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 • 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

9. Medical Tourism • US citizens traveling abroad for care (750,000 in 2007, 1 million in 2010) • 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

10. 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

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

12. Competitive Strategies • More aggressive billing practices / charging the uninsured higher prices • Result: class action suits • 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”

14. Competitive Strategies • Outsource radiology/transcription services to physicians in developing world • e.g., MGH and Yale X-rays → India (they have since ended agreements) • 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

15. Recruitment of Wealthy Non-US Citizens • 70,000 patients/yr • Estimated 1-2% of hospitals’ revenues • Number estimated to quadruple in next few years

16. Recruitment of Wealthy Non-US Citizens • Doctors sent on overseas speaking and recruitment tours • Payment at “retail rate,” well above what government and private insurance reimburse

17. Recruitment of Wealthy Non-US Citizens • Patients have not paid taxes in support of medical education and health care subsidies • 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

18. 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

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) • Qliance • Premier Care, Valet Care, VIP Care, Gold Care, Platinum Care • Luxury Primary Care / Executive Health Clinics

22. Other Specialized Primary Care Clinics • Retail outlet clinics • On-site corporate clinics • 1,200 companies host 2,200 clinics • Serve 4% of working Americans

23. 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

24. 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

25. Luxury Primary Care Clinics • Some affiliated with large corporations • Executive Health Registry • Executive Health Exams International • OneMD • MDVIP • 24 practices in 7 states, with 40 more practices in the works • Purchased by Procter and Gamble

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

27. 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

28. 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

29. 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”)

30. 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

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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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…..

40. 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” • aka “CT scams”

41. 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

42. 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

43. 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

44. 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 inequities between rich and poor nations • U.S. largest “consumer” of health workers from the developing world

45. 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 • Increases health disparities between rich and poor

46. 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

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

48. 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

49. Other 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

50. 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