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Luxury Primary Care, Academic Medical Centers, and the Erosion of Science and Professional Ethics


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Title: Luxury Primary Care, Academic Medical Centers, and the Erosion of Science and Professional Ethics

Luxury Primary Care,Academic Medical Centers,
and the Erosion of Science and Professional Ethics
  • Martin Donohoe, MD, FACP

Luxury Primary Care
  • Introduction
  • Sources
  • Research

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
  • Academic and community hospitals depleted of
    income stream used to cross-subsidize indigent
    care, ER, trauma, burn wards, and mental health
  • Incentives for overtreatment
  • gt1/3 may violate Medicares conditions for

Competitive Strategies
  • Increase alliances with pharmaceutical and
    biotech industries
  • Recruit wealthy, non-U.S. citizens as patients
  • More aggressive billing practices / charging the
    uninsured higher prices
  • Result class action suits

Competitive Strategies
  • Increase cash services (botox treatments,
    cosmetic surgery) and re-imburseable, covered
    services (e.g., cardiac catheterization, bone
    density testing)
  • Cut back on uncovered services e.g., ER staffing

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)

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
  • 70,000 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 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

Recruitment of Wealthy Non-US Citizens
  • Academic medical centers often refuse
    non-emergent care to non-US citizen refugees and
    undocumented aliens
  • Reason Fear of depletion of financial resources
  • Costs of care itself
  • Development of informal referral base

Boutique Medicine
  • Retainer Fee Medical Practice
  • Premier Care, Valet Care, VIP Care, Gold Care,
    Platinum Care
  • Luxury Primary Care / Executive Health Clinics
  • Medi-Spas
  • Travel medicine clinics for exotic destinations
  • Direct sales to patients of health and
    nutritional products

Factors Which Might Encourage Retainer Fee
Medical PracticeJ Clin Ethics 2005(Spring)72-84
  • Tight office schedules, long delays for
    appointments, shorter 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

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
  • Some affiliated with large corporations
  • Executive Health Registry
  • Executive Health Exams International
  • OneMD

Luxury Primary Care Clinics
  • Mission Assist doctors in transitioning from
    traditional to retainer-style practices
  • Phenomenal growth rate
  • 24 practices in 7 states, with 40 more practices
    in the works

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/yr) Cleveland Clinic
    (3500/yr) MGH (1950/yr)
  • Johns Hopkins, Penn, New York Presbyterian,
    Washington University, UCSF, UCLA, many others

Luxury Primary Care Clinics
  • Annual exams last 1-2 days
  • Average baseline cost 2000 - 4000 per visit for
    baseline package
  • Additional tests extra
  • (range 1500 - 20,000)

Luxury Primary Care Clinics
  • Physicians available 24/7/365 by phone/pager for
    additional fee
  • Patient/physician ratios 10-25 of typical
    managed care levels

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

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

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
  • 2008 TX legislation proposed to require
    insurance companies to cover
  • 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
  • MRI breastscreens 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

  • 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
  • US patients going abroad for procedures medical
    tourism supported by many insurance companies

The Medical Brain Drain
  • 1998 UN/WHO Study 56 of all migrating doctors
    flow from developing to developed nations, while
    only 11 migrate in the opposite direction
  • 2007 WHO estimates 2.4 million too few
    physuicians, nurses, and midwives to provide
    essential health services to developing world
  • U.S. largest consumer of health workers from
    the developing world
  • Even greater imbalance for nurses

The Medical Brain Drain
  • Health care and financial loss to developing
    country gain for developed country
  • Example of inverse care law
  • Those countries that need the most health care
    resources are getting the least

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
  • 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

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
  • Physicians with boutique practices are also still
    obligated to provide care to patients in need
  • Robin Hood practices
  • Retainer-style practices shouldnt be marketed as
    providing better diagnostic and therapeutic

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

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

Meanwhile, Outside the US
  • One 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
  • 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.
  • Surprise?

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
  • 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 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 or sex
  • 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

  • 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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