Body of Evidence

Body of Evidence | Human Resource Executive Online Executive physicals have long been considered a perk that's also necessary for the health of corporate leaders. But some critics say they're ineffective -- not to mention inequitable.

By Harvey Meyer

The CEO's stress test revealed nothing abnormal. But because of his family history and other risk factors, clinicians looked at the calcium in his coronary arteries, which proved alarmingly high. A catheterization showed significant artery blockage and, during the same procedure, stents were inserted to open up three vessels.

"The tests we recommended as part of an executive physical identified a problem that likely would have soon led to a heart attack for this CEO. Fortunately, he is doing well today," says Marilyn Howarth, medical director of the Penn Center for Executive Health at the University of Pennsylvania in Philadelphia.

The University of Pennsylvania's Penn Center is one of dozens of specialty centers nationally offering executive physicals, comprehensive annual exams that often feature a battery of diagnostic tests and evaluations and same-day, personalized interpretation of the results to organizations' top managers and executives. Many examinations also emphasize healthy lifestyle counseling.

Corporations offer these in-depth examinations to protect their investment in highly prized assets -- their executives. The theory is the extensive series of medical tests and exams are more likely to expose health risks, perhaps even life-threatening ones. Identifying these concerns early helps ensure executives aren't sidelined, thus minimizing chances for leadership disruptions and productivity losses.

Considering this bundle of benefits, who would oppose executive physicals?

Brian Rank, for one. Rank is medical director of HealthPartners Medical Group and Clinics in Bloomington, Minn. He wrote a stinging critique of the comprehensive examinations in the Oct. 2, 2008 edition of the New England Journal of Medicine. They are costly, he says, and the multiple tests and exams could actually end up harming patients.

"They aren't evidence-based and don't follow U.S. Preventive Services Task Force recommendations; there's no science published on their effectiveness," says Rank. "I would challenge any [executive physical] program to produce anything besides anecdotes" on their value.

However, Dr. Deborah Rhodes, director of the Rochester, Minn.-based Mayo Clinic's executive-health program, says an unpublished pilot study of Mayo patients shows about 5 percent were diagnosed with a potentially life-threatening disease and that more than one-third had a previously undiagnosed "severe" condition.

"I agree that there are probably no good scientific data (on executive physical programs), but that doesn't mean the programs are harmful, wasteful or of no benefit," she says. "Not all inherent truths are proven in the scientific literature. There's no data to support [Rank's] position, either."

Thus the debate: Are executive physicals really that worthwhile? Let's take a closer look.

A "Good Idea"

Executive physicals have reportedly been around since well into the 20th century. Their popularity seems to have waxed and waned, but some believe executive physicals are on the upswing. A Towers Perrin survey reported that 22 percent of Fortune 500 CEOs had executive physicals in 2008 at a median individual cost of $2,295, an amount not usually covered by insurance.

Moreover, the report noted 30 percent of Fortune 500 firms provided the comprehensive exams to at least one other top executive officer at a median cost of $2,259. Some executives pay for the examinations themselves.

The intensive evaluations, often involving a variety of clinicians from physicians to dieticians, run for one or two days, depending on the facility and patient's needs. They range from lean and efficient programs offered by top-flight medical institutions to deluxe packages at resort-like venues that include lodging, golf, fine dining, massage, cosmetic surgery, personal trainer sessions and other amenities.

A 2002 study in the Journal of Occupational and Environmental Medicine reported that executives who got physicals lost 45 percent fewer work days and had 20 percent fewer health claims than those who didn't. The study, conducted by the University of Michigan Management Research Center, concluded that efficient, evidence-based executive physicals performed by qualified physicians were "of value."

"I think executive physicals are a good idea," says Helen Darling, president of the National Business Group on Health, a Washington-based nonprofit with a membership of mostly larger corporations. "I personally would tell all my members to get them."

Proponents say a major benefit of executive physicals is their comprehensiveness. At the Cooper Clinic in Dallas, a one-day evaluation for most men over 50 examines dozens of markers, including blood pressure, blood sugar, vitamin D and omega-3 levels, cholesterol, prostate, and kidney, liver and thyroid function.

Additionally, it includes an exercise stress test, an upper-torso CT scan, skin-cancer screening, body-fat analysis, hearing, vision and pulmonary tests, a laryngoscopic exam and a brain-health evaluation. If warranted, a second day may include a colonoscopy.

At Cooper and other executive health centers, executives receive up to one hour of counseling, often emphasizing a healthy lifestyle. Their fitness, nutrition, family history, stress factors, sleep patterns, medications, supplements, vaccinations and other issues are discussed.

"The one thing [executives] can't fathom before taking the exam is the amount of care and time they have with a physician," says David Atkinson, a Cooper executive who oversees the executive physical program.

Carolyn Coneys, benefits and HR service-center manager at Wawa Inc., a 17,000-employee suburban Philadelphia-based convenience-store chain, says 187 Wawa executives 35 years and older are eligible for the in-depth physicals. Many receive them at the University of Pennsylvania's Penn Center for Executive Health, where Wawa receives a discount, but they can take similar exams elsewhere.

Wawa, which has been offering executive physicals for at least 20 years, does not require co-pays for them. Coneys, who became eligible this year for the executive physical, is a fan of their comprehensiveness -- especially when compared to routine annual exams.

"I went to my general practitioner for a standard exam," says Coneys. "I had a couple of bangs on my knees, had my ears, general vision, breasts and under-arms checked, and that was about it. There was no stress test and no blood work, so I had no idea if I had high cholesterol, thyroid or other concerns. I really didn't get anything out of it."

While HealthPartners' Rank understands executive physicals' appeal to some -- for instance, their aura of exclusivity, the pampering that may include a complimentary bathrobe and slippers, and the programs' one-stop shopping -- he says the tests and evaluations in many examinations are often unnecessary, and even harmful.

Added tests lead to more false-positive findings, which require unwarranted follow-up visits and costs and produce needless worry for patients, says Rank, who's a medical oncologist. And, for example, ordering unnecessary colonoscopies increases the potential for perforated colons while unneeded electrocardiograms and chest X-rays elevate radiation levels, he says. An abdominal CT scan alone, he says, is equivalent to hundreds of chest X-rays.

"There's good evidence that doing more can harm somebody," says Rank, whose journal article drew fire from the Mayo Clinic and Johns Hopkins, both of which provide executive physicals. "For instance, there's no evidence that the benefits of a CT scan looking for coronary heart disease outweigh the risk for an asymptomatic and routine-risk population."

Plus, he adds, the U.S. Preventive Services Task Force doesn't recommend cardiac CT scans for low-risk patients.

Tom Brinsko, CEO of the YMCA of Greater St. Paul, took a two-day executive physical several years ago at the Mayo Clinic. He no longer does, largely because Rank convinced Brinsko, HealthPartners' board chairman, that multiple same-day tests don't translate into better healthcare.

"There is the notion that, because you're doing all these tests, and at once, that it must be better," says Brinsko. "I look at that as an illusion."

The Fairness Factor

Perhaps not surprisingly, supporters refute arguments that multiple tests and exams exacerbate patients' health. At Wawa, Coneys says, she's received no complaints about false-positive findings, for example.

At Cooper, Atkinson says, false-positives are minimized by purchasing more efficient test equipment, regularly performing quality checks and ensuring that training protocols are followed. Atkinson and Howarth of Penn Center insist their health centers judiciously -- and strategically -- deploy executive physical tests.

"I think we've struck a balance in that we order tests that are necessary and appropriate for each individual," says Howarth. "I agree that if a test provides radiation, for instance, or has risk associated with it, you must be sure it offers value to the patient. There are some tests we've specifically excluded, like virtual colonoscopies, because we don't feel the benefit outweighs the risk."

But it's not just multiple tests that bother opponents. They say the comprehensive examinations are unnecessarily pricey.

"Executive physicals ... reinforce a related misperception that costlier is better, that a $3,000 examination must be worth more than one that costs one-tenth of that amount," Rank wrote. "This is an indefensible idea that should not be promoted by the healthcare industry," particularly during a period of heightened cost-containment measures.

"In today's economy, because of rising healthcare costs, we must do everything possible to keep expenses down," says Brinsko. "Unfortunately, today employees are picking up a greater share of costs. Given that, why would you add a costly executive physical?"

Rank says executive physicals are hinged to another motive: They serve as an emerging profit center. In the Journal article, he wrote that prestigious healthcare facilities such as the Mayo Clinic and Cleveland Clinic heavily market the in-depth examinations. Rank referred to their costs "outrageous," adding that many corporate boards have been hoodwinked about executive physicals and that they contribute to overuse of already-strained healthcare resources.

Another strike against executive physicals, says Rank, is that they send the wrong message to rank-and-file employees, particularly during a time of rising premiums, co-pays and deductibles.

"Perhaps the most lamentable idea perpetrated by the executive physical is the implication that some patients -- namely, those who have the ability to pay out-of-pocket or with company resources -- are more worthy of effective, respectful and personalized treatment than others," Rank wrote. That, he says, runs counter to trends to reduce healthcare disparities based on income and other factors.

Adds Robin Hanson, an economics professor at George Mason University in Fairfax, Va.: "There is a symbolic component of executive physicals that may be important. People might say, 'If the CEO gets it, then I should, too, because we all deserve the same healthcare.' "

What about offering executive physical-equivalents to all employees?

"Obviously, it would be cost-prohibitive to do that," says Tom Stubbins, vice president of human resources at Vought Aircraft Industries, a 7,000-employee Dallas-based company. Stubbins says a majority of other "direct-report" executives and about half of Vought's board members receive the examinations. Beyond the cost are logistical challenges, such as finding time for the rank-and-file to take the evaluations and scheduling them, he says.

Probably the most damning accusations Rank leveled against executive physicals are that they aren't evidence-based, offer no measurable return on investment and don't produce better patient outcomes. He notes that there is wide variation in what is included in the evaluations and that no solid scientific studies prove their merit.

"Doctors should guide people based on the best preventive services evidence available," says Rank. "There is no science that, with executive physicals, you find health problems any earlier or that you get better results."

A Wellness Mind-set

While the Mayo Clinic's Rhodes agrees on the paucity of studies examining executive physicals, she says the clinic's internal review of its executive-health program showed it uncovered significant health concerns. That review, which revealed almost half of the program's patients risked developing a serious health condition, has led to a larger-scale study now underway.

Meanwhile, proponents are quick to argue the exams are worth the extra money. They view the examinations as protecting companies' investment in highly valued executives.

In part, top-to-bottom exams make sense for executives, because they are exposed to added health risks, says Darling of the National Business Group on Health. Consider, she says, the heapings of chronic stress they endure and often-grueling travel schedules.

"Certainly corporations must consider the cost and quality of care to an executive who is no longer productive and lost from work because of a heart attack or chronic disease," says Atkinson. In that respect, he says, an extensive, high-quality executive physical is "priceless."

Proponents say a major advantage of executive physicals is their one-stop shopping convenience. Penn Center's Howarth says executives' busy work schedules preclude many from making multiple discreet appointments. Because insurance isn't involved, she adds, no time-wasting referrals are needed if executives prefer same-day consulting with other clinicians.

"Sometimes, executives are so busy they don't take time to schedule an appointment," says Howarth. "If they're not doing that, then they may end up with advanced or complicated health problems. In that sense, that is a barrier for them to receive appropriate care."

Executive physicals may play a role in recruiting, especially at larger companies, where the evaluations are more common. Some believe not offering them is a disadvantage.

"If an employer doesn't offer an executive physical to a senior executive, it might make that individual think the company isn't taking him or her as seriously as another firm," says Dr. Jeff Dobro, a physician and principal at Towers Perrin in Valhalla, N.Y. "It seems like a small point, but it may be an important perk for some individuals."

Supporters suggest another, often underestimated, benefit: Executives who receive the in-depth physicals often end up championing a sustained wellness campaign in their organizations. Some executive health centers, such as Cooper, facilitate that by managing companies' wellness strategies remotely or onsite.

"Our CEO has taken the executive physical and is now very committed to wellness," says Vought's Stubbins. "In a sense, we're using the executive physical to drive the wellness message throughout the organization. It's that much easier to do when the CEO is behind it."

The ultimate value of executive physicals, backers assert, is the anecdotal evidence suggesting many health problems are averted, and sometimes even lives are saved. At Penn Center, Howarth credits the evaluations with regularly detecting prostate and colon cancers. Stubbins says the exams have uncovered serious, possibly "catastrophic," health conditions among the executives at his company.

"For me, the [executive physical] has been life-changing," says Stubbins. "Once you better understand your health and have had a consultation with the physician, it changes your perspective. I am now exercising every day and eating differently."

With their somewhat cyclical history, it's difficult to forecast future trends for executive physicals. While many believe the comprehensive exams are on the rise now, the continuing focus on healthcare cost containment, among other factors, may deter organizations from paying for them.

Executive physicals have their demerits. But many commend their emphasis on prevention -- in fact, some experts say the physicals can perhaps serve as a model for everyone, especially if the physicians giving them follow U.S.. Preventive Services Task Force guidelines. While their cost for the masses is prohibitive, Carolyn Coneys of Wawa, among others, favors many preventive services common to executive physicals becoming standardized and insurance-eligible in routine annual exams.

Currently, Wawa provides executive physicals only to executives. Nevertheless, Coneys says, the goal should be to treat all employees equally when it comes to healthcare.

"We're on a continuing wellness journey," she says. "Whatever road we follow must include provisions for being cost effective and preventive for all employees."

October 16, 2009

Copyright 2009© LRP Publications