boutique medicine health care for the 1%: science, ethics, and policy martin donohoe

Boutique MedicineBoutique MedicineHealth Care for the 1%:Health Care for the 1%:

Science, Ethics, and PolicyScience, Ethics, and Policy

Martin DonohoeMartin Donohoe

Am I Stoned?Am I Stoned?

A 1999 Utah anti-drug pamphlet A 1999 Utah anti-drug pamphlet warns:warns:

““Danger signs that your child Danger signs that your child may be smoking marijuana may be smoking marijuana include excessive preoccupation include excessive preoccupation with social causes, race with social causes, race relations, and environmental relations, and environmental issues”issues”

OutlineOutline

Financial problems facing academic Financial problems facing academic medical centersmedical centers

Competitive strategiesCompetitive strategies Boutique/concierge/luxury care clinicsBoutique/concierge/luxury care clinics

Erosion of scienceErosion of science Erosion of professional ethicsErosion of professional ethics

Relevance to Social JusticeRelevance to Social Justice SolutionsSolutions

Academic Medical Centers Academic Medical Centers Hurting FinanciallyHurting Financially

US health care crisisUS health care crisis

Costs associated with medical Costs associated with medical trainingtraining

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

Academic Medical Centers Academic Medical Centers Hurting FinanciallyHurting Financially

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

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

Competitive StrategiesCompetitive Strategies

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

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

Open hospitals in other countriesOpen hospitals in other countries


More aggressive billing practices / More aggressive billing practices / charging the uninsured higher charging the uninsured higher pricesprices

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


AdvertisingAdvertisingOften promote high-paying, Often promote high-paying,

unproved, or cosmetic servicesunproved, or cosmetic services Cut back on uncovered services: Cut back on uncovered services:

e.g., ER staffinge.g., ER staffing ““Triaging out” – redirecting low Triaging out” – redirecting low

acuity patients from ER to acuity patients from ER to “other facilities”“other facilities”


Outsource radiology/transcription Outsource radiology/transcription services to physicians in services to physicians in developing worlddeveloping world

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

MetsMets


Develop luxury primary care Develop luxury primary care clinicsclinicsVIP clinicsVIP clinicsExecutive health clinicsExecutive health clinicsBoutique medicineBoutique medicineConcierge careConcierge care

Luxury Primary Care Luxury Primary Care ClinicsClinics

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

4,400 - 5,000 physicians4,400 - 5,000 physicians

Includes “direct primary care” Includes “direct primary care” and “hybrid” practicesand “hybrid” practices


Direct primary careDirect primary care E.g., Qliance ($44-$129 per month, E.g., Qliance ($44-$129 per month,

70-75% already insured)70-75% already insured) Hybrid Practice: Physicians see both Hybrid Practice: Physicians see both

concierge (80%) and regular (20%) concierge (80%) and regular (20%) patientspatients E.g., Concierge Choice Physicians, Atlas MDE.g., Concierge Choice Physicians, Atlas MD

Paying by timePaying by time E.g., DocTalker Family Medicine - $300-E.g., DocTalker Family Medicine - $300-

$400 per hour$400 per hour


Groups affiliated with large Groups affiliated with large corporationscorporationsExecutive Health RegistryExecutive Health RegistryExecutive Health Exams InternationalExecutive Health Exams InternationalOneMDOneMD

MDVIP (largest concierge corporation)MDVIP (largest concierge corporation) 24 practices in 7 states, with 40 more 24 practices in 7 states, with 40 more

practices in the workspractices in the works Purchased by Procter and GamblePurchased by Procter and Gamble


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

Cleveland Clinic (3500 pts/yr); Cleveland Clinic (3500 pts/yr); MGH (2000 pts/yr)MGH (2000 pts/yr)

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


Annual exams last 1-2 daysAnnual exams last 1-2 days $2000 - $4000 per visit for $2000 - $4000 per visit for

baseline package baseline package (range $1500 (range $1500 - $20,000)- $20,000)

Additional tests extraAdditional tests extra Physicians available 24/7/365 by Physicians available 24/7/365 by

phone/pager for additional feephone/pager for additional fee


Patient/physician ratios 10-25% Patient/physician ratios 10-25% of typical managed care levelsof typical managed care levelsPhysicians cut current panel Physicians cut current panel

size, but often keep some size, but often keep some patients, including the patients, including the uninsured (“hybrid practice”)uninsured (“hybrid practice”)

Luxury Primary Care Luxury Primary Care Clinics:Clinics:

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

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

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


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

elsewhere) always availableelsewhere) always available Valet parkingValet parking EscortsEscorts Plush bathrobesPlush bathrobes High thread count sheetsHigh thread count sheets


Perks and PamperingPerks and Pampering Fancy decorationsFancy decorations Oak-paneled waiting rooms with Oak-paneled waiting rooms with

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

Polished marble bathroomsPolished marble bathrooms TVs, computers, fax machinesTVs, computers, fax machines Dedicated chefsDedicated chefs Saunas and massagesSaunas and massages


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

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

Clients / PatientsClients / Patients

Predominantly healthy / Predominantly healthy / asymptomaticasymptomatic

US and non-US citizensUS and non-US citizens Corporate executivesCorporate executives

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

Clients / Patients:Clients / Patients:Upper ManagementUpper Management

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

Health ProgramHealth Program Women:Women:

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

Lower SES of non-CaucasiansLower SES of non-Caucasians

Luxury Primary Care:Luxury Primary Care:MarketingMarketing

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

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

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

Luxury Primary Care:Luxury Primary Care:MarketingMarketing

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

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

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

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

Many tests not clinically- or cost-Many tests not clinically- or cost-effectiveeffectivePercent body fat Percent body fat

measurementsmeasurementsChest X rays in smokers and Chest X rays in smokers and

non-smokers over age 35 to non-smokers over age 35 to screen for lung cancerscreen for lung cancer


Electron-beam CT scans and stress Electron-beam CT scans and stress echocardiograms for coronary artery echocardiograms for coronary artery diseasediseaseUnnecessary radiation raises cancer riskUnnecessary radiation raises cancer risk

Abdominal-pelvic ultrasounds to screen for Abdominal-pelvic ultrasounds to screen for liver and ovarian cancerliver and ovarian cancer

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

3535


VIP Syndrome: Clinicians deviate VIP Syndrome: Clinicians deviate from practice guidelines and thus from practice guidelines and thus offer lower quality careoffer lower quality care

False positive tests may lead to False positive tests may lead to unnecessary investigations, unnecessary investigations, higher costs and needless anxietyhigher costs and needless anxietyAnd increased profits to the And increased profits to the

clinic…..clinic…..

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

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

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

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

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

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

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

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

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

OverseasOverseas The greatest good for the The greatest good for the

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

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

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

Ethics/JusticeEthics/Justice

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

The Medical Brain DrainThe Medical Brain Drain

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


U.S. is largest consumer of U.S. is largest consumer of health care personnelhealth care personnel

Five times as many migrating Five times as many migrating doctors flow from developing to doctors flow from developing to developed nations than in the developed nations than in the opposite directionopposite direction Even greater imbalance for nursesEven greater imbalance for nurses


2011: WHO estimates 2011: WHO estimates developing world shortage of 4.3 developing world shortage of 4.3 million health professionalsmillion health professionalsUS: 280 physicians/100K US: 280 physicians/100K

populationpopulation India: 60/100KIndia: 60/100KSub-Saharan Africa: 18/100K Sub-Saharan Africa: 18/100K


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

health care resources are getting health care resources are getting the leastthe least

Voluntary WHO Global Code of Voluntary WHO Global Code of Practice on the International Practice on the International Recruitment of Health Care Personnel Recruitment of Health Care Personnel (adopted 2010)(adopted 2010)U.S. working on implementingU.S. working on implementing

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

EthicsEthics Public contributes substantially to the Public contributes substantially to the

education and training of new physicianseducation and training of new physicians May object to doctors limiting their May object to doctors limiting their

practices to the wealthy, not accepting practices to the wealthy, not accepting Medicare or Medicaid patientsMedicare or Medicaid patients Over 1/3 of physicians not accepting new Over 1/3 of physicians not accepting new

Medicaid patients; ¼ see no Medicaid Medicaid patients; ¼ see no Medicaid patientspatients

Increases health disparities between Increases health disparities between rich and poorrich and poor


EthicsEthics Alternatively, debt-ridden Alternatively, debt-ridden

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

prejudiceprejudice


EthicsEthics Academic medical centers’ justifications for Academic medical centers’ justifications for

LPC clinics:LPC clinics: Enhance plurality in health care deliveryEnhance plurality in health care delivery Increase choices available to health care Increase choices available to health care

consumersconsumers Cross-subsidization of training or indigent Cross-subsidization of training or indigent

care programscare programs Tufts, Virginia-Mason, UCLATufts, Virginia-Mason, UCLA Otherwise, evidence lacking due to Otherwise, evidence lacking due to

secrecysecrecy Variant of “trickle down economics”Variant of “trickle down economics”


EthicsEthics AMA Guidelines:AMA Guidelines:

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

Dearth of primary care providersDearth of primary care providers


EthicsEthics AMA Guidelines:AMA Guidelines:

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

Otherwise risk charges of abandonmentOtherwise risk charges of abandonment Physicians with boutique practices are also still Physicians with boutique practices are also still

obligated to provide care to patients in needobligated to provide care to patients in need Retainer-style practices shouldn’t be marketed Retainer-style practices shouldn’t be marketed

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


EthicsEthics 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

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


49 million uninsured patients in US49 million uninsured patients in US Millions more underinsuredMillions more underinsured

Remain in dead-end jobsRemain in dead-end jobsGo without needed prescriptions Go without needed prescriptions

due to skyrocketing drug pricesdue to skyrocketing drug prices Public and charity hospitals closingPublic and charity hospitals closing

Headline from Headline from The OnionThe Onion

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

Week On Week On HouseHouse


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

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

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

outcomes of care persistoutcomes of care persist

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

1 billion people lack access to 1 billion people lack access to clean drinking waterclean drinking water

3 billion lack adequate 3 billion lack adequate sanitation servicessanitation services

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

Declaration of Independence

“All men are created equal.”

George OrwellGeorge Orwell

““Some people are Some people are more equal than more equal than

others”others”

Hudson River, 2009Hudson River, 2009

Physician Physician Dissatisfaction/Cynicism/ErDissatisfaction/Cynicism/Er

osion of Professionalismosion of Professionalism

Increasing dissatisfaction and cynicism among Increasing dissatisfaction and cynicism among patients, practicing physicians and traineespatients, practicing physicians and trainees High levels of career dissatisfaction and High levels of career dissatisfaction and

physician burnoutphysician burnout Educators increasingly concerned over adequacy Educators increasingly concerned over adequacy

of trainees’ humanistic and moral developmentof trainees’ humanistic and moral development Doctors fabricating/upgrading publications on Doctors fabricating/upgrading publications on

training program applications, cheating on training program applications, cheating on board examsboard exams

Ethical DistortionsEthical Distortions

Insurance/Medicare fraudInsurance/Medicare fraud Seeding trialsSeeding trials Taking bribesTaking bribes Doctors offering varying levels Doctors offering varying levels

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


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


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

Conclusion:Conclusion:Erosion of ScienceErosion of Science

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

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

Potential for harmPotential for harm

Conclusion:Conclusion:Erosion of EthicsErosion of Ethics

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

SolutionsSolutions

Renounce the marketplace as dominant Renounce the marketplace as dominant standard or value in medicinestandard or value in medicine

Combat corporate activities antithetical Combat corporate activities antithetical to medicine and public healthto medicine and public health

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

SolutionsSolutions

Address social factors Address social factors responsible for illness and deathresponsible for illness and death

Promote a more egalitarian Promote a more egalitarian societysociety

Confront racial disparitiesConfront racial disparities Improve the status of women Improve the status of women

worldwideworldwide

Maldistribution of Maldistribution of Wealth is DeadlyWealth is Deadly

880,000 deaths/yr in U.S. 880,000 deaths/yr in U.S. would be averted if the would be averted if the country had an income gap country had an income gap like Western European like Western European nations, with their stronger nations, with their stronger social safety netssocial safety nets

BMJ 2009;339:b4471BMJ 2009;339:b4471

Address Racial Disparities Address Racial Disparities in Health Carein Health Care

Equalizing the mortality rates of Equalizing the mortality rates of whites and African-Americans whites and African-Americans would have averted 686,202 deaths would have averted 686,202 deaths between 1991 and 2000between 1991 and 2000 Whereas medical advances Whereas medical advances

averted 176,633 deathsaverted 176,633 deaths

(AJPH 2004;94:2078-2081)(AJPH 2004;94:2078-2081)

Status of WomenStatus of Women

Worldwide, women do 2/3 of the world’s Worldwide, women do 2/3 of the world’s paid and unpaid work (1/3 paid, 2/3 paid and unpaid work (1/3 paid, 2/3 unpaid)unpaid) receive 10% of global incomereceive 10% of global income hold less than 10% of legislative seatshold less than 10% of legislative seats own 1% of global propertyown 1% of global property

Women face educational, legal, political, Women face educational, legal, political, and social marginalizationand social marginalization

Limited access to reproductive health Limited access to reproductive health servicesservices

SolutionsSolutions

Close some academic Close some academic medical centersmedical centers

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

SolutionsSolutions

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

makingmaking Augmenting philanthropic Augmenting philanthropic

contributionscontributions Increasing alliances with industry?Increasing alliances with industry?

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

SolutionsSolutions

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

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

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

SolutionsSolutions

Empathic and equal provision of Empathic and equal provision of care to all individuals, regardless of care to all individuals, regardless of insurance status, financial insurance status, financial resources, race, gender, or sexual resources, race, gender, or sexual orientationorientation

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

SolutionsSolutions

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

SolutionsSolutions

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

SolutionsSolutions

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

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.”

Contact InformationContact Information

Public Health and Social Public Health and Social Justice WebsiteJustice Website

http://www.publichealthandsocialjustice.org

http://[email protected]

boutique medicine health care for the 1%: science, ethics, and policy martin donohoe

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cosmetic services

uncovered services

boutique medicine health

patients open hospitals

bone density testing

medical training costs

low acuity patients

policy martin donohoe