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


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

The Spectrum of Concierge CareScientific,
Ethical, and Policy Issues
  • Martin Donohoe

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

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

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

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

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

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

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
  • gt1/3 may violate Medicares conditions for

Medical Tourism
  • US citizens traveling abroad for care (750,000 in
    2007, 1 million in 2010)
  • Insurance plans increasingly cover (large cost
  • Mostly for cardiac, orthopedic, and cosmetic
  • Sometimes for pharmaceuticals or procedures
    unavailable or illegal US (e.g., PAS)
  • Adverse effects on health care availability in
    foreign countries

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

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

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)

Competitive Strategies
  • Cut back on uncovered services e.g., ER staffing
  • Triaging out redirecting low acuity patients
    from ER to other facilities

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

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

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

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

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

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
  • Johns Hopkins Cancer center in Singapore
    International Medical Center

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

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

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

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

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 specialists

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

Luxury Primary Care
  • Professional Organization
  • American Society of Concierge Physicians (ASCP) ?
    Society for Innovative Medical Practice Design

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

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

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

Luxury Primary Care ClinicsPerks and Pampering
  • Tests, subspecialty consultations available same
  • Patients jump the queue, sometimes delaying tests
    on other patients with more appropriate and
    urgent needs
  • Special shirts
  • Gold cards

Luxury Primary Care ClinicsPerks and Pampering
  • Vaccines (in short supply elsewhere) always
  • Valet parking
  • Escorts
  • Plush bathrobes

Luxury Primary Care ClinicsPerks 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

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

Clients / PatientsUpper Management
  • Disproportionately white males
  • Data available from one Executive Health Program
  • Women
  • 46 of the workforce
  • Hold lt 2 of senior-level management positions in
    Fortune 500 Companies
  • Lower SES of non-Caucasians

Luxury Primary CareMarketing
  • Directed at the heads of large and small
  • Hospitals hope high-level managers will steer
    their companies lucrative health care contracts
    toward the institution and its providers

Luxury Primary CareMarketing
  • 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

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

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 2004232735-8)
  • Raise cancer risk
  • Abdominal-pelvic ultrasounds to screen for liver
    and ovarian cancer

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..

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 its too late
  • aka CT scams

The Use of Clinically-Unjustifiable Tests
  • Erodes the scientific underpinnings of medical
  • 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

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

Ethics/JusticeTreating 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

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
  • U.S. largest consumer of health workers from
    the developing world

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
  • Increases health disparities between rich and poor

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

LPC Clinics and The Erosion of Professional Ethics
  • Academic medical centers justifications for LPC
  • Enhance plurality in health care delivery
  • Increase choices available to health care
  • Cross-subsidization of training or indigent care
  • Tufts, Virginia-Mason
  • Otherwise, evidence lacking due to secrecy
  • Variant of trickle down economics

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

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

  • 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

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

  • 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

Meanwhile, Outside the US
  • 1 billion people lack access to clean drinking
  • 3 billion lack adequate sanitation services
  • Hunger kills as many individuals in two days as
    died during the atomic bombing of Hiroshima

  • The comfort of the rich rests upon an abundance
    of the poor

Hudson River, 2009
Physician Dissatisfaction/Cynicism/Erosion of
  • Increasing dissatisfaction and cynicism among
    patients, practicing physicians and trainees
  • Educators increasingly concerned over adequacy of
    trainees humanistic and moral development

Ethical Distortions
  • Doctors offering varying levels of testing and
    treatment based on patients ability to pay
  • J Gen Int Med 200116412-8.

Ethical Distortions
  • 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
  • JAMA 20002381858-65
  • Arch Int Med 20021621134-9

Ethical Distortions
  • ¼ of the public sanctions deception (½ of those
    who believe doctors have inadequate time to
    appeal coverage decisions)
  • Ann Int Med 2003138472-5
  • Am J Bioethics 20044(4)1-7

ConclusionErosion of Science
  • LPC clinics offer care based on unsound science
    and non-evidence-based medicine
  • Motives
  • Marketability
  • Profitability
  • Patient satisfaction/demand
  • Potential for harm

ConclusionErosion of Ethics
  • The promotion of LPC clinics 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

  • Renounce the marketplace as dominant standard or
    value in medicine
  • Combat corporate activities antithetical to
    medicine and public health
  • Divert intellectual and financial resources to
    more equitable and just investments in community
    and global health

  • Close some academic medical centers
  • Consolidate redundant educational and clinical
    programs in nearby teaching hospitals

  • Reduce costs through
  • Quality improvement programs
  • Improved governance and decision-making
  • Augmenting philanthropic contributions
  • Increasing alliances with industry?
  • Risks undue corporate influence on academic
    institutions agendas

  • Improved training and practice of professionalism
    in medicine
  • Heal schism between medicine and public health
  • Service-oriented learning, research-based
    activist courses, volunteerism, political
  • Increase numbers of primary care physicians

  • Empathic and equal provision of care to all
    individuals, regardless of insurance status,
    financial resources, race, gender, or sexual
  • Confront and work to abolish the reality of
    rationing promote equal access and care in all
    spheres of medicine

  • Educate public and policymakers regarding the
    important roles they play in research, education
    and patient care
  • Particularly in terms relevant to individuals and
    their families

  • Communicate these ideas to business leaders,
    government representatives, and purchasers of
    health care
  • Particularly deans, hospital presidents and
    department chairs

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

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.

  • 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
  • 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).

  • Donohoe MT. Luxury primary care, academic medical
    centers, and the erosion of science and
    professional ethics. J Gen Int Med 20041990-94.
    Available at http//
  • Donohoe MT. Retainer practice Scientific issues,
    social justice, and ethical perspectives.
    American Medical Association Virtual Mentor 2004
    (April)6(4). Available at http//

Contact Information
  • Public Health and Social Justice Website
  • http//