The dangers of high-end health care
Economists love to praise the freemarket benefits of first-class air travel. Travelers of means pay more for early boarding, a comfortable seat, a drink before economy passengers board and a few other niceties. The price these travelers pay (or, more accurately, the price paid by those bearing the cost of their tickets) helps subsidize the prices paid by economy passengers, and everyone gets to his or her destination. If the premium paid by first-class passengers also bought an increased likelihood of physical harm and unwarranted anxiety, this would be an irrational model — one that resembles hospital executive health programs.
Executive health programs are common at academic medical centers across the United States. Each of the country’s 10 largest metropolitan areas has at least one such program, and most have many more. Four of the hospitals in the Baltimore/ Washington area offer such programs, including Johns Hopkins, which describes its program as giving “busy executives an efficient way to receive a confidential, comprehensive, head-to-toe health assessment from one of the world’s leading institutions” at their convenience.
The programs generally charge a set fee for a comprehensive visit in an elegant setting with scheduling that allows consultations with multiple physicians and affiliated health-care professionals, testing and discussion of results all in a single visit. They offer personalized care organized around a person’s schedule and are marketed toward professionals and their employers.
The benefits of these programs to patients and institutions are obvious. Patients generally receive high-level care without the scheduling hassles common at academic centers. For the medical centers, executive health programs generate income — directly, in the fees they charge, and indirectly, by attracting well-insured patients who may eventually seek to continue their care at the institution or even become benefactors. Medical centers use the income generated by executive health programs to support less wellfunded aspects of a medical center’s mission: research, education and the care of the uninsured or underinsured patients. So what is the harm? There is competition between medical centers for the relatively small number of people and companies willing to pay for this service. Because basic health maintenance services are standardized and far from complex, medical centers compete by offering what seems like better care. In reality, the care they offer is not better care, it is just more care — care that offers no proven benefit but very often risk of harm.
Executive health sites we reviewed list procedures such as screening cardiac stress tests, skin and prostate cancer screening, peripheral artery disease screening and screening for carotid artery stenosis. Of these five practices, the United States Preventive Services Task Force (USPSTF) recommends against three of them and, because of insufficient evidence, cannot make recommendations about the other two.
The USPSTF is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It is the most respected arbiter of preventive and screening interventions in the United States. When the USPSTF chooses not to recommend an intervention, it does so because there is either no evidence that the intervention is effective or because there is evidence of futility or actual harm. The USPSTF does not consider costs when making recommendations; it does not withhold a recommendation because the cost of the intervention is too great.
What are the problems with offering unproven, and thus inappropriate, tests? Excess care frequently leads to findings of uncertain significance. These findings lead to patient anxiety and falsely label a previously healthy person as ill. Follow-up of these findings requires unnecessary evaluations and, sometimes, treatments. Physical harm may occur during these evaluations. Even when no physical harm is done, unnecessary costs are accrued. These costs are usually paid for by private or government insurance. Treatment of incidental findings has no proven benefit.
If you doubt that unnecessary evaluations can do harm, ask any doctor whohas practiced in the last two decades; you will soon be awash in anecdotes of patients suffering consequences of a “routine” blood test or x-ray. Dr. Michael B. Rothberg, in a now famous article published in JAMA in 2014 entitled “The $50,000 Physical,” recounts the harrowing tale of a patient who ran up a $50,000 bill and required a transfusion of 10 units of blood, among other things, as the consequence of an ill-advised physical exam.
Executive health programs have considerable potential. They offer busy people of means a way to obtain care in a comfortable setting that also fits into their schedule. By allowing people to address chronic issues or to access warranted screening that they have been too busy to pursue, they may even improve health outcomes. They also enable academic medical centers to benefit financially from what they do best, providing excellent, evidence-based care.
Today’s executive health programs, however, tempt medical centers to offer a dubious product. People who enroll in these programs deserve clarity about what they are paying for — a nice waiting room, patient centered scheduling, care that is more attentive than today’s norm — and, very often, expensive, unproven and potentially harmful care.