At $10 billion or so a year, some question the value of annual physicals
Today, as healthcare providers – and consumers – preach the importance of preventive healthcare and population health, why would anyone diss the annual physical? An annual rite of passage for as many as one-third of U.S. adults, the physical is coming under attack from some providers, who question its value and its cost. Many consumers are left wondering what to do.
In September 2013, the Society of General Internal Medicine, as part of the Choosing Wisely initiative of the ABIM Foundation, recommended against routine health checks for asymptomatic adults, and suggested that such checks can actually lead to more harm than good.
“In contrast to office visits for acute illness, specific evidence-based preventive strategies, or chronic care management such as treatment of high blood pressure, regularly scheduled general health checks without a specific cause, including the ‘health maintenance’ annual visit, have not shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing,” wrote the Society.
Poorly defined
Two years later, in an October 2015 editorial in the New England Journal of Medicine, two physicians – Ateef Mehrotra, M.D., MPH, and Allan Prochazka, M.D – continued the attack.
“One of the difficulties in assessing the role of the annual physical is that its content is poorly defined and its focus has evolved over time,” they write. “The potential components of the annual physical include history taking, screening questions designed to uncover undetected illness or risk factors such as smoking, counseling to address those risk factors, a full physical exam, ordering of recommended preventive services, and routine testing (e.g., complete blood counts, electrocardiograms, and urinalyses) in asymptomatic patients. Many of these components are included because of billing regulations established by health plans and Medicare.”
Annual physicals may reduce patient worry and even increase use of preventive care services, but studies have shown they fail to reduce morbidity or mortality, according to the two doctors. “Moreover, the annual physical may actually be harmful,” they point out. “Some aspects of traditional annual physicals, such as the comprehensive physical exam (which might, for example, detect thyroid nodules) and routine tests (such as urinalysis), have low specificity, which means that most positive results in asymptomatic patients will be false positives.”
Reducing the incidence of annual physicals could save money and time, they continue. “Though on a per-visit basis, the annual physical is not costly, it is the single most common reason that U.S. patients seek care, and cumulatively these visits cost more than $10 billion per year – similar to the annual costs of all lung-cancer care in the United States.”
Reducing the number of physicals could also free up primary care providers’ time, they argue. “Approximately 10 percent of all visits with primary care physicians are for annual physicals, which might be crowding out visits for more urgent health issues,” they say. “Poor access to primary care has been cited as one reason why patients seek care in emergency departments for low-acuity conditions.”
On the other hand…
But by no means was that editorial the last word on the subject.
In a January 2016 Annals of Internal Medicine editorial, David U. Himmelstein, M.D., and Russell S. Phillips, M.D., punched holes in the “evidentiary support” for recommendations against the annual physical, particularly a study published in 2012 referred to as the “Cochrane review.” That study – conducted by the Cochrane Collaboration, a global, independent network of researchers, professionals and others interested in health – concluded that regular health checks failed to reduce morbidity or mortality.
The Cochrane review was full of flaws, according to Himmelstein and Phillips. It encompassed mostly outdated studies conducted in settings where control patients had frequent primary care visits and faced few access barriers, and the interventions assessed were not part of a 21st-century wellness visit.
“[W]e, like many colleagues, view the routine (although not necessarily annual) well-patient visit as a mainstay of the physician–patient relationship and worry that abandoning it risks undermining proven benefits of primary care, including better patient outcomes and attenuation of disparities,” write Himmelstein and Phillips. “In our experience, such visits have led to new diagnoses of melanoma, colon and breast cancer, alcohol abuse, opiate addiction and depression – diagnoses that would otherwise have been delayed or missed.”
What’s more, vulnerable patients – particularly low-income people who have little access to primary care physicians and little money to pay them – could suffer the most if the annual physical is eliminated, they say. “Without solid evidence, affluent, well-educated patients with unfettered access to care might reasonably choose longer intervals between routine visits. However, for vulnerable patients and groups at high risk for intercurrent illness (such as the elderly), regular, even annual, visits may be appropriate.”
Some resolutions
In their editorial, Mehrotra and Prochazka offer three solutions that might appease both sides:
- Create a new type of visit whose exclusive function is to establish relationships. “The majority of patients who receive a physical every year have established relationships with their physicians and come to the practice regularly for other reasons,” they write. “For those who have not seen a primary care physician recently, valid arguments can be made that a physical serves as a mechanism for establishing a relationship.”
- Change the methods by which primary care providers ensure that patients’ preventive care is up to date. “[P]assively waiting for patients to come in for physicals has not been an effective strategy, as evidenced by the low rates of receipt of preventive care in the United States,” they say. “We believe that the emphasis in a practice needs to shift from such passivity to active engagement of the patient population,” including automated methods of screening, such as online health risk assessments, questionnaires delivered in the waiting room, and delivery of preventive care at any type of healthcare encounter. Payers could encourage such a shift by using pay-for-performance incentives.
- Payers should stop reimbursing providers for annual physicals or using the incidence of such physicals as a measure of health care quality. “Many private health plans have created a financial incentive for physicians to provide annual physicals by reimbursing for them at a higher rate than for other office visits. Eliminating this reimbursement differential would be an important step.”
“These payment changes would not eliminate all annual physicals,” write Himmelstein and Phillips. “Physicians would, in many cases, substitute regular office visits, but they would reduce their prevalence. Any savings achieved could be invested in other aspects of primary care, such as remote chronic care management or health coaching – care that’s typically not reimbursed but that has been shown to improve outcomes.”