The Spectrum of Concierge Care:
Scientific, Ethical, and Policy Issues
Martin Donohoe
Am I Stoned?
A 1999 Utah anti-drug pamphlet warns:
“Danger signs that your child may be
smoking marijuana include excessive
preoccupation with social causes, race
relations, and environmental issues”
“All
men are created equal”
Declaration
of Independence
“Some
people are more equal
than others”
George
Orwell
Outline
 Financial
problems facing academic
medical centers
 Single specialty hospitals
 Medical tourism
 Recruitment of wealthy, non-U.S.
citizens
Outline
 Other
competitive strategies
 Overseas clinics/hospitals
 Boutique/concierge/luxury care clinics
 Erosion
of science
 Erosion of professional ethics
 Solutions
Academic Medical Centers Hurting
Financially
 US
health care crisis
 Costs
associated with medical training
 Disproportionate
share of complex
and/or uninsured patients
Academic Medical Centers Hurting
Financially
 Erosion
of infrastructure
 Shrinking funding base
 Increased competition with more
efficient private and community
hospitals
Single Specialty Hospitals
Over 100 nationwide
 Often physician-owned
 PPACA limits physician-owned hospitals
from starting or expanding
 Provision being challenged in courts
 Boom from 2000-2010, now on decline

Single Specialty Hospitals

Problems:
Cherry pick healthier patients with good coverage
 No ER
 No need to cross-subsidize indigent care, ER, burn
wards, and mental health care
 Incentives for overtreatment
 >1/3 may violate Medicare’s conditions for
participation

Medical Tourism


US citizens traveling abroad for care
 750,000 in 2007
 1 million in 2010
 vs. 400,000 non-Americans visiting the U.S.
annually for care)
Estimated $100 billion industry
Medical Tourism





Insurance plans increasingly cover (large cost savings)
Mostly for cardiac, orthopedic, and cosmetic
procedures
Sometimes for pharmaceuticals or procedures
unavailable or illegal US (e.g., PAS)
Adverse effects on health care availability in foreign
countries
May contribute to spread of infectious diseases

E.g., NDM-1 per some scientists, others
Reproductive Tourism


20,000 to 25,000 IVF procedures on US citizens
done abroad
Rent-a-womb abuses


India, 25,000 children/yr, surrogacy unregulated
Converse situation is “maternity tourism” –
undocumented immigrants entering U.S. to give
birth (to babies guaranteed citizenship by the
14th Amendment)
Transplant Tourism

Transplant Tourism:
Black market for organs (10-25% of all kidneys
transplanted worldwide each year)
 Spurred on by marked organ scarcity in US
 Stem cell tourism increasing



Many procedures highly experimental, of dubious benefit
(and possibly harm)
Clinical and ethical issues of treating patients post-op
Competitive Strategies
Increase alliances with pharmaceutical and
biotech industries
 Recruit wealthy, non-U.S. citizens as
patients
 Open hospitals in other countries
 But non-profit hospitals flourishing

 tax
breaks
 net income up
Competitive Strategies

More aggressive billing practices / charging
the uninsured higher prices
 Average 2.5X what most health insurers
pay and > 3 times actual costs
 Result: class action suits
 PPACA outlaws
Competitive Strategies

Increase cash services (botox treatments,
cosmetic surgery) and reimbursable,
covered services (e.g., cardiac
catheterization, bone density testing)

High end maternity suites
Competitive Strategies
Cut back on uncovered services: e.g., ER
staffing
 “Triaging out” – redirecting low acuity
patients from ER to “other facilities”

University of Chicago overturned policy in response
to protests (2009)
 ACEP and AAEM opposes such policies

Competitive Strategies


Advertising
 Often promote high-paying, unproved, or
cosmetic services
 Arch Int Med 2005;165:645-51
Outsource radiology/transcription services to
physicians in developing world
 e.g., MGH and Yale X-rays → India (they
have since ended agreements)
 Privacy, quality concerns
Competitive Strategies

Pay sports teams for privilege of being
team doctors (in return for free publicity)
 Methodist
Hospital – Houston Texans
 NYU Hospital for Joint Diseases – NY Mets

Develop luxury primary care clinics
 AKA “executive health clinics”,
“boutique medicine”, “concierge care”,
“VIP clinics”
Recruitment of Wealthy Non-US
Citizens



60,000 – 85,000 patients/yr
 Estimated 1-2% of hospitals’ revenues
 Number estimated to quadruple in next few
years
Recruitment worldwide
Hospitals forming consortia to target certain
countries, including those with national health
plans
Recruitment of Wealthy Non-US
Citizens

Doctors sent on overseas speaking and
recruitment tours

Patients offered rapid access to state-ofthe-art care
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
 Academic medical centers often refuse
non-emergent care to non-US citizen
refugees and undocumented aliens

Overseas Clinics and Hospitals
Academic medical centers owning and/or
operating clinics and hospitals overseas
 Substantially lower costs (most surgeries
50-90% less expensive)
 Many hospitals accredited, staffed by U.S.trained physicians

Overseas Clinics and Hospitals

AMA guidelines exist

Regulations imperfect

Risks include lack of follow-up, exposure to
regional infectious diseases, limited malpractice
options
Overseas Clinics and Hospitals

Examples:
 Cleveland Clinic: Abu Dhabi, UAE
 Duke University: Duke-National
University of Singapore
 Johns Hopkins: Cancer center in
Singapore International Medical Center
Overseas Clinics and Hospitals

Examples:
 Harvard, Mayo Clinic : Dubai
 Cornell-Weill Medical College: Qatar
 University of Pittsburgh: transplant center in
Palermo, Sicily, Italy
 MD Anderson Cancer Center: MD Anderson
International-España in Madrid, Spain
Boutique Medicine




Retainer Fee Medical Practice
 Large/expensive vs. small/less expensive
(sometimes for the uninsured)
Qliance
Premier Care, Valet Care, VIP Care, Gold Care,
Platinum Care
Luxury Primary Care / Executive Health Clinics
Boutique Medicine

Medi-Spas
Cosmetic procedures, massage, aromatherapy,
cosmeceutical sales
 Generate over $1 billion annually in US



Travel medicine clinics for exotic destinations
Direct sales to patients of health and nutritional
products, home laboratory and genome testing
kits
Urgent Care Clinics

9,300 nationwide

3 million visits /wk

Could avert 1/5 ER visits
Other Specialized Primary Care
Clinics
On-site corporate clinics
 1,200 companies host 2,200 clinics
 Serve 4% of working Americans
 Telemedicine/videomedicine )advice lines,
cannot prescribe, increasingly common
overseas (take U.S. calls)
 Self-service kiosks/video visits

Retail Outlet Clinics



Approximately 1450 in U.S. (2013)
 5.1 million visits (2011)
 44% of visits on nights and weekends
MinuteClinic (CVS Caremark); Health Systems
LLC (Walgreen’s); Walmart; others
Major health insurers opening retail clinics,
hoping to sell new policies
Retail Outlet Clinics
Quality of care good for simple problems
 Number may increase with PPACA (due to
lack of primary care providers)
 Almost 2/3 of current customers have
no PCP

Retail Outlet Clinics

Problems include
 Fragmentation of care
 Incomplete records
 Inadequate communication with PCPs
 Lost opportunity for ongoing contact with PCP
 Less common in low SES and minority
neighborhoods
 May increase inappropriate antibiotic prescribing

AAP says avoid retail clinics
Factors Which Might Encourage
Retainer Fee Medical Practice
J Clin Ethics 2005(Spring):72-84
 Tight
office schedules, long delays for
appointments, short visit lengths
 Authorization requirements of
insurance companies, HMOs, and
Medicare
Factors Which Might Encourage
Retainer Fee Medical Practice



Insufficient time to return phone calls
 Non-reimbursable
Congested ERs, with long delays for patients
with minor illnesses who are unable to access
PCP
Patients referred to specialists for problems that
do not necessarily require a specialist’s care
 Specialist referrals up outside luxury care,
partly due to busy, short PCP visits
Factors Which Might Encourage
Retainer Fee Medical Practice

Frequent changes in PCP, abetted by:
Hospitalist movement
 Employers seeking cheaper plans, which provide
narrower range of coverage
 Insurance company de-listing of physicians based on
economic criteria
 Physician extenders (NPs and Pas)
 Less time for patient-care advocacy
 Less time for CME

Luxury Primary Care Clinics
Some are solo and small group practices
 “Doctrepeneurs”
 4,400 - 5,000 physicians (includes “direct
primary care” and “hybrid” practices)


May be higher, as Medscape’s 2013 Compensation
Survey of 22,000 doctors found 4% of pediatricians
and 7% of internists and family physicians reported
being in concierge or cash-only practices (similar
percentage range for specialists)
Luxury Primary Care Clinics

Direct primary care
 E.g., Qliance ($44-$129 per month, 70-75%
already insured)
 Some evidence shows cost reductions,
unnecessary tests averted, ER visits reduced,
hospital stays shorter
Luxury Primary Care Clinics

Hybrid Practice: Physicians see both concierge (80%)
and regular (20%) patients


Paying by time


E.g., Concierge Choice Physicians, Atlas MD
E.g., DocTalker Family Medicine - $300-$400 per
hour
Cash-only practices

To avoid insurance company hassles, simplifies
billing
Luxury Primary Care Clinics
Some affiliated with large corporations
 Executive Health Registry
 Executive Health Exams International
 OneMD
 MDVIP (largest concierge corporation)

 24
practices in 7 states, with 40 more practices
in the works
 Purchased by Procter and Gamble
Luxury Primary Care
 Professional
Organization:
 American Society of Concierge
Physicians (ASCP) → Society for
Innovative Medical Practice Design
(SIMPD)
 American Academy of Private
Physicians (AAPP)
Luxury Primary Care Clinics

University-affiliated:
 Mayo Clinic (3000 pts/yr); Cleveland
Clinic (3500 pts/yr); MGH (2000 pts/yr)
 Johns Hopkins, Penn, New York
Presbyterian, Washington University,
UCSF, UCLA, many others
Luxury Primary Care Clinics
Annual exams last 1-2 days
 $2000 - $4000 per visit for baseline
package (range $1500 - $20,000)
 Additional tests extra
 Physicians available 24/7/365 by
phone/pager for additional fee

Luxury Primary Care Clinics

Patient/physician ratios 10-25% of typical
managed care levels
 Physicians cut current panel size, but
often keep some patients, including the
uninsured (“hybrid practice”)
Luxury Primary Care Clinics:
Perks and Pampering

Tests, subspecialty consultations available
same day
 Patients jump the queue, sometimes
delaying tests on other patients with
more appropriate and urgent needs
Special shirts
Gold cards
Luxury Primary Care Clinics:
Perks and Pampering
Vaccines (in short supply elsewhere) always
available
 Valet parking
 Escorts
 Plush bathrobes
 High thread count sheets

Luxury Primary Care Clinics:
Perks and Pampering






Fancy decorations
Oak-paneled waiting rooms with high-backed
leather chairs and fine art
Polished marble bathrooms
TVs, computers, fax machines
Dedicated chefs
Saunas and massages
Aside Regarding Amenities
Improvements in amenities cost hospitals
more than improvements in quality of care,
but improved amenities have a greater
effect on hospital volume
 Unclear what effect is on patients’ welfare
and overall costs of care

Luxury Primary Care Clinics
Capitalize on widespread dissatisfaction
with managed care and too-busy physicians
with inadequate time to provide
comprehensive care and counseling
 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
employees

Clients / Patients:
Upper Management

Disproportionately white males:
 Data available from one Executive Health
Program
 Women:
 46% of the workforce
 Hold < 2% of senior-level management
positions in Fortune 500 Companies
 Lower SES of non-Caucasians
Luxury Primary Care:
Marketing



Directed at the heads of large and small
companies
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 Care:
Marketing

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
care
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, crosssubsidization
LPC Clinics and The Erosion of
Science

Many tests not clinically- or cost-effective
 Percent body fat measurements
 Chest X rays in smokers and non-smokers
over age 35 to screen for lung cancer

VIP Syndrome: Clinicians deviate from practice
guidelines and thus offer lower quality care
LPC Clinics and The Erosion of
Science
Electron-beam CT scans and stress echocardiograms
for coronary artery disease
 Radiation from a full-body CT scan comparable
to dose with increased cancer mortality in lowdose atomic bomb survivors (Radiology
2004;232:735-8)
 Raise cancer risk
 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 lifethreatening diseases in the arteries, heart,
lungs, liver and other major vital organs –
before it’s too late”
 aka
 MRI
“CT scams”
breast screens: detect “nearly 100% of all
breast cancers”
 Virtual colonoscopies
The Use of Clinically-Unjustifiable
Tests



Erodes the scientific underpinnings of medical
practice
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/Justice:
Treating Patients from Overseas
 The
greatest good for the greatest
number
 Liver transplant for wealthy foreign
banker vs. treating undocumented
farm laborers for TB and pesticiderelated diseases
Ethics/Justice:
Treating 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
Ethics/Justice
 Market
forces have spurred for-profit
health care companies to export the
most inefficient, unjust elements of
American medicine to the developing
world
The Medical Brain Drain

Migration of medical professionals from
the developing world, where they were
trained at public expense, to the US further
depletes health care resources in poor
countries and contributes to increasing
inequities between rich and poor nations
The Medical Brain Drain

U.S. is largest consumer of health care
personnel

Five times as many migrating doctors flow
from developing to developed nations than
in the opposite direction

Even greater imbalance for nurses
The Medical Brain Drain

2011: WHO estimates developing world
shortage of 4.3 million health professionals
 Europe: 330 physicians/100K
population
 US: 280/100K
 India: 60/100K
 Sub-Saharan Africa: 20/100K
The Medical Brain Drain
Example of “inverse care law”:
 Those countries that need the most
health care resources are getting the least
 Voluntary WHO Global Code of Practice
on the International Recruitment of Health
Care Personnel (adopted 2010)
 U.S. working on implementing

LPC Clinics and The Erosion of
Professional Ethics

Public contributes substantially to the education
and training of new physicians
 May object to doctors limiting their practices
to the wealthy, not accepting Medicare or
Medicaid patients
 Over
1/3 of physicians not accepting new
Medicaid patients; ¼ see no Medicaid patients
 Increases
poor
health disparities between rich and
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
clinics:
 Enhance plurality in health care delivery
 Increase choices available to health care consumers
 Cross-subsidization of training or indigent care
programs
 Tufts, Virginia-Mason
 Otherwise, evidence lacking due to secrecy
 Variant of “trickle down economics”
LPC Clinics and The Erosion of
Professional Ethics

AMA Guidelines:
 Physicians switching to LPC practices must
facilitate the transfer of patients who don’t
pay retainers to other physicians
 Shifts un- and poorly-compensated patient
care onto fewer providers; risks domino
effect
 Dearth of primary care providers
LPC Clinics and The Erosion of
Professional Ethics

AMA Guidelines:
 If non-retainer care is not locally available,
physicians may be obligated to continue to care for
patients without charging them a premium

Otherwise risk charges of abandonment
Physicians with boutique practices are also still
obligated to provide care to patients in need
 Retainer-style practices shouldn’t be marketed as
providing better diagnostic and therapeutic services

LPC Clinics and The Erosion of
Professional Ethics

ACP Ethics Manual:

“All physicians should provide services to uninsured
and underinsured persons. Physicians who choose to
deny care solely on the basis of inability to pay
should be aware that by thus limiting their patient
populations, they risk compromising their
professional obligation to care for the poor and the
credibility of medicine’s commitment to serving all
classes of patients who are in need of medical care.”
Legal Risks of Boutique Practices

Violations of:
Medicare regulations (prohibit charging Medicare
beneficiaries additional fees for Medicare-covered
services)
 False Claims Act
 Provider agreements with insurance companies
 Anti-kickback statutes and other laws prohibiting
payments to induce patient referrals

Other Limitations on Boutique
Practices




Some hospitals use economic credentialing to
deny hospital privileges
New Jersey prevents insurers from contracting
with physicians who charge additional fees
New York prohibits concierge medicine for
enrollees in HMOs
States investigating payment mechanisms
Ethics/Justice
48 million uninsured patients in US
 Millions more underinsured
 Remain in dead-end jobs
 Go without needed prescriptions due to
skyrocketing drug prices

Ethics/Justice

Public and charity hospitals closing

Hospitals provide very little charitable care
(<1% when adjusted for Medicare charges;
includes bad debt)
Ethics/Justice

Retail outlet clinics increasing (Wal Mart, CVS,
etc.)
Approximately 1400 currently
 Hopes for increasing stores’ profits through sales of
merchandise, over-priced pharmaceuticals
 Less likely to be located in underserved areas
 No guarantee of continuity of care
 Most not profitable

Retail Outlet Clinics

Study of visits for OM, pharyngitis, and UTI





Ann Int Med 2009;151:321-8.
Quality same as in physician offices and urgent
care clinics, better than in ER
Prescription costs similar
Overall costs significantly lower
Convenience factor
Headline from The Onion
Uninsured Man Hopes His
Symptoms Diagnosed This Week
On House
Ethics/Justice
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

Ethics/Justice
Widening disparity between what hospitals
charge uninsured and self-pay patients
compared with insured patients
 Private hospitals charging more than public
hospitals for end-of-life care
 No effect on outcomes, quality of
life/death

Declaration of Independence
“All men are created equal.”
George Orwell
“Some people are more equal
than others”
Hudson River, 2009
Meanwhile, Outside the US…
1 billion people lack access to clean
drinking water
 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
Professionalism



Increasing dissatisfaction and cynicism among patients,
practicing physicians and trainees
 High levels of career dissatisfaction and physician
burnout
Educators increasingly concerned over adequacy of
trainees’ humanistic and moral development
Doctors fabricating/upgrading publications on training
program applications, cheating on board exams
Ethical Distortions
 Insurance/Medicare
fraud
 Seeding
trials
 Taking bribes
 Doctors offering varying levels of
testing and treatment based on
patient’s ability to pay
J
Gen Int Med 2001;16:412-8.
Doctor-Patient Communication re
Out-of-Pocket Costs
15-20% of U.S. health care costs paid by
patients out-of-pocket
 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
2000;238:1858-65
 Arch Int Med 2002;162:1134-9
Ethical Distortions
¼
of the public sanctions deception
(½ of those who believe doctors have
inadequate time to appeal coverage
decisions)
 Ann
Int Med 2003;138:472-5
 Am J Bioethics 2004;4(4):1-7
Conclusion:
Erosion of Science



LPC clinics offer care based on unsound science
and non-evidence-based medicine
Motives:
 Marketability
 Profitability
 Patient satisfaction/demand
Potential for harm
Conclusion:
Erosion 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
Solutions
Renounce the marketplace as dominant
standard or value in medicine
 Combat corporate activities antithetical to
medicine and public health
 Divert intellectual and financial resources
to more equitable and just investments in
community and global health

Address Social Factors
Responsible for Illness and Death

Deaths in 2000 attributable to:
 Low education: 245,000
 Racial segregation: 176,000
 Low social support: 162,000
 Individual-level poverty: 133,000
 Income inequality: 119,000 (population-attributable
mortality – 5.1%)
 Area-level poverty: 39,000 (population-attributable
mortality – 1.7%) (AJPH 2011;101:1456-1465)
Address Social Factors Responsible for
Illness and Death

Deaths in 2000 attributable to:
 AMI – 193,000
 CVD – 168,000
 Lung CA – 156,000

AJPH 2011;101:1456-1465
Deaths per year


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
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

Tobacco = 400,000 (+ 50,000 ETS)
Obesity = 300,000
Alcohol = 100,000
Microbial agents = 90,000
Toxic agents = 60,000 (likely higher)
Firearms = 35,000
Sexual behaviors = 30,000
Motor vehicles = 25,000
Illicit drug use = 20,000
Major Contributors to Illness and
Death
40% of US mortality due to tobacco, poor
diet, physical inactivity, and misuse of
alcohol
 Every $1 invested in programs covering
above items saves $5.60 in health care
costs

Prevention



2-4% of national health care expenditures
Every $1 spent on building biking trails and
walking paths would save nearly $3 in medical
expenses
Every $1 spent on wellness programs,
companies would save over $3 in medical costs
and almost $3 in absenteeism costs
Public Health Spending

Public health spending minimal

Mortality rates fall 1-7% for every 10%
increase in public health spending
Maldistribution of Wealth is
Deadly
 880,000
deaths/yr in U.S. would be
averted if the country had an income
gap like Western European nations,
with their stronger social safety nets

BMJ 2009;339:b4471
Address Racial Disparities in Health
Care

Equalizing the mortality rates of whites
and African-Americans would have averted
686,202 deaths between 1991 and 2000
 Whereas medical advances averted
176,633 deaths
(AJPH 2004;94:2078-2081)
Improve Education
Medical advances averted a maximum of
178,000 deaths between 1996 and 2002
 Correcting disparities in educationassociated mortality would have save 1.3
million lives during the same period
 AJPH 2007;97:679-83

Solutions
 Close
some academic medical centers
 Consolidate
redundant educational and
clinical programs in nearby teaching
hospitals
Solutions

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
Solutions
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

Solutions
 History
 Role
and literature
models/mentors
 Refocus
ethics training
Solutions

Empathic and equal provision of care to all
individuals, regardless of insurance status,
financial resources, race, gender, or sexual
orientation

Confront and work to abolish the reality of
rationing; promote equal access and care in
all spheres of medicine
Solutions
 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
Solutions
 Communicate
these ideas to business
leaders, government representatives,
and purchasers of health care
 Particularly deans, hospital
presidents and department chairs
Solutions

Society/legislators should provide
increased funding for the education and
training of medical students and resident
physicians and for the continued health of
vital academic medical centers, to allow
them to carry out their missions of
education, research, and patient care,
particularly for the underserved
Primo Levi
“A country is considered the more
civilized the more the wisdom and
efficiency of its laws hinder a weak
man from becoming too weak or a
powerful one too powerful.”
References


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 http://phsj.org/?page_id=22
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).
References


Donohoe MT. Luxury primary care, academic medical
centers, and the erosion of science and professional
ethics. J Gen Int Med 2004;19:90-94. Available at
http://www.blackwellsynergy.com/doi/pdf/10.1111/j.15251497.2004.20631.x
Donohoe MT. Retainer practice: Scientific issues, social
justice, and ethical perspectives. American Medical
Association Virtual Mentor 2004 (April);6(4). Available
at http://www.amaassn.org/ama/pub/category/12249.html
Contact Information
Public Health and Social Justice Website
http://www.publichealthandsocialjustice.org
http://www.phsj.org
martindonohoe@phsj.org