 Her interests are in the doctor-patient communication and shared decision-making among racial and ethnic minorities. She's gonna talk to us about ethical implications of concierge medicine. Monica. Great, thank you. I'm really glad to be here. And I wanna give a shout out before I start to one of our students who is with us this summer, but not with us today. Mara Haplamazian and to Mark. Oh, I'm wearing a mic. Okay, it's not working, so can I stand? Okay, I'll stand here. Is this good? Great, okay, so I just wanna give a shout out to one of our students that was with us this summer and to Mark Siegler who helped us think about some of these issues. So we're talking today about the ethics of concierge medicine and the implications that it particularly has for health disparities. So the first question is exactly what is concierge medicine? Some of us may think of Canyon Ranch, which is delightful. I've never been, but I plan to go. It also goes by several other names, retainer medicine, boutique medicine, luxury primary care, or executive health. And these are truly websites that I've pulled off the internet last week that sort of give you a sense of the message that physicians are trying to send to potential patients and trying to attract them for their concierge practices. So this one right here as well as this one right here. So essentially there are issues of financing and the services that people actually get. So in addition, separate from regular medical care where people rely exclusively on health insurance if you have it, with concierge medicine there's a monthly and or annual fee ranging on average but not certainly with a ceiling of $20,000 between 1,500 and 20,000 for an annual fee plus or minus monthly fees. And for that you get a broader range of physician services. There are two kinds, one is called direct primary care where there's cash only. So if you need a test or procedure all of this coming directly out of your pocket insurance is not accepted at all. The majority of them, 80% actually do accept insurance which has I think more important implications for the rest of us in that the additional tests and procedures that are ordered by the physicians are actually covered by insurance companies and so we all share the burden of or pay for additional tests that are happening under the auspices of concierge medicine. What people get in return are essentially faster clinic visits so you can get to see the doctor faster you have more time with the physician. We a lot of times think about two key areas in concierge medicine. In addition to physicians there's a whole team-based approach to care so they may have a nutritionist, a physical trainer, a variety of subspecialists that are there on the same day so you can go and get everything done at once and you have a lot of time. You can talk about lifestyle issues and you really get in depth counseling which sounds great, we all want that. The other aspect that we a lot of times think about for concierge medicine is the idea of asymptomatic screening for procedures. So someone who has no cardiac risk factors is not having chest pain or shortness of breath but getting a stress test or getting routine pelvic ultrasounds or screening for cervical ovarian cancer which we know right now is not considered a standard of care. So in addition to having the nice array of services that we would all want, part and parcel of what we typically think about for concierge medicine is the additional access to unnecessary tests and treatment that may otherwise people not have access to. So you have additional, a broader, faster access to your doctor, more access to your doctor as far as time spent, you have additional goods and services and then ready access as far as basically 24-7 access to your physician. In some cases they will fly to wherever you are be that internationally or not with the very least 24 access to their cell phone, their email for ongoing consultation services. And then there's sort of the distal end, the most extreme end where there are amenities that we normally associate with things like Canyon Ranch, where there's saunas and massages and buffet lunches and plush bathrobes and things that you would order there. Think about I'm getting when you go to a high-end hotel. The difference is that this is not a high-end hotel. These are healthcare goods and services. We've seen a remarkable rate of the growth of concierge services just in the past few years, both as far as time and in key cities like Chicago. So concierge medicine is something that really sort of draws for physicians upon, the reason it's so appealing is that we get to do what all of us want to do as physicians, spend more time with patients, have a smaller number of patients that we cater to for patients. I certainly would want to sign up for that. I don't think anyone loves a spa more than I do. And if I can get that and see my physician at the same time, well, that sounds like a really great idea. Here's the challenge or the problem that may seem obvious, but I want to explore a little bit more over the next few minutes and I will try and stay on time. It's the paradigm in which this occurs. So we know that, for example, oh, this is just a slide about physician salaries. Most concierge medicine is within the realm of primary care. So family medicine, internal medicine, pediatrics, where we typically are on the lower end of the pay scale. And this is just a broad spectrum of the enhancement of physician salaries that are possible. So in addition to the things about having more time with patients, certainly you can make a lot more money as a physician who's in concierge medicine as opposed to standard private practice or academic practice. The paradigm shift that we, I think that is my sort of proposal today is where we currently are with concierge medicine is that people who have a higher social class, people have more access to goods and services and income are the ones who are primarily utilizing concierge services because they're able to afford the retainer fees. We know that in general, death and dying and illness affects everyone, but it is protective if you have additional income, if you have additional access to goods and resources. This is a study that was done in England a few years ago and basically the X-axis just shows you a lower, increasingly lower social status. So the farther you are to the right, the lower you are on the social scale and then the Y-axis shows you the expected life expectancy. And so you see that the worst, your social position is the lower your life expectancy is and this is not necessarily new to us, but this is just another way of categorizing the effects of class on people's actual life expectancy, the mortality, the morbidity. And so within the concept of concierge medicine, what we have is essentially a population that has the most access to goods and services, the most access to better health, actually getting a disproportionate amount of healthcare goods and services. And so I would like to sort of flip that on its head. I think this raises a couple of key questions for us, both in terms of clinical ethics, but also in terms of health disparities. So I'm gonna try to use, to interweave those two paradigms for having us think a little bit more about concierge medicine. So the first ethical issue I would say was one of medical professionalism. And so we have sort of a few key principles in that around patient welfare, autonomy and social justice. But as we are seeing increasing concerns about the erosion of medical professionalism in our country, what does the impact of concierge medicine do for our role as physicians in society? If people are under the impression that we're more in it for the money, we're in it for ourselves than we are for the welfare of our patients. Certainly there are concerns about the influence of trainees and what that tells their future generations of physicians about what it means to be a good physician. That means that you're primarily going to be focusing on a very small subset of patients who are more affluent as opposed to trying to care for all patients who may need your services. In 2003 and 2012, the American Medical Association and the American College of Physicians essentially came out and said, well, within our pluralistic society, I think that there's an adequate space for concierge medicine. And I will then turn this over to a paper that, Dr. Sealer's Smiling, that our own Lydia Dugdale, Mark Sealer and David Rubin published in Perspective in Biology and Medicine in 2008, thinking specifically about medical professionalism and what it means in the context of the doctor-patient relationship. They identified about six key tenets. Some of those are directly relevant to our conversation today around being a good steward of society's resources, having support for policies that decrease health disparities and really developing and maintaining strong and effective doctor-patient relationships. So we see that at least half of those are directly relevant or particularly challenged with the idea of how we're implementing concierge medicine within our country today. And so despite the fact that the ACP has a more neutral position about concierge medicine, there was a paper that came out that our own Dan Salmezzi was on, he's listed as a co-author, that came out about managed care. But because it has to do with health plans and medicine and professionalism, I'm using that as an example for us to draw upon as we think about some of these issues as applied more broadly to retainer medicine, boutique medicine, this was published in 2004. So it came out in Annals officially under the advisory committee for American College of Physicians, but there are a number of subspecialty organizations who signed on to this and who were listed at the front of the paper as well, representing a broad swath of medical specialties, including general internal medicine, which is where I find my medical home. One of the, there are many things in this paper, but one of the points was that clinicians should advocate just as vigorously for the needs of their most vulnerable and disadvantaged as well as they do for their most articulate patients. And so this really gets to the heart of health disparities. The Institute of Medicine in 2001 showed us by culminating all the literature that we see that there are differences, not just in health and health outcomes, but in the kind of care that's delivered by race and ethnicity. So within our country, certainly within other countries too, but within the United States, healthcare is not equally distributed. And that is an ongoing cause and contributor to the disparities that we see in health outcomes. So in addition to thinking about some of the potential erosion of medical professionalism and some of the key components of medical professionalism that are relevant to our conversation today, there are a few that are highlighted. So again, the mention of the just fair allocation of health resources. So that paper referenced that clinicians have a responsibility to practice effective and efficient healthcare and to use healthcare resources responsibly. And again, Dr. Siegler and colleagues noted that in their paper as well. So again, sort of coming back to this, the picture of reminding us who is actually receiving concierge medicine and what that means as far as their overall life expectancy as far as their ability to buffet some of the disease and morbidity and mortality based on their access to good and services. The paradigm that we have where a small population of relatively well healthy people are getting disproportionate amounts of good and services is not one that is just or sort of an efficient use of our limited healthcare resources and dollars. It comes, so this draws upon the part of this model from the Institute of Medicine that attributes some of the disparities we see to what we call the ecology of healthcare systems and environmental factors, basically structural inequities that we see within our healthcare system and how those structural inequities contribute to healthcare disparities. So I'm gonna talk a little bit more just about that. So Norman Daniels and his distributive theory of justice as applied to healthcare really gives us a sense of how we can think about resource allocation as a contributor to health, particularly as related to healthcare. And so we see the potential for exacerbations of structural inequality that we've already documented, but the exacerbation of that structural inequality with the emergence and sort of explosion of concierge medicine within this country. So if you think about the physician workforce as a goods and services, so we already know that right now, or let's say last year, we already had a primary care physician shortage. So we had too few primary care physicians. It's primary care physicians that make up the probably 90% of concierge practices. With the implementation of the Affordable Care Act, we have millions of people who are now coming into the medical system that we didn't have before. And so that puts additional pressures on our system for primary care physicians. And if we're seeing sort of a mass exodus from primary care in the wake of current existing and increasing need for those very services, and I think that makes a strong case for the exacerbation of some of the structural inequalities. I would say the same thing for not just the physicians themselves, but the goods and services that we provide. We know that there is a limited healthcare pie and that this part of how we conceptualize concierge medicine is that there is some extra ordering and implementation of unnecessary tests and procedures that are paid for by insurance that we all contribute to. So we're all, as society, disproportionately funneling resources that may be inappropriate and may not be evidence-based. And so as we're having what we see with the Affordable Care Act is, in addition to expanding access, they're trying to do that by implementing efforts of cost containment. And so the question is, will that disproportionate burden of cost containment be borne by those who are least able to actually afford that from a health perspective? Third key ethical issues about the patient position relationship itself. As far as issues of continuity of care, we have research that shows that the more continuity a person has with their provider, the better their health, patients are inherently by definition. Some of those patients are gonna be left behind when a physician goes from their regular practice into a concierge practice. Usually they reduce their patient load by at least 50%. Those who are left behind are those who can afford to pay the retainer fee. And so those are more likely to be people who have fewer resources, who are low income, racial ethnic minorities, who may be disproportionately burdened by the lack of continuity of care as far as their health outcomes and subsequent health disparities. Same thing for provider trust. We know that trust is the mediator between physician recommendation and treatment adherence and that minorities disproportionately experience a trust or disproportionately have higher mistrust of their healthcare provider and healthcare team. And so if we are breaking, sort of forcibly breaking relationships that may have existed for decades by transitioning people out of their primary care and their physicians move on to retainer practice, then we have several mechanisms in play by which we can anticipate seeing an exacerbation of health disparities. Two others are with cultural competency and shared decision making, which is actually where I spent a lot of my time sort of thinking about all of these things are related to health care and health outcomes. And so within the context of retainer or concierge medicine, there are issues that are at play that can have a direct impact on health disparities. And last I would say is physician practice variation. So not sort of this is a Dartmouth map of geographic variation, but really thinking about the individual variation within a single physician practice. And so this gets more to the model that looks at discrimination, bias, stereotyping, mainly unconscious bias by physicians when we're providing care to a broad swath of patients. And so the question is, will our unconscious biases that we all have, all of us as physicians, as people have these, will they get exacerbated by the conflation of who deserves care versus who can actually afford their care and what that means for future generations of physicians. So in conclusion, I would say that our current practice of concierge medicine creates a number of ethical dilemmas for our profession and for us individuals, physicians, and it has the potential to exacerbate existing health disparities that we know currently exist. And that what we really need is a paradigm shift so that we're risk stratifying for resource allocation based on health need. So the ones that are sickest among us, the ones that are the most vulnerable, the oldest minorities who may have disproportionate inadequate access to care, those are the ones that we actually are funneling additional resources to. And that actually is in line with current health policy trends is we're thinking about global payments, bundled payments, population health management. So I would just suggest not that concierge medicine in and of itself is inherently evil, but that we rethink how we're reallocating the limited healthcare dollars that we have to ameliorate the health of the most vulnerable amongst us and to improve population health in general. I'd like to say thank you and to acknowledge the various homes, I'll use only some of these in which I sit here at the University of Chicago. Finished early enough, we have time for one or two questions, so yes, please. Hi Monica, thank you so much. I'm not only sir from the Department of Surgery at the University of Chicago. I wanted to thank you for that talk and then also so where I trained in residency, this sort of reminds me of the concierge floor sort of where many hospitals, not actually University of Chicago, but many hospitals have sort of a private floor where you can get the sort of hotel-like treatment and we used to joke that that floor was near a hospital because it actually was, from the trainee's point of view, the worst place to be. You often didn't have nurses that were specialized for the operations you had had and it was kind of like the big joke that the people with the most access were getting access to what they thought was like the best care and what they were actually receiving was the opposite. And certainly as physicians, we know that when we become patients, we're sometimes, we sometimes get a VIP treatment and that can lead to increased intervention. So do we have evidence that concierge medicine is really leading to better outcomes for these patients? It seems like it might be on the spectrum where it might actually lead to the opposite. Yeah, that's a good question and there isn't a lot of literature on that, partially because it's off the grid. So for some of the practices, it's cash only, we can't track them with insurance purposes. Some of the studies that have looked at, for example, reduced hospitalization rates weren't really fair studies because they weren't looking at people who were otherwise similar for socio-demographics. And we know again that if you have a lot of money and a lot of access to goods and resources, then your social position is already inherently different. So you can't compare those to just regular people in Medicare. And so the comparison groups aren't equal so it's hard to say that, just like we used to think HRT was a great thing, we totally realized that actually women who were taking hormone replacement therapy were just healthier women and it's not that it was the actual pill themselves. So people who are going into concierge medicine are healthier at baseline and so we don't really have a whole lot of comparative studies that can look at outcomes in a way that has equal comparison groups. Thank you. Just one more question, I guess Dan, please. Thanks. Yeah, it's an interesting topic, but just to pick up on the last question, I mean, the whole notion that more medicine is necessarily better medicine, treating it like a commodity, that the more you get of it, the better you'll do is an obvious fallacy, right? And because we know that more diagnostic testing results in more false positives. And so I see this as sort of one of the dangers of being wealthy is getting really excessive medical care that can actually hurt people. Absolutely, so I didn't sort of have time to comment on that, but you're exactly right. The incidentalomas, sort of the, we do the whole body CT scan and oh, we find these things and they're probably just benign, but now we have to go biopsy, then oops, you bled too much and you had a reaction to the anesthesia and gosh, I really hate that. And so there are unintended negative consequences from not in addition to cost consequences of doing too much, certainly. Thank you. Thank you. Thank you.