Abstract
Taking care of Very Important Persons (VIPs) has always been a contentious area of medicine. Access to private healthcare in privileged classes is often linked to socioeconomic status, and the concept role of executive health medicine has emerged. The provision of care for VIP patients requires innovative approaches to assure that their status does not influence the quality of care they receive, and this is precisely what physicians should aim for while providing Executive VIP care. This review intends to highlight the important characteristics of Executive Medicine and the future of VIP Executive Medicine operating within a Value-Based Healthcare system. We have proposed a model of value-based executive medicine in this review in an attempt to describe the basic concept of executive medicine and its various dimensions. This model is inspired by the value-based healthcare delivery framework of Michael Porter and various executive health programs offered by academic medical centers in the United States of America.
Keywords
“Executive health programs will evolve with advancements in healthcare and increasingly discriminating prospective patients.”
Introduction
VIP Medicine or Executive medicine is described as the provision of all healthcare needs of the VIPs, including preventive and specialty care, treatment of acute and chronic illnesses, and case management services. 1 The sophisticated care delivery process for VIP patients and their demands may result in unsound clinical judgment and deleterious outcomes during the efforts to meet unrealistic expectations. Groves suggested a tripartite typology of these patients: the celebrities, the VIPs, and the Potentates, that is, the well-known, the well-connected, and the very well-off. 2 While many healthcare professionals and even laypeople support the ideology behind accommodating wealthy and influential personalities and treating them differently than the rest of the population, many practitioners still believe in quite the opposite. In 1964, the term VIP Syndrome was coined by Weintraub, which implied that the patients’ social status influences the delivery of medical care. 3
The concept of executive health medicine has been practiced in various forms ever since there has been a hierarchy amongst people living in a society based on their financial status. 4 It is observed that from kings in older times to celebrities and politicians in today’s modern world, this vaguely described practice has been catering to their medical needs ensuring quality services. They’ve been provided with tailor-made preventive and therapeutic approaches in an attempt to accommodate them based on their busy schedules and varied personal preferences. 5
Sometimes the caregivers end up not giving the appropriate care in order to please the VIP patient. These concerns can also be resolved by not bending the rules for VIPs if it harms the patient. This is one of the nine principles mentioned in a study about the care of VIP patients. 6 Some claim that while treating VIPs, some key hospital resources are diverted from other patients who need them, thereby creating an ethical argument against treating a VIP differently. However, this concern can be resolved by diverting the resources only if it won’t be at the cost of worsening care for other patients. 4 Others claim that due to the influence of numerous stakeholders in the well-being of the VIP, the delivery of patient care entirely revolves around the demands and comfort of the patient resulting in the medical practitioner not making the right choice, inevitably leading to dispensing poor healthcare services. 5 Risk to confidentiality is another concern that troubles most of the VIPs as well as the healthcare professionals.
This review aimed to discuss the implementation of value-based principles of healthcare, viz. evidence-based practice; patient-centredness inclusive of carers and the community, continuous and coordinated across settings; and ethically sound and regulated in the executive medicine practice. It will discuss how the values-based practice framework, a new approach to incorporating values in clinical decision-making, can contribute to such ends. The niche for a new value approach will be sought by outlining how the values-based practice framework relates to other values and evidence-based medicine approaches. The paper will also consider what changes to practice, education, and research may be required so that primary care and healthcare, in general, can become more individual value based.
Methodology
An unstructured review of the English language medical literature focused on adult subjects was performed. The source of information involved collecting data from PubMed, Google Scholar, Web of Science, and SCOPUS databases. The databases were searched for the terms “executive medicine,” “executive health,” “concierge medicine,” “dignitary medicine,” “royal health,” “presidential health,” “royal physicians,” “presidential physician,” and “VIP Medicine.” Institutional review board (IRB) approval was unnecessary, as human subjects were not involved in this project.
The inclusion criteria included articles reviewed in English and published in peer-reviewed journals. The articles included dignitaries, executives, VIPs’ or celebrities as a patient population, their respective physicians, or practice related to those populations. Articles addressing politics, news reports, advertisements, and healthcare professionals other than physicians were excluded. Two team members reviewed each of the abstracts and the related titles. Studies marked for potential inclusion by both reviewers underwent a full-text review by 2 separate team members. If the second team agreed that a given study did not merit inclusion, the study was excluded. In instances where the reviewers did not agree, the disagreement was resolved through consensus and discussion with additional team members.
At the end of our search string, only 18 articles were finalized that satisfied the criterion for inclusion. The relevant articles were screened based on their titles and abstracts, and finally, the most appropriate articles were chosen to be included in the review. Articles up till January 2021 are included in this review. The articles were thoroughly read, and the relevant information was selected and extracted from these articles. Selection criteria of articles is given in Figure 1. Flow diagram for selection of articles.
Executive VIP Care
Executive VIP care is often confused with Concierge medicine. The former focuses exclusively on VIPs that are high-income earners, such as celebrities and CEOs, whereas the latter concerns treatment options based on the affordability of the clients. 7 While Executive health services, such as offering basic health checkups involving vision, hearing, and cardiovascular checkups, are provided to some of the chief executive officers that are seen to be very demanding and resourceful, there has been observed an ongoing debate regarding the requirements for these extensive health services due to the cost-effectiveness and necessity of such programs. The major challenge while delivering care to the executives is to avoid the “Very Important Person syndrome.” The syndrome can present in a variety of ways. There may be a change in the patient’s regular care, such as fewer testing, diagnostic procedures, or therapeutic maneuvers. This decision is frequently motivated by a desire to relieve the VIP of pain. Choosing to skip the uncomfortable process frequently results in a misdiagnosis. It is imperative for physicians to bear in mind that there’s nothing biologically different in VIPs and that they shall be managed accordingly. 8
Dignitary Medicine (DM) involves providing healthcare services to dignitaries. It is the practice of providing healthcare to government officials and other high-profile individuals collectively referred to as “dignitaries.” DM’s foundations are based on the White House, State Department, and other physicians with a significant travel history with dignitaries. This practice was proposed as a novel discipline of medical training, called “Dignitary Medicine,” offering recommendations for DM trainees’ core competencies. 9 Dignitaries often require vigorous preventive, provocative, and personalized medical treatment—24 hours a day and seven days a week, high-quality, individualized healthcare, and even more privacy than ordinary citizens, mainly since traveling internationally, particularly as a part of humanitarian or political missions, can expose them to new infections or illnesses. Their health status can potentially influence the political and economic health of a city, a country, or perhaps the whole world. For this reason, increased worldwide tour by business executives and government officials has necessitated an increase in competency in this new area of specialization. 10
Furthermore, with such a wide range of illnesses requiring expert medical care, it is apparent that DM providers require particular training and abilities to provide the best possible care for dignitaries. Several methods are available to achieve this goal, including post-residency specialist fellowship training. Practice standardization and creating a formal curriculum and criteria for DM can also be used to provide such training. Such training strives to ensure that physicians working in this field have the expertise to safeguard the health and safety of dignitaries. 9
Services for VIPs at Premium Healthcare Settings
Caring for VIP patients necessitates personalized medicine approach to ensure that their status does not affect the quality of treatment they receive, and that is exactly what the clinicians should set out to do while delivering Executive VIP Care. VIP care is designed exclusively for CEOs and individuals who can afford such medical treatments. The concerned dignitary will have a customized and in-depth appointment, which normally lasts 4 hours, as part of their executive health assessment. A comprehensive examination is offered at offices that include a detailed health history of the VIP along with a review of the dignitary’s lifestyle, every diagnostic test available in the medical industry, an extensive gender-oriented evaluation, and private counsel on the multiple health hazards present in the environment. The special executive packages include a variety of laboratory and diagnostic tests, lifestyle assessments of the dignitary, and potential risk factors, health conditions, and diseases that the VIP may face in the long run. The occupational health screening for senior executives of the corporate sector has a different scope as compared to routine medical examination. 11
Hospitals can continue to monitor the treatment of their executive patients by utilizing contemporary information and technologies to keep in touch with them. These tools will also let physicians diagnose, treat, and coordinate patient care without being physically there. Executive health encompasses different aspects, including routine physical examinations to emergency treatments and healthcare solutions. At the same time, to execute operations and specialized medical interventions, practitioners of executive health programs must understand and employ the most up-to-date, cutting-edge technologies. 12
To be a productive and thorough DM physician, the doctor must possess a high level of technical expertise in their profession. Based on a recent Delphi analysis, the authors suggested critical skills required to practice DM, including executive healthcare, protective medicine, clinical competence, wellness, advances in medical technology, and leadership. Executive health includes concierge medical skills and understanding the unique needs of the dignitary physician relationship, especially the dignitary’s need for privacy. Protective medicine involves tactical, travel, and disaster-related medical skills. It also includes coordinating care with security forces and other teams involved with the dignitary. 13
Clinical competence is the maintenance of skills and ongoing board certification in a DM physician’s base specialty. Wellness focuses on screening, preventive medicine, and the best care for chronic illness in the dignitary. Emphasis on personalized medicine and guideline-based practice/clinical key performance indicators (KPIs) is critical. Advances in medical technology include the dignitary physician being up-to-date on technological resources, electronic medical records, cybersecurity, and the role of telemedicine in providing timely consultation from anywhere in the world. Leadership involves the skills needed to coordinate and orchestrate care for the dignitary, including managing the entourage around the dignitary. One good example of a healthcare facility providing several benefits to VIPs is that of Canada Based “Lifemark Health Group,” which knows the challenges and stresses of a dignitary’s busy executive schedule and routine. 14
Apart from that, the Lifemark also makes every effort to contact as many dignitaries, VIPs, and high-ranking authorities as possible. They do this to ensure that their visits are coordinated smoothly, and the schedule is precisely followed so that the dignitaries and their medical unit are not inconvenienced. Lifemark is willing to create tailor-made executive health programs based only on the needs and budgets of the dignitary, the physician, and their staff. Similar efforts are made at premium health setups to keep up with the VIPs visiting a particular healthcare facility.
Packages and Services for VIPs
Different healthcare facilities provide different packages and services. A typical package aims to provide the greatest medical care to the VIPs and maintain its reputation for many years. One of the important aspects of executive healthcare services in the market is to adopt a customized approach and assist the dignitary physician and team in selecting a program that suits the VIP’s particular needs.
The services provided under the umbrella of these executive packages could include individualized medical care, including diet treatment plans, exercise regimens, and nutritional diets based on the genetic profiles and predispositions of the people who use them. Because no institute can accommodate a large number of VIPs at the same time, several executive health programs are only provided at specific places across the USA. The top 20 US medical schools were recently identified to offer at least one affiliated VIP care program. These clinics promise comprehensive, customized, dedicated care focused on a brief, efficient itinerary full of laboratory testing, imaging, and other sought-after screenings and procedures—vision and hearing tests, dieticians, physical therapists, genetic counselors, wellness coaches, and cosmetic surgeons in one to 2 days. 15
Executive Health Programs in Academic Medical Centers.
Controversies in “VIP Medicine”
Several authors have criticized the practice of VIP medicine. These objections can be broadly categorized as focusing on issues of fairness (elitism), economy (wastefulness), and safety (lax standards). Some authors object that, although it is not surprising that those with fame or wealth receive more attention when sick, it seems unfair that they should get “better” medical care than others, especially in cases where scarce resources, including time, are reallocated to accommodate them. 16
VIP medicine could be extravagant and wasteful. Excessive drug prescriptions may be written and imaging studies ordered. For example, some health care programs for corporate executives involve periodic full-bodyCT scans as screening tests as part of the “chairman’s physical,” a measure considered entirely unjustified as routine care. A VIP may insist on the senior-most specialist at an academic institution or teaching hospital—the chair of the department of medicine or surgery, for instance. But the senior-most or most eminent caregiver is not necessarily the most skilled at performing a given procedure. Such an individual may be out of practice or no longer up-to-date, and the “no name” subordinate may be much more skilled. 17
In their haste to attend to a VIP without stint, star-struck administrators, doctors, and nurses may, in their distraction and frustration, provide substandard care. Many VIP wings have physically removed some distance from the rest of the hospital; even proper routine staffing with the appropriate specialist nursing care (cardiac nurses, orthopedic nurses, or others.) may not get all the way out to an exceptional, isolated patient. VIPs also have particular issues with privacy because everyone is interested in their health and may compromise confidentiality when managing medical records and studies. Medical personnel may acquiesce to a VIP’s unorthodox requests, even when doing so represents a breach of standards or is frankly dangerous to other patients. 18
Ethical Issues in VIP Care
Value-Based Healthcare
Values-based practice is one of several new approaches to support clinical decision-making where complex and sometimes conflicting values are in play. Derived from work in analytic philosophy, 3 it provides a clinical skills-based approach to link the generalized scientific knowledge of evidence-based practice to the particular values, needs, wishes, and expectations that individual patients bring to the clinical encounter. The principles of evidence-based practice and values-based practice thus work together as a basis of shared decision-making between practitioners, their patients, and families. 20
Values-based practice is also complementary to ethics: ethical principles, together with medical law, provide a framework of shared values, such as “best interests” and “confidentiality”; values-based practice provides an approach for reaching balanced decisions where framework values conflict. 21
Michael Porter, in his book titled “Redefining Health Care Creating Value-Based Competition on Results,” described how healthcare had fallen into a pattern of dysfunctional competition where providers were competing on the wrong things at the wrong level resulting in spending more on healthcare and getting worse health outcomes in the developed countries like the USA. Porter defines value as the “health outcomes achieved per dollar spent.” Thus, value-based care constitutes health services that create added value by focusing on how the service is organized, performed, and paid for about the outcomes achieved in terms of, for instance, patients’ health and experiences of health services. 22
Important in value-based healthcare is the transition towards reimbursement for patients’ entire care cycle rather than for a visit to a single care provider. A cycle of care can contain several episodes; although it might be possible to delineate the cycle in the context of a surgical procedure, doing so is more challenging in the context of a complex long-term health condition. Moreover, a core element in value-based healthcare is an effective measure of quality Health outcomes are to be measured from the patient’s perspective, and their support networks (e.g., families) rather than using process measures and should, when it comes to complex long-term conditions, including measurements of the patient’s maintained functioning. The authors also proposed a radical healthcare restructuring focused on competition and improvement, including a single unifying goal for healthcare: to deliver value for the patient. Hence they suggested 6 major elements necessary for a truly value-based system.20,23 Elements of value-based healthcare delivery system are described in Figure 2. Value-based healthcare delivery.
Discussion
Very limited literature has been published regarding the practice of Executive Health, and even less about DM. No set of universal standard protocols regarding these practices exists; hence, there is a dire need for devising standard protocols and well-formulated universal guidelines about the practice of Executive Health Medicine that practitioners from all over the world can use. Executive health programs will evolve with advancements in healthcare and increasingly discriminating prospective patients. This evolution is a function of advances in medical technology and care, more demanding patients able to afford the healthcare advances, and the economic needs of the hospitals and medical practices. Medical institutions, for example, are probably going to build into their executive health programs ongoing evaluation capabilities. This is possible because of new and continuing developments in telemedicine. Digital Health is a burgeoning field that will enable hospitals to provide continuous care and connection to their executive patients. These technologies will also enable hospital-based physicians to diagnose, treat and coordinate care for patients while away from home, thereby improving access to care and reducing travel costs.
Comprehensive longevity planning in executive health programs should be planned by the medical institutions expanding into delivering such care. The cutting-edge hospitals should integrate both genomic and biomarker testing with the design of a holistic and enduring preventive healthcare and risk management plan and at the same time, patients’ wealth managers should be called upon to create fiscal savings to cover the ongoing costs of these programs. This resource is critical and should also be put in place for any patient desiring the means to pay for credible cutting-edge treatment options not yet covered by conventional health insurance or Medicare. For some hospitals and medical practices, executive health and wellness programs are important to their financial prosperity, especially looking forward. The opportunities available to these healthcare providers, from incorporating digital health evaluations and treatment to comprehensive longevity planning, are considerable. With the economics of healthcare, many times working against providers, the evolution of executive health programs will prove very beneficial to all involved.
The proposed model is based on 5 dimensions that stem from a value-based care delivery model and the prevalent executive medicine programs in the United States. Some dimensions like wellness, health promotion, personalized health, and executive medical checkup in different categories are mostly practiced. However, these programs need to focus on digital health, insurance, and medical escort aspects of executive health. The proposed model is drawn below. The proposed model for value-based executive medicine is described in Figure 3. Proposed value-based executive medicine model.
Conclusion
By proposing this model, it is expected to improve the approach for VIPs treatment and to define a Value-Based Executive Health Program. Our team has realized that due to it being an emerging area of medicine, it’s imperative for researchers and Executive Medicine practitioners to further expand the available literature and knowledge regarding VIP care. However, according to the literature available as of now, we hope this model helps elucidate and improvise the current status of the practice of VIP care.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
