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. 

33 replies »

  1. 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.

  2. 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?

  3. 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 help to clear this up? Where does the ACA require that annual “wellness” checkups or physicals be covered without copays of deductibles?

  4. 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…

  5. 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 of us – that is, it has ‘network effects’ that we all benefit from the more people engage with it, and the more appropriately we engage with it. Sure, some of those engagements will be “inefficient”, particularly in the early going. Just like with things like the telephone.

    Your insinuation that any provision of any statute is carved in stone and will almost certainly never change and exists mostly to be complained about is the stuff of the nightmares that plague our most reactionary politicians. That kind of cartoonish worldview isn’t fit for serious consideration among adults.

    If we were all homo economicus, Al, we’d change our own motor oil and bone up on self-care and only go to doctors when we needed to.

    Not many of us are that animal, Al, and no matter how much self-congratulatory ridicule you and Vic attempt to heap on us (not that much of anyone is actually paying you any attention), you won’t change that.

  6. 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?

  7. 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.

  8. 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 don’t go because they’re free and especially don’t go because your employer is paying you or fining you.

  9. 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.

  10. 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 want with my doctor. That PAP indicated low levels of candida, indicating that what I thought were yeast infections for about 8 years, was actually bacterial vaginosis and required a different, over the counter treatment. My PCP was also very pro-active in offering holistic treatments as well. I’ve used my “free checkup” as an opportunity to establish a relationship with my PCP so that future “free checkups” (also known as a wellness visit) are more productive and not a waste of time. For example, I found out that I don’t have to do another PAP for 5 years. without the wellness visit, and the ACA, I would have been getting unnecessary PAPs (and paying for them) every year.

  11. Annual checkup screening is not very effective. Eventually, we would transition to continuous screening via wearable device or cheaper, more frequent home test kits.

  12. 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

  13. 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.

  14. 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.

  15. 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

  16. 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 you after almost 20 years of doing Commercial Driver physicals, many of these folks come in feeing fine, but having high blood pressures and high blood sugars.
    Thirdly, once we have now legislated that certain things are to be included in every American’s insurance benefit package,( but wait, maybe we don’t need that so much), how does this change what happens with the way we view insurance and what it’s really for? 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?

  17. 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.

  18. I don’t think we fundamentally disagree. First, the proposal isn’t to ban checkups. it’s to stop subsidizing them annually — there simply isn’t enough evidence to say these visits are worth so much to society that society should pay for them totally, and what evidence there is says the opposite. (Even a free checkup every few years is OK in this proposal.) Because for every example you offer–less the many false positives — someone who needs the doctor’s help and wants it, is being bumped to later on the schedule.

    Second, I don’t think we’d say “interested” people shouldn’t go to the doctor. Clearly, if you’re interested enough to pay a $20 copay, you’re going to be more receptive to findings and more interested in building a relationship than an employee who is going because they are forced to get someone to sign off on their screens in order not to pay a penalty.

    And remember, there are USPSTF guidelines for screening that we would recommending adhering to. They are designed to weigh the costs and benefits of catching things, vs. false positives.

  19. It is illogical to say that it doesn’t do any good to have a visit with someone who cares about your health every so often. Do you think that hypertension will always be recognized by the patient? Or glaucoma? Or actinic keratoses? Will the patient always know about a dysplastic nevus developing on his back or scalp? Will the woman sense HGSIL developing on her cervix? Do people sense occult blood in their stool by looking at it themselves? Do they automatically review their lymph nodes in their axillae and cervical regions? Are you trained to see icterus? Do you know what it is? Does itching mean anything? What about acrocyanosis? and paresthesia? Jugular distension?Just wait on these? How long do you advise waiting?

    You can not be AGAINST having an interested person seeing you periodically and, at the same time, being FOR preventative health and FOR catching things early when they are easier to treat. It doesn’t compute.

    It does compute if you don’t want the doctor to take a biopsy too early or treat white coat hypertension or whack off too many seborrheic keratoses, that is, do the wrong thing on these periodic visits. But this is a totally different subject, isnt it?

  20. As a salaried FP physician at a good (as it gets) HMO, I would be overjoyed to be freed of the largely largely useless “preventive health visits” incentivized by the Feds (esp. after the second-plus annual appt), e.g.,”Medicare Wellness Exams”:
    Those “8% of PCP visits” wouldn’t disappear: they would be more than made up: they would be displaced by the serious health problems of my sick patients who can’t see me me because I am attending to the worried well, who want their “free visit.” (Then complain when they are billed by their insurance for their other concerns they brought up and were addressed.)

  21. In the confusing and commercially driven world where entire industries are built on selling people things they do not need (including but not limited to health care), one of the things I try to do as a PCP is use the time and energy in the ‘preventive’ visit slots to help patients understand what the evidence does and doesn’t say, and what the benefits and risks of various options are.

    Much – most – of what happens at the typical ‘check-up’ is at best pointless (and at worst, contributes to the problem). That doesn’t mean there would be no value in regular communication between patients and a health care advocate who could be a PCP.

    I’d rather hear more talk and see more effort aimed at how to structure useful regular education and evidence-informed shared decision making, and less talk about uselessness.

  22. Don’t expect the Republicans to take the Democrat candy from the baby. The baby will have to get sick and give it back

  23. An elegant proposal to easily solve an easily solvable problem–which of course means it has no chance of happening.

  24. re Charles Kenney comment:
    “This is a very important piece that I hope will be widely read and discussed”

    Agreed. This should be picked up by the popular medical journalism community…..should have been a long time ago, as it has long been well established that the annual physical is wasteful…even harmful (due to over-diagnosis/testing).

  25. This is a very important piece that I hope will be widely read and discussed. We are up against a longstanding cultural belief that a bedrock element of good health includes the annual physical. The other challenge, of course, lies within the provider community where significant chunks of a PCPs schedule is roped off for these physicals. Are doctors ready to make the shift away from physicals? How should providers communicate with patients on this? It is an awkward communications challenge: Dear patient, you know that appointment every year that I have always told you is so important? Well, it’s not.

  26. Ha!

    I save tons of money every time I fly, by not flying business class. Do you think I’m a monetary genius?

  27. Totally with you on that. That’s what makes their don’t-get-checkups recommendation so shocking. Whereas the other interventions they diss may account of <1% of the specialty's income, 8% of PCP visits would disappear if anyone actually followed this recommendation.

  28. The key is in your “beyond the obvious” — do those three parenthetical things well and you’re doing what you can. Also, even USPSTF doesn’t say “do nothing.” Get screened according to their accommodating schedule. This is all they do — weigh harms-vs-benefits of screening (without taking costs into account) — so you could stick to their schedules, as I do.

    Remember, screening carries its own risks. This is especially true when some half-witted wellness vendor is doing the screening. https://thehealthcareblog.com/blog/2013/11/07/hyperdiagnosis-the-wellness-industry-doubles-down-on-overdiagnosis/ was one of our most popular columns on just that topic.

  29. Al – It’s hard to argue with your points, however a question I often get when making a similar point is, “is the best bet to just wait for symptoms or adverse medical events?” Beyond the obvious (eat/sleep/exercise well), I guess the question is “what do/will you do to ensure your long-term health?”

  30. Yes–it’s like the New Yorker cartoon showing a couple living in very close quarters, with the caption: “We saved $3000 this month by not living in a $4000/month apartment.”

    Entire industries have grown up around those two words.

  31. Two of the most capacious words in the modern medical vocabulary are “avoidable” and “preventable.”

    They have propped up entire industries. They have introduced new sciences.

    They are promissory. They can never be disproven.

    Wellness programs and free check ups are just the tip of the iceberg.

  32. Looks like Choosing Wisely feels the same way http://www.choosingwisely.org/doctor-patient-lists/health-checkups/

    Please credit Zeke Emanuel for pointing this out. I have great respect for Dr. Emanuel and notwithstanding my oversized ego, I would not place be so bold as to place myself on the same plane as he is, but one thing we both have in common is not realizing this factoid in time for our respective writings on this subject. (He mentioned this to me after I had sent him a copy.)