “direct primary care” and “hybrid” practices

12. Luxury Primary Care Clinics • Direct primary care • E.g., Qliance ($44-$129 per month, 70-75% already insured) • Hybrid Practice: Physicians see both concierge (80%) and regular (20%) patients • E.g., Concierge Choice Physicians, Atlas MD • Paying by time • E.g., DocTalker Family Medicine - $300-$400 per hour

13. Luxury Primary Care Clinics • Groups affiliated with large corporations • Executive Health Registry • Executive Health Exams International • OneMD • MDVIP (largest concierge corporation) • 24 practices in 7 states, with 40 more practices in the works • Purchased by Procter and Gamble

14. 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

15. 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

16. 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”)

17. 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

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

19. Luxury Primary Care Clinics:Perks and Pampering • Fancy decorations • Oak-paneled waiting rooms with high-backed leather chairs and fine art • Polished marble bathrooms • TVs, computers, fax machines • Dedicated chefs • Saunas and massages

20. 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

21. Clients / Patients • Predominantly healthy / asymptomatic • US and non-US citizens • Corporate executives • Some from insurance companies, whose own policies increasingly limit the coverage of sick individuals, including their own lower level employees

22. 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

23. 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

24. 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

25. 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

26. LPC Clinics and The Erosion of Science • Electron-beam CT scans and stress echocardiograms for coronary artery disease • Unnecessary radiation raises cancer risk • Abdominal-pelvic ultrasounds to screen for liver and ovarian cancer • Other tests controversial • Genetic testing • Mammograms in women beginning at age 35

27. LPC Clinics and The Erosion of Science • VIP Syndrome: Clinicians deviate from practice guidelines and thus offer lower quality care • False positive tests may lead to unnecessary investigations, higher costs and needless anxiety • And increased profits to the clinic…..

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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 inequalities between rich and poor nations

34. The Medical Brain Drain • U.S. is largest consumer of health care personnel • Five times as many migrating doctors flow from developing to developed nations than in the opposite direction • Even greater imbalance for nurses

35. The Medical Brain Drain • 2011: WHO estimates developing world shortage of 4.3 million health professionals • Europe: 330 physicians/100K population • US: 280/100K • India: 60/100K • Sub-Saharan Africa: 20/100K

36. The Medical Brain Drain • Example of “inverse care law”: • Those countries that need the most health care resources are getting the least • Voluntary WHO Global Code of Practice on the International Recruitment of Health Care Personnel (adopted 2010) • U.S. working on implementing

37. 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 • Over 1/3 of physicians not accepting new Medicaid patients; ¼ see no Medicaid patients • Increases health disparities between rich and poor

38. 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

39. 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, UCLA • Otherwise, evidence lacking due to secrecy • Variant of “trickle down economics”

40. 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

41. 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

42. LPC Clinics and The Erosion of Professional Ethics • ACP Ethics Manual: • “All physicians should provide services to uninsured and underinsured persons. Physicians who choose to deny care solely on the basis of inability to pay should be aware that by thus limiting their patient populations, they risk compromising their professional obligation to care for the poor and the credibility of medicine’s commitment to serving all classes of patients who are in need of medical care.”

43. 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

44. 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

45. Ethics/Justice • 48 million uninsured patients in US • Millions more underinsured • Remain in dead-end jobs • Go without needed prescriptions due to skyrocketing drug prices

46. Ethics/Justice Public and charity hospitals closing Hospitals provide very little charitable care (<1% when adjusted for Medicare charges; includes bad debt)

47. Headline from The Onion Uninsured Man Hopes His Symptoms Diagnosed This Week On House

48. 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

49. 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

50. Declaration of Independence “All men are created equal.”