For the past five years, top-ranking Democratic Party official Bradley Marshall has squeezed time into his jammed schedule to visit Baltimore - for his annual physical.
But getting an appointment isn't as easy as it used to be.
Marshall is one of more than a thousand people who participate each year in Johns Hopkins Medicine's Executive Health Program, a project created a decade ago by Dr. George H. Sack Jr. in part to change the way doctors administer annual physical exams.
"It used to be your doctor looked down your throat, checked your blood pressure and sent you on your way," says Marshall, 50, the chief financial officer for the Democratic National Committee in Washington. "This is much more comprehensive. I'm sold on it."
Others appear to be sold on the concept as well, because, across the country, the annual physical is undergoing a facelift.
Leading hospitals and wellness center such as the Mayo Clinic, Cleveland Clinic and Princeton Longevity Center now offer full-day physicals, at costs of as much as $4,000. These "Cadillac" physicals cover everything from blood tests to bone scans. Patients are sent home with thick medical dossiers.
Doctors also are setting up smaller, exclusive offices - nicknamed concierge or boutique practices. A limited number of patients join with annual fees of about $1,000. In return, they get unlimited access to their doctors. And they never have to spend a day in a waiting room.
In addition, companies such as HeartSavers in Timonium and Virtual Physical in Pikesville are setting up shop to scan everything from hearts to lungs to colons.
All of this comes at a time of crisis for the country's health care system. More than 45 million Americans are uninsured, according to the American Medical Association. Those with health insurance are being expected to shoulder more of their own health care costs. And doctors are being squeezed, saying they have to take on more patients to make the same amount of money.
As a result, patients who can afford it are going outside the system for more convenient care.
"There's no doubt we are moving in the direction of consumer-driven health care," says Dr. William Hazel, a trustee of the American Medical Association.
Insurance companies rarely cover the complete cost of extensive physicals or tests such as body scans, sparking debate about whether care is degenerating along class lines.
But there are plenty of people who don't mind paying. And doctors say more in-depth physicals or smaller boutique practices give them more time with patients. The result: Doctors can shift from treating illness to preventing it.
"It used to be that we focused simply on putting out fires," says Sack, a Hopkins internist. "This lets us focus on preventative health care. I say this isn't a program for the sick. It's a program to keep you healthy."
Sack jokes that his Executive Health Program, at Hopkins' Outpatient Center on Caroline Street in East Baltimore, isn't as nice as some of the nation's elite wellness centers. But the waiting room does have upholstered furniture, and patients are treated to a spa-like breakfast after they've had their blood drawn. More important, patients getting an executive physical spend more than 90 minutes with an internist.
The Executive Health Program was started as a response to inquiries from high-ranking business executives trying to find a way to protect their most valued assets - their highly paid employees.
With contracts from a few companies such as the former USF&G; and Rite Aid Corp., Sack launched the program with 35 patients. The employers usually paid the $2,000 fee for the exam, which lasted all day and included everything from neurological testing to nutrition counseling.
Over the years, the program has grown to 1,400 patients a year, with 40 percent of them paying their own way. Companies including T. Rowe Price, Chrysler and General Motors still send executives.
Marshall, the Democratic official, who lives in Washington, heard about the program through friends. He was in his mid-40s at the time, and couldn't remember the last time he had checked in with a doctor.
He made an appointment, and now returns each year. Although he is healthy, Marshall is confident Hopkins doctors would pick up problems early.
"It's worth every penny," he says. "We established a baseline and every year we can come back and compare against that."
The exam is comprehensive. Patients often arrive with laptops and cell phones, Sack says, only to find that they don't have a minute in their eight-hour day to check them. The physical includes a neurological exam, eye exam, resting electrocardiogram and exercise stress test. From blood work, doctors check for everything from Vitamin D deficiency to C-reactive proteins, a possible marker for coronary artery disease.
"Most people know they need to have these tests," says Sack. "But they are too busy. They don't have the time to schedule them over many weeks."
Of those seen at the Executive Health Center, Sack estimates, one in three leave with a diagnosis. A recent middle-aged patient, for example, learned he had early signs of macular degeneration, a leading cause of blindness.
If serious problems arise, Sack taps into high-tech resources at Hopkins. Dr. Elliot K. Fishman, director of diagnostic imaging, can conduct virtual physicals with the click of a computer mouse.
With a new, $1.5 million CT scanner, one of the first of its kind in the country, Fishman says, he can virtually examine levels of the body down to individual blood vessels.
"We like to call these the physicals of the 21st century," he says.
Sack and other doctors don't advise extensive scanning on healthy people because of radiation exposure. But the high-tech equipment can provide instant, valuable information if illness is suspected, he says.
In addition to plunking down money for extensive annual exams, people also are willing to pay for the privilege of spending more time with their doctors.
About 200 of the nation's 850,000 doctors are forming smaller concierge offices, according to the Society for Innovative Medical Practice Design, a Michigan-based trade group that advises doctors.
Dr. William Queale, a Baltimore County internist, has formed such a practice, called Personal Healthcare Providers, in Lutherville. Queale, 38, has limited his patients to 250 and charges them each a $1,500 annual fee.
The New England Journal of Medicine in 2001 reported on two studies that showed doctors spend on average between 16 minutes and 20 minutes with patients during an office visit.
By contrast, Queale provides service on demand for his patients, either in his office or on the telephone. "People never wait," says office manager Karen Mentzel.
Mentzel coordinates executive-style physicals for Queale's patients, but it can take as long as a week to get all the testing completed.
Many doctors use local facilities such as HeartSavers in Timonium for high-tech body scanning. The facility, operated by a California company, accepts patients by referral and charges up-front for organ and body scans. It costs anywhere from $350 for a heart scan to $1,200 for a complete body and colon scan.
Marsha Modell, a former real estate agent from Pikesville, recently paid about $650 for a heart and lung scan at HeartSavers, at the request of her physician.
"I'm going to submit my bill" to the insurance company, says Modell, "but I may have to pay out of pocket."
Last spring, her husband, Gene Modell, paid $500 for a heart scan because he was worried about his family history of heart disease. No problems were found.
To the Modells and others, the cost of extensive physicals and supplemental testing is worth the cost.
Executive physicals
During full-day physicals at Johns Hopkins Medicine's Executive Health Program, doctors conduct many tests, at a cost of about $2,000. Here's a sample:
Detailed physical exam. An internist spends about 90 minutes with a patient, compared with the national average, which one study found to be 16 minutes to 20 minutes.
Comprehensive lab screening. Blood tests look for anemia, diabetes, thyroid disease, liver and kidney disease. Hopkins also tests for the C-reactive protein, an inflammation indicator that may point to coronary artery disease.
Fecal occult blood test. Looks for gastrointestinal bleeding from tumors, ulcers or polyps.
Resting electrocardiogram (EKG). Checks the heart's electrical activity. Can be used to look for irregular heartbeats or artery blockage.
Exercise stress test. A treadmill test to assess the heart's ability to respond to physical activity.
Eye exam. Performed at the Wilmer Eye Clinic.
Nutrition counseling.