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Bankrupt Health Care
The Expensive Myth of the Necessary Annual Physical

If you’re healthy and you’re planning on an annual physical at the doctor’s, don’t. Kaiser Health News reports on the enduring popularity of the annual physical, despite the poor evidence for its necessity:

92 percent of Americans say it is important to get an annual head-to-toe physical exam, according to a Kaiser Family Foundation poll (KHN is an editorially independent program of the foundation). And 62 percent of those polled said they went to the doctor every year for their exam.

But the evidence is not on their side. “I would argue that we should move forward with the elimination of the annual physical,” says Dr. Ateev Mehrotra, a primary care physician and a professor of health policy at Harvard Medical School […]

He says randomized trials going back to the 1980s just don’t support it.

The ingrained habit of seeking an annual physical comes with a big price tag: $10 billion, according to Dr. Mehrotra. Awareness is growing: the Society for General Internal Medicine now discourages doctors from giving annual physicals, according to Kaiser. This story is an example of the many opportunities for cost-cutting that are scattered throughout the U.S. health care system. Individually, better remote monitoring of individuals with chronic conditions, more rational health care behavior (e.g. jettisoning the annual physical), or greater price transparency won’t fix our health care cost problem, but collectively they could make an important dent in U.S. health expenditures.

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  • Dan Greene

    >>”If you’re healthy and you’re planning on an annual physical at the doctor’s, don’t.’

    But isn’t the point of an annual physical to give you a better idea of just how healthy you are? It’s not as though a cancer or other conditions can be detected relatively early just by how you feel. Does TAI advocate doing away with semi-annual dental hygiene appointments as well?

    What happened to “an ounce of prevention is worth a pound of cure?” This piece is nothing but a mindless endorsement of Kaiser Health’s stance without regard to preventive considerations whatever? I wonder whether TAI was attacking Obama for “death panels” when that was a hot topic.

    • Andrew Allison

      Surely you jest? See my other comments.

      • Dan Greene

        Just so I’m clear, could you tell me whether you agree with the thesis of this piece that an annual physical is a waste of resources or not? I’m not quite grasping it from your comment above. It sounds to me as though your issue is with overprescribed tests rather than with an annual physical, but I’m not sure I’m understanding your point.

        I see you reply to RK. But does that mean you think annual physicals should be done away with or that they should be more comprehensive?

        • Andrew Allison

          My point was that annual physicals are typically cursory, and therefore largely useless. Note “largely”. There’s an argument for at-risk patients being monitored (but “at-risk” is patient, not general population specific). There are age-and/or pre-existing condition, recommendations for more detailed examination but, for example, after over a decade of undetectable PSA following treatment for PCa, an annual test is clearly not called for.

          • Dan Greene

            OK–I understand your point of view now. I guess one question is how much the quality of annual physicals varies between providers. I’ve found mine to be pretty good.

          • Andrew Allison

            Your follow-up question hits the nail on the head. The usefulness of routine annual physicals depends upon the provider, and therefore recommending it for everybody (and thus by every primary care provider) doesn’t make sense.
            I suspect, incidentally, that this whole issue may be another symptom of our totally dysfunctional health insurance market, which by inadequately reimbursing providers encourages them to seek ways to increase revenue. Then there’s the whole issue of CYA testing to protect from malpractice malfeasance. The perverse incentives in healthcare are truly monumental.

          • jeburke

            There are clear ways to address wasteful practices like CYA testing — ie, tort reform. Also, if the unevenness of physician quality is a reason not to have an annual checkup, it’s a reason not to go to your doc at all. A crummy doc is a crummy doc. That some docs are crummy is hardly an excuse for telling everyone not to see their docs.

          • Andrew Allison

            With respect, your logic is defective. Furthermore, nobody is suggesting telling everyone not to see their docs, just that routine annual check ups (and screening, see below) are largely a waste of time and money.

          • jeburke

            Respect be damned, it’s your logic that’s defective. Any physician who is so incompetent that he/she is not worth seeing for a preventive checkup is likewise to be avoided if you have a symptom that requires diagnosis. What’s more, no one, least of all the couple of docs quoted in the linked article, had demonstrated that “annual checkups…are largely a waste of time and money.” In fact, Kaiser Health could easily have found experts to refute what their chosen sources had to say.

          • Andrew Allison

            Because the vast majority of patients have no way of determining the competency of their primary care physician, recommending routine annual physicals lumps the good with the bad; preventative checks checks are, by definition asymptomatic; and Kaiser uses the US Task Force recommendations.

          • jeburke

            That’s a non-response and a total dodge. You cannot make any case for retiring preventive visits based on thd supposed incompetence of some docs (a “fact” not incidentally which I do not concede) without assuming that it’s pointless for symptomatic patients to visit the same incompetent docs. This dead end is what happens when you argue without thought.

          • jeburke

            Not true. In my case, I had PSA tests annually for more than 10 years. Then, a suspicious jump prompted a biopsy that disclosed a dangerous cancer. There is a reason they call it “screening.”

          • Andrew Allison

            The US Preventive Services Task Force recommends against PSA screening for PCa (http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/prostate-cancer-screening), for women with no family history of BrCa, etc. Routine screening for individuals not at risk is largely a waste of money.

          • jeburke

            Your link is messed up. Whatever a cost-cutting task force says, I am living proof that PSA screening is essential to diagnose prostate cancer.

          • Andrew Allison

            You, in fact, are living proof that most PSA testing is unnecessary.

          • jeburke

            That’s just patently ridiculous. I had no symptoms and for years a PSA well under value regarded as problematic. The only sign of trouble came with a routine annual PSA test which was still within the normal range but quite a lot higher than the previous year’s. My doc then suggested a biopsy which disclosed a cancer. If I had no routine PSA, I would have had no biopsy and no diagnosis. End of story. I don’t know how old you are but if you’re past 40 and don’t have routine PSA tests (and digital exams) you’re crazy.

  • RK

    For many diseases the earlier one can detect their onset, the better off one will be. Cancer is a big one, high blood pressure, and other chronic illnesses would benefit if patients pay attention to their symptoms earlier. As Mr Greene below astutely observed, one does not know “if one’s healthy”. My friend’s melanoma was not discovered until stage IV. He would have benefited from annual exams that checked out the skin on his back. Besides under Obamacare, annual checkup is mostly paid for except for some of the lab tests. From a consumer perspective, there is absolutely no reason not to do an annual checkup especially for those older than 40.

    • Andrew Allison

      The Medical Guild speaks: the reason to get an annual physical is that the cost is paid for with OPM! In my experience, annual exams are perfunctory — and don’t include the full-body dermatological exam (or palpitation) suggested as a justification for them.

  • Loader2000

    I think this makes sense. Either the data lies or it doesn’t. I tend to agree with the studies based on my personal experience. Unless you are already experiencing symptoms, the annual check-up won’t catch a problem that you aren’t already aware of in some way. They don’t do a colonoscopy. They don’t check you for carcinoma. They don’t do a biopsey of any of your tissues or an MRI of your brain. They won’t know if you have an artery that is 70% blocked. They look in your ear, your throat, ask you to cough while listening to your lungs and check reflexes, things like that. They will be able to tell you if you have a fever, polio, an ear infection, fluid in your lungs, basically things that would bring you to the doctor anyway if you halfway aware of how you felt. I think the annual physical was much more relevant when diseases like small pox, polio, tuberculosis and other, mostly eradicated diseases were common.

    • Dan Greene

      Sorry, but I’m not understanding your argument. There was no cure for small pox, polio or tuberculosis. Smallpox and polio attacked rapidly and tuberculosis was a slow death sentence. A cowpox vaccine for smallpox was developed early on (18th century) but the technologies of today allow for X-rays and the review of lipids and other issues from blood and stool tests, and it acts as a prompter for an individual to discuss things with the doctor that might not have impelled him to come otherwise. It seems to me that a physical now has the potential to do a lot more good than in, say, 1850 or 1900. As RK says, if a doctor had examined his friend then his carcinoma might have been caught earlier.

      You are not, it seems to me, making a serious effort to capture the benefits of a periodical review of one’s health. I understand that there is a cost to administering annual physicals, but where is the cost-benefit analysis here rather than a toting up of the costs alone?

    • jeburke

      On the contrary, a typical checkup of a person over 40 should include a cardiogram, a chest xray every few years, monitoring of blood pressure and blood screens that can identify high cholesterol, etc. Taken together, along with family and personal history, these can single out patients who should see a cardiologist. At a minimum, it will head off high blood pressure which can be 100% controlled by medication (there is a reason why few people die of strokes these days).

  • Andrew Allison

    It’s not just the annual physical exam. After my last annual visit my primary care doc expressed (on a second visit to review the lab results) some concern about my kidney function, and told me to get it checked in six months. When I called to get the necessary lab slip, I was told that an office visit would be required (in addition to the one to discuss the results) to get it. Those visits were necessitated by the fact that, although all four of my expiring Rxs were for lifetime problems, somebody is required to pay for two office visits and blood tests once a year in order to renew them. Another example: the recommended frequency of endoscopy for sufferers of Barrett’s Disease is every 18 months. Six months after my last one the criminal enterprise which is my gastro clinic wrote to tell me to schedule another appointment.

  • GS

    I could see how such argument would apply to the healthy people in their 20s. However, I would think that starting at perhaps age 40, the need for the periodic check-ups increases [in parallel with the body wear and tear].

  • FriendlyGoat

    Would we be wrong for asking whether our doctors are going to want to do more physicals, not less, if we move to payment models that reward our doctors in advance, or on some kind of per diem, or with bonuses for “controlling our conditions”, or “keeping us well”?

    I personally do not believe I needed annual physicals in the years of my 40-60 life and I mostly didn’t have them, but I would never tell someone else to skip theirs if they like having that assurance. But a question we ought to be asking about these contemplated new payment models is this? Who will be in control? You or your doc? What will your doc’s priorities be? You, or hitting the metrics?

  • Arkeygeezer

    I am 76 years old. I have had annual physicals for the past 40 years. My physicals have caught problems with my heart, arteries, and other organs that could have killed me off long before now. If you are immortal and bullet-proof, you don’t need an annual physical. Save your money if you want to, but my advice is to get an annual physical if you are over 50 years old.

    • jeburke

      Exactly. I’m 73 and have scrupulously had regular checkups since I was 37. I might well have been dead of prostate cancer years ago if not for this (no symptoms but a suspicious jump in PSA from one year to the next prompted biopsy which revealed a fairly dangerous but still treatable cancer).

  • Boritz

    I’ll go along with whatever congress and the administration decide — for themselves. That is the most reliable way to determine what is necessary.

  • fastrackn1

    This is about the dumbest advice I have heard in a long time. And it seems to be based on cost savings.
    I think most people have enough money to pay for an annual physical, even if they have to pay the full amount.
    “If you are healthy” you don’t need an annual physical? People are “healthy” until they get sick. The point of the physical is to catch sickness early so people stay healthy longer.

  • jeburke

    Nonsense.This “advice” is of a piece with other sudden reconsideration of the value of various tests urged on everyone for decades like mammograms. It’s all about cutting costs — more or less blindly. If 99% of annual checkups reveal nothing wrong, so what. The whole point is to unearth the problems. How else will anyone ascertain they have high blood pressure? High cholesterol? High PSA? The early signs in blood tests of diabetes? Elusive breast tumors? Signs of cervical cancer? Tiny, outwardly unconcerning skin tumors? Or a dozen other common and potentially dangerous conditions. Even the perfectly healthy can benefit by a checkup because it’s an opportunity to get some expert guidance.

    Frankly, I find it reprehensible that this awful “advice” is being peddled.

  • Boritz

    Can we also dispense with pre-flight checklists and regularly scheduled aircraft inspections for the same reason: save money.

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