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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
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Conflict of Interests
None
I do not own or financially benefit from any executive health programs (unfortunately)
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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.
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Protagonist
Supporter of a cause
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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
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All these extra testing must be good for
someone...The one who is running the executive physicals programs
Insurance companies with increase premiums
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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
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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
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Executive Physicals
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Executive Physicals
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Executive Physicals
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Executive Physicals
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Executive Physicals
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Executive Physicals
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The Testimonials
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The Evidence
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The Press
Time/CNN 2001
NEJM 2008
CBC 2008
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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
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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
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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
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False Positivity
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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
)P
ost-
test
Lik
elih
ood
(Pre
dict
ive
Val
ue)
+VE
-VE
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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.
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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?
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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
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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
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Costs
In fact our health care system should reinforce:
Cost-effectiveness
Transparency
Competition
Accountability
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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
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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.
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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
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“I will do my executive physical exam first to make sure I am OK
before I apply for my life insurance!”