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Title: Boutique%20Medicine%20Health%20Care%20for%20the%201%:%20Science,%20Ethics,%20and%20Policy

Boutique MedicineHealth Care for the
1Science, Ethics, and Policy
  • 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

  • Financial problems facing academic medical
  • Competitive strategies
  • Boutique/concierge/luxury care clinics
  • Erosion of science
  • Erosion of professional ethics
  • Relevance to Social Justice
  • 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

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

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)

Competitive Strategies
  • Advertising
  • Often promote high-paying, unproved, or cosmetic
  • 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
  • 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

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

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

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
  • 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

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

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 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

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
  • Unnecessary radiation raises cancer risk
  • Abdominal and pelvic ultrasounds to screen for
    liver and ovarian cancer
  • Other tests controversial
  • Genetic testing
  • Mammograms in women beginning at age 35

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..

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 inequalities 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
  • Over 1/3 of physicians not accepting new Medicaid
    patients ¼ see no Medicaid patients
  • 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, UCLA
  • 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

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

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)

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

Declaration of Independence
  • All men are created equal.

George Orwell
  • Some people are more equal than others

Hudson River, 2009
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.

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 often 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
  • Promote a more egalitarian society
  • Confront racial disparities
  • Improve the status of women worldwide

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

Status of Women
  • Worldwide, women do 2/3 of the worlds paid and
    unpaid work (1/3 paid, 2/3 unpaid)
  • receive 10 of global income
  • hold less than 10 of legislative seats
  • own 1 of global property
  • Women face educational, legal, political, and
    social marginalization
  • Limited access to reproductive health services

  • 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

  • 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.

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