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Title: The%20Spectrum%20of%20Concierge%20Care:%20Scientific,%20Ethical,%20and%20Policy%20Issues

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
  • PPACA limits physician-owned hospitals from
    starting or expanding
  • Provision being challenged in courts
  • Boom from 2000-2010, now on decline

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
  • gt1/3 may violate Medicares conditions for

Medical Tourism
  • US citizens traveling abroad for care
  • 750,000 in 2007
  • 1 million in 2010
  • vs. 400,000 non-Americans visiting the U.S.
    annually for care)
  • Estimated 100 billion industry

Medical Tourism
  • 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
  • May contribute to spread of infectious diseases
  • E.g., NDM-1 per some scientists, others

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)

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)
  • Clinical and ethical issues of treating patients

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

Competitive Strategies
  • More aggressive billing practices / charging the
    uninsured higher prices
  • Average 2.5X what most health insurers pay and gt
    3 times actual costs
  • Result class action suits
  • PPACA outlaws

Competitive Strategies
  • Increase cash services (botox treatments,
    cosmetic surgery) and reimbursable, covered
    services (e.g., cardiac catheterization, bone
    density testing)
  • High end maternity suites

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

Competitive Strategies
  • Advertising
  • Often promote high-paying, unproved, or cosmetic
  • Arch Int Med 2005165645-51
  • 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

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

Recruitment of Wealthy Non-US Citizens
  • 60,000 85,000 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

Recruitment of Wealthy Non-US Citizens
  • Doctors sent on overseas speaking and recruitment
  • Patients offered rapid access to state-of-the-art

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

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
  • 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
  • Substantially lower costs (most surgeries 50-90
    less expensive)
  • Many hospitals accredited, staffed by
    U.S.-trained physicians

Overseas Clinics and Hospitals
  • AMA guidelines exist
  • Regulations imperfect
  • Risks include lack of follow-up, exposure to
    regional infectious diseases, limited malpractice

Overseas Clinics and Hospitals
  • 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
  • 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

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

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

Urgent Care Clinics
  • 9,300 nationwide
  • 3 million visits /wk
  • Could avert 1/5 ER visits

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)
  • Self-service kiosks/video visits

Retail Outlet Clinics
  • Approximately 1450 in U.S. (2013)
  • 5.1 million visits (2011)
  • 44 of visits on nights and weekends
  • MinuteClinic (CVS Caremark) Health Systems LLC
    (Walgreens) Walmart others
  • Major health insurers opening retail clinics,
    hoping to sell new policies

Retail Outlet Clinics
  • Quality of care good for simple problems
  • Number may increase with PPACA (due to lack of
    primary care providers)
  • Almost 2/3 of current customers have no PCP

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

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
  • Non-reimbursable
  • 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
  • Specialist referrals up outside luxury care,
    partly due to busy, short PCP visits

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

Luxury Primary Care Clinics
  • Some are solo and small group practices
  • Doctrepeneurs
  • 4,400 - 5,000 physicians (includes direct
    primary care and hybrid practices)
  • May be higher, as Medscapes 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

Luxury Primary Care and Other Clinics
  • Direct primary care
  • E.g., Qliance (44-129 per month, 70-75 already
  • Some evidence shows cost reductions, unnecessary
    tests averted, ER visits reduced, hospital stays
  • Hybrid Practice Physicians see both concierge
    (80) and regular (20) patients
  • E.g., Concierge Choice Physicians, Atlas MD

Luxury Primary Care and Other Clinics
  • Paying by time
  • E.g., DocTalker Family Medicine - 300-400 per
  • 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

Luxury Primary Care Clinics
  • Some 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

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

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
  • 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
  • High thread count sheets

Luxury Primary Care ClinicsPerks 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, aromatherapy, manipulation

Aside Regarding Amenities
  • Improvements in amenities cost hospitals more
    than improvements in quality of care, but
    improved amenities have a greater effect on
    hospital volume
  • Unclear what effect is on patients welfare and
    overall costs of care

Luxury Primary Care Clinics
  • Capitalize on widespread dissatisfaction with
    managed care and too-busy physicians with
    inadequate time to provide comprehensive care and
  • Appeal to patients desires to receive the latest
    high-tech diagnostic and therapeutic interventions

Clients / Patients
  • Predominantly healthy / asymptomatic
  • US and non-US citizens
  • Corporate executives
  • Some from companies with extensive histories of
    harming health through environmental pollution,
    tobacco sales
  • 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
  • Some programs give discounted rates in exchange
    for a donation to the hospital

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

Programs are Secretive
  • Stating that I was a physician researching the
    phenomenon of LPC clinics, I wrote and then
    called 13 LPC clinics
  • Only one person at one clinic would answer basic
    questions relating to the of providers,
    involvement of residents, funding,

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
  • VIP Syndrome Clinicians deviate from practice
    guidelines and thus offer lower quality care

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 and 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
  • MRI breast screens detect nearly 100 of all
    breast cancers
  • Virtual colonoscopies

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

Ethics/JusticeTreating 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

  • Market forces have spurred for-profit health care
    companies to export the most inefficient, unjust
    elements of American medicine to the developing

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

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

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

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

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

LPC Clinics and The Erosion of Professional Ethics
  • Over 1/3 of physicians not accepting new Medicaid
    patients ¼ see no Medicaid patients
  • Overall physician acceptance rates (2014)
  • Medicaid 46
  • Medicare 76
  • Varies by region of country
  • 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

LPC Clinics and The Erosion of Professional Ethics
  • AMA Guidelines
  • Physicians switching to LPC practices must
    facilitate the transfer of patients who dont pay
    retainers to other physicians
  • Shifts un- and poorly-compensated patient care
    onto fewer providers risks domino effect
  • Dearth of primary care providers

(No Transcript)
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 shouldnt be marketed as
    providing better diagnostic and therapeutic

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
    medicines commitment to serving all classes of
    patients who are in need of medical care.

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

  • 42 million uninsured patients in US
  • Translates into 42,000 excess deaths/yr
  • Millions more underinsured
  • Remain in dead-end jobs
  • Go without needed prescriptions due to
    skyrocketing drug prices

  • Public and charity hospitals closing
  • Hospitals provide very little charitable care
    (lt1 when adjusted for Medicare charges includes
    bad debt)

  • Retail outlet clinics increasing (Wal Mart, CVS,
  • Approximately 1400 currently
  • Hopes for increasing stores profits through
    sales of merchandise, over-priced pharmaceuticals
  • Less likely to be located in underserved areas
  • No guarantee of continuity of care
  • Most not profitable

Retail Outlet Clinics
  • Study of visits for OM, pharyngitis, and UTI
  • Ann Int Med 2009151321-8.
  • Quality same as in physician offices and urgent
    care clinics, better than in ER
  • Prescription costs similar
  • Overall costs significantly lower
  • Convenience factor

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

  • Widening disparity between what hospitals charge
    uninsured and self-pay patients compared with
    insured patients
  • Private hospitals charging more than public
    hospitals for end-of-life care
  • No effect on outcomes, quality of life/death

Declaration of Independence
  • All men are created equal.

George Orwell
  • Some people are more equal than others

Hudson River, 2009
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

Physician Dissatisfaction/Cynicism/Erosion of
  • Increasing dissatisfaction and cynicism among
    patients, practicing physicians and trainees
  • High levels of career dissatisfaction and
    physician burnout
  • Educators increasingly concerned over adequacy of
    trainees humanistic and moral development
  • Doctors fabricating/upgrading publications on
    training program applications, cheating on board

Ethical Distortions
  • Insurance/Medicare fraud
  • Seeding trials
  • Taking bribes
  • Doctors offering varying levels of testing and
    treatment based on patients ability to pay
  • J Gen Int Med 200116412-8.

Doctor-Patient Communication re Out-of-Pocket
  • 15-20 of U.S. health care costs paid by patients
  • Physician-patient communication hindered by
    discomfort (patients) and perceived lack of
    time/nihilism (physicians)
  • Relevant/important

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

Address Social Factors Responsible for Illness
and Death
  • Deaths in 2000 attributable to
  • Low education 245,000
  • Racial segregation 176,000
  • Low social support 162,000
  • Individual-level poverty 133,000
  • Income inequality 119,000 (population-attributabl
    e mortality 5.1)
  • Area-level poverty 39,000 (population-attributabl
    e mortality 1.7) (AJPH 20111011456-1465)

Address Social Factors Responsible for Illness
and Death
  • Deaths in 2000 attributable to
  • AMI 193,000
  • CVD 168,000
  • Lung CA 156,000
  • AJPH 20111011456-1465

Deaths per year
  • Tobacco 400,000 ( 50,000 ETS)
  • Obesity 300,000
  • Alcohol 100,000
  • Microbial agents 90,000
  • Toxic agents 60,000 (likely higher)
  • Firearms 35,000
  • Sexual behaviors 30,000
  • Motor vehicles 25,000
  • Illicit drug use 20,000

Major Contributors to Illness and Death
  • 40 of US mortality due to tobacco, poor diet,
    physical inactivity, and misuse of alcohol
  • Every 1 invested in programs covering above
    items saves 5.60 in health care costs

  • 2-4 of national health care expenditures
  • Every 1 spent on building biking trails and
    walking paths would save nearly 3 in medical
  • Every 1 spent on wellness programs, companies
    would save over 3 in medical costs and almost 3
    in absenteeism costs

Public Health Spending
  • Public health spending minimal
  • Mortality rates fall 1-7 for every 10 increase
    in public health spending

Maldistribution of Wealth is Deadly
  • 880,000 deaths/yr in U.S. would be averted if the
    country had an income gap like Western European
    nations, with their stronger social safety nets
  • BMJ 2009339b4471

Address Racial Disparities in Health Care
  • Equalizing the mortality rates of whites and
    African-Americans would have averted 686,202
    deaths between 1991 and 2000
  • Whereas medical advances averted 176,633 deaths
  • (AJPH 2004942078-2081)

Improve Education
  • Medical advances averted a maximum of 178,000
    deaths between 1996 and 2002
  • Correcting disparities in education-associated
    mortality would have save 1.3 million lives
    during the same period
  • AJPH 200797679-83

  • 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 activism

  • History and literature
  • Role models/mentors
  • Refocus ethics training

  • 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//
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