Economics

What Zeke Missed on an Annual Physical

flying cadeuciiIn January, Ezekiel Emanuel – one of the country’s foremost health experts – threw a presumptive grenade into the national discourse: the annual physical is worthless. As we watched the initial burst of reactionary fervor following hisNew York Times opinion piece, we weren’t quite sure what to think.

Then we realized why: in our training and burgeoning careers in primary care, neither of us has ever scheduled an “annual physical” for a patient. To us, the notion of such a visit – for scheduled, non-urgent care, and one not specifically for chronic disease management – is already dated. Given current trends in American health care delivery and professional training, we argue it is one that may well soon be obsolete.

But does that obsolescence change the value of that time – whether 15 minutes or 60 – with a patient, on a regular interval? Our perspective from medicine’s emerging front line offers a resounding no.

The most obvious argument for regular primary care visits is preventive care. Dr. Emanuel bases much of his argument on the validity (or lack thereof) of annual physicals. Drawing off that same evidence base, the U.S. Preventive Services Task Force sets recommendations for evidence-based screening in various populations. Even the young and healthy benefit from cervical cancer screening, initiated at 21 years of age and continued every three years provided negative results until the age of 30 (when the recommendations change slightly). Patients with higher risk earn further screenings, based on whether they smoke, their weight, their age and their family history.

As American medicine shifts away from volume-based reimbursement, we have learned – from the outset of our practice – to not order testing indiscriminately, but instead to choose wisely. Judicious application of validated preventive screens offers societal value – even though, to Dr. Emanuel’s point, we must weigh the downstream implications of that testing as we deliver care. Listening to heart sounds and checking reflexes may not have value, as he suggests – but then again, we are part of a generation taught not to reflexively order echocardiography for every aberrant noise we hear. The value proposition of preventive screening, then, may be shifting in favor of its utility.

The larger, more subtle argument, though, rests on the value of the patient-provider (and care team) relationship – one that is increasingly quantifiable. It’s true that in the 10 minute appointments so often seen in primary care, we can’t – and don’t – fit everything important into the visit. Many practices ask providers and patients to agree on 2-3 issues to discuss per visit. The important questions of alcohol use, depression, food and housing access, and other life stresses are usually deferred. Care teams’ understanding of those issues, however, is critical to providing good care. Recently, at a ‘wellness’ visit, a colleague discovered her patient did not understand why he was taking his blood pressure medications and aspirin, and also did not understand what blood pressure actually is. He has been her patient for two years. To have the time to explain that high blood pressure alone is asymptomatic and to gain increased insight into a patient’s health literacy will provide benefits longitudinally in that patient’s care, as we’ve seen from recent pilots that enable certain patients – particularly the sickest of the sick – that critical time. From both that evidence and our own experiences in novel primary care delivery models (such as the Veterans Healthcare Administration’s Patient Aligned Care Teams and the ambulatory ICU), we know this information is rarely captured in one or two visits.

The same is true when we consider planning for end of life care and setting personal goals of care – another effort best accomplished within an established, trusted relationship. Some of the most impressive end of life care may be in Shiprock, New Mexico on the Navajo reservation. Physicians there take care of their patients across the spectrum of care – from the clinic to the ICU. People die with their families around them, peacefully, and often without ventilators and aggressive interventions. This can almost fully be attributed to the indelible patient-provider relationships in that community.

Strong relationships between patients and care teams have the potential to motivate and empower individuals to better manage their health – either through preventive measures or chronic disease management. At Iora Health, each patient is assigned a health coach who works with them to meet their needs and better their health. The Iora practices have met their patients where they are in order to help them take charge of their own health. This includes “drive-by” lab checks for patients on blood-thinning medications who did not have more than a couple minutes to stop at the clinic due to work and family obligations. Patients call their health coaches with questions and clarifications and are able to access a health coach or physician at any time.

As a profession, we need to change the way we portray and practice primary care in the U.S. The notion of an “annual physical” as an appointment where a full exam is done and an array of non-specific tests ordered should be diffused. Rather, people should know their health care team and view them as partners and enablers to better health. Individuals should feel that the exams done and tests ordered are tailored to their particular needs. Work remains to be done – but the progress being made in pockets across America gives hope that we can achieve that lofty goal.

Telling the public to skip their annual physicals sends the wrong message. The upfront, unyielding investment in people and relationships – supporting topics as wide ranging as smoking cessation, housing insecurity and the struggles of raising children – will save innumerable dollars downstream. Primary care practices connected with and imbedded in communities in meaningful ways, where visits are a driver of change, not revenue, will achieve the impact that the annual physical initially aimed to effect.

In an era where we are moving the proverbial needle in reducing disparities in access to care, with millions of uninsured Americans finally entering the health care system, let’s focus on thoughtful, nuanced medical care that prioritizes relationships above all else. To attack the annual physical as low-value misses the emerging point: that the value is in the partnership created – and that that partnership is worth all the time in the world.

Ali Khan, MD, MPP is a clinician-innovator at Iora Health and a clinical instructor of medicine at Yale. He currently serves as the chair of the American College of Physicians’ National Council of Resident/Fellow Members.

Leah Marcotte, MD is a senior medicine resident at the University of Washington. As a medical student at Penn, she served as a fellow at the Office of the National Coordinator for Health Information Technology. Among her varied policy pursuits, she serves as an associate editor for the journal Health Care.

 The views expressed here are those of the authors and do not necessarily reflect those of any of the affiliated organizations, including Iora Health, the American College of Physicians, Yale University and the University of Washington.

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RachelAmy BermanEd Corbett, MDSusan DentzerNeil Quinn Recent comment authors
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Rachel
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Rachel

This is an interesting debate; the annual health physical is worthless? That is quite a shock coming from one of the country’s foremost health experts. I thought annual health physicals were important in preventative care. I foresee that if annual health physicals become obsolete, there would be a much higher cost for diseases that could have been prevented.

Amy Berman
Guest
Amy Berman

Bravo, Leah and Ali. Proactive primary care offers the chance to support health, not just respond to presenting issues. Routine care is a significant opportunity to inform and affect health. It is surprising to see the range of comments suggesting there may or may not be value in the annual. I suggest readers consider a world with no routine care, only reactive care in illness or crisis. How much of that higher cost care (often provided in the walls of a hospital) could be prevented? It is not just routine dental care that is of value. In infants we look… Read more »

William Palmer MD
Guest
William Palmer MD

Well, we unequivocally know that it is important for some of health care to have periodic examinations. That “some” is dentistry.

Ed Corbett, MD
Guest
Ed Corbett, MD

The physician – patient interaction will need to change due to value based payment models. Former standard practices like the annual physical will give way to more evidenced based care, with better data driven clinical content, deployed by more efficient care teams. As a physician, I can envision this leading to more productive physician-patient communication.

Susan Dentzer
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Susan Dentzer

Ali’s and Leah’s best recommendation is the notion of diffusing many (but not all) of the activities often conducted at an annual physical throughout the care process — for example, conversations between physicians and patients over such critical issues as healthful lifestyle habits, or even end-of-life; reviewing immunizations; determining the need for preventive measures or screening exams. The new care models such as Iora’s, plus regular electronic health record or registry reviews followed up by patient reminders, should allow those aspects of care to occur on a continuous basis, and outside the context of a single annual encounter. We can’t… Read more »

Neil Quinn
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Neil Quinn

Has anyone noticed that “Physicial” is spelled incorrectly in the article’s title? Perhaps it’s meant to rhyme with Ezekiel, as the great Dr. Seuss would have it. 😉

Lotty
Guest
Lotty

Here’s the fun part of an Obamacare visit. I am told I should have extensive tests to check a lump in my breast. Tests are ordered without any concern I have to pay CASH for these tests! After calling the clinic, I find I cannot afford these tests because I am paying $800 a month for a 50 yr old couple to have this wonderful insurance with a $12,600 deductible before insurance begins picking up a percentage. WE ARE ALL GOING TO BE IN WORSE CONDITION because we cannot afford testing! Even the blood work is costing us now. I… Read more »

William Palmer MD
Guest
William Palmer MD

When you have a bronze or silver plan (actuarial value 60% and 70% respectively), you are paying out of pocket 40% and 30% of the covered services yourself….in the form of deductibles, co-payments and co-insurance. The warm fuzzy secure feeling that good insurance is supposed to give a person can hardly be felt with such imperfect insurance. In fact, you could feel less insured than if you had none. This is because you must feel on the hook for coming up with the complete deductible and all the co-pays when you are in the midst of an episode of care.… Read more »

Leslie Kernisan, MD MPH
Guest

Correct me if I’m wrong, but I believe the ACA might allow people to combine a direct-pay primary care plan — like Doc Rob’s practice — with a high-deductible catastrophic coverage plan.

Some direct-pay practices charge a pretty reasonable monthly fee…just looked at Doc Rob’s site and it’s $30-60/month depending on age.

This might be better for people than buying a “shabby” insurance product (I agree, those bronze plans do sound shabby!). And esp if you have chronic conditions or significant health risks, it’s better than skipping primary care and “paying the tax”.

Peter1
Guest
Peter1

“but I believe the ACA might allow people to combine a direct-pay primary care plan — like Doc Rob’s practice — with a high-deductible catastrophic coverage plan.”

I don’t think it’s up to ACA is it? ACA is not an insurance plan. If an insurance carrier wants to offer this then I think they can??

Leslie Kernisan, MD MPH
Guest

The ACA defines what it means to have health insurance, in order to avoid the tax penalty.

Barry Carol
Guest
Barry Carol

“When you have a bronze or silver plan (actuarial value 60% and 70% respectively), you are paying out of pocket 40% and 30% of the covered services yourself….in the form of deductibles, co-payments and co-insurance.” This is not accurate. The actuarial value percentage term means the percentage of costs likely to be paid by insurance for a standard average risk POPULALTION. A healthy individual who only needs preventive care will have 100% of his costs covered. Conversely, if your Bronze plan deductible is $6.350 for an individual or $12,700 for a couple / family and you have a catastrophe like… Read more »

William Palmer MD
Guest
William Palmer MD

@Carol I think I was talking about an average risk person in an average risk population. How else can I talk? But you make an excellent point: some folks can pay more than the average as estimated in the actuarial value. So we might have Lotty paying 40% of her “covered” costs OOP even though she is in a silver plan with 70% actuarial value plan. And, of course, as you pointed out, she could pay much less than 30% also. Let’s hope that the folks who are really ill do not have the bronze or even the silver plans.… Read more »

Peter1
Guest
Peter1

William, that ‘s the failure of HDHPs . People buy them because that’s all the premium they can afford, not because they’re prepared to fork over the deductibles.

If the huge deductible is due in the first or second year of the plan insured may not have the war chest saved to pay them – if they ever save for that hurricane day.

Peter1
Guest
Peter1

“I was with Anthem (individual) for years and never had these problems!”

You mean you never had breast cancer with Anthem, or you never had to pay deductibles? Did you not know you were signing up for a high deductible plan?

You’ll have to be more specific about Antham’s Plan and the plan under ACA with another insurance carrier. Were you private pay with Anthem or through an employer?

Are you getting a subsidy with ACA?

Lotty
Guest
Lotty

We have had health issues but you never had to worry with Anthem. Like I can no longer go to the clinic where all my other mammograms were and that specialized in breast cancer. The deductible was $3000 and payments were $200 a month. Anthem doubled my premium when the Marketplace kicked in and the deductible went up. My husband’s insurance was going up to $1000 a month. These are both individual policies. If we didn’t have subsidies, our insurance as a couple would run over $1400 a month with this same crappy insurance. We can’t afford the Anthem plans.… Read more »

Lotty
Guest
Lotty

Another thing I should add: Policies are either national or local. I could only afford one that was “In Network” in Indiana. The Insurance company owner picked a national plan. We don’t travel much so I have to pray when we do, nothing happens. The way the plan reads “Out of Network” equals zero coverage. That’s it. Doesn’t give you a warm fuzzy when you have a husband with 3 vessel coronary heart disease…

Peter1
Guest
Peter1

Lotty, I understand your frustration. Part of these increases are due to greater coverage because of ACA. No lifetime minimums, no pre-exist as well as other coverages. I’m not sure why Indiana is so high. At 64 I can get a policy for $565/mth. with about a $6500 deductible – no subsidy. If you are a business owner you can deduct from your income tax, as an individual you can also deduct but not until a threshold of income is reached – but that doesn’t pay the bills now. A subsidy of $600/mth is quite high, at least the ACA… Read more »

Barry Carol
Guest
Barry Carol

Peter1, Your quote of $565 per month in NC is for one person, I presume, whereas Lotty’s $1,400 per month (pre-subsidy) quote is for two people. That’s a 25% difference on a per person basis but it’s not unusual. It would probably cost even more in NY and NJ as premiums for the same coverage for people of the same age can easily vary by 2X or more across the country. Lotty probably could have purchased a policy pre-ACA that didn’t cover maternity benefits which would make a significant difference in the premium but that’s not possible now. It does… Read more »

Peter1
Guest
Peter1

Thanks for responding Barry. Yes, my coverage is for single person.This year I’m on Medicare, so I squeaked through without ACA.

Barry, I’ve talked to a couple of shocked people buying post ACA coverage and not understanding the mandated coverage additions. Even with subsidy these people are paying more than previous a-la-cart coverage, although the added pre-exist and no lifetime max is popular, I guess not when they have to pay for it.

Philip Lederer
Guest

agree, face to face best

William Palmer MD
Guest
William Palmer MD

You want someone who can pick up the signs and symptoms of polymyalgia rheumatica and will search for dysplastic nevi and skin signs of vascular insufficiency. Do they understand IBS and the Rome criteria?

In other words, you probably need to visit someone with an advanced nursing degee, a PA or an MD or DO.

Leah Marcotte
Guest
Leah Marcotte

My apologies! Ceci**

Ceci Connolly
Guest
Ceci Connolly

Gosh, where to begin with this one! I fear this discussion has got apples, oranges, peaches, grapefruit and watermelons all mixed up together. A clinician can learn a patient has gained weight without an annual physical. A doctor can develop a solid, trusting relationship with a patient without an annual physical. And who says it has to be a doctor? What if a patient develops that bond with a nurse practitioner? It’s not that it is “bad” to visit someone periodically with expertise in medicine and health. It’s that the system’s misaligned incentives are more about items to code (tests,… Read more »

Leah Marcotte
Guest
Leah Marcotte

Cici, Thanks so much. Our argument wasn’t to encourage the return of ‘annual physicals’ and was certainly not to promote the traditional FFS system, but to highlight the value of primary care, particularly in non-acute care visits. (I also prefer the term ‘health review’ or ‘health check-in’ as was coined at an SGIM Town Hall on the topic.) One of the concerns we had after reading Dr. Emanuel’s article, though, was that it is rather discouraging of routine primary care in general presented to a population where there is a lot of morbidity (obesity, diabetes, heart disease, depression, etc). Could… Read more »

Leslie Kernisan, MD MPH
Guest

I think it’s certain better to think of an “annual review of your health” rather than annual physical. It’s good to make an effort to review the big picture of a person’s health, and also to make sure that clinician and patient are on the same page as to prevention, management of chronic disease, etc. Incidentally I do these reviews in my geriatric consultation practice because the beleaguered PCPs are not getting around to it and many frail older people have very fragmented care. In my experience these kinds of meetings are most productive when done face-to-face, AND when everyone’s… Read more »

Philip Lederer
Guest

Ideally this preventive health maintenance would all be done in the community, with family doctors / nurses who live near the patient… that’s how it’s done in some places in the world. But not America…

Peter1
Guest
Peter1

“Ideally this preventive health maintenance would all be done in the community…But not America…”

Wholeheartedly agree, especially for at risk communities. Caregivers need to see where and how people live to fully understand their health needs.

William Palmer MD
Guest
William Palmer MD

How can it be bad to visit with someone who knows more about physiology, medicine and pathology than you do?…periodically? Ideally, such a person should be in our own family and we could talk to them every day. You don’t have to call these visits a “physical” if that term is too scary. Now, if that expert is too proactive and costing you too much money or time or hassle or adding too much risk to your life, that is a different problem. These faults can be corrected, but having too much knowledge about your own body or mind seems… Read more »