Examining Executive Physicals

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Fifteen years ago it was common to see parked semi trucks with CT scanners in the trailer, advertising “whole-body CT scans” as a preventive measure. Thankfully the trend eventually petered out. I can’t find reliable information on why the practice died. It’s possible that the worried segment of the population simply all had their CTs done, and no one else was willing to pay. But from a medical safety perspective, I hope the practice died because people–patients, regulators, or others–decided that the risk of “false positive” tests, with their necessary biopsies and follow-up testing, all of which carries its own risk, was not justified by the small chance of finding a potentially treatable abnormality. Or people simply decided they didn’t want the relatively large radiation dose (a whole-body CT exposes a person to ~15 mSv radiation, roughly a tenth of the exposure of Hiroshima survivors).

But the practice of whole-body CT scans lives on in the tiny corner of the market known as “executive physicals.”

In a recent paper in JAMA, Deborah Korenstein, Maha Mamoor, and Peter Bach used a combination of internet searching and phone calls to identify highly ranked hospitals offering executive physicals. Executive physicals at these prestigious institutions routinely offered:

  • Electrocardiograms (USPSTF grade D or I for low-risk patients)

  • Chest x-rays (not addressed at all by the USPSTF, but not generally paid for by any insurance company in asymptomatic patients)

  • Pulmonary function testing (USPSTF grade D for asymptomatic patients), and

  • You guessed it: whole-body CT scans.

Unnecessary testing has downsides

The unnecessary testing of anyone–let alone your most highly-paid employees–is a three-headed spear. First, the exams themselves are expensive: around $5,000 each. Second, much of the testing that is unsupported by evidence is likely a waste of money, as we’ve discussed in a previous post, especially since your highly paid professionals are likely to outlive your other employees based on their income alone. But maybe more important is the potential real harm done by unnecessary testing.

A well-known example of this comes from South Korea. That country’s national health insurance program initiated an aggressive cancer screening program in 1999 that screened for breast, cervical, colon, gastric, and liver cancers, mostly free of charge. With certain cancers this is a potentially good idea, even though cancer screening doesn’t seem to make people live longer as a whole. But patients in South Korea were frequently offered thyroid cancer screening with neck ultrasound as an optional add-on for a modest cash price.

By 2011, the rate of thyroid cancer diagnoses in South Korea had jumped 15-fold. This was not because of a new toxin in South Korean drinking water or because of radiation exposure. The entire increase was due to the new detection and diagnosis of “papillary” thyroid cancers that were too small and slow-growing to be felt on physical examination, but were easily detected with ultrasound testing. Because they were small and slow-growing the cancers were also unlikely to ever kill the patients in whom they were discovered.

So what was the downside? All the surgeries to remove cancerous thyroids had consequences (in addition to the surgery’s ~$5,000 cost). In addition to thousands of people who now needed to be on a daily thyroid hormone pill for life, South Korean patients experienced a huge increase in common complications of the surgery: two percent experienced permanent hoarseness due to paralysis of one of the vocal cords, and a whopping eleven percent now needed to take high-potency vitamin D and high-dose calcium multiple times a day for the rest of their lives to prevent muscle cramping because of damage to the calcium-controlling parathyroid glands that lie next to the thyroid.

This might be acceptable if a significant number of years were added to patients’ lives as a result of this. But that has not happened. A person in South Korea has the exact same (very small) chance of dying of thyroid cancer now as she did before this movement. That is to say, all this testing had only downside; there was no upside.

So the next time your company is negotiating the health benefits of its executives it might be worth asking what evidence supports any additional testing offered to C-suite folks. It may cost more than you think.

Health literacy is not just important for C-suite individuals.  Considering that only 12% of Americans having proficient health literacy, and that health-illiterate people spend 80% more on healthcare than their health-literate counterparts, it’s crucial to educate your employees!  The Kansas Business Group on Health offers discounts on resources to educate you employees on how to be better consumers of healthcare.