Concierge Medicine and Boutique Medical Practices: Cure or Disease?

Some time ago, I rented a car during a visit to another city. I chose among the various categories of vehicles which are listed from the last expensive to the most costly. Here were my choices.


• Economy

• Compact

• Intermediate

• Standard

• Full Size

• Premium

• Luxury

As I have pointed out on this blog with regard to medical care, people spend other people’s money much more easily than they spend their own. This is why I have argued that patients need to have some ‘skin in the game’ to serve as a brake on profligate medical spending. There may be other effective brakes to consider, but diagnostic and therapeutic restraint demanded by patients is a potent and reasonable option.

In the rental car case, I was not on someone else’s expense account, but was handing over Kirsch cash. I chose a standard sized vehicle. Of course, I could have saved $$$ by driving off in an economy vehicle, but rental cars are priced like movie popcorn. For a few dollars more per day, you can drive a bigger car. It is a brilliant pricing strategy that encourages the consumer to upgrade.

Here’s the point. I ordered and paid for a standard sized car. I cannot expect that I will be presented with a luxury automobile when I arrive at the rental car lot. Of course, I can upgrade to a higher category, but I will have to pay more. Isn’t this fair? If you are paying for a Chevy, don’t expect to drive away in a Cadillac.



This concept relates to the practice of concierge medicine, also known by the even more derogatory description of boutique medicine. In these practices, patients pay a premium to the physician in return for higher level medical services. These physicians can earn the same income, or more, while caring for much fewer patients.

Why Do Insured Patients Pay More For Concierge Care?

• Same day appointments

• On time office visits that last as long as needed

• Direct access to the physician’s cell phone

• Physicians accompanying patients to specialists’ offices

• Comprehensive annual physical examinations and health review

• Emphasis on preventive medicine, nutrition and wellness

• Posh waiting rooms with New Age soothing music

Concierge Medicine Criticisms

• It’s not fair

• Insured patients should be getting these services anyway

• It’s elitist

• It siphons primary care physicians away from those who can’t afford concierge care

Concierge medicine didn’t emerge in a vacuum. It was not concocted by greedy physicians who were seeking to provide Cadillac care so they could continue to drive Cadillacs.

1903 Cadillac



Boutique medical practices have become popular because private practice primary care physicians faced three mounting challenges.

• Financial pressure with declining reimbursements and rising overhead

• Declining quality of care from seeing higher volume of patients

• Burnout

Concierge medicine is a response to this reality. Concierge practices are financially solvent and provide premier quality medical care to a smaller group of patients. This is not exclusively a benefit for the wealthy. Many average income folks have decided that spending $100 each month for superior medical services is worth it for them and their families. How much do you spend each month on your cell phone? Is concierge medical care more important to you than an iPad, a smart phone or joining a pricey gym? We all make choices in how we spend our money.

For those who want this higher level service for their families, they may need to cut back on other expenses. What kind of car are your driving now? Full size? Luxury? Sports Car? Hybrid? Perhaps, it is worth downsizing your wheels and upgrading your medical care.

I realize that many folks don’t have this option right now, particularly under current economic conditions. We all wish that they, and everyone, could receive concierge level medical care, but this is not how our society works.

Concierge medicine isn’t the avaricious aggressor here. It’s self-defense.

Does Revised American College of Physicians Ethics Manual Need Revision?

I regard myself as a spirited patient advocate. (What doctor doesn’t?) When facing a patient, I try to focus entirely on the patient’s interest. My advice is hopefully not tainted by the patient’s insurance status or external influences. A patient without medical insurance should receive the same medical advice as a corporate CEO, although the former may reject the medical advice for financial reasons.

As Whistleblower readers know, I am a conservative practitioner of the art and science of gastroenterology. I first developed this medical world view as an intern and resident, and remained a parsimonious practitioner even after completing a gastroenterology fellowship at an institution where patients were routinely subjected to a tsunami of testing.

I don’t pull the colonoscopy trigger easily or order many imaging studies. I prefer to prescribe a tincture of time instead of a test. Most patients appreciate this measured approach, although some prefer the tsunami.

I don’t practice conservatively because it is cost-effective. I do so because I think it’s best for patients. I think it is inarguable that our patients are over imaged, over treated and over tested. I am convinced that there is more than enough wasted money in the health care system to rescue it. Reminiscent of Eisenhower’s warning of a military industrial complex, we are now trying to chip away at a medical industrial complex that is an expanding hydra that takes no prisoners. This is not to suggest that I support Obamacare as a remedy,.  I don't. For a fuller airing of my Obamacare opposition, I invite you to wander through the Health Care Reform Quality category on this blog. But, our health care system surely needs better health. It has inadequate access for millions of patients, conflicts of interests, misaligned incentives and quality lapses that must be addressed. I think that Obamacare aims to restrain excesses and remedy deficiencies by settling for mediocrity. I’d rather strive for excellence.

Physicians are strongly advised to practice cost-effective medicine, a practice that is often resisted by patients who interpret this as an effort to save money at their expense. Of course, the term cost-effective communicates that the mission is to save dollars and not save lives. Perhaps, the medical linguists who have concocted phrases including pay-for-performance and medical provider and pharmacy benefit manager can create a more appealing label. Here are some suggestions.

• No Frills Medicine
• Cheapo Medicine
• Medicine on Five Dollars a Day

Seriously, even the hackneyed evidenced base medicine (EBM) phrase would be a step forward. However, EBM is limited since so many clinical issues that doctors face must be addressed without any available medical evidence to guide us. Perhaps, readers have a suggestion of a better phrase than cost-effective. 

Recently, the American College of Physicians issued revised guidelines in its newly published ethics manual that instructs physicians that our responsibility extends beyond the patient before us. Here’s an excerpt.

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.

This is an ethical game changer. According to the updated ethics manual, physicians should consider preserving health care resources for the population at large, which may conflict with our patient’s interest. Now, we are told that we are ethically obligated not only to advocate for our own patient, but also for hundreds of millions of other patients. If this becomes standard operating procedure, how will it impact the doctor-patient relationship? Will patients, who are increasingly skeptical of the medical profession, trust us? Will they suspect that we are restraining their care to serve the greater good?

I think that the merits of cost-effective medicine can be persuasively made to individual patients without having to consider society’s needs. Of course, preserving medical resources and health care reform are legitimate issues. But, do they belong in the exam room?

How would patients respond to the following question?

When seeing your doctor in the office, do you expect that he is focused on

(a) your medical interests exclusively?


(b) your medical interests exclusively on Mondays and Wednesdays?


(c) your medical interests exclusively if you are a concierge medical patient?


(d) your medical interests and society’s need to save money?

Physicians are trained advocates. Remind me, who are we advocating for?

As always, your comments are most welcome.

Cigarette Warning Labels May Go Up in Smoke

We live in a free society. One of our most treasured freedoms is our right to free speech. This means that we are free to advertise goods and services to potential customers, although commercial speech does not enjoy the same constitutional protection as does noncommercial speech. Some advertised products are good for us and others aren’t. In many cases, the worth and value of the product are in dispute. Nevertheless, if a product is legal, the manufacturer is entitled to advertise and to lure customers.

While an advertisement may not be false, it may not be the complete truth either. We expect that these pitches will be buffed and sanitized to present the product in a favorable light. That’s why they’re called advertisements, and not testimony.

It would be absurd for a company to include negative material about its products in its promotional materials, barring a legal requirement to do so. While issuing product warnings and legal disclaimers may be a laudable public interest maneuver, it’s not a way to run a company.

Imagine the following scenarios.

Join Our Tanning Salon. Get skin cancer!

Join Our Gym. Have a stroke on our treadmills!

Dine at our Family Restaurant. We don't wash hands!

Computer Protective Services Our PCs have viruses!

Expert Car Repair. We're Crooks!

The tobacco companies, the mother of all villains, had been required by the Food and Drug Administration (FDA) to include graphic and dire death and illness warnings prominently on their packages. One of the warnings depicts a corpse with the traditional autopsy incision visible. I don’t dispute the accuracy of the health claims. Indeed, I’ve often issued them personally as a doctor in my office. But is it fair, reasonable and necessary to compel cigarette companies to scare folks from purchasing their legal products? It would be more rational and intellectually honest for the FDA and the federal government to declare tobacco to be illegal. How can they permit a product so dangerous to be freely sold to the public? The reasons that restrain them from doing so are self-evident. Readers are free to offer their own views on the government’s paradoxical (in)action.

A federal judge recently issued a preliminary injunction against the FDA’s edict arguing that the cigarette companies were likely to prevail in a First Amendment challenge. The judge recognized that graphic and macabre material likely exceeded a reasonable government requirement to inform smokers of health risks on cigarette packaging. Their purpose was quite transparently to shock, not inform. Not surprising, my beloved liberal New York Times has editorialized that the judge’s injunction was wrong. This judge, in my view, was spot on. I predict that his ruling will be upheld on appeal.

As an aside, are there folks out there who are not aware that smoking cigarettes is not a salubrious activity?

Our medical office needs new promotional material. Since I’m a taxpayer, perhaps the FDA can assist me. Here's my draft.

Michael Kirsch, MD

Specialist in Screening Colonoscopy

WARNING!

 He Has Perforated Many Colons.

You Might End Up Here!

 

Can Spiral CT Scans Detect Curable Lung Cancer? But Wait, There's More!

A hundred bucks doesn’t buy much these days. A crisp Ben Franklin can be exchanged for

• 50 Big Macs
• A Broadway show ticket
• A night in a New York City hotel (just joking)
• A college textbook (paperback)
• Your life

Your life? Yes, 5 crumpled Andy Jacksons can save your life, as was reported earlier this year in a front page article in The Plain Dealer, Cleveland’s only daily newspaper. University Hospitals is now offering a $99 spiral computed tomography (CT scans) of the chest in individuals who are at increased risk of developing lung cancer. The rationale is that if cancers can be detected early, then the cure rate for surgical removal is very high.

Gary Schwitzer, medical blogger and press watchdog, tries to bring some balance to the distorted media coverage of CT lung cancer reportage.

The test is not covered by insurance, so consumers will have to hand over 10 Al Hamiltons to get in the door.

I’m a deep skeptic of this effort, and predict that with some more time, the promised benefits will prove to have been exaggerated and the drawbacks will become clear. Although one national study suggested that spiral CT scanning was effective, one study shouldn’t change the course of medical practice. If you’ve been reading medical journals for a while, as I have, you realize that today’s breakthrough may break apart tomorrow. Let’s see what future studies on screening for lung cancer with spiral CT scans conclude. I predict growing medical dissent on this issue.

Although I am uncertain about the early promise of saving lives, I am quite certain that the scans will uncover zillions of 'abnormalities'. Undoubtedly, folks will be discovered with benign, insignificant lung lesions, which physicians call incidentalomas. This term refers to abnormalities found by radiologic tests that have no medical significance, but inexorably generate a cascade of medical testing. Every physician can attest to this phenomenon.

Most lesions that spiral CT scans discover will be incidentalomas. Of course, unless there exists a prior CT scan that would prove that the lesion was present years ago and is unchanged, then the incidentaloma will be described as suspicious. So, although most of the abnormalities are benign, they will have a malignant effect on patients and their families. Here is what these folks have to look forward to.

• Anxiety that cancer is present
• Diminishment of quality of life
• Referral to a pulmonary specialist for more fun and games
• Prospect of periodic CT scans for 2 years to verify the lesion is stable
• Consideration of a biopsy of the lesion (Ouch!)
• Consideration of surgery to remove the lesion (Mega-ouch!)
• Medical complications from biopsy or surgery
• Waste of health care dollars

Although The Plain Dealer’s piece was gushing, there is another side to the story. Is University Hospital pursuing this for medical or for marketing reasons? Will other area hospitals start hawking their own screening CT scans so as not to be left out? Will a bidding war begin driving prices down. This sounds like it could become a 2 a.m. TV telemarketing pitch.

“You won’t pay $250, or even $200. No, you won’t pay $150. For just 5 easy payments of $19.99, you get a state-of-the-art spiral CT scan. And, if you order in the next 10 minutes, we will include a set of Japanese steak knives guaranteed for life. These knives alone are a $200 value. But wait, there’s more. If you promise to tell a friend about this special TV offer, we will include a cigarette lighter that opens up to form an ashtray. No smoker should be without one. And, if for any reason, you are not completely satisfied with your scan, we will return the full purchase price, minus a shipping and handling charge, no questions asked. Return the knives, but keep the lighter/ashtray as our gift.”

My view? I recommend that smokers find a better use for 20 Abe Lincolns than a spiral CT scan. My suggestion? See a Broadway show.

Happy New Year to All!

Whistleblower Holiday Cheer 2011!

Jingle Bells, jingle bells,

Romney cracks a smile,

Oh what fun it is to watch

The Gingrich pompous style.

Bachman bleats, Cain retreats,

Huntsman tries to please.

Oh what fun it is to watch,

When Perry’s brain goes freeze!

Ron Paul’s weird, Very weird,

Santorum has no chance,

Oh what fun it is to watch

His Tea Party romance.

Who will win? Who will Spin?

Who won Debatorama?

The winner dancing in the streets

Is Barack Obama!


Wishing you Joy & Peace

Colt McCoy's Concussion Fumbled by Team Physicians

The Cleveland Browns have been in the news this week, and not because of newfound success on the gridiron. While sports is not among my highest priorities, I have developed increasing interest over the years since professional sports is religion to so many here in Cleveland and in Ohio. Cleveland sports teams all enjoy great success, provided that success is not defined by victories. It’s not if you win or lose but how…



I watched the Cleveland Browns compete against the Pittsburgh Steelers two Thursdays ago. I cringed as I witnessed our young quarterback, Colt McCoy, take a blow to the head that could have landed the perpetrator a 10 year prison sentence had this act occurred on the street. I wasn’t worried that McCoy would have to miss the rest of the game. I feared that he might have to miss the rest of his life. Violence sells tickets.

If an activity requires a participant to don a helmet and a coat of armor, then clearly it is an unwise activity for a human to engage in.

McCoy was taken off the field and reentered the arena 2 plays later, after an exhaustive evaluation that was completed in about 100 seconds. Since everything in sports and medicine is now measured, we know that McCoy was sidelined for a total of 3 minutes and 50 seconds before his soggy head reentered the arena. Perhaps, emergency room physicians should consult the Browns’ medical staff to learn how they can expedite their medical evaluations in their emergency rooms. With a little training, a heart attack patient, for example, can be treated in 3 minutes or less.

McCoy’s father went public chastising the Browns for the decision and the process that led to his son Colt returning to the field. While the NFL is now investigating, the Browns maintain that proper procedures were followed.

As more facts dribble out, we learn that McCoy did not receive the standard medical evaluation that is required after a suspected concussion known as the SCAT2 (Standard Concussion Assessment Tool , version 2). Apparently, Browns’ medical personnel were attending to others and did not witness the helmet-to-helmet collision. Are these folks aware of the futuristic technology commonly known as instant replay?

If the only medical training you ever had was how to swallow aspirin or apply Band-Aids, it is likely you would know that a 4 minute time out is not a sufficient assessment period after a cannon ball blow to the skull. Initially, the Browns were vague on the extent of neurologic testing that was performed on the concussed quarterback. We now know that there was no evaluation.

As a physician who has been sued, I am sensitive to applying blame retroactively. I can understand based on the available facts why McCoy was sent back in. But this event shows that either the process is flawed or that proper procedures were not followed. This episode warrants investigation for the right reasons, not simply to apply the broad brush of blame to make some folks feel good.

Nevertheless, this is a particularly galling vignette for physicians like since we are trained and dedicated to practice high levels of patient advocacy. We advise our patients on what we believe to be in their best interests. Sometimes, we take heat for this. We may, for example, advise an individual that they should surrender their driver’s license. We may counsel a patient not to travel even though a family trip was planned months ago. We may warn a patient that his job is threatening his health.

Our advice should not be contaminated by external considerations. We would not, for example, clear a patient to return to work prematurely because this would serve the employer’s interest.

In professional sports, team physicians advocate for the team. Obviously, there is an enormous conflict between serving the team and serving the player. If McCoy’s primary care physician were consulted after the head thrashing incident, do you think he might have offered a second opinion? Let’s hope so.

Colonic Hydrotherapy and Colon Cleansing; Time to Bend Over?

Garden Hoses in Assorted Colors

A few times each month, a patient asks me for my opinion on colonics. They ask me because I am a gastroenterologist, and I am supposed to know this stuff. After 2 decades of performing colonic intrusions, I should be well qualified to respond to these alimentary inquiries.

To those who are unfamiliar with the concept of colonic detoxification, I offer a brief rationale of the procedure. Those who have been lured into the Fraternal Association of Rare Toxins (acronym not provided) have been persuaded that stagnant stool within the colon is a source of toxins that seep into the body causing disease. According to the anti-toxin crowd, when stool overstays its colonic welcome, it can lead to chronic fatigue, lassitude, restlessness, irritability, mood disorders, skin rashes, arthritis, cardiac rhythm disturbances, seizures, allergies, dementia and the murky diagnosis of candidiasis, or yeast infection. This symptom list could apply to half of my medical practice. So far, I've never prescribed a colonic to any of these sufferers. Have I been medically negligent to withhold this treatment from them?  Could a plaintiff attorney accuse me for failure to cleanse?

This is a scary symptom list, which is only a partial listing of the maladies attributed to a slothful colon. Patients reading through these symptoms, might be inclined to use a garden hose for an unintended purpose. Amateurs, however, are strongly advised not to do try this at home. Leave it to the professionals, who are trained to separate you from your stool and you from your money. They succeed on both counts.

To assist you in your research efforts, be aware that there are various names for colonics.

• Colonic cleansing
• Colonic hydrotherapy
• Colonic irrigation
• High colonics
• Wallet cleansing

Then names may change, but the mission doesn’t. The objective is to get the colon toxins out. The motto of the Society of Hydrotherapists Investigating Toxins (acronym not provided)  is, Don’t just die, detoxify!

If any readers at this point are tremulous over your toxins, let me reassure you.  There is no science that supports colonic cleansing and no responsible medical doctor will prescribe them.  Indeed, if a health professional does recommend that your colon gets hosed down, I'd look for a second opinion.  Obviously, stool is waste matter.  That's why your intestinal system reliably and regularly eliminates it from your body. There is no persuasive scientific evidence that dangerous 'toxins' in your stool leech into your body and cause disease in normal folks. Hydrocolonic power washing can't compete against millions of years of human evolution. 

But, colonic hydrotherapy is big business, and I'm aiming to get a piece of the action.When health care reform gets underway in a few years, and doctors are on salary working supervised by government bureaucrats, I’ll need a side job to make a living. The colon can again be my pathway to success, particularly as colonscopy becomes obsolete. I’ll need a niche as the colonics competition will be fierce, from out-of-work gastroenterologists who will be on the street corner with a sign that reads, Will Do Colonic for Food. However, it won’t be enough to offer routine colonics to gain a foothold in the marketplace. I will need to provide a Bionic Colonic, or perhaps a Supersonic Colonic to turn a profit. Of course, there will be family discounts and volume pricing. Kids under 12 will be half-price. Tuesdays will be Ladies Night. Pets? Endless possibilities.

A year ago, I was worried that health care reform legislation, if it became law, would erode my livelihood. More wiser now, I realize health care reform will be a fountain of opportunities for resourceful physicians. For this gastroenterologist, there’s light at the end of the tunnel.