Executive physicals, and what the Mayo Clinic doesn’t want you to know

The Mayo Clinic has been touted by policy wonks as a low-cost, high-quality integrated health system that American physician practices should aspire to.

What’s somewhat less publicized is that they are also a leader in so-called “executive physicals.” (via Schwitzer)

These exams, which often exceed thousands of dollars, offer CEOs and other executives a battery of tests that are often not evidenced-based. These can include stress tests, cardiac CT scans, and other full-body scans. Bluntly put, they symbolize the excessive testing pervading American medicine today.

Indeed, a blistering critique in The New England Journal of Medicine puts executive physicals in its place: “As efforts to reform the health care system continue, the executive physical is a perfect example of what American medicine should be working to expunge: the expensive, the ineffective, and the inequitable.”

The Mayo Clinic certainly enjoys the publicity and popularity it receives from the health policy community. But they can’t have it both ways. You can’t be a supposed leader in cost-conscious care yet enjoy the financial rewards of lavish executive physicals.

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  • Matt

    “You can’t be a supposed leader in cost-conscious care yet enjoy the financial rewards of lavish executive physicals.”

    Why not? This comment and the NEJM comment illustrate the physician disconnect with the free market. There is no reason that people willing to pay extra for additional testing shouldn’t get it. You may conclude it is a waste of resources, but if the resources are their own, who cares? Likewise, I may not think my physician needs a 5000 square foot home when a 2000 square foot one will meet his needs, but it’s his money.

    The fact that they offer innovative services to keep costs down for those who don’t want to or can’t spend that much isn’t incompatible with “executive physicals”.

  • http://thehappyhospitalist.blogspot.com Happy Hospitalist

    I agree with Matt. Why not? If an executive wants to pay cash, or their company wants to pay cash for a service that shows no benefit that is entirely their right to pay it and it is entirely the right of Mayo to make millions or more off offering of useless medicine.

    That’s the beauty of cash. Everyone accepts it.

  • a different Matt

    I agree with Matt. If you can afford to pay for it, you should be able to get that sort of exam. Its not like executive physicals are being paid for by medicare, or being subsidized by lower income folks. In fact, my understanding is that companies pay for it directly – not the insurance- , and the employee/exec receiving it pays a little into it as well (at least I did).

    I’ve had the benefit of being able to have 2 executive physicals done, 5 years apart, and it provided a really excellent view of what changed during that time (within the inherent error of the tests). I expect it to be useful in the future as well, as a baseline report on my condition, to show future docs.

  • Backus

    Agreed. Toyota can be known for producing value-conscious cars and still produce top end luxury models. One does not preclude the other.

  • Carol

    I agree, why not? Since when can’t you spend your money on what you see as important?

  • http://thehappyhospitalist.blogspot.com Happy Hospitalist

    Matt #2. For every executive physical that is done on an asymptomatic patient, I can assure you that lots of invasive unnecessary evaluation is performed that could potentially cause great harm.

    Imagine, for a moment that you go to a bank and deposit $1000. Now imagine that bank is owned by Madoff.

    You have just witnessed the end result of the executive physical. You go in all happy and cheerful believing you have an inside track towards excellence and you end up abused and broke and maybe even physically harmed by the stress of the whole thing.

  • http://holtzreport.com Andrew Holtz

    I could agree with the “Why not?” comments, IF the executives (or their companies) pay for follow-up tests and treatments, without shifting any of the charges to private or public insurers.

    But it is not okay for someone without symptoms or other indications to get a coronary artery CT, for example, (even at their own expense), if they then stick their insurance company (and ultimately all the other clients in that insurance pool) with the far larger bill for follow up examinations.

    Studies of “whole-body CT” find that most people will have something show up that prompts further tests. So even if they paid for the first scan, others get stuck with the rest of the bill… even though there is no evidence that this sort of screening produces better overall health outcomes.

  • R Watkins

    And when the findings on the stress tests and full-body scans are worked up and proven to be “false positives,” does Mayo reimburse Medicare and other payers for the expenses incurred?

  • Sam P

    R Watkins: There’s no way Medicare is paying for the health care of these high-earning executives. The executives are the ones who pay taxes that cover medicare for others.
    I’m somewhat familiar with the clinic, and I actually do want people to know that Mayo does this sort of care. It cements Mayo’s reputation for providing the best care when the affluent seek it. Moreover when these executives go in and pay Mayo loads of extra money because they can afford it that gives Mayo more leeway to turn around and offer essential care—at the same high quality level—to those who can’t afford it.

  • CHenry

    Many of these companies carry high-value insurance policies on these key executives in the event of death or disability, to cover the loss to the company for sudden disruption of management. I am sure that these examinations (which may well be of dubious merit) are also requirements of the underwriters.

  • http://www.twitter.com/dublindoc dublindoc

    You’re forgetting another important fact – that the tests themselves can have harmful consequences.

    Coronary CT scans seem to be in vogue on this side of the Atlantic for these ‘executive physicals’, but the radiation dose from these is significantly high. These tests, when used carelessly, are causing cancer. This is a fact. Similarly, an ‘incidenteloma’ can itself lead to unnecessary follow-up testing and procedures, which in themselves can be harmful.

    If one of the principal rules of medicine is to do what is best for your patient, and to do no harm, then I think doctors are ethically obliged to recognise these ‘physicals’ for what they are – a money making racket – and “Just say no”!

  • Matt

    “without shifting any of the charges to private or public insurers.”

    If it’s a private insurer, they already contracted to provide the care, so where’s the harm. They can deny it if they don’t think it’s warranted. That’s a contract between two parties and isn’t anyone’s concern.

    As for reimbursing for false positives, do doctors reimburse for false positives resulting from what they call “defensive medicine”? Does anyone ever reimburse for false positives? I’m betting the answer is no, so why should this be any different?

    It’s physicians’ fear of and lack of understanding of the free market and the fact that they are selling a service and their time which keeps them in the outmoded payment schedules they currently have.

  • Andy

    Why is it considered high cost?
    It contributes jobs to the economy.
    High GDP doesn’t make healthcare a bad industry.
    For example, you give jobs to the CT Tech, pharmaceutical company, radiologist, biller, etc.
    I guess Obama and NEJM want to ruin healthcare along with the banks, auto, etc.

  • http://www.twitter.com/dublindoc dublindoc

    To quote Matt:

    “It’s physicians’ fear of and lack of understanding of the free market and the fact that they are selling a service and their time which keeps them in the outmoded payment schedules they currently have.”

    Shouldn’t doctors be doctors first and businesspeople second?

  • Mike

    This also ignores that the machines themselves must be paid for. Let the executives pay the cost of the machine. That way, the doctors won’t feel compelled to order tests for non-executives to cover the machine cost.

    What’s that? You say it isn’t fair that the executives should have to pay for the machine? well, they insisted on getting the battery of useless tests they are “entitled” to because they are so affluent. The machines aren’t free. And one out-of-pocket cardiac CT doesn’t cover it. Or even 100. And then, other places like MAyo want to do business, so they have to have the “me too” machine. And then they have to order a lot of scans to cover costs.

    Does this pattern not seem evident to the brilliant scribes like MAtt #1, #2, etc? It is wrecking the system, it is wrong, and they are not entitled to it. Kevin is correct.

  • Matt S.

    The problem is this misconception that the Mayo is offering “the best care when the affluent seek it” (Sam P, 2009). Over-imaging, over-biopsying, and generally over-testing the heck out of these executives is actually harmful. Don’t get me wrong: many of these executives probably SHOULD be placed in harms way. ;) Unfortunately, this platinum package of medical care sends the wrong message to the masses. More is NOT always better.

    Those claiming that executives can spend (read: waste) their money however they please are completely in the right. As far as I can tell, it’s the Mayo which is preying on the ignorance of the CEOs and high-ranking managers. I wonder if the supporters posting to this thread would be so quick to endorse the Mayo’s actions if their–I don’t know–rhodium package featured a colonoscopy every day. “The ultimate in colon cancer prevention!”

    It’s easy to see that that’s just plain dangerous, non?

  • Steve B

    From the NEJM article:

    “…the executive physical is a perfect example of what American medicine should be working to expunge: the expensive, the ineffective, and the inequitable.”

    There, fixed that for ya.

  • http://tarl.net/tarl Tarl Neustaedter

    Both ineffective *and* inequitable?

    That sounds a tad like the lawyer who was going to prove his client didn’t do it, and was insane when it did it, besides.

  • http://www.futurewaredc.com Chuck Brooks

    Nothing ‘inequitable’ about earning the means to maintaining good health, and hardly ‘ineffective’ when considering the failures of institutional medical practices. The authors aren’t as pure as they purport to be, but must be envious judging by their ramblings.
    Chuck Brooks
    FutureWare SCG

  • Matt

    Mike,

    You’re not making sense. Probably because you view medicine as some vast “system”. It’s not. It’s people selling professional expertise and the use of equipment to the public. If the public wants to utilize it, great. If they don’t, well you made a bad business decision buying that particular piece of equipment. Why is this so offensive to you?

    As for those who think doctors should be doctors first, agreed. But that doesn’t mean you can ignore the fact you have to earn a living. You guys certainly aren’t afraid to protect your bottom line when Medicare cuts reimbursements, or when you want a break on your liability insurance. Where is that line then? If you’re not earning a living, you can’t be much of a doctor.

  • http://www.twitter.com/dublindoc dublindoc

    I disagree with the premise, to be honest – carried through it implies that doctors who earn more are better doctors. Thankfully, I’m privileged to work in a system where business hasn’t pervaded, molested and fundamentally changed the practice of medicine as it has in the USA.

  • Matt

    It doesn’t imply that at all. One may be an excellent doctor and choose to charge less, work less, or may simply earn less because they live in a less affluent area. Just as one may be an excellent architect and make the same choices.

    Either making more money or saving more of the taxpayers’ money in your case pervades, molests and fundamentally changes the practice of any profession. You cannot divorce the two, because money is what is required for equipment, your salary, etc. Someone pays for all those things, and that someone will affect your practice.

  • Mike

    MAtt, you are the one not making sense. Your analogy is inapt because Medicare (i.e. taxpayers) pay for scans that are “reasonably” indicated. CArdiac CT is a perfect example. It’s benefit is clear, but only in a minority of cases is it indicated. Do you not see how MAyo is likely pushing the scans more than is necessary to cover the cost of the machine? So a few “executives” can have the test they deem “superior”? And on YOUR dime???

    This has nothing to do with medicine as a “system” (whatever that means). I’m an internist in NY and I see this over-ordering of tests to cover the costs of newer technology, in an attempt to woo an un-saavy public, over-influenced by the internet and television ads, demanding MRI’s of every organ. And I waste so much time explaining why that shouldn’t be done, But according to you, if they can afford it, then I should just let them at it. That’s why medicine is sucking lately. Thanks, Matt.

  • Matt

    “Your analogy is inapt because Medicare (i.e. taxpayers) pay for scans that are “reasonably” indicated.”

    Then why are physicians constantly claiming that they perform test after test (which presumably includes scans) that aren’t medically indicated but are solely for “defensive” purposes? They claim the lawyers make them do it, but now you’re telling me it’s done for profit? You guys should make up your minds and stick with a story, lest the public start questioning you more closely.

    Medicare is almost certainly not paying for these executive physicals, btw.

  • Matt

    I forgot to mention – Medicare pays for these “defensive” scans as well – except the physicians say they aren’t really defensive but necessary when they’re submitting the bill presumably.

  • Bridg

    I have problems with your article’s title. “…what Mayo clinic doesn’t want you to know” – Why does Mayo clinic not want me to know? It was a short post and it was not much of an argument.

    Sounded more like a rant to me.

  • Mike

    Matt, I didnt say medicare is paying for the physicals. I said they are helping pay for the machines that the “affluent” executives need. If 100 executives pay out of pocket, that doesn’t even BEGIN to cover the cost. Does this make sense?

    In addition, if you honestly believe that radiologists and physician owners of these machines are not pushing the scans to cover costs, then I don’t know what else to say. But I personally do not own machines and do not profit from scans. So as far as your point about physicians “making up their minds”, it’s not most physicians. Please stop generalizing.

    My original point is when you say its okay to let the “affluent” executives have their scans, I repeat, it is NOT okay, and it is harming everyone, including YOU.

  • Zarah

    I didn’t know about the executive physicals. I agree that they have the potential to do harm (unnecessary radiation, biopsies, further testing, etc.); this is a discussion that the doctors ordering these tests should have with each patient. Based on the risk benefit ratio, it may be that many people would not opt for this type of testing. I don’t think it should be forced on executives. The companies’ money might be better spent on programs to help prevent disease in all employees – smoking cessation, exercise programs, diet education, etc.

  • TrenchDoc

    There are 2 key point you all are missing here. One is patient ascess to face to face time with physician and the other is reassurance.
    In my practice I offer an executive health evaluation. I DO NOT accept insurance. My patients who choose to pay for this service are delighted to spend up 6 hours with me adressing their concerns and developing a treatment plan. Needless to say the response and compliance I am getting is tremendous compared to my 15 minute Medicare visit.

  • http://www.corrupt.org/blogs/bhetti_ameen Bhetti

    Unnecessary testing based on no sound clinical reasoning seems to be hugely unethical to me. Largely the risks outweight benefits via the evidence base and a physician is first and foremost obliged to do no harm.

    I thought House MD was meant to be divorced from reality in medicine, American or otherwise.

    This clearly cannot be happening, you cannot offer anything in medicine simply because someone will pay for it. Is there no more to the picture?

    Anyway, the sentiment seems to be towards phasing this out, which is a blessing.

  • j.

    Hmmm….look a little further into Mayo Clinic, especially satellites in Scottsdale and Jacksonville and the stench will nauseate. They do not take Medicare Assignment and charge patients 15% above what Medicare allows. Mayo actually sent out a letter to their patients stating that they know that their patients would like to pay them more money than what is allowed but the patient’s insurance companies will not allow it.

    They have been known to send patient home from ER without a thorough work up as surgeons decide who gets hospital beds.

    We see some employees as patients. Mayo is not patient centered and not physician run. Administrative counsels don’t just fire they disenigrate confidence to the point of obliterating self esteem, trying to make them quit so they are not eligible for benefits.

    Some community PCPs have challenged Mayo and then cannot get patient records unless patients sign for them, even though the PCP ordered the tests and referred the patient over to them.

    They were formed as a surgery center and that is what they are best doing. Yes, they have great doctors in other areas, but surgery is their main behind the scenes focus.

    When we see President Obama hold them up as cost effective we laugh as it is well known that their physicians do not work together side by side with patients, and to pad their bottom line they run tests like crazy with no regard to cost to patient, or insurance companies, never checking with PCPs to see what tests have already been done. We “lose” patients in the system when sending them over for one test they internally refer and never let PCP know.

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