“Income from your business last year?”

I paused.

“We’re early,” I said.

“I see, that’s no issue. And how many employees currently?”

“Twenty-five.”

“So you’re not publicly listed on any exchange?” she asked.

“No, not this year.”

For the first time, I wasn't grappling with pointless questions from a Stanford MBA on a two-year venture fund tenure, but instead from an intake expert at the country's leading executive health program.

“I‘m afraid our program is booked out for at least ten months,” she concluded, “but we'd be happy to get you in next February.” It was April, 2022.

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If you want to know what a society prioritizes, just look at its tax code. In America, for example, tax incentives encourage us to use debt to buy as much real estate as possible, max out capital gains income, and travel for work in the most expensive ways possible. Then, because employers can expense healthcare benefits — and they don’t add to employee taxable income — American businesses are incentivized to heap as much money as they can into the maw of the healthcare industry. And the king of all untaxable healthcare benefits is the executive physical.

Over my years working, investing, and struggling in healthcare, I’d become vaguely aware of the executive physical: an intensive, no-expenses-spared annual check-up catering solely to the ultra-rich and selective. Offered as a kicker alongside compensation packages measured in the tens of millions to executives at companies you’ve never heard of, top medical centers like Duke and the Cleveland Clinic see thousands of these patients a year, promising unparalleled care, ease, and discretion. Executive physicals are the Emerald City of healthcare — who wouldn’t want to go there, if they could?

I wound up getting mine by accident. Hoping to outmaneuver the 80,000 IRS supersoldiers I figured were hot on my trail, I had been funneling paychecks into a healthcare flexible spending account (FSA) — a tax-advantaged savings vehicle for medical expenses that reduces taxable income — naively assuming I could easily spend it in a decade. But when I learned FSAs vaporize unspent savings yearly, I booked the earliest opening and volunteered to pay upfront.

In December, eight months after my initial screening, I had a call with my “care concierge.” In our hour-long discussion, we reviewed my medical goals: the knee pain I couldn’t fix, suspicious spots on the skin, hearing fading too swiftly.

The clinic was “basically in the middle of nowhere,” she told me, so many patients opted to fly private. They could, of course, refer me to a selection of private charters, but Delta would work if I was open to driving or being driven from the airport. The hotel they would arrange was linked to the facilities by a glass skyway so I could avoid the sub-zero outdoors. And my care concierge would schedule entertainment and restaurants for the weekend, since the small town offered little other than three restaurants and a hotel bar or two.

By January, I had received four pounds of literature printed on literally gilded paper — golden maps, pamphlets, personal and professional bios of each doctor I would see. My entire visit was scheduled in advance, down to the minute.

A few weeks later, I took a flight from New York to the airport nearest to the clinic. When I got there, I checked into my hotel room, which they had upgraded as a courtesy.

I woke to a knock at 5:00 the next morning, the start of three days of meticulously orchestrated elite care. My hosts, suspiciously from the donor relations department, gave me a tour of the tunnel and skyway system connecting the clinic, hotel, and local restaurants, then escorted me to the Executive Lounge — a discreet building tucked away in a corner of the otherwise glassy and open campus. Aesthetically somehow an unholy combination of a Trump Hotel and a WeWork, it had gold carpets, endless call rooms, and a full kitchen stocked with everything from Jello cubes to high-end keto meal plans.

My first visit began with an hour-long meet-and-greet in a room that felt more Amangiri than medical facility, and my doctor had all the time in the world for even my smallest worry, pausing every now and then to engage in small talk unheard of in normal medicine. The more embarrassing parts of a medical visit — the head turning, the coughing — were orchestrated behind a series of sheets. When they needed a urine sample, the request came delicately, in veiled euphemism. Could I “rest” in a private waiting area featuring piped in ocean sounds, until “nature called”? I could deliver my urine discreetly to a dropbox, so no one would know about my bodily functions.

The three days were a blur. I went through comprehensive blood work, full chest imaging, a treadmill test that included a DIY chest waxing experience I’ve yet to recover from, a full ultrasound exam of my vascular system, a hearing test (my hearing, perfect, except for my girlfriend's voice range, a result they offered to print and send home with me), a sports medicine consult that promised to fix my tight hamstrings, an eye exam, a secondary cardiac exam, and countless other check-ups. These appointments were offered alongside a battery of not-so-medical services: massages, nutritionists, haircuts, personal training, and even cosmetic surgery. My requests for certain “lifestyle” drugs, including semaglutide, were firmly denied.

Each appointment was unrushed, but began precisely on time. Any concern I had was addressed same-day, not months later as is common with specialist appointments. The lounge and its constant flow of snacks, refreshments, and strange company made it all too easy to lose track of time. One day, in conversation with the general contracting king of eastern Oklahoma over some non-alcoholic beers, I missed multiple appointments. They were promptly rescheduled.

Despite the rumors I’d heard, the operation wasn’t a backdoor pharmacy for off-label medications or off-shore bloodboys. It was just diligent and exhaustive care. It was everything we should want out of the medical industry. But in the favela of American medicine, it also felt like everything we can’t have.

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One of the most surprising things about the experience was that my assumptions about who I’d meet there were completely wrong. None of them were Fortune 500 executives; most were well off but few could be considered “rich.” In fact, it was mostly normal people who had spent a huge percentage of their income to fly across the country in search of healthcare they can’t get anywhere else. Most patients I met were in their fifth, sixth, even tenth year at the program.

Never was it more clear than when I was at the executive physical that America’s healthcare system is better at putting out fires than it is at helping people stay healthy. The issues that brought the people I met to the program were things that typically get written off as “subclinical” in traditional healthcare settings — persistent mental fog, undiagnosable chest pains, unexplained side effects of earlier surgeries. Issues like these weren’t acute enough for insurance to warrant real follow-up. Instead, patients get passed around in a long game of hot potato between disinterested specialists.

Studies on the advantages of executive physicals over normal ones find that they’re at best unclear, and at worst introduce all manner of risks, from over-detection to just poorly constructed visits. My doctor friends, many drowning under overwhelming care volume in their daily practice, almost universally told me that executive physicals are scams for people with too much money.

But for many people I met at the program, uncertainty about the value of an ultra-premium product wasn’t nearly as bad as the certainty of mediocre care. The executive physical, whether anyone thinks it is worth the premium, is a bellwether for the quality of care that every patient deserves: competent medical experts that listen to your issues and address them with confidence and precision. Unfortunately, for too many Americans, this type of care is in short supply, so it’s no wonder that more and more are going to such extremes.

-Will Manidis