For busy people, time is money. And when you've got more money than time, the cost of an executive physical examination is kind of like the price of a yacht. If you have to ask, you can't afford it.
Tom Gilmore arrived at L.A.'s Good Samaritan Hospital on a bright Friday morning, sporting a dark blue Nike warmup suit the hospital had sent. Priscilla Castillo, VIP patient service manager, was waiting at valet parking to escort him to a waiting room, where coffee, tea, juices, fresh fruit and yogurt were continually replenished.
But he didn't have to wait long. Soon he was being escorted to an exam room, where the bathrobe he changed into was so plush and soft that he couldn't resist holding out an elbow for Castillo to touch, saying, "Wow, feel this. What do you think? Some sort of microfiber?" The slippers were just as snuggly, and they, along with the bathrobe and warmup suit, were his to keep. "For $2,000, it better be mine," he says.
That's the cost, not covered by insurance, of the most extensive physical examination he's ever had.
It's not your usual checkup. It's called an executive physical, and Gilmore, downtown real estate developer, was patient No. 1 at Good Samaritan Hospital's new program, which aims to market its preventive health services to busy downtown corporate types.
Such programs for years have quietly attracted those who can pay and want fast, excellent and comprehensive medical service. "They cast a halo over the public image of the hospital and might attract more admissions from well-insured patients," says Alan Sager, professor of health policy and management at Boston University School of Public Health.
Now, with a rich lode of high-income earners starting to occupy newly renovated lofts, marketers for the downtown hospital figured new residents need more than a place to walk their dogs and buy their groceries. They need a medical home, says Andy Leeka, chief executive of Good Samaritan Hospital. Similar programs are available in other area hospitals, including Scripps Center for Executive Health in La Jolla, Cedars-Sinai Executive Medical Services and UCLA’s Comprehensive Health Program.
Some so-called boutique medical practices offer equally comprehensive physicals. Such practices charge a flat annual fee, do not accept insurance and promise their patients quick appointments and plenty of time with the doctor. But the full complement of state-of-the-art testing and laboratory technology available at large hospitals isn't available under one roof at a boutique, or concierge, practice.
The emphasis with hospital-based executive exams is on a quick and painless in and out.
Rolls Royce of physicals
The baseline costs range from $2,000 to about $2,700, possibly more depending on the tests deemed appropriate for the person's age, sex and medical history. The granddaddy of the hospital-based executive physical is the Mayo Clinic program in Rochester, Minn., chronicled in orifice-probing detail by James McManus in his book, "Physical: An American Checkup."
The exams represent the Rolls Royce of physicals. "We market specifically to affluent individuals who can pay the toll," says Dr. Scott Carstens, medical director of the Scripps program. "We have corporations that provide it as a perk to their employees. But we have other individuals who are tired of being constrained by insurance companies and providers. They want an absolutely no-holds-barred review of how they're doing physically."
The exams emphasize thoroughness, efficiency, top-of-the-line technology and on-site laboratories to hurry results along.
Gilmore, 55, had his blood drawn and his urine analyzed. He had an EKG to test for heart abnormalities; a chest X-ray for images of heart, lungs, airway and bones of the spine and chest; a carotid ultrasound to check for artery narrowing that could put him at risk for a stroke; a bone-density scan to check for early signs of osteoporosis; and a 64-slice CT scan to look for signs of calcium plaque on artery walls, early signs of heart disease.
By noon, Dr. William Howell was explaining the results and making recommendations.
"All of this is done in a VIP area," Leeka says. That means no coughing, hacking, contagious masses sharing the fruit plates and mineral water.
Theoretically, it's what any basic physical exam should be: all about you. "That one-stop-shopping kind of exam brings all the results together in one place," Sager says. "This is one way of integrating across the chaos that many of us see in our healthcare."
All about the patient
By the time patients arrive, a team of physicians will have gone over their medical histories, filled out beforehand in 20-plus-page detail. The battery of tests will be based on broad medical guidelines, with a sharp eye on the individual's age, sex, family history, lifestyle and personal concerns.
Even then, some people who sign up for executive physicals ask for more than they need, says Dr. Benjamin Ansell, director of UCLA's Comprehensive Health Program. "We tailor the program for an individual's needs but also based on the results from their last exam," he says. "If I have a 48-year-old man who's been a couch potato for years, I have to assume the worst and look for plaque buildup." But if a man is already on medication to control blood pressure and cholesterol levels, he says, there would be no added benefit of having a coronary CT scan. "There's radiation involved that's not trivial," he says. "We actually end up talking patients out of certain expectations."
A good primary-care physician who knows a patient well can be just as thorough as a VIP exam. But the hospital-based programs carry the advantage of doing it all in one place, in a condensed time period. "The patient comes in, and they don't have to leave till it's all done. This is an ideal way of delivering preventive healthcare," Carstens says. "But unfortunately, the costs involved are not for the masses."
Individuals, and individual companies, however, have far different standards for determining what health is worth. Providing an executive physical for top-tier employees could result in a CEO not having a heart attack, not getting colon cancer, and the company not being forced to replace a key executive. Individuals could make their own calculations on what additional years of quality life are worth. Claudine Williams, 87, for example, just made her second trip in about eight years to Scripps in La Jolla for an exam that she'll pay for herself. She once owned the Silver Slipper and Holiday casinos in Las Vegas. She still serves on corporate boards, but she took time off for a trip to California because her hometown offers nothing as thorough.
"I would have been in 20 different buildings and seen 10 different doctors," she says. "Here they get it all together."
No more office hopping
She was describing just the kind of office-hopping routine that turned Gilmore's 81-year-old father off to preventive care. He recently moved to Los Angeles, and Gilmore wanted to make sure his medical care was under control. "We spent the first four weeks he was here, in and out of hospitals, to get him up to speed," Gilmore says. By then, he says, his father was ready to bag the whole thing. "He just didn't want to go to any more appointments," Gilmore says.
That experience, coupled with his own recent birthday, prodded Gilmore into looking for a better way to get a thorough exam. He'd had one a few years ago, but his doctor spent about five minutes with him, he says, and he waited a couple of weeks for test results. Specifically, what Gilmore wanted was reassurance that 38 years of a vegetarian diet and consistent bike riding offset the damage of several decades of smoking and occasional heavy drinking. "I don't smoke anymore, but I wonder what those years have done," he says.
Those were the same questions that sent McManus to the Mayo Clinic, as a journalist researching his book, in 2003. "I already had excellent health insurance and access to wonderful doctors," he says. "I didn't need the Mayo Clinic exam. But I fell in love with the place as a model for how healthcare should be done."
The process, McManus says, respects a patient's time by providing efficiency. It respects a patient's feelings with thorough discussion. It understands a patient's anxiety about test results and responds with timely answers.
Pinpointing problems, however, doesn't solve them. Patients have to follow medical advice.
McManus was advised to lose 25 pounds. He has, instead, gained a couple of pounds in the four years since his exam. But he also was told to quit smoking, advice that certainly didn't come as a surprise. "I knew that smoking was bad," he says. "From my docs in Chicago, and from about 500 other sources, I knew it was bad." The "don't smoke" message that finally got through was the culmination of everything he already knew, plus a rapport with the cardiologist who told him how bad it was for his heart, all in the context of a hospital with a stellar reputation. "Now I drink less than I did before [the exam], I exercise about the same, but I don't smoke," he says.
The programs want people to return every year, and each year, the tests will be different. People in their 50s, for example, need a colonoscopy every five years, not every year. In the binder full of test results that patients take home are charts. Year after year, they can track the progress, or deterioration, of their blood pressure, cholesterol levels, pulmonary function and other physical measures.
Four hours later
Gilmore spent about four hours padding through hospital halls, steered from one exam to the next by Castillo. He peered over the shoulders of technicians reading his carotid ultrasound. He saw with his own eyes that his lungs were a little larger than normal but free of any horrible consequence of cigarette smoking. He gave a thumbs up to each report on the health of his innards. "It's funny," he says. "You look at this stuff, and you start rooting for yourself."
He wrapped up his day by hearing from Howell that he probably should add walking or weight-bearing exercise to his biking routine to build his bone strength. He'll go back for a follow-up cholesterol test because his level was borderline. But basically, he found out that he's in great shape.
He put his warmup suit back on as Castillo packed up his fuzzy bathrobe and slippers. Then they walked arm in arm to the front door to await the arrival of his car.
(BEGIN TEXT OF INFOBOX)
Deciding what's cost-effective
Alas, such a thorough exam is not likely to be available for average Joe's and Joellen's who can't afford to shell out an unreimbursed couple of thousand dollars.
"I think, in the end, it can't spread," says Dr. Benjamin Ansell, director of UCLA's Comprehensive Health Program. "Not that it shouldn't. But what we're practicing is, by definition, cost-ineffective."
The determinant of what is medically cost-effective is a long-held standard, developed by the military half a century ago, called "cost per quality-adjusted life year." It continues as a rule of thumb for setting public health standards for Americans, and the bottom line for today is that if something costs $50,000 and gives someone an additional year of quality life, it is deemed worth it. It's part of the public health equation statisticians use to calculate such things as the age at which it becomes cost-effective to start screening women for breast cancer. Very few women in their 20s get breast cancer, for example, so screening all women of that age would yield a handful of lives saved at an enormous overall cost.
Providing aspirin to prevent heart disease, statins to lower cholesterol levels and seat belts to prevent injuries meets the cost-effective standard, Ansell says. Not so for a high-tech, 64-slice computed tomography scan to check for calcium plaque in every middle-aged American.
-- Susan Brink