October 20, 2015

Doctors debate: Are annual physicals worthwhile?

Daily Briefing

    See the Advisory Board's take on this story.

    In separate NEJM editorials, two doctors argue that insurers should stop reimbursing for annual checkups—while another physician says that would be a terrible mistake.

    Argument against the annual physical

    Ateev Mehrotra of Harvard Medical School and Beth Israel Deaconess Medical Center and Allan Prochazka of the University of Colorado Denver contend that the annual physical is unnecessary in their NEJM editorial.

    They note that recent studies have found that annual checkups may decrease patients' worrying—but they don't reduce mortality or morbidity. Further, they argue that annual physicals "may actually be harmful," citing the low precision and specificity of certain routine tests and the physical exam, which may lead to false positives for some patients.

    In addition, Mehrotra and Prochazka say that eliminating the annual physical would save time for the one-third of American adults who get their annual checkup in any given year and for primary care physicians (PCPs). For instance, they cite one study that found PCPs spend 10% of all their visits on annual physicals, and argue that doctors may able to better use that time on patients with more pressing health needs.

    The authors argue that eliminating annual checkups would save money, too, since physicals cost a total of more than $10 billion annually in the United States—similar to the cost per year of care for lung cancer.

    Mehrotra and Prochazka recommend that:

    • Officials create a new type of visit focused exclusively on establishing the doctor-patient relationship;
    • PCPs should shift from seeing "the annual physical as a stop-gap measure for providing preventive care" and instead focus on "active engagement of the patient population," such as using electronic health records to assess whether patients' preventive services are up-to-date; and;
    • Payers stop reimbursing for annual physicals and no longer use yearly checkups as a quality measure.

    In addition, Mehrotra tells HealthDay that he supports having a regular checkup for individuals who have not seen their doctors in two to three years.

    Argument for a modified annual physical

    Meanwhile, Allan Goroll of Harvard Medical School and Massachusetts General Hospital in a separate editorial defends the importance of the annual physical, but does call for changes to improve it.

    Goroll argues that the yearly checkup is critical to maintaining a trusting doctor-patient relationship, which he says has several established benefits, including medication adherence, patient satisfaction, and enhancements in patients' functional status.

    In addition, Goroll says that those calling for the elimination of the annual physical "ignore the powerful effect of the 'laying on of hands,'"—in which the physical exam can help build trust and communicate caring. Goroll adds that such an approach can help create a therapeutic environment, foster a better doctor-patient relationship, and reap clinical benefits.

    Goroll does acknowledge that in its current form, some physicians feel that the annual physical is a "rushed, impersonal, and largely bureaucratic exercise." That's why he advocates for enhancing the annual checkup by making it an annual health review—a team-based approach, similar to the medical home model, wherein:

    • Non-physician team members could take on routine roles such as data collection and screening; and
    • Physicians would review data collected by team members and have longer, in-depth discussions with patients about the patient's wellbeing, values, and preferences.

    Goroll writes that improving on the annual physical with a health review "represents an opportunity to create new value for both patients and doctors, enabling the latter to serve as physicians rather than merely health care providers" (Marshall, Becker's Hospital Review, 10/16; Thompson, HealthDay/CBS News, 10/15; Mehrotra/Prochazka, NEJM, 10/15; Goroll, NEJM, 10/15).

    The Advisory Board's take

    John Kontor, Clinovations

    It's a good point that there's not much evidence in the literature about the clinical-, cost-, or relationship-value of an annual physical. Further, "annual physical exam" is poorly defined because what this involves varies widely from one provider to another. That said, of course many patients still expect and find value in the assurance provided by the encounter (whether this is justified or not).

    Interestingly, CMS has created the Annual Wellness Visit (AWV) for Medicare beneficiaries, along with a substantive reimbursement. And other payers are following suit. By developing the capabilities to deliver AWVs well, provider organizations also have the opportunity to promote and fund transformational change in the office-based care delivery model. Central to that change is incorporating non-providers working at top-of-license to become even more important members of the care team, assessing and quantifying risks for unrecognized disability or chronic illness.

    Maximize Medicare annual wellness visits: How we can help

    In addition to generating net revenues, getting good at delivering AWVs will help provider organizations become better "air-traffic controllers" of patient populations, and better at communicating with and engaging individual members of that population.

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