Be It Resolved ThatSuperior Medical Care Leads To Substandard

Ratings: A Case of Unintended

Consequences

Chi-Ming Chow MD MSc FRCPCCardiologist, St. Michael’s Hospital

Associate Professor, University of TorontoMedical Consultant, Munich Re

Conflict of Interests

None

I do not own or financially benefit from any executive health programs (unfortunately)

WARNING•The following presentation may be

offensive to those who work for or financially benefit from executive health physical programs.

•This presentation is only for CLIMOA only. Any reproduction or unauthorized use is strictly prohibited.

Protagonist

Supporter of a cause

Rephrasing The Argument

Superior testing (Executive Physicals) is bad for you !

Not only cost you time and money

Leads to more downstream tests

Make you worry

No scientific proof

Jack up your life/CI/DI insurance premiums

All these extra testing must be good for

someone...The one who is running the executive physicals programs

Insurance companies with increase premiums

Testing & Risk Classification in Insurance Medical

UnderwritingHistorically ...

Urine specimens since early 1900s

Identifying diabetes and renal diseases

Blood sampling

Early glucose intolerance, liver disease, renal disease, HIV, lipid abnormalities

Oral fluid testing

HIV, cocaine, cotinine

Risk Assessment TestingScreening Tests

Based of age and insurance amount

“Sentinel effect” - discourage at risk group from applying

Reflex Tests

Based on screening tests (e.g. HgbA1C with elevated glu)

Testing for cause

Ordered in response to medical history or other info

SPEP for an elevated globulinz

Executive Physicals

Executive Physicals

Executive Physicals

Executive Physicals

Executive Physicals

Executive Physicals

The Testimonials

The Evidence

The Press

Time/CNN 2001

NEJM 2008

CBC 2008

How Executive Physical Fails On

Three Counts

Rank B. Executive Physicals - Bad Medicine on Three Counts. N Engl Med 359; 14. Oct 2008. P1424-5

1. Efficacy

2. Cost

3. Equity

Efficiency

Inherent believe for health care

More is better.

Most is the best.

So 3 tests is good. 20 is better

So 1 hour is good. 2 days is better

EfficiencyResearch argues otherwise!

Unnecessary testing may cause more harm than good:

False positive findings

Unwarranted follow-up visits or referrals

Additional costs ($$$)

Needless worry

Harmful side effects of tests

False Positivity

Low Pre-Test Likelihood(Hypothetical Test with 90% Sensitivity and 90% Specificity)(Hypothetical Test with 90% Sensitivity and 90% Specificity)

Pretest Likelihood (Prevalence)Pretest Likelihood (Prevalence)

.1.1 .2.2 .3.3 .4.4 .5.5 .6.6 .7.7 .8.8 .9.9 1.01.0

.1.1

.2.2

.3.3

.4.4

.5.5

.6.6

.7.7

.8.8

.9.9

1.01.0

Pos

t-te

st L

ikel

ihoo

d (P

redi

ctiv

e V

alue

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ost-

test

Lik

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ood

(Pre

dict

ive

Val

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+VE

-VE

CT Coronary Angio Cancer Risk

Radiation = 600 CXR

Young women have the highest risk

1/143 women (20s) may ever develop cancer due to CT Coronary angio

1/219 when radiation reduction method used

Breast CA most common in woman. In man lung CA.

Don’t know what to do ...

45 y.o. man executive

40M Life Insurance Case

No cardiac risk factor

No family history

Calcium score = 45 (90th percentile for age)

What should you do?

How Executive Physical Fails On

Three Counts

Rank B. Executive Physicals - Bad Medicine on Three Counts. N Engl Med 359; 14. Oct 2008. P1424-5

1. Efficacy

2. Cost

3. Equity

Costs

Executive exams reinforce a related mispreception:

Costlier is better

$3,000 exam must be worth a lot more than an exam costs 1/10 of that amount

Costs

In fact our health care system should reinforce:

Cost-effectiveness

Transparency

Competition

Accountability

How Executive Physical Fails On

Three Counts

Rank B. Executive Physicals - Bad Medicine on Three Counts. N Engl Med 359; 14. Oct 2008. P1424-5

1. Efficacy

2. Cost

3. Equity

EquityExecutive physical perpetuated the idea:

Those who can afford personally or with company resources are more worthy of:

Effective, respectful, and personalized treatment than others.

This is in contrary to the work:

Reduce health care disparities based on income, race, geography, or other demographic factors.

In ConclusionSuperior testing (Executive Physicals) is bad for you !

Not only cost you time and money

Leads to more downstream tests

Make you worry

No scientific proof

Jack up your life/CI/DI insurance premiums

“I will do my executive physical exam first to make sure I am OK

before I apply for my life insurance!”