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  1. 1. Luxury Primary Care,Luxury Primary Care, Academic Medical Centers, andAcademic Medical Centers, and the Erosion of Science andthe Erosion of Science and Professional EthicsProfessional Ethics Martin Donohoe, MD, FACPMartin Donohoe, MD, FACP
  2. 2. Luxury Primary CareLuxury Primary Care  IntroductionIntroduction  SourcesSources  ResearchResearch
  3. 3. Academic Medical Centers HurtingAcademic Medical Centers Hurting FinanciallyFinancially  US health care crisisUS health care crisis  Costs associated with medical trainingCosts associated with medical training  Disproportionate share of complexDisproportionate share of complex and/or uninsured patientsand/or uninsured patients
  4. 4. Academic Medical Centers HurtingAcademic Medical Centers Hurting FinanciallyFinancially  Erosion of infrastructureErosion of infrastructure  Shrinking funding baseShrinking funding base  Increased competition with moreIncreased competition with more efficient private and communityefficient private and community hospitalshospitals
  5. 5. Single Specialty HospitalsSingle Specialty Hospitals  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 incomeAcademic and community hospitals depleted of income stream used to cross-subsidize indigent care, ER, trauma,stream used to cross-subsidize indigent care, ER, trauma, burn wards, and mental health careburn wards, and mental health care  Incentives for overtreatmentIncentives for overtreatment  >1/3 may violate Medicare’s conditions for participation>1/3 may violate Medicare’s conditions for participation
  6. 6. Competitive StrategiesCompetitive Strategies  Increase alliances with pharmaceutical andIncrease alliances with pharmaceutical and biotech industriesbiotech industries  Recruit wealthy, non-U.S. citizens asRecruit wealthy, non-U.S. citizens as patientspatients  More aggressive billing practices / chargingMore aggressive billing practices / charging the uninsured higher pricesthe uninsured higher prices  Result: class action suitsResult: class action suits
  7. 7. Competitive StrategiesCompetitive Strategies  Increase cash services (botox treatments,Increase cash services (botox treatments, cosmetic surgery) and re-imburseable,cosmetic surgery) and re-imburseable, covered services (e.g., cardiaccovered services (e.g., cardiac catheterization, bone density testing)catheterization, bone density testing)  Cut back on uncovered services: e.g., ERCut back on uncovered services: e.g., ER staffingstaffing
  8. 8. Competitive StrategiesCompetitive Strategies  AdvertisingAdvertising  Often promote high-paying, unproved, orOften promote high-paying, unproved, or cosmetic servicescosmetic services  Arch Int Med 2005;165:645-51Arch Int Med 2005;165:645-51  Outsource radiology/transcription servicesOutsource radiology/transcription services to physicians in developing worldto physicians in developing world  e.g., MGH and Yale X-rayse.g., MGH and Yale X-rays →→ IndiaIndia (they have since ended agreements)(they have since ended agreements)
  9. 9. Competitive StrategiesCompetitive Strategies  Pay sports teams for privilege of beingPay sports teams for privilege of being team doctors (in return for free publicity)team doctors (in return for free publicity)  Methodist Hospital – Houston TexansMethodist Hospital – Houston Texans  NYU Hospital for Joint Diseases – NY MetsNYU Hospital for Joint Diseases – NY Mets  Develop luxury primary care clinicsDevelop luxury primary care clinics  AKA “executive health clinics”,AKA “executive health clinics”, “boutique medicine”, “concierge care”,“boutique medicine”, “concierge care”, “VIP clinics”“VIP clinics”
  10. 10. Recruitment of Wealthy Non-USRecruitment of Wealthy Non-US CitizensCitizens  70,000 patients/yr70,000 patients/yr  Estimated 1-2% of hospitals’ revenuesEstimated 1-2% of hospitals’ revenues  Number estimated to quadruple in next fewNumber estimated to quadruple in next few yearsyears  Recruitment worldwideRecruitment worldwide  Hospitals forming consortia to target certainHospitals forming consortia to target certain countries, including those with national healthcountries, including those with national health plansplans
  11. 11. Recruitment of Wealthy Non-USRecruitment of Wealthy Non-US CitizensCitizens  Doctors sent on overseas speaking andDoctors sent on overseas speaking and recruitment toursrecruitment tours  Patients offered rapid access to state-Patients offered rapid access to state- of-the-art careof-the-art care
  12. 12. Recruitment of Wealthy Non-USRecruitment of Wealthy Non-US CitizensCitizens  Payment at “retail rate,” well above whatPayment at “retail rate,” well above what government and private insurancegovernment and private insurance reimbursereimburse  Immediate access to face-to-faceImmediate access to face-to-face translatorstranslators  Only spottily available to uninsured,Only spottily available to uninsured, non-English speaking patientsnon-English speaking patients
  13. 13. Recruitment of Wealthy Non-USRecruitment of Wealthy Non-US CitizensCitizens  Patients have not paid taxes in support ofPatients have not paid taxes in support of medical education and health care subsidiesmedical education and health care subsidies  The federal government spends about $10The federal government spends about $10 billion/yr to pay medical schools and teachingbillion/yr to pay medical schools and teaching hospitals for medical education and traininghospitals for medical education and training  State and local governments provide $2-3State and local governments provide $2-3 billion/yr in additional subsidiesbillion/yr in additional subsidies
  14. 14. Recruitment of Wealthy Non-USRecruitment of Wealthy Non-US CitizensCitizens  Health needs may not be as pressingHealth needs may not be as pressing (and are usually more costly) than the(and are usually more costly) than the needs of those living in poverty inneeds of those living in poverty in their home countriestheir home countries
  15. 15. Recruitment of Wealthy Non-USRecruitment of Wealthy Non-US CitizensCitizens  Academic medical centers often refuseAcademic medical centers often refuse non-emergent care to non-US citizennon-emergent care to non-US citizen refugees and undocumented aliensrefugees and undocumented aliens  Reason: Fear of depletion of financialReason: Fear of depletion of financial resourcesresources  Costs of care itselfCosts of care itself  Development of informal referral baseDevelopment of informal referral base
  16. 16. Boutique MedicineBoutique Medicine  Retainer Fee Medical PracticeRetainer Fee Medical Practice  Premier Care, Valet Care, VIP Care, Gold Care,Premier Care, Valet Care, VIP Care, Gold Care, Platinum CarePlatinum Care  Luxury Primary Care / Executive Health ClinicsLuxury Primary Care / Executive Health Clinics  Medi-SpasMedi-Spas  Travel medicine clinics for exotic destinationsTravel medicine clinics for exotic destinations  Direct sales to patients of health and nutritionalDirect sales to patients of health and nutritional productsproducts
  17. 17. Factors Which Might EncourageFactors Which Might Encourage Retainer Fee Medical PracticeRetainer Fee Medical Practice J Clin Ethics 2005(Spring):72-84J Clin Ethics 2005(Spring):72-84  Tight office schedules, long delays forTight office schedules, long delays for appointments, shorter visit lengthsappointments, shorter visit lengths  Authorization requirements ofAuthorization requirements of insurance companies, HMOs, andinsurance companies, HMOs, and MedicareMedicare
  18. 18. Factors Which Might EncourageFactors Which Might Encourage Retainer Fee Medical PracticeRetainer Fee Medical Practice  Insufficient time to return phone callsInsufficient time to return phone calls  Congested ERs, with long delays forCongested ERs, with long delays for patients with minor illnesses who arepatients with minor illnesses who are unable to access PCPunable to access PCP  Patients referred to specialists forPatients referred to specialists for problems that do not necessarilyproblems that do not necessarily require a specialist’s carerequire a specialist’s care
  19. 19. Factors Which Might EncourageFactors Which Might Encourage Retainer Fee Medical PracticeRetainer Fee Medical Practice  Frequent changes in PCP, abetted by:Frequent changes in PCP, abetted by:  Hospitalist movementHospitalist movement  Employers seeking cheaper plans, which provideEmployers seeking cheaper plans, which provide narrower range of coveragenarrower range of coverage  Insurance company de-listing of physicians based onInsurance company de-listing of physicians based on economic criteriaeconomic 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
  20. 20. Luxury Primary Care ClinicsLuxury Primary Care Clinics  Some are solo and small groupSome are solo and small group practicespractices  Some affiliated with large corporationsSome affiliated with large corporations Executive Health RegistryExecutive Health Registry Executive Health ExamsExecutive Health Exams InternationalInternational OneMDOneMD
  21. 21. Luxury Primary Care ClinicsLuxury Primary Care Clinics  MDVIPMDVIP  Mission: “Assist doctors in transitioningMission: “Assist doctors in transitioning from traditional to retainer-stylefrom traditional to retainer-style practices”practices”  Phenomenal growth ratePhenomenal growth rate  24 practices in 7 states, with 40 more24 practices in 7 states, with 40 more practices in the workspractices in the works
  22. 22. Luxury Primary CareLuxury Primary Care  Professional Organization:Professional Organization: American Society of ConciergeAmerican Society of Concierge Physicians (ASCP)Physicians (ASCP) →→ Society for Innovative Medical Practice Design (SIMPD)
  23. 23. Luxury Primary Care ClinicsLuxury Primary Care Clinics  University-affiliated:University-affiliated:  Mayo Clinic (3000/yr); Cleveland ClinicMayo Clinic (3000/yr); Cleveland Clinic (3500/yr); MGH (1950/yr)(3500/yr); MGH (1950/yr)  Johns Hopkins, Penn, New YorkJohns Hopkins, Penn, New York Presbyterian, Washington University,Presbyterian, Washington University, UCSF, UCLA, many othersUCSF, UCLA, many others
  24. 24. Luxury Primary Care ClinicsLuxury Primary Care Clinics  Annual exams last 1-2 daysAnnual exams last 1-2 days  Average baseline cost $2000 - $4000Average baseline cost $2000 - $4000 per visit for baseline packageper visit for baseline package  Additional tests extraAdditional tests extra  (range $1500 - $20,000)(range $1500 - $20,000)
  25. 25. Luxury Primary Care ClinicsLuxury Primary Care Clinics  Physicians available 24/7/365 byPhysicians available 24/7/365 by phone/pager for additional feephone/pager for additional fee  Patient/physician ratios 10-25% ofPatient/physician ratios 10-25% of typical managed care levelstypical managed care levels
  26. 26. Luxury Primary Care Clinics:Luxury Primary Care Clinics: Perks and PamperingPerks and Pampering  Tests, subspecialty consultations availableTests, subspecialty consultations available same daysame day  Patients jump the queue, sometimesPatients jump the queue, sometimes delaying tests on other patients withdelaying tests on other patients with more appropriate and urgent needsmore appropriate and urgent needs Special shirtsSpecial shirts Gold cardsGold cards
  27. 27. Luxury Primary Care Clinics:Luxury Primary Care Clinics: Perks and PamperingPerks and Pampering  Vaccines (in short supply elsewhere) alwaysVaccines (in short supply elsewhere) always availableavailable  Valet parkingValet parking  EscortsEscorts  Plush bathrobesPlush bathrobes
  28. 28. Luxury Primary Care Clinics:Luxury Primary Care Clinics: Perks and PamperingPerks and Pampering  Oak-paneled waiting rooms with high-backedOak-paneled waiting rooms with high-backed leather chairs and fine artleather chairs and fine art  TVs, computers, fax machinesTVs, computers, fax machines  Buffet meals, herb teasBuffet meals, herb teas  Saunas and massagesSaunas and massages
  29. 29. Luxury Primary Care ClinicsLuxury Primary Care Clinics  Capitalize on widespread dissatisfactionCapitalize on widespread dissatisfaction with managed care and too-busy physicianswith managed care and too-busy physicians with inadequate time to providewith inadequate time to provide comprehensive care and counselingcomprehensive care and counseling  Appeal to patients’ desires to receive theAppeal to patients’ desires to receive the latest high-tech diagnostic and therapeuticlatest high-tech diagnostic and therapeutic interventionsinterventions
  30. 30. 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 histories ofSome from companies with extensive histories of harming health through environmental pollution,harming health through environmental pollution, tobacco salestobacco sales  Some from insurance companies, whose ownSome from insurance companies, whose own policies increasingly limit the coverage of sickpolicies increasingly limit the coverage of sick individuals, including their own lower levelindividuals, including their own lower level employeesemployees
  31. 31. Clients / Patients:Clients / Patients: Upper ManagementUpper Management  Disproportionately white males:Disproportionately white males:  Data available from one Executive HealthData available from one Executive Health ProgramProgram  Women:Women: 46% of the workforce46% of the workforce HoldHold < 2% of senior-level management< 2% of senior-level management positions in Fortune 500 Companiespositions in Fortune 500 Companies  Lower SES of non-CaucasiansLower SES of non-Caucasians
  32. 32. Luxury Primary Care:Luxury Primary Care: MarketingMarketing  Directed at the heads of large and smallDirected at the heads of large and small companiescompanies  Hospitals hope high-level managers will steerHospitals hope high-level managers will steer their companies’ lucrative health care contractstheir companies’ lucrative health care contracts toward the institution and its providerstoward the institution and its providers  Some programs give discounted rates inSome programs give discounted rates in exchange for a donation to the hospitalexchange for a donation to the hospital
  33. 33. Luxury Primary Care:Luxury Primary Care: MarketingMarketing  Promotional materials imply that wealthyPromotional materials imply that wealthy executives are busier and lead more hectic livesexecutives are busier and lead more hectic lives than othersthan others  We cater to “the busy executive” who “demandsWe cater to “the busy executive” who “demands only the best”only the best”  In fact, lower SES patients’ lives are often busierIn fact, lower SES patients’ lives are often busier and their health outcomes worse, renderingand their health outcomes worse, rendering them in greater need of efficient, comprehensivethem in greater need of efficient, comprehensive carecare
  34. 34. Programs are SecretivePrograms are Secretive  Stating that I was a physician researching theStating that I was a physician researching the phenomenon of LPC clinics, I wrote and thenphenomenon of LPC clinics, I wrote and then called 13 LPC clinicscalled 13 LPC clinics  Only one person at one clinic would answerOnly one person at one clinic would answer basic questions relating to the # of providers,basic questions relating to the # of providers, involvement of residents, funding, cross-involvement of residents, funding, cross- subsidizationsubsidization
  35. 35. LPC Clinics and The Erosion ofLPC Clinics and The Erosion of ScienceScience  Many tests not clinically- or cost-Many tests not clinically- or cost- effectiveeffective Percent body fat measurementsPercent body fat measurements Chest X rays in smokers and non-Chest X rays in smokers and non- smokers over age 35 to screen forsmokers over age 35 to screen for lung cancerlung cancer
  36. 36. LPC Clinics and The Erosion ofLPC Clinics and The Erosion of ScienceScience  Electron-beam CT scans and stress echocardiogramsElectron-beam CT scans and stress echocardiograms for coronary artery diseasefor coronary artery disease  Radiation from a full-body CT scan comparable to doseRadiation from a full-body CT scan comparable to dose with increased cancer mortality in low-dose atomic bombwith increased cancer mortality in low-dose atomic bomb survivors (Radiology 2004;232:735-8)survivors (Radiology 2004;232:735-8)  Raise cancer riskRaise cancer risk  2008: TX legislation proposed to require insurance2008: TX legislation proposed to require insurance companies to covercompanies to cover  Abdominal-pelvic ultrasounds to screen for liver andAbdominal-pelvic ultrasounds to screen for liver and ovarian cancerovarian cancer
  37. 37. LPC Clinics and The Erosion ofLPC Clinics and The Erosion of ScienceScience  Other tests controversialOther tests controversial  Genetic testingGenetic testing  Mammograms in women beginning at age 35Mammograms in women beginning at age 35  False positive tests may lead to unnecessaryFalse positive tests may lead to unnecessary investigations, higher costs and needless anxietyinvestigations, higher costs and needless anxiety  And increased profits to the clinic…..And increased profits to the clinic…..
  38. 38. Direct Marketing of High-TechDirect Marketing of High-Tech Tests to PatientsTests to Patients  Ameriscan:Ameriscan:  Full body scans: “detect over 100 life-Full body scans: “detect over 100 life- threatening diseases in the arteries, heart,threatening diseases in the arteries, heart, lungs, liver and other major vital organs –lungs, liver and other major vital organs – before it’s too late”before it’s too late”  MRI breastscreens: detect “nearly 100% of allMRI breastscreens: detect “nearly 100% of all breast cancers”breast cancers”  Virtual colonoscopiesVirtual colonoscopies
  39. 39. The Use of Clinically-UnjustifiableThe Use of Clinically-Unjustifiable TestsTests  Erodes the scientific underpinnings of medicalErodes the scientific underpinnings of medical practicepractice  Sends a mixed message to trainees about whenSends a mixed message to trainees about when and why to utilize diagnostic studiesand why to utilize diagnostic studies  Runs counter to physicians’ ethical obligationsRuns counter to physicians’ ethical obligations to contribute to the ethical stewardship of healthto contribute to the ethical stewardship of health care resourcescare resources
  40. 40. The Use of Clinically-UnjustifiableThe Use of Clinically-Unjustifiable TestsTests  Some might argue that if a patient is willing toSome might argue that if a patient is willing to pay for a scientifically-unsupported test that shepay for a scientifically-unsupported test that she should be allowed to do so. However,should be allowed to do so. However,  ““Buffet” approach to diagnosis makes aBuffet” approach to diagnosis makes a mockery of evidence-based medical caremockery of evidence-based medical care  Diverts hardware and technician time awayDiverts hardware and technician time away from patients with more appropriate andfrom patients with more appropriate and possibly urgent indications for testingpossibly urgent indications for testing
  41. 41. Ethics/Justice:Ethics/Justice: Treating Patients from OverseasTreating Patients from Overseas  The greatest good for the greatestThe greatest good for the greatest numbernumber Liver transplant for wealthy foreignLiver transplant for wealthy foreign banker vs. treating undocumentedbanker vs. treating undocumented farm laborers for TB and pesticide-farm laborers for TB and pesticide- related diseasesrelated diseases
  42. 42. Ethics/Justice:Ethics/Justice: Treating Patients OverseasTreating Patients Overseas  Deploying medical students andDeploying medical students and physicians overseas to provide carephysicians overseas to provide care and educate local practitioners in theand educate local practitioners in the care of respiratory and water-bornecare of respiratory and water-borne infectious diseasesinfectious diseases Kill thousands worldwide each dayKill thousands worldwide each day
  43. 43. Ethics/JusticeEthics/Justice  Market forces have spurred for-profitMarket forces have spurred for-profit health care companies to export thehealth care companies to export the most inefficient, unjust elements ofmost inefficient, unjust elements of American medicine to the developingAmerican medicine to the developing worldworld
  44. 44. Ethics/JusticeEthics/Justice  Migration of medical professionals from theMigration of medical professionals from the developing world, where they were trained atdeveloping world, where they were trained at public expense, to the US further depletes healthpublic expense, to the US further depletes health care resources in poor countries and contributescare resources in poor countries and contributes to increasing inequities between rich and poorto increasing inequities between rich and poor nationsnations  US patients going abroad for procedures;US patients going abroad for procedures; medical tourism; supported by many insurancemedical tourism; supported by many insurance companiescompanies
  45. 45. The Medical Brain DrainThe Medical Brain Drain  1998 UN/WHO Study: 56% of all migrating1998 UN/WHO Study: 56% of all migrating doctors flow from developing to developeddoctors flow from developing to developed nations, while only 11% migrate in the oppositenations, while only 11% migrate in the opposite directiondirection  2007: WHO estimates 2.4 million too few2007: WHO estimates 2.4 million too few physuicians, nurses, and midwives to providephysuicians, nurses, and midwives to provide essential health services to developing worldessential health services to developing world  U.S. largest “consumer” of health workersU.S. largest “consumer” of health workers from the developing worldfrom the developing world  Even greater imbalance for nursesEven greater imbalance for nurses
  46. 46. The Medical Brain DrainThe Medical Brain Drain  Health care and financial loss toHealth care and financial loss to developing country; gain for developeddeveloping country; gain for developed countrycountry  Example of “inverse care law”:Example of “inverse care law”:  Those countries that need the mostThose countries that need the most health care resources are getting the leasthealth care resources are getting the least
  47. 47. LPC Clinics and The Erosion ofLPC Clinics and The Erosion of Professional EthicsProfessional Ethics  Public contributes substantially to thePublic contributes substantially to the education and training of new physicianseducation and training of new physicians  May object to doctors limiting theirMay object to doctors limiting their practices to the wealthy, not acceptingpractices to the wealthy, not accepting Medicare or Medicaid patientsMedicare or Medicaid patients  Increases health disparities between richIncreases health disparities between rich and poorand poor
  48. 48. LPC Clinics and The Erosion ofLPC Clinics and The Erosion of Professional EthicsProfessional Ethics  Alternatively, debt-ridden physicians mightAlternatively, debt-ridden physicians might justify limiting their practices to thejustify limiting their practices to the wealthy by claiming a right to freely choosewealthy by claiming a right to freely choose where they practice and for whom theywhere they practice and for whom they carecare  Limits: HIV patients, racial prejudiceLimits: HIV patients, racial prejudice
  49. 49. LPC Clinics and The Erosion ofLPC Clinics and The Erosion of Professional EthicsProfessional Ethics  Academic medical centers’ justifications for LPCAcademic medical centers’ justifications for LPC clinics:clinics:  Enhance plurality in health care delivery;Enhance plurality in health care delivery; increase choices available to health careincrease choices available to health care consumersconsumers  Cross-subsidization of training or indigentCross-subsidization of training or indigent care programscare programs Evidence lacking due to secrecyEvidence lacking due to secrecy Variant of “trickle down economics”Variant of “trickle down economics”
  50. 50. LPC Clinics and The Erosion ofLPC Clinics and The Erosion of Professional EthicsProfessional Ethics  AMA Guidelines:AMA Guidelines:  Physicians switching to LPC practices mustPhysicians switching to LPC practices must facilitate the transfer of patients who don’tfacilitate the transfer of patients who don’t pay retainers to other physicianspay retainers to other physicians Shifts un- and poorly-compensated patientShifts un- and poorly-compensated patient care onto fewer providers; risks dominocare onto fewer providers; risks domino effecteffect
  51. 51. LPC Clinics and The Erosion ofLPC Clinics and The Erosion of Professional EthicsProfessional Ethics  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 forphysicians may be obligated to continue to care for patients without charging them a premiumpatients without charging them a premium  Physicians with boutique practices are also stillPhysicians 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 asRetainer-style practices shouldn’t be marketed as providing better diagnostic and therapeutic servicesproviding better diagnostic and therapeutic services
  52. 52. Ethics/JusticeEthics/Justice  45 million uninsured patients in US45 million uninsured patients in US  Millions more underinsuredMillions more underinsured  Remain in dead-end jobsRemain in dead-end jobs  Go without needed prescriptions due toGo without needed prescriptions due to skyrocketing drug pricesskyrocketing drug prices  Public and charity hospitals closingPublic and charity hospitals closing
  53. 53. Headline fromHeadline from The OnionThe Onion Uninsured Man Hopes HisUninsured Man Hopes His Symptoms Diagnosed This WeekSymptoms Diagnosed This Week OnOn HouseHouse
  54. 54. Ethics/JusticeEthics/Justice  US ranks near the bottom amongUS ranks near the bottom among westernized nations in life expectancy andwesternized nations in life expectancy and infant mortalityinfant mortality  20-25% of US children live in poverty20-25% of US children live in poverty  Gap between rich and poor wideningGap between rich and poor widening  Racial inequalities in processes andRacial inequalities in processes and outcomes of care persistoutcomes of care persist
  55. 55. Ethics/JusticeEthics/Justice  Widening disparity between what hospitalsWidening disparity between what hospitals charge uninsured and self-pay patients comparedcharge uninsured and self-pay patients compared with insured patientswith insured patients  Private hospitals charging more than publicPrivate hospitals charging more than public hospitals for end-of-life carehospitals for end-of-life care  No effect on outcomes, quality of lifeNo effect on outcomes, quality of life
  56. 56. Meanwhile, Outside the US…Meanwhile, Outside the US…  One billion people lack access to cleanOne billion people lack access to clean drinking waterdrinking water  3 billion lack adequate sanitation services3 billion lack adequate sanitation services  Hunger kills as many individuals in twoHunger kills as many individuals in two days as died during the atomic bombing ofdays as died during the atomic bombing of HiroshimaHiroshima
  57. 57. PhysicianPhysician Dissatisfaction/Cynicism/Erosion ofDissatisfaction/Cynicism/Erosion of ProfessionalismProfessionalism  Increasing dissatisfaction and cynicismIncreasing dissatisfaction and cynicism among patients, practicing physicians andamong patients, practicing physicians and traineestrainees  Educators increasingly concerned overEducators increasingly concerned over adequacy of trainees’ humanistic and moraladequacy of trainees’ humanistic and moral developmentdevelopment
  58. 58. Ethical DistortionsEthical Distortions  Doctors offering varying levels ofDoctors offering varying levels of testing and treatment based ontesting and treatment based on patient’s ability to paypatient’s ability to pay  J Gen Int Med 2001;16:412-8.J Gen Int Med 2001;16:412-8. Surprise?Surprise?
  59. 59. Doctor-Patient Communication reDoctor-Patient Communication re Out-of-Pocket CostsOut-of-Pocket Costs  15-20% of U.S. health care costs paid by15-20% of U.S. health care costs paid by patients out-of-pocketpatients out-of-pocket  Physician-patient communication hinderedPhysician-patient communication hindered by discomfort (patients) and perceived lackby discomfort (patients) and perceived lack of time/nihilism (physicians)of time/nihilism (physicians)  Relevant/importantRelevant/important
  60. 60. Ethical DistortionsEthical Distortions  A sizeable minority of physiciansA sizeable minority of physicians admit to “gaming the system” byadmit to “gaming the system” by manipulating reimbursement rules somanipulating reimbursement rules so their patients can receive care thetheir 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
  61. 61. Ethical DistortionsEthical Distortions  ¼ of the public sanctions deception; ½¼ of the public sanctions deception; ½ of those who believe doctors haveof those who believe doctors have inadequate time to appeal coverageinadequate time to appeal coverage decisionsdecisions  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
  62. 62. Conclusion:Conclusion: Erosion of ScienceErosion of Science  LPC clinics offer care based on unsound scienceLPC clinics offer care based on unsound science and non-evidence-based medicineand non-evidence-based medicine  Motives:Motives:  MarketabilityMarketability  ProfitabilityProfitability  Patient satisfaction/demandPatient satisfaction/demand  Potential for harmPotential for harm
  63. 63. Conclusion:Conclusion: Erosion of EthicsErosion of Ethics  The promotion of LPC clinics and theThe promotion of LPC clinics and the recruitment of wealthy foreigners byrecruitment of wealthy foreigners by academic medical centers erodesacademic medical centers erodes fundamental ethical principles offundamental ethical principles of equity and justice and promotes anequity and justice and promotes an overt, two-tiered system of health careovert, two-tiered system of health care
  64. 64. SolutionsSolutions  Renounce the marketplace asRenounce the marketplace as dominant standard or value indominant standard or value in medicinemedicine  Divert intellectual and financialDivert intellectual and financial resources to more equitable and justresources to more equitable and just investments in community and globalinvestments in community and global healthhealth
  65. 65. SolutionsSolutions  Close some academic medical centersClose some academic medical centers  Consolidate redundant educational andConsolidate redundant educational and clinical programs in nearby teachingclinical programs in nearby teaching hospitalshospitals
  66. 66. SolutionsSolutions  Reduce costs throughReduce costs through  Quality improvement programsQuality improvement programs  Improved governance and decision-makingImproved governance and decision-making  Augmenting philanthropic contributionsAugmenting philanthropic contributions  Increasing alliances with industry?Increasing alliances with industry? Risks undue corporate influence onRisks undue corporate influence on academic institutions’ agendasacademic institutions’ agendas
  67. 67. SolutionsSolutions  Improved training and practice ofImproved training and practice of professionalism in medicineprofessionalism in medicine  Heal schism between medicine and publicHeal schism between medicine and public healthhealth  Service-oriented learning, research-basedService-oriented learning, research-based activist courses, volunteerism, politicalactivist courses, volunteerism, political activismactivism
  68. 68. SolutionsSolutions History and literatureHistory and literature Role models/mentorsRole models/mentors Refocus ethics trainingRefocus ethics training
  69. 69. SolutionsSolutions  Empathic and equal provision of care to allEmpathic and equal provision of care to all individuals, regardless of insurance status,individuals, regardless of insurance status, financial resources, race or sexfinancial resources, race or sex  Confront and work to abolish the reality ofConfront and work to abolish the reality of rationing; promote equal access and care inrationing; promote equal access and care in all spheres of medicineall spheres of medicine
  70. 70. SolutionsSolutions  Educate public and policymakersEducate public and policymakers regarding the important roles they playregarding the important roles they play in research, education and patient carein research, education and patient care Particularly in terms relevant toParticularly in terms relevant to individuals and their familiesindividuals and their families
  71. 71. SolutionsSolutions  Communicate these ideas to businessCommunicate these ideas to business leaders, government representatives,leaders, government representatives, and purchasers of health careand purchasers of health care particularly deans, hospitalparticularly deans, hospital presidents and department chairspresidents and department chairs
  72. 72. SolutionsSolutions  Society/legislators should provideSociety/legislators should provide increased funding for the education andincreased funding for the education and training of medical students and residenttraining of medical students and resident physicians and for the continued health ofphysicians and for the continued health of vital academic medical centers, to allowvital academic medical centers, to allow them to carry out their missions ofthem to carry out their missions of education, research, and patient care,education, research, and patient care, particularly for the underservedparticularly for the underserved
  73. 73. ReferencesReferences  Donohoe MT. “Standard vs. luxury care,” inDonohoe MT. “Standard vs. luxury care,” in Ideological Debates in Family MedicineIdeological Debates in Family Medicine, S, S Buetow andBuetow and T Kenealy, Eds. (T Kenealy, Eds. (New York, Nova Science Publishers,New York, Nova Science Publishers, Inc., 2007). Available atInc., 2007). Available at http://http://phsj.org/?page_idphsj.org/?page_id=22=22  Donohoe MT. Elements of professionalism for aDonohoe MT. Elements of professionalism for a physician considering the switch to a retainer practice.physician considering the switch to a retainer practice. InIn Professionalism in Medicine: The Case-based GuideProfessionalism in Medicine: The Case-based Guide for Medical Studentsfor Medical Students, Editors: Spandorfer, Pohl,, Editors: Spandorfer, Pohl, Rattner, and Nasca (Cambridge University Press, 2008,Rattner, and Nasca (Cambridge University Press, 2008, in press).in press).
  74. 74. ReferencesReferences  Donohoe MT. Luxury primary care, academic medicalDonohoe MT. Luxury primary care, academic medical centers, and the erosion of science and professionalcenters, and the erosion of science and professional ethics. J Gen Int Med 2004;19:90-94. Available atethics. J Gen Int Med 2004;19:90-94. Available at http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525  Donohoe MT. Retainer practice: Scientific issues, socialDonohoe MT. Retainer practice: Scientific issues, social justice, and ethical perspectives. American Medicaljustice, and ethical perspectives. American Medical Association Virtual Mentor 2004 (April);6(4). AvailableAssociation Virtual Mentor 2004 (April);6(4). Available atat http://www.ama-assn.org/ama/pub/category/12249.htmlhttp://www.ama-assn.org/ama/pub/category/12249.html
  75. 75. Contact InformationContact Information Public Health and Social Justice WebsitePublic Health and Social Justice Website http://www.phsj.orghttp://www.phsj.org martindonohoe@phsj.orgmartindonohoe@phsj.org

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