A New Form of Health Inequality

There is one group that by their actions, rather than words, loves a good screening test; the top hospitals for heart and cardiac surgery, our premier academic medical centers. Researchers [1] called administrators at these top hospitals inquiring about their executive wellness programs. For the unacquainted, these executive wellness programs carry out half and one-day evaluations of executives, or the wealthy worried well specifically looking for diseases to be treated, as well as lifestyle, behavior modifications. Since the authors are cardiologists and cardiovascular disease remains the #1 cause of death they focused on the testing provided. 

The Results

• Of the 21 hospitals, in US News and World Reports, top 25, 18 offered various executive health screening programs
• The cost ranged from $995 at #13 Houston Methodist Hospital to $25,000 for “a Premier Executive Health Program at Cleveland Clinic (ranked 1)” Only 3 of those hospitals submitted charges to an insurance carrier
• A resting EKG as offered by everyone, with roughly two-thirds offering a lipid panel and a cardiac stress test.
• A CT scan to evaluate the coronary arteries non invasively, using a calcium score and visualization was offered roughly by half of these hospitals.
• 2 offered cardiovascular consultation, 1 threw in an exercise consultation. 
• Other testing including imaging of the aorta, looking for aneurysms, the carotid artery, searching for narrowing that could lead to stroke, and several blood tests to look for inflammatory biomarkers. 

Of the 12 tests, none of them are recommended by the ACC/AHA (American College of Cardiology/American Heart Association), the USPSTF (United States Preventative Services Task Force, or ACPM (American College of Preventative Medicine) to be applied indiscriminately to asymptomatic adults.

And you can be sure that members of the faculty at all these institutions were involved in setting those standards. There are flaws, freely acknowledge, in the study. Most importantly, the information came from administrators, not the actual clinicians so perhaps these tests were not applied to everyone, without consideration of their symptoms or risk. And while we have the charges, in a world of medical opacity, we don’t really know what was paid by insurance or out of pocket. But the researchers' final point is, to my mind, the most important, so I will leave them the last words.

“In addition to clinical care, the top cardiology hospitals also provide medical education. Offering executive physicals with tests that are not recommended for healthy persons to anyone who can pay out of pocket potentially sends the message to trainees that a 2-tier health care system is acceptable, and that evidence is not important. Furthermore, indiscriminate screening can create a cascade effect and thus violate the principle of primum non nocere (first do no harm) wherein unnecessary tests may create a chain of events resulting in additional ill-advised tests or treatments that may cause avoidable physical or psychological harm.”  

[1] Researchers were from Washington University School of Medicine and the St. Louis School of Medicine not part of the top 20, so no conflict of interest although the cynical might cry sour grapes.

Source: Assessment of Cardiovascular Diagnostic Tests and Procedures Offered in Executive Screening Programs at Top-Ranked Cardiology Hospitals JAMA Internal Medicine DOI: 10.1001/jamainternmed.2019.6607