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

Luxury Primary Care,Luxury Primary Care,Academic Medical Academic Medical Centers, and the Centers, and the

Erosion of Science and Erosion of Science and Professional EthicsProfessional Ethics

Martin Donohoe, MD, Martin Donohoe, MD, FACPFACP

Luxury Primary CareLuxury Primary Care

IntroductionIntroduction

SourcesSources

ResearchResearch

Academic Medical Centers Academic Medical Centers Hurting FinanciallyHurting Financially

US health care crisisUS health care crisis

Costs associated with medical Costs associated with medical trainingtraining

Disproportionate share of complex Disproportionate share of complex and/or uninsured patientsand/or uninsured patients

Academic Medical Centers Academic Medical Centers Hurting FinanciallyHurting Financially

Erosion of infrastructureErosion of infrastructureShrinking funding baseShrinking funding base Increased competition Increased competition

with more efficient private with more efficient private and community hospitalsand community hospitals

Single Specialty Single Specialty HospitalsHospitals

Over 100 nationwideOver 100 nationwide Often physician-ownedOften physician-owned Problems:Problems:

Cherry pick healthier patients with good coverageCherry pick healthier patients with good coverage No ERNo ER Academic and community hospitals depleted of Academic and community hospitals depleted of

income stream used to cross-subsidize indigent income stream used to cross-subsidize indigent care, ER, trauma, burn wards, and mental health care, ER, trauma, burn wards, and mental health carecare

Incentives for overtreatmentIncentives for overtreatment >1/3 may violate Medicare’s conditions for >1/3 may violate Medicare’s conditions for

participationparticipation

Medical TourismMedical Tourism

US citizens traveling abroad for care US citizens traveling abroad for care (750,000 in 2007, expected 1 million (750,000 in 2007, expected 1 million in 2010)in 2010) Insurance plans increasingly coverInsurance plans increasingly cover

Transplant tourismTransplant tourism Black market for organs (1/5 of all Black market for organs (1/5 of all

kidneys transplanted worldwide kidneys transplanted worldwide each year)each year)

Competitive StrategiesCompetitive Strategies

Increase alliances with Increase alliances with pharmaceutical and biotech pharmaceutical and biotech industriesindustries

Recruit wealthy, non-U.S. Recruit wealthy, non-U.S. citizens as patientscitizens as patients

Open hospitals in other Open hospitals in other countriescountries


More aggressive billing practices / More aggressive billing practices / charging the uninsured higher charging the uninsured higher pricesprices Result: class action suitsResult: class action suits

Increase cash services (botox Increase cash services (botox treatments, cosmetic surgery) and treatments, cosmetic surgery) and re-imburseable, covered services re-imburseable, covered services (e.g., cardiac catheterization, bone (e.g., cardiac catheterization, bone density testing)density testing)


Cut back on uncovered services: Cut back on uncovered services: e.g., ER staffinge.g., ER staffing

““Triaging out” – redirecting low Triaging out” – redirecting low acuity patients to ER to “other acuity patients to ER to “other facilities”facilities” University of Chicago overturned policy University of Chicago overturned policy

in response to protests (2009)in response to protests (2009) ACEP and AAEM opposes such policiesACEP and AAEM opposes such policies


AdvertisingAdvertising Often promote high-paying, unproved, Often promote high-paying, unproved,

or cosmetic servicesor cosmetic services Arch Int Med 2005;165:645-51Arch Int Med 2005;165:645-51

Outsource radiology/transcription Outsource radiology/transcription services to physicians in developing services to physicians in developing worldworld e.g., MGH and Yale X-rays e.g., MGH and Yale X-rays →→ India India

(they have since ended (they have since ended agreements)agreements)


Pay sports teams for privilege of being Pay sports teams for privilege of being team doctors (in return for free team doctors (in return for free publicity)publicity) Methodist Hospital – Houston TexansMethodist Hospital – Houston Texans NYU Hospital for Joint Diseases – NY NYU Hospital for Joint Diseases – NY

MetsMets Develop luxury primary care clinicsDevelop luxury primary care clinics

AKA “executive health clinics”, AKA “executive health clinics”, “boutique medicine”, “concierge “boutique medicine”, “concierge care”, “VIP clinics”care”, “VIP clinics”

Recruitment of Wealthy Recruitment of Wealthy Non-US CitizensNon-US Citizens

70,000 patients/yr70,000 patients/yr Estimated 1-2% of hospitals’ Estimated 1-2% of hospitals’

revenuesrevenues Number estimated to quadruple in Number estimated to quadruple in

next few yearsnext few years Recruitment worldwideRecruitment worldwide Hospitals forming consortia to target Hospitals forming consortia to target

certain countries, including those with certain countries, including those with national health plansnational health plans


Doctors sent on overseas Doctors sent on overseas speaking and recruitment speaking and recruitment tourstours

Patients offered rapid access Patients offered rapid access to state-of-the-art careto state-of-the-art care


Payment at “retail rate,” well Payment at “retail rate,” well above what government and above what government and private insurance reimburseprivate insurance reimburse

Immediate access to face-to-face Immediate access to face-to-face translatorstranslators Only spottily available to Only spottily available to

uninsured, non-English uninsured, non-English speaking patientsspeaking patients


Patients have not paid taxes in support Patients have not paid taxes in support of medical education and health care of medical education and health care subsidiessubsidies The federal government spends The federal government spends

about $10 billion/yr to pay medical about $10 billion/yr to pay medical schools and teaching hospitals for schools and teaching hospitals for medical education and trainingmedical education and training

State and local governments provide State and local governments provide $2-3 billion/yr in additional subsidies$2-3 billion/yr in additional subsidies


Health needs may not be as Health needs may not be as pressing (and are usually pressing (and are usually more costly) than the needs more costly) than the needs of those living in poverty in of those living in poverty in their home countriestheir home countries


Academic medical centers often Academic medical centers often refuse non-emergent care to non-US refuse non-emergent care to non-US citizen refugees and undocumented citizen refugees and undocumented aliensaliens

Reason: Fear of depletion of financial Reason: Fear of depletion of financial resourcesresources Costs of care itselfCosts of care itself Development of informal referral Development of informal referral

basebase

Boutique MedicineBoutique Medicine

Retainer Fee Medical PracticeRetainer Fee Medical PracticeLarge/expensive vs. small/less Large/expensive vs. small/less expensive (sometimes for the expensive (sometimes for the uninsured; not the focus of this uninsured; not the focus of this talk)talk)

Premier Care, Valet Care, VIP Care, Premier Care, Valet Care, VIP Care, Gold Care, Platinum CareGold Care, Platinum Care

Luxury Primary Care / Executive Luxury Primary Care / Executive Health ClinicsHealth Clinics

Boutique MedicineBoutique Medicine

Retail outlet clinicsRetail outlet clinics Medi-SpasMedi-Spas Travel medicine clinics for exotic Travel medicine clinics for exotic

destinationsdestinations Direct sales to patients of health Direct sales to patients of health

and nutritional products, home and nutritional products, home laboratory and genome testing laboratory and genome testing kitskits

Factors Which Might Factors Which Might Encourage Retainer Fee Encourage Retainer Fee

Medical PracticeMedical PracticeJ Clin Ethics 2005(Spring):72-84J Clin Ethics 2005(Spring):72-84

Tight office schedules, long Tight office schedules, long delays for appointments, delays for appointments, shorter visit lengthsshorter visit lengths

Authorization requirements of Authorization requirements of insurance companies, HMOs, insurance companies, HMOs, and Medicareand Medicare


Medical PracticeMedical Practice Insufficient time to return phone Insufficient time to return phone

callscalls Congested ERs, with long delays Congested ERs, with long delays

for patients with minor illnesses for patients with minor illnesses who are unable to access PCPwho are unable to access PCP

Patients referred to specialists Patients referred to specialists for problems that do not for problems that do not necessarily require a specialist’s necessarily require a specialist’s carecare


Medical PracticeMedical Practice Frequent changes in PCP, abetted by:Frequent changes in PCP, abetted by:

Hospitalist movementHospitalist movement Employers seeking cheaper plans, which Employers seeking cheaper plans, which

provide narrower range of coverageprovide narrower range of coverage Insurance company de-listing of Insurance company de-listing of

physicians based on economic criteriaphysicians based on economic criteria Physician extenders (NPs and Pas)Physician extenders (NPs and Pas) Less time for patient-care advocacyLess time for patient-care advocacy Less time for CMELess time for CME

Luxury Primary Care Luxury Primary Care ClinicsClinics

Some are solo and small group Some are solo and small group practicespractices

Some affiliated with large Some affiliated with large corporationscorporationsExecutive Health RegistryExecutive Health RegistryExecutive Health Exams Executive Health Exams InternationalInternational

OneMDOneMD


MDVIPMDVIPMission: “Assist doctors in Mission: “Assist doctors in

transitioning from traditional transitioning from traditional to retainer-style practices”to retainer-style practices”

Phenomenal growth ratePhenomenal growth rate24 practices in 7 states, with 24 practices in 7 states, with

40 more practices in the works40 more practices in the works

Luxury Primary CareLuxury Primary Care

Professional Organization:Professional Organization:American Society of American Society of Concierge Physicians Concierge Physicians (ASCP) (ASCP) →→

Society for Innovative Medical Practice Design (SIMPD)


University-affiliated:University-affiliated: Mayo Clinic (3000/yr); Mayo Clinic (3000/yr);

Cleveland Clinic (3500/yr); Cleveland Clinic (3500/yr); MGH (1950/yr)MGH (1950/yr)

Johns Hopkins, Penn, New York Johns Hopkins, Penn, New York Presbyterian, Washington Presbyterian, Washington University, UCSF, UCLA, many University, UCSF, UCLA, many othersothers


Annual exams last 1-2 daysAnnual exams last 1-2 days

Average baseline cost $2000 - Average baseline cost $2000 - $4000 per visit for baseline $4000 per visit for baseline packagepackage Additional tests extraAdditional tests extra (range $1500 - $20,000)(range $1500 - $20,000)


Physicians available 24/7/365 Physicians available 24/7/365 by phone/pager for additional by phone/pager for additional feefee

Patient/physician ratios 10-Patient/physician ratios 10-25% of typical managed care 25% of typical managed care levelslevels

Luxury Primary Care Luxury Primary Care Clinics:Clinics:

Perks and PamperingPerks and Pampering Tests, subspecialty consultations Tests, subspecialty consultations

available same dayavailable same day Patients jump the queue, Patients jump the queue,

sometimes delaying tests on sometimes delaying tests on other patients with more other patients with more appropriate and urgent needsappropriate and urgent needsSpecial shirtsSpecial shirtsGold cardsGold cards


Perks and PamperingPerks and Pampering Vaccines (in short supply Vaccines (in short supply

elsewhere) always availableelsewhere) always available

Valet parkingValet parking

EscortsEscorts

Plush bathrobesPlush bathrobes


Perks and PamperingPerks and Pampering Oak-paneled waiting rooms with Oak-paneled waiting rooms with

high-backed leather chairs and fine high-backed leather chairs and fine artart

TVs, computers, fax machinesTVs, computers, fax machines

Buffet meals, herb teasBuffet meals, herb teas

Saunas and massagesSaunas and massages


Capitalize on widespread Capitalize on widespread dissatisfaction with managed care dissatisfaction with managed care and too-busy physicians with and too-busy physicians with inadequate time to provide inadequate time to provide comprehensive care and counselingcomprehensive care and counseling

Appeal to patients’ desires to Appeal to patients’ desires to receive the latest high-tech receive the latest high-tech diagnostic and therapeutic diagnostic and therapeutic interventionsinterventions

Clients / PatientsClients / Patients

Predominantly healthy / asymptomaticPredominantly healthy / asymptomatic US and non-US citizensUS and non-US citizens Corporate executivesCorporate executives

Some from companies with extensive Some from companies with extensive histories of harming health through histories of harming health through environmental pollution, tobacco salesenvironmental pollution, tobacco sales

Some from insurance companies, whose Some from insurance companies, whose own policies increasingly limit the own policies increasingly limit the coverage of sick individuals, including coverage of sick individuals, including their own lower level employeestheir own lower level employees

Clients / Patients:Clients / Patients:Upper ManagementUpper Management

Disproportionately white males:Disproportionately white males: Data available from one Executive Data available from one Executive

Health ProgramHealth Program Women:Women:

46% of the workforce46% of the workforceHold Hold < 2% of senior-level < 2% of senior-level management positions in Fortune management positions in Fortune 500 Companies500 Companies

Lower SES of non-CaucasiansLower SES of non-Caucasians

Luxury Primary Care:Luxury Primary Care:MarketingMarketing

Directed at the heads of large and Directed at the heads of large and small companiessmall companies

Hospitals hope high-level managers Hospitals hope high-level managers will steer their companies’ lucrative will steer their companies’ lucrative health care contracts toward the health care contracts toward the institution and its providersinstitution and its providers

Some programs give discounted Some programs give discounted rates in exchange for a donation to rates in exchange for a donation to the hospitalthe hospital

Luxury Primary Care:Luxury Primary Care:MarketingMarketing

Promotional materials imply that Promotional materials imply that wealthy executives are busier and wealthy executives are busier and lead more hectic lives than otherslead more hectic lives than others We cater to “the busy executive” who We cater to “the busy executive” who

“demands only the best”“demands only the best” In fact, lower SES patients’ lives are In fact, lower SES patients’ lives are

often busier and their health often busier and their health outcomes worse, rendering them in outcomes worse, rendering them in greater need of efficient, greater need of efficient, comprehensive carecomprehensive care

Programs are SecretivePrograms are Secretive

Stating that I was a physician Stating that I was a physician researching the phenomenon of LPC researching the phenomenon of LPC clinics, I wrote and then called 13 LPC clinics, I wrote and then called 13 LPC clinicsclinics

Only one person at one clinic would Only one person at one clinic would answer basic questions relating to the answer basic questions relating to the # of providers, involvement of # of providers, involvement of residents, funding, cross-subsidizationresidents, funding, cross-subsidization

LPC Clinics and The LPC Clinics and The Erosion of ScienceErosion of Science

Many tests not clinically- or Many tests not clinically- or cost-effectivecost-effectivePercent body fat Percent body fat measurementsmeasurements

Chest X rays in smokers Chest X rays in smokers and non-smokers over age and non-smokers over age 35 to screen for lung cancer35 to screen for lung cancer


Electron-beam CT scans and stress Electron-beam CT scans and stress echocardiograms for coronary artery echocardiograms for coronary artery diseasedisease

Radiation from a full-body CT scan comparable Radiation from a full-body CT scan comparable to dose with increased cancer mortality in low-to dose with increased cancer mortality in low-dose atomic bomb survivors (Radiology dose atomic bomb survivors (Radiology 2004;232:735-8)2004;232:735-8)

Raise cancer riskRaise cancer risk 2008: TX legislation proposed to require 2008: TX legislation proposed to require

insurance companies to coverinsurance companies to cover Abdominal-pelvic ultrasounds to screen for Abdominal-pelvic ultrasounds to screen for

liver and ovarian cancerliver and ovarian cancer


Other tests controversialOther tests controversial Genetic testingGenetic testing Mammograms in women beginning Mammograms in women beginning

at age 35at age 35 False positive tests may lead to False positive tests may lead to

unnecessary investigations, higher unnecessary investigations, higher costs and needless anxietycosts and needless anxiety And increased profits to the And increased profits to the

clinic…..clinic…..

Direct Marketing of High-Direct Marketing of High-Tech Tests to PatientsTech Tests to Patients

Ameriscan:Ameriscan: Full body scans: “detect over 100 Full body scans: “detect over 100

life-threatening diseases in the life-threatening diseases in the arteries, heart, lungs, liver and arteries, heart, lungs, liver and other major vital organs – before it’s other major vital organs – before it’s too late”too late”

MRI breastscreens: detect “nearly MRI breastscreens: detect “nearly 100% of all breast cancers”100% of all breast cancers”

Virtual colonoscopiesVirtual colonoscopies

The Use of Clinically-The Use of Clinically-Unjustifiable TestsUnjustifiable Tests

Erodes the scientific underpinnings Erodes the scientific underpinnings of medical practiceof medical practice

Sends a mixed message to trainees Sends a mixed message to trainees about when and why to utilize about when and why to utilize diagnostic studiesdiagnostic studies

Runs counter to physicians’ ethical Runs counter to physicians’ ethical obligations to contribute to the obligations to contribute to the ethical stewardship of health care ethical stewardship of health care resourcesresources

The Use of Clinically-The Use of Clinically-Unjustifiable TestsUnjustifiable Tests

Some might argue that if a patient is Some might argue that if a patient is willing to pay for a scientifically-willing to pay for a scientifically-unsupported test that she should be unsupported test that she should be allowed to do so. However,allowed to do so. However, ““Buffet” approach to diagnosis makes a Buffet” approach to diagnosis makes a

mockery of evidence-based medical caremockery of evidence-based medical care Diverts hardware and technician time Diverts hardware and technician time

away from patients with more away from patients with more appropriate and possibly urgent appropriate and possibly urgent indications for testingindications for testing

Ethics/Justice:Ethics/Justice:Treating Patients from Treating Patients from

OverseasOverseas The greatest good for the The greatest good for the

greatest numbergreatest numberLiver transplant for wealthy Liver transplant for wealthy foreign banker vs. treating foreign banker vs. treating undocumented farm undocumented farm laborers for TB and laborers for TB and pesticide-related diseasespesticide-related diseases

Ethics/Justice:Ethics/Justice:Treating Patients OverseasTreating Patients Overseas

Deploying medical students and Deploying medical students and physicians overseas to provide physicians overseas to provide care and educate local care and educate local practitioners in the care of practitioners in the care of respiratory and water-borne respiratory and water-borne infectious diseasesinfectious diseasesKill thousands worldwide each Kill thousands worldwide each dayday

Ethics/JusticeEthics/Justice

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


Migration of medical professionals from Migration of medical professionals from the developing world, where they were the developing world, where they were trained at public expense, to the US trained at public expense, to the US further depletes health care resources further depletes health care resources in poor countries and contributes to in poor countries and contributes to increasing inequities between rich and increasing inequities between rich and poor nationspoor nations

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

The Medical Brain DrainThe Medical Brain Drain 1998 UN/WHO Study: 56% of all 1998 UN/WHO Study: 56% of all

migrating doctors flow from developing migrating doctors flow from developing to developed nations, while only 11% to developed nations, while only 11% migrate in the opposite directionmigrate in the opposite direction 2007: WHO estimates 2.4 million too 2007: WHO estimates 2.4 million too

few physuicians, nurses, and few physuicians, nurses, and midwives to provide essential health midwives to provide essential health services to developing worldservices to developing world

U.S. largest “consumer” of health U.S. largest “consumer” of health workers from the developing worldworkers from the developing world

Even greater imbalance for nursesEven greater imbalance for nurses

The Medical Brain DrainThe Medical Brain Drain

Health care and financial loss to Health care and financial loss to developing country; gain for developing country; gain for developed countrydeveloped country

Example of “inverse care law”:Example of “inverse care law”:Those countries that need the Those countries that need the

most health care resources are most health care resources are getting the leastgetting the least

LPC Clinics and The LPC Clinics and The Erosion of Professional Erosion of Professional

EthicsEthics Public contributes substantially to Public contributes substantially to

the education and training of new the education and training of new physiciansphysiciansMay object to doctors limiting their May object to doctors limiting their

practices to the wealthy, not practices to the wealthy, not accepting Medicare or Medicaid accepting Medicare or Medicaid patientspatients

Increases health disparities Increases health disparities between rich and poorbetween rich and poor


EthicsEthics Alternatively, debt-ridden Alternatively, debt-ridden

physicians might justify limiting physicians might justify limiting their practices to the wealthy by their practices to the wealthy by claiming a right to freely choose claiming a right to freely choose where they practice and for where they practice and for whom they carewhom they careLimits: HIV patients, racial Limits: HIV patients, racial

prejudiceprejudice


EthicsEthics Academic medical centers’ Academic medical centers’

justifications for LPC clinics:justifications for LPC clinics: Enhance plurality in health care Enhance plurality in health care

delivery; increase choices available delivery; increase choices available to health care consumersto health care consumers

Cross-subsidization of training or Cross-subsidization of training or indigent care programsindigent care programsEvidence lacking due to secrecyEvidence lacking due to secrecyVariant of “trickle down Variant of “trickle down economics”economics”


EthicsEthics AMA Guidelines:AMA Guidelines:

Physicians switching to LPC Physicians switching to LPC practices must facilitate the practices must facilitate the transfer of patients who don’t pay transfer of patients who don’t pay retainers to other physiciansretainers to other physiciansShifts un- and poorly-Shifts un- and poorly-compensated patient care onto compensated patient care onto fewer providers; risks domino fewer providers; risks domino effecteffect


EthicsEthics AMA Guidelines:AMA Guidelines:

If non-retainer care is not locally available, If non-retainer care is not locally available, physicians may be obligated to continue to care physicians may be obligated to continue to care for patients without charging them a premiumfor patients without charging them a premium

Physicians with boutique practices are also still Physicians with boutique practices are also still obligated to provide care to patients in needobligated to provide care to patients in need

““Robin Hood practices”Robin Hood practices” Retainer-style practices shouldn’t be marketed Retainer-style practices shouldn’t be marketed

as providing better diagnostic and therapeutic as providing better diagnostic and therapeutic servicesservices


45 million uninsured patients in 45 million uninsured patients in USUS

Millions more underinsuredMillions more underinsuredRemain in dead-end jobsRemain in dead-end jobsGo without needed Go without needed

prescriptions due to prescriptions due to skyrocketing drug pricesskyrocketing drug prices


Public and charity hospitals closingPublic and charity hospitals closing Retail outlet clinics increasing (Wal Retail outlet clinics increasing (Wal

Mart, CVS, etc.)Mart, CVS, etc.) Mechanism for increasing stores’ Mechanism for increasing stores’

profits through sales of merchandise, profits through sales of merchandise, over-priced pharmaceuticalsover-priced pharmaceuticals

Less likely to be located in Less likely to be located in underserved areasunderserved areas

No guarantee of continuity of careNo guarantee of continuity of care

Headline from Headline from The OnionThe Onion

Uninsured Man Hopes His Uninsured Man Hopes His Symptoms Diagnosed This Symptoms Diagnosed This

Week On Week On HouseHouse


US ranks near the bottom among US ranks near the bottom among westernized nations in life westernized nations in life expectancy and infant mortalityexpectancy and infant mortality

20-25% of US children live in 20-25% of US children live in povertypoverty

Gap between rich and poor wideningGap between rich and poor widening Racial inequalities in processes and Racial inequalities in processes and

outcomes of care persistoutcomes of care persist


Widening disparity between what Widening disparity between what hospitals charge uninsured and self-hospitals charge uninsured and self-pay patients compared with insured pay patients compared with insured patientspatients

Private hospitals charging more than Private hospitals charging more than public hospitals for end-of-life carepublic hospitals for end-of-life care No effect on outcomes, quality of lifeNo effect on outcomes, quality of life

Meanwhile, Outside the Meanwhile, Outside the US…US…

One billion people lack access to One billion people lack access to clean drinking waterclean drinking water

3 billion lack adequate 3 billion lack adequate sanitation servicessanitation services

Hunger kills as many individuals Hunger kills as many individuals in two days as died during the in two days as died during the atomic bombing of Hiroshimaatomic bombing of Hiroshima

Physician Physician Dissatisfaction/Cynicism/ErDissatisfaction/Cynicism/Er

osion of Professionalismosion of Professionalism

Increasing dissatisfaction and Increasing dissatisfaction and cynicism among patients, practicing cynicism among patients, practicing physicians and traineesphysicians and trainees

Educators increasingly concerned Educators increasingly concerned over adequacy of trainees’ over adequacy of trainees’ humanistic and moral developmenthumanistic and moral development

Ethical DistortionsEthical Distortions

Doctors offering varying Doctors offering varying levels of testing and levels of testing and treatment based on patient’s treatment based on patient’s ability to payability to pay J Gen Int Med 2001;16:412-8.J Gen Int Med 2001;16:412-8.

Surprise?Surprise?

Doctor-Patient Doctor-Patient Communication re Out-of-Communication re Out-of-

Pocket CostsPocket Costs 15-20% of U.S. health care costs 15-20% of U.S. health care costs

paid by patients out-of-pocketpaid by patients out-of-pocket Physician-patient communication Physician-patient communication

hindered by discomfort (patients) hindered by discomfort (patients) and perceived lack of and perceived lack of time/nihilism (physicians)time/nihilism (physicians)

Relevant/importantRelevant/important


A sizeable minority of A sizeable minority of physicians admit to “gaming physicians admit to “gaming the system” by manipulating the system” by manipulating reimbursement rules so their reimbursement rules so their patients can receive care the patients can receive care the doctors perceive is necessarydoctors perceive is necessary JAMA 2000;238:1858-65JAMA 2000;238:1858-65 Arch Int Med 2002;162:1134-9Arch Int Med 2002;162:1134-9


¼ of the public sanctions ¼ of the public sanctions deception; ½ of those who deception; ½ of those who believe doctors have believe doctors have inadequate time to appeal inadequate time to appeal coverage decisionscoverage decisions Ann Int Med 2003;138:472-5Ann Int Med 2003;138:472-5 Am J Bioethics 2004;4(4):1-7Am J Bioethics 2004;4(4):1-7

Conclusion:Conclusion:Erosion of ScienceErosion of Science

LPC clinics offer care based on LPC clinics offer care based on unsound science and non-evidence-unsound science and non-evidence-based medicinebased medicine

Motives:Motives: MarketabilityMarketability ProfitabilityProfitability Patient satisfaction/demandPatient satisfaction/demand

Potential for harmPotential for harm

Conclusion:Conclusion:Erosion of EthicsErosion of Ethics

The promotion of LPC clinics The promotion of LPC clinics and the recruitment of wealthy and the recruitment of wealthy foreigners by academic medical foreigners by academic medical centers erodes fundamental centers erodes fundamental ethical principles of equity and ethical principles of equity and justice and promotes an overt, justice and promotes an overt, two-tiered system of health two-tiered system of health carecare

SolutionsSolutions

Renounce the marketplace as Renounce the marketplace as dominant standard or value in dominant standard or value in medicinemedicine

Divert intellectual and financial Divert intellectual and financial resources to more equitable resources to more equitable and just investments in and just investments in community and global healthcommunity and global health

SolutionsSolutions

Close some academic Close some academic medical centersmedical centers

Consolidate redundant Consolidate redundant educational and clinical educational and clinical programs in nearby teaching programs in nearby teaching hospitalshospitals

SolutionsSolutions

Reduce costs throughReduce costs through Quality improvement programsQuality improvement programs Improved governance and decision-Improved governance and decision-

makingmaking Augmenting philanthropic Augmenting philanthropic

contributionscontributions Increasing alliances with industry?Increasing alliances with industry?

Risks undue corporate influence on Risks undue corporate influence on academic institutions’ agendasacademic institutions’ agendas

SolutionsSolutions

Improved training and practice Improved training and practice of professionalism in medicineof professionalism in medicine

Heal schism between medicine Heal schism between medicine and public healthand public health

Service-oriented learning, Service-oriented learning, research-based activist courses, research-based activist courses, volunteerism, political activismvolunteerism, political activism

SolutionsSolutions

History and literatureHistory and literature

Role models/mentorsRole models/mentors

Refocus ethics trainingRefocus ethics training

SolutionsSolutions

Empathic and equal provision of care Empathic and equal provision of care to all individuals, regardless of to all individuals, regardless of insurance status, financial resources, insurance status, financial resources, race or sexrace or sex

Confront and work to abolish the Confront and work to abolish the reality of rationing; promote equal reality of rationing; promote equal access and care in all spheres of access and care in all spheres of medicinemedicine

SolutionsSolutions

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

SolutionsSolutions

Communicate these ideas to Communicate these ideas to business leaders, government business leaders, government representatives, and representatives, and purchasers of health carepurchasers of health careparticularly deans, hospital particularly deans, hospital presidents and department presidents and department chairschairs

SolutionsSolutions

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

ReferencesReferences Donohoe MT. “Standard vs. luxury care,” Donohoe MT. “Standard vs. luxury care,”

in in Ideological Debates in Family Ideological Debates in Family MedicineMedicine, S , S Buetow and T Kenealy, Eds. Buetow and T Kenealy, Eds. ((New York, Nova Science Publishers, Inc., New York, Nova Science Publishers, Inc., 2007). Available at 2007). Available at http://phsj.org/?page_id=22

Donohoe MT. Elements of professionalism Donohoe MT. Elements of professionalism for a physician considering the switch to a for a physician considering the switch to a retainer practice. In retainer practice. In Professionalism in Professionalism in Medicine: The Case-based Guide for Medicine: The Case-based Guide for Medical StudentsMedical Students, Editors: Spandorfer, , Editors: Spandorfer, Pohl, Rattner, and Nasca (Cambridge Pohl, Rattner, and Nasca (Cambridge University Press, 2008, in press).University Press, 2008, in press).

ReferencesReferences Donohoe MT. Luxury primary care, Donohoe MT. Luxury primary care,

academic medical centers, and the academic medical centers, and the erosion of science and professional ethics. erosion of science and professional ethics. J Gen Int Med 2004;19:90-94. Available at J Gen Int Med 2004;19:90-94. Available at http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525-1497.2004.20631.x

Donohoe MT. Retainer practice: Scientific Donohoe MT. Retainer practice: Scientific issues, social justice, and ethical issues, social justice, and ethical perspectives. American Medical perspectives. American Medical Association Virtual Mentor 2004 Association Virtual Mentor 2004 (April);6(4). Available at (April);6(4). Available at http://www.ama-assn.org/ama/pub/category/12249.html

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