THCB

The High Cost of Free Checkups

flying cadeuciiA predictable irony of the never-ending Affordable Care Act (ACA) debate is that the one provision that the Republicans should be attacking — free “checkups” for everyone — is one of the few provisions they aren’t attacking. Why should they attack them? Simple — checkups, on balance, are worthless. Why provide a 100 percent subsidy for a worthless good? Where is the GOP when you need it?

How worthless are checkups? Dr. Ezekiel Emanuel — one of the architects of the ACA and its “free” checkup centerpiece — recently recommended not getting them. As if “free” is not cheap enough, the ACA also pushes ubiquitous corporate wellness programs, which often pay employees to get checkups — or fine them if they don’t. This policy establishes a de facto negative price for millions of workers, making checkups the only worthless service on earth that one could get paid to utilize.

Those economics of a “negative price” trump Dr. Emanuel’s advice, and have made preventive care the fastest-growing component of employer health spending. Though hard statistics on checkups themselves are elusive, Dr. Emanuel estimates about 45-millon adult checkups are conducted each year, the equivalent of roughly 8 percent of America’s PCPs doing nothing but checkups, a curious use of their time when experts say the country could soon face a shortage of PCPs.

Shortage or not, subsidies and incentives might make economic sense if checkups improved health. However, when generally healthy adults go to the doctor for no reason, just the opposite is true: the Journal of the American Medical Association (JAMA) supports Dr. Emanuel assertion that annual checkups for asymptomatic adults are at best worthless, saying that additional checkups are “not associated with lower rates of mortality” but “may be associated with more diagnoses and more drug treatment.”

At worst, checkups are counterproductive. The British Medical Journal adds to JAMA’s conclusion that “important harms [of checkups] were not reported.” Overtreatment following overdiagnosis is the most common harm: Canada’s former prime minister spent six weeks in the hospital due to complications of a biopsy investigating two spots on his lung that, like most apparent abnormalities, proved completely harmless. No wonder Slate concluded: “If you’re not sick, don’t go to the doctor.” (One could also make the argument that the people who most need to have checkups are disproportionately the ones least likely to get them no matter what the economics.)

None of these findings discourage workplace wellness vendors, who — empowered by ACA provisions encouraging financial incentives for all preventive care — want physicians to order “biometric screens” during these checkups, or spend time discussing the screens performed at the employee’s worksite. As with the visits themselves, most of this screening has no value, and literally no one in health care other than wellness vendors and consultants who make their money off the practice defends annual screening. By contrast, there is no blood-based test that the United States Preventive Services Task Force (USPSTF) recommends be done annually on healthy people.

So checkups driven by an overzealous corporate screening agenda, for patients who participate largely due to the incentives or penalties, exacerbate the worthlessness of the entire endeavor by crowding out the most useful part of any patient-provider interaction, relationship-building, in favor of signing off on a screening report card allowing employees to get their money.

The solution to this orgy of overscreening and overdoctoring is remarkably simple: remove the ACA provision that makes annual checkups automatically immune from deductibles and copays; if they are going to be free at all, it should only be every few years. The proposal could still allow employers to override this provision — and even to attach money (incentives and penalties) to checkups — if they are willing to summarize the above-cited clinical findings for their employees.

If the only way they can continue the subsidy is by summarizing the literature, corporate human resources departments would predictably and immediately curtail this expensive corporate medical campaign. That would free up PCP time to work with patients who actually need medical care, while reducing counterproductive and costly healthcare utilization by those who do not.

Note: Just to show the bipartisanship of this proposal, this posting was written in collaboration with my Surviving Workplace Wellness co-author , Vik Khanna, who could never be confused with a Democrat.

Al Lewis is not related to Michael Lewis, although he is frequently mistaken for him on the street.  He is, however, together with his writing partner Vik Khanna, the author of Surviving Workplace Wellness the best selling guide to staying healthy in the Wellness era. 

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Al Lewis
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Al Lewis

It’s definitely there. Preventive services and checkups are two different issues. There are nuances and loopholes, like if a checkup finds something under some circumstances it’s not a “preventive” visit.

You’ll have to find it on your own, though — I unfortunately have to get back to my day job.

Christian
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Christian

Just following up on my query above. Where in the ACA does it require that annual checkups or annual physicals be covered? I keep seeing this claim but I can’t find the basis in the law. I know certain preventive services must be covered for adults, but isn’t that different than the idea of the annual checkup this article references?

Christian
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Christian

Hi all, I’m really confused and was hoping someone could clear this up for me. I work as a content marketer and produce content aimed at helping people understand health insurance and the affordable care act. I’m well aware that the ACA entitles women and children to annual “wellness visits,” comprised of certain named preventive services, but I’ve also been constantly told the equivalent doesn’t exist for men. There’s no ACA provision that says men are entitled to an “annual checkup” or “annual physical” despite wide reporting of this to be the case. I’m sure I’m missing something, can anyone… Read more »

Al Lewis
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Al Lewis

Here is the list of all the media who aren’t paying any attention to us (not yet updated for the last 4 articles to come in) http://www.dismgmt.com/in-the-news

I guess the reason we are still in business is that we aren’t making any money doing this?

PS The way laws change is that people advocate for change. It doesn’t happen automatically…

civisisus
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civisisus

Al, why has no one yet pointed out to you that ACA is a) new and b) people often do not do things they should do because of ‘barriers’ like cost that aren’t REALLY barriers but that are treated as barriers, because, well, just because (I’m not a fan of “free”, either; I’m just not as disingenuous as you or Vic are). I don’t know about anyone else, but I fully expect ACA to evolve as people get used to the idea that health care has value to any of us in proportion to the value it has for all… Read more »

Brian
Guest

Healthcare is always going to be a difficult area to curb spending in any economy. Low cost drugs, spends on lower cost healthcare equipment would be a start.

Al Lewis
Guest
Al Lewis

I could counter these two with personal stories going the other way, like my sister-in-law who went to the doctor because of a wellness program and ended up short a thyroid that turned out to be cancer-free, or a guy who works for my publisher who got a clean bill of health and ignored heart attack symptoms a week later because he had just been to the doctor. However, it’s not a question of dueling anecdotes. Our proposal isn’t for you to be barred from checkups. it’s that they don’t deserve special subsidies. If you want to go, go. Just… Read more »

Scott Hodson
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This is an important topic that is bound to be widely discussed. On a personal level, during an annual exam three years ago my PCP saw a skin discoloration that I had been ignoring for months. Confessing that he might be overly cautious, I was referred to a dermatologist. Sure enough, it was melanoma. Fortunately it was very early stage and highly treatable. Without the annual checkup, I would have surely ignored the issue until it became much more serious. My PCPs intervention not only saved my life, it also save my insurance company tens of thousands of dollars.

MD as HELL
Guest
MD as HELL

You were ignoring it….

Ever hear of a little concept called “evolution”?

Think of the generations of ignorers we would not have had but for your family doctor changing the course of history and evolution…

You were ignoring it? You needed a nanny to get you moving?

Jess
Guest
Jess

I want to start by saying that I am no expert in this field. Just a normal American citizen who is extremely happy to get my free annual check-up. I’d like to point out that there are a lot of Men talking about this, in both the article and in the comments, and It’s seems that you forget that annual check-ups are something that many women do since they are about 13 years old. To have this now available for free has allowed me to, actually go annually, get a breast exam, a PAP and discuss any other issues I… Read more »

martin
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martin

Dr. Ezekiel Emanuel – is hardly a poster child for neutrality on any medical /financial subject

I am not sure about over-treatment, that is nominally under the purview of reimbursement or insurabillty – and as such, whether treatment is too much – is not a legislative thing p one size fits all, even with 25,000 pages of regs – as if anyone would know them

and you offer that data are sparse

which is why we don’t think much of the entire debate and would rather have over- than under- treatment

Al Lewis
Guest
Al Lewis

You’re the man, Bird. That is the most concise statement of the futility of this provision of the ACA that I have yet seen.

And thank you to others for your comments as well.

bird
Guest
bird

Perry is exactly correct.
“Frankly, I would much rather be sure to get my cancer treatment or surgery for a ruptured aneurysm paid for than a yearly physical. Who’s to say all of these patients will take advantage of these benefits anyway?”

I am tired of having healthy 40 yo who run 20 miles a week and have had 10 normal yearly cholesterols in a row come and get a “free biometric wellness exam” While my 65 year old diabetic falls in the donut hole by september.

Don Levit
Guest

I agree annual physicals should not be subsidized or paid for by insurance
That concept is known as trading dollars with the insurance company
That is a trade I do not support for the insurer usually comes out ahead on the trade
At a minimum you want to get $3 dollars of benefits for every dollar paid in
This multiple can be achieved in a series of transactions one of which should not be the annual physical
Premiums tend to rise higher than the benefits paid out which makes the lunch quite costly over time
Don Levit

Perry
Guest
Perry

This really rankles me. First, this is not free, someone is paying for it, either the government is subsidizing with our taxes, or our premiums are being adjusted by the insurance companies. For every benefit included in the ACA, someone is paying for it. You can say no “out of pocket” expense, but it is not Free. Secondly, I agree with both William and Al. While I think some routine evaluations are beneficial, it is going to vary between age, family history and other factors as to how much or how often folks need to be checked. I can tell… Read more »

LeoHolmMD
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LeoHolmMD

Unfortunately, these visits are mostly about data mining and human cataloguing by insurance companies and CMS. They can’t do it themselves without suspicion, so they get a trusted character like your personal physician to do them. The aforementioned do not want any barriers to this endeavor, so the visits are free.