Will Manidis Profile picture
Aug 29 23 tweets 6 min read Twitter logo Read on Twitter
Last year, I paid thousands of dollars for a physical at one of the best hospitals in America

I wanted to see how different healthcare was for the ultra-rich, and what this meant for the rest of the healthcare system

Here's what I learned: Image
I work in healthcare.

I was always aware that executive physicals— ultra-high-end, luxury concierge care— existed, but I had never met someone who went through one.

and now, due to an accident with my flexible spending account, I ended up with enough cash to try it out.
The core of an executive physical is a multi-day, exhaustive medical exam

advertised as a way to both optimize your health and mitigate long-term risks.

Almost every major academic medical center in America offers one at a cost of a few thousand dollars per year.
To prevent losing the thousands I accidentally contributed to my FSA, I signed up for the eight-month waiting list to get a spot.

The appointment begins months before you arrive, with a set of intake surveys designed to match your health concerns to a battery of possible appt
From this intake, they curate an onsite agenda. In my case, three twelve-hour days of specialist appointments and tests.

the schedule addresses both your stated concerns and includes an exhaustive panel hand-built to detect and address concerns appropriate for your age Image
I received my 6-page schedule a few weeks before I was set to fly out.

The concierge called to make sure I had no additional concerns, helped me book a local hotel, arranged transport from the airport, and even offered to assist with dinner and entertainment reservations.
On arrival, the visit could not be more unlike a normal hospital visit.

You are escorted to the "Executive Health Center" - a luxury WeWork-like space with Wi-Fi, a free catered kitchen, and call rooms so you can work while onsite.

This will be your home base during the visit. Image
Every piece is curated—there's a dedicated desk to assist with any scheduling worries, and handlers to make sure you don't get lost.

The executive lounge, even on a sub-zero February day, was absolutely packed. Every month, thousands of people seemingly pass through this program
The experience is a bit of a whirlwind—mine involved blood tests, peeing in cups, imaging, dermatology workups, a half a dozen hours of PT, a full eye and hearing exam, and a cardiac test that has you running on a treadmill with all manner of wires attached. Image
Each appointment was similar to the kind of care you'd receive anywhere in any other hospital,

but each was delivered without rush, beginning exactly on time, with the kindest doctor you've ever met.

Any concerns raised could yield a same-day follow-up, not a many-month wait.
A battery of non-medical services—from massages at a full-service spa, to culturally-aware dietitians—were offered to fill in the gaps between your appointments.

My FSA sadly had been tapped out by this point, but other participants raved about them as the highlight Image
Your visit is bookended by two 60-minute sit-downs with your new primary care provider to delve into, in exacting detail, your care roadmap and any recommended interventions.

My provider was kind, extremely willing to indulge my weird questions, and very thorough.
I got the results I largely expected—my chronic stuff was well managed. I should probably do more cardio and find ways to lower my stress. I was also reminded, repeatedly, that I should pay less attention to Ray Peat

I walked away with incredible comfort, knowing all was okay.
I walked away believing that executive physicals are the most obvious sign of what is to come for our healthcare system.

Middle/upper-class patients are opting out of the system entirely, replacing it with cash pay for as-needed services to "enhance and optimize" their health.
This trend seemed to begin a few years ago with the rise of ad hoc telemedicine (hims/rho) providing prescriptions as a service, and I think it has become more obvious with Huberman optimizers.

The "worried well" don't want 13-minute physicals, and are willing to pay for better.
This leaves our normal healthcare system in the dust—struggling with access, cost of care, and increasingly burnt-out providers.

More patients leaving this system en masse for an even more inaccessible level of care is perhaps unavoidable but it's a disaster waiting to happen.
This style of care is not without critique either.

The effectiveness of executive physicals seems, at best, unclear, with plenty of literature calling into question all manner of risks, from over-detection to just poorly constructed visits at many sites.

Services like Prenuvo have offered a more tech-enabled vision of the same services, centered around services previously unheard of in healthy patients like full body MRIsthat have much more nebulous outcome data

and are growing at incredible rates

Executive physicals remain a massive business.

It's insane how little attention these get from the healthcare commentary class—written off for having a reputation for being largely throw away expenses for executives at legacy F500s

but thats not what I witnessed at the clinic.
None of the folks I met were Fortune 500 executives—sure, many were well-off—but most were not.

Many were normal people spending huge percentages of their income and flying across the country to receive a quality of healthcare they feel has been gutted elsewhere
It seems obvious there's a huge opportunity for a modern executive physical that blurs the lines of medical/lifestyle care.

Instead of riding off the reputation of a prestigious hospital, imagine what a luxury medical retreat co-branded with a Huberman would look like.
While I do believe, amangiri-as-cleveland-clinic-with-andrew-huberman is a massive business to be built

the executive physical is ultimately a bellwether for the quality of care every patient desires, and scaling this kind of care seems within reach for the first time in decades
Ultimately, what an executive physical provides is a five-thousand-dollar ticket to having the world's top medical experts tell you that it's all going to be okay.

A level of personal comfort and security with your health that is available no where else

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More from @WillManidis

Nov 25
what’s the best truly banned book?

not like 1984 banned — I mean PDFs that are literally unprintable, truly arcane knowledge
the McKinsey internal firm history is an obvious one though easy to get these days

the sequoia history that mm wrote is an obvious one (unless @shaunmmaguire 🤝)
@shaunmmaguire the nick sleep letters were great and esoteric for a while but now easily available as well
Read 5 tweets
Nov 17
The AI/healthcare discourse has reached new levels of insane this week

A close friend, a MD at a prestigious medical center, recently shared the following memo with me. He asked me to share this anonymously.

"What we don't talk about when we talk about AI/medicine"
1. Standard of Care isn't Standard Care

Novel modalities of care (AI-assisted, etc.) are measured against a platonic ideal of SOC that doesn't exist in clinic

Medicine is as much of an art as a science, providers are overworked, tired, and often veer dramatically from SOC.
Novel care modalities are killed in the cradle as they can never measure up to the textbook provider with infinite knowledge and time.

This isn't what most patients receive. Less efficacious care that scale to many more patients are an obvious moral good but are difficult today
Read 12 tweets
Oct 30
The Executive Order on AI issued by the White House today represents the beginning of a complete overhaul of the regulatory landscape for healthcare AI.

Here are my notes on what matters from the 100+ pages:
Let's start with a quick summary of the EO's requirements:

- Within 180 days, HHS shall publish a plan to promote responsible AI use in public benefits like Medicare/Medicaid. The plan should address access to benefits, notice, evaluation for unjust denials, etc

(Section 7.2b)
- Within 365 days, HHS shall establish an AI safety program that partners with Patient Safety Organizations to create a framework for capturing clinical errors caused by AI, analyzing data, and developing informal guidance aimed at avoiding these harms.

(Section 8biv)
Read 14 tweets
Oct 18
healthcare is having its top deck of the titanic moment

what happens in the next year will define the next century of american healthcare, and basically everyone is ignoring it.

here's the real story:
Healthcare has been defined by four factors:
1. Extremely limited supply (MDs are scarce and costly).
2. Principal-agent problem with payments (your insurance pays, not you).
3. Inelastic demand and high trust (you need it and have confidence in it).
4. Regulatory capture.
this has allowed the industry to behave in incredibly weird ways

cost can constantly grow, patient experience can constantly degrade, and clinics will still fill up with waitlists.

because patients trust it, need it, aren't paying for it, and have no choice.
Read 17 tweets
Oct 3
You can outperform most venture funds by buying LEGO.

I analyzed the last 20 years of secondhand LEGO pricing data, and found randomly purchasing sets will match most VC's returns

if you're somewhat intentional about what you buy-- you massively outperform even the best firms Image
I pulled data on 16,000 LEGO releases since the year 2000. I dropped any promotional items, duplicate items, or any other oddballs. This got me down to 10k or so.

For each, I then pulled in resell data from bricklink for each item to get current market price (ebay prices higher) Image
This allowed me to calculate a net IRR, assuming you bought it at release, and held it until 2023.

The VC benchmark data is sourced from the Cambridge Associates

recent years are iffy because of extreme paper markups (30%+ mean IRR). The data seems best through 2010/2015 Image
Read 6 tweets
Sep 13
Norton Commons is the most underappreciated development project of the last few decades.

A hyper-walkable, basically car free, traditional community built in the middle of Kentucky in 2003

No venture funding, no twitter threads on vitality. They simply chose to build well.

Norton Commons is in Prospect-- a farming community roughly 15 miles west of Louisville.

The land was originally a family farm owned by the Norton Trust. Mary Shands inherited the farmland in 1988 and wanted to preserve the rural character of the land.

Enter, Charles Osborn III a Baptist preacher from Texas that left the church to found houseboat manufacturer Kings Craft

He ultimately would settle in Louisville and open a sports club and senior care facility, before becoming obsessed with the idea of New Urbanism Image
Read 13 tweets

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