Executive Health Care Update
Genomic testing, one-day comprehensive physical examinations and “concierge-level” health care plans are becoming mainstream choices for time-crunched executives.
By Kris Grant
In what it believed to be a first for a health system in the United States, Scripps Health is now offering genetic testing as part of its care for cardiovascular patients preparing to undergo elective stent procedures.
Scripps Health provides more cardiovascular care than any other provider in California. Last year, Scripps treated more than 45,000 cardiovascular patients. Scripps is currently designing the Scripps Cardiovascular Institute (SCI), which is planned to open in 2015.
“We’re putting the genome to work,” said Dr. Matthew Price, director of the cardiac cauterization lab at Scripps Clinic and director of interventional cardiology research, Scripps Genomic Medicine. “The timing has emerged for individualized medicine, tailoring our drugs for the particular patient based on their genes.”
In coronary stent procedures, of which about 1.2 million are performed annually, the standard protocol includes prescribing the anti-clotting drug, Plavix (clopidrogel), the second most prescribed drug in the country. It is given to most patients after they receive a stent, which is a man-made tube inserted into a natural passage in the body to prevent or counteract flow restriction.
A number of research studies show that a variation in a certain gene is a marker of risk for heart attacks and other bad outcomes in patients who receive stents, Price explained. “We believe that’s because Plavix needs to be metabolized by the body in order to work,” he said. “Now we’ve found that there is an enzyme in the body that is in charge of that metabolism. How strongly this enzyme works varies among people based on one’s genes.”
Price said the research, reported in JAMA, (Journal of the American Medical Association) in a breakthrough paper, confirmed that the specific gene, Cyp2c19, interferes with the metabolism of Plavix. It included analysis of patients who had Plavix and stents with subsequent problems, then isolate their DNA and compare it to the DNA of patients without subsequent problems.
Genetic testing, generally done at the time of the stent procedure, involves simply taking a blood or saliva sample and sending it to Quest Diagnostics Nichols Institute laboratory in San Juan Capistrano for analysis. “The turn-around time is within a few days, acceptable because most of the events come months to years later,” Price explained.
“Seventy percent of the population will be fine with Plavix,” Price said. But about one out of every four people is a carrier for a gene that doesn’t work, and about three percent of the population have two bad gene markers, putting them at a higher risk. For patients who have a gene, Price said the decision on treatment will be based on the patient and overall risk of having blood clots. “One decision might be to follow them closely and not change their medicines,” he said. “There is an efficient drug that is somewhat similar to Plavix but doesn’t need that enzyme. And there are other medicines one could add to Plavix or we could increase of the dose of Plavix.
The genetic testing is being offered at Scripps Green Hospital and may be expanded to other hospitals within the Scripps system.
Genetic testing is also being offered as an additional component of annual physicals for patients who are part of the MDVIP network, a relatively new “primary physician” model is growing rapidly in San Diego County and throughout the nation. There is an additional fee charged for the genetic testing service.
Patients pay “MDVIP” physicians $1,800 annually to receive a “concierge level” of medical care. Physicians in the nationwide network agree to a maximum patient load of 600. MDVIP reaches over 120,000 patients through 330 physicians in 28 states plus the District of Columbia. In San Diego County, MDVIP physicians are located in La Jolla, Solana Beach, Encinitas and Oceanside.
Dr. Andre Sanschagrin, an Encinitas MDVIP physician, says that the affiliation has “reincorporated normalcy into a patient provider bond.” The model, he says, allows for continuity of care. “I have the time to take care of them in the hospital, in a skilled nursing and, when there’s a final call, through hospice,” he says.
Sanschagrin had been a solo practitioner in North County since 1990, operating in an environment he considered “in decline and deterioration.”
“Being in practice alone is no longer economically viable. Historically, insurance companies will pay for stitches in body parts but won’t pay to evaluate complex situations,” he said. “I had been through a host of transitions with managed care, as all physicians did, where the focus of priorities was not patient centered but insurance centered or even doctor group centered.”
The traditional model, he said, required a patient load of 2,000 to 3,000, just to maintain a practice. “That means spending about six or seven minutes with a patient and that didn’t set well with me.”
Sanschagrin says he has also utilized MDVIP’s affiliations with Centers of Excellence on throughout the country on behalf of his patients.
He recalls when he referred a patient requiring complex surgery to her pituitary gland to UCLA through the Centers of Excellence vehicle. “I was able to refer her to a surgeon whose volume as a tertiary center was within my comfort zone. It’s a type of surgery done by a select few. And I referred another patient needing a leading edge robotic heart valve to the Cleveland Clinic.”
The MDVIP program requires that every patient receive a Mayo Clinic-type executive comprehensive physical exam which is included in the annual fee. It includes genetic testing for predispositions to 26 diseases that can be held at bay through preventive measures.
That works well for Sanschagrin who says his patients include a mix from younger (30 and up) who have “a family history laden with land mines ahead who are looking to remain proactive in offsetting the premature heart event” and an elder pool who are in need of maintenance measures to stay out of the hospital.
After their annual physical, MDVIP patients are then provided with a wellness plan. MDVIP’s executive health program was named in Worth Magazine as one of the top 10 executive health programs in America — the only group that was not a facility-based health program.
MDVIP provides patient records including tests, medications, and conditions on a mini wallet-sized CD that can be used in the case of an emergency or when visiting another specialist. The medical records also are available to the patient online Through the network’s travel program, patients who visit or travel to another state and need to see a doctor due to an emergency can see any of the MDVIP physicians in that area on a “same day” basis.
MDVIP’s standard office visits are a minimum of 30 minutes and unhurried, and the primary physician is always available to patients via cell phone and e-mail.
Rancho Santa Fe resident Bret Jorgensen, with more than 20 years of experience in health services, assumed the chief executive officer role at MD VIP last February, following a variety of executive positions in the industry, including president and CEO of InSight Health Corp. and chairman and CEO of Directfit.
“Our typical patient runs the full spectrum, from lower middle class to professionals,” said Jorgensen. “We’re priced at a point that is very affordable of the market and our model medically works. We have unparalleled outcomes, including 50 to 70 percent reductions in hospitalizations over multi-year studies that have just been updated. That is the result of a much more pro-active doctor-patient relationship. And it’s a savings of tens of millions of dollars to various insurance payers.”
MDVIP is growing rapidly, up by more than 30 percent year over year, said Jorgensen. Most doctors are recruited via referrals from physicians already in the network. “And we try to identify terrific physicians; we look for a high model of care.” Reducing the size of a patient load is a model that allows our physicians to deliver more personalized service and our members like it,” said Jorgensen. “And it’s born out in a 94 percent satisfaction level of all metrics, plus a retention models in excess of 90 percent.”
Full-day executive physicals in a spa-like setting are proving extremely popular at Scripps Health. The physicals, called the WholePerson examination, streamline the exam process and create economies of scale and efficiencies, according to James Tuck, manager of the business unit for Scripps Health.
“It’s not designed to take the place of a primary care doctor,” said Tuck. “But we pull together all the components of a complete exam, and don’t tell the patient to go here for cardiology, or make an appointment for imaging and make another appointment at a lab for a blood draw”
The process, said Tuck, also is extremely comprehensive, examining stress levels, nutrition and holistic practices.
The day begins at 6:45 a.m. when patients arrive, having fasted for at least 12 hours and come prepared with surveys they have filled out on lifestyle, nutrition and stress levels. “The facility is very much like a spa,” says Tuck, with men and women’s locker rooms and a luxurious waiting room, where juices, water, coffee, tea, and a flat screen TV are provided.
First up are blood draws and a urinalysis. Next, an internal medicine specialist will spend 45 minutes to an hour doing an exam, going over the medical history questionnaire, reflexes, and doing a prostrate exam for men and a pap smear for women clients. Next, an EKG technician will escort the patient to the cardiac assessment wing for an EKG test on a treadmill; the testing takes about 30 to 45 minutes. Then it’s vision, glaucoma and hearing tests, followed by a body fat assessment.
The patient next meets with a dermatologist for a total body skin cancer screening, which Scripps deems important, especially in the warm San Diego climate. This screening can require anywhere from 10 minutes to a half hour. Next, the patient is escorted to the downstairs imaging center for a chest x-ray and then back up for pulmonary function lung testing.
Now it’s lunchtime and catered lunches that offer healthy choices such as tossed salads, fruit, perhaps a turkey on whole wheat sandwich and baked chips are provided in the waiting lounge.
After lunch, the patient moves into the preventive side of the WholePerson exam, with a series of lifestyle consultations — three sessions of 45 minutes each are held with an exercise physiologist, a clinical psychologist and a holistic consultant who provides information on mind-body modalities such as meditation, yoga and diaphragmatic breathing and visual imagery. The day concludes with a 30-minute revitalizing massage.