Annual Physicals

The greater the ignorance the greater the dogmatism - Sir William Osler

Annual Physicals

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The past few decades have seen numerous calls to eliminate the annual physical examination. In 1979, the Canadian Task Force on the Periodic Health Examination recommended “that the annual checkup, as practised almost ritualistically for several decades in North America, be abandoned.” In 2013, as part of the Choosing Wisely campaign, the Society of General Internal Medicine recommended against annual preventive examinations in asymptomatic patients.

Nevertheless, about one third of U.S. adults receive an annual physical (also called an annual preventive exam or periodic health exam) in any given year, and that trend has not abated. This ongoing practice is not surprising, since surveys reveal that the majority of both patients and physicians are strong proponents of the annual physical. In the face of this disconnect between expert recommendations and real-world practice, how do we move forward?

One of the difficulties in assessing the role of the annual physical is that its content is poorly defined and its focus has evolved over time. The potential components of the annual physical include history taking, screening questions designed to uncover undetected illness or risk factors such as smoking, counseling to address those risk factors, a full physical exam, ordering of recommended preventive services, and routine testing (e.g., complete blood counts, electrocardiograms, and urinalyses) in asymptomatic patients. Many of these components are included because of billing regulations established by health plans and Medicare.

Acknowledging the heterogeneity in the content of the visits studied, two systematic reviews summarizing both randomized trials and observational studies showed that annual physicals do not reduce morbidity or mortality, though they may be associated with reduced patient worry and increased use of preventive care. Moreover, the annual physical may actually be harmful. Some aspects of traditional annual physicals, such as the comprehensive physical exam (which might, for example, detect thyroid nodules) and routine tests (such as urinalysis), have low specificity, which means that most positive results in asymptomatic patients will be false positives.

Reducing the use of annual physicals could also save money and time. Though on a per-visit basis, the annual physical is not costly, it is the single most common reason that U.S. patients seek care, and cumulatively these visits cost more than $10 billion per year — similar to the annual costs of all lung-cancer care in the United States. Reducing the number of physicals could free up another societal resource — primary care providers' time. Approximately 10% of all visits with primary care physicians are for annual physicals, which might be crowding out visits for more urgent health issues.

Poor access to primary care has been cited as one reason why patients seek care in emergency departments for low-acuity conditions. Finally, there are large societal costs to asking all 220 million adults in the United States to spend several hours of their lives each year traveling to and waiting for care, when they could use that time productively elsewhere. Given this evidence base, it appears unlikely that annual physicals in their current forms lead to any substantive net clinical benefit.

Past calls to simply eliminate annual physicals have proven ineffective in changing clinical practice. That failure has probably been driven by a belief in the clinical community that there are potential benefits. Physicians are skeptical of research that was conducted decades ago, and they tend to believe that the annual physical is a key method for identifying and ordering missing preventive care. Most important, they see the annual visit as a critical mechanism for establishing and renewing relationships with their patients — though the question of whether physicals improve these relationships has not been well studied.

We believe three key steps could help address both the views of the clinical community and the prior evidence base. First, a new type of visit could be created whose exclusive role is to establish relationships. The majority of patients who receive a physical every year have established relationships with their physicians and come to the practice regularly for other reasons. For those who have not seen a primary care physician recently, valid arguments can be made that a physical serves as a mechanism for establishing a relationship. Many new health care delivery models such as accountable care organizations and primary care medical homes are built on established patient–physician relationships. With that need in mind, these “primary care maintenance” visits could be limited to the minority of patients who have not seen a physician for a given period, perhaps 3 years, or who are switching to a new primary care provider.

Such visits would focus solely on building a relationship through questions about the patient's medical history and social situation, not on the physical exam or screening laboratory tests. Health plans and Medicare and definitions of relevant Current Procedural Terminology codes would play critical roles in defining the content of these visits as part of billing regulations.

Second, primary care providers could change their approach to ensuring that patients' preventive care is up to date. Many physicians see the annual physical as a stop-gap measure for providing preventive care. But the majority of preventive care is ordered or provided at visits outside the annual physical, and passively waiting for patients to come in for physicals has not been an effective strategy — as evidenced by the low rates of receipt of preventive care in the United States. We believe that the emphasis in a practice needs to shift from such passivity to active engagement of the patient population.

For example, new criteria for meaningful use of electronic health records emphasize active surveillance to ensure that preventive care services are up to date. Other approaches, including automated methods of screening such as online health risk assessments, questionnaires delivered in the waiting room, and delivery of preventive care at any type of health care encounter, could better ensure that preventive care is current for the entire patient population. Payers could encourage such a shift by using pay-for-performance incentives.

Third, except for relationship-initiation visits, we recommend that health plans and federal payers no longer reimburse for annual physicals or use receipt of physicals as a measure of health care quality. Many private health plans have created a financial incentive for physicians to provide annual physicals by reimbursing for them at a higher rate than for other office visits. Eliminating this reimbursement differential would be an important step. The Centers for Medicare and Medicaid Services could also eliminate coverage for the annual Medicare wellness exam and change its policies to discourage Medicaid plans from paying for such visits.

These payment changes would not eliminate all annual physicals — physicians would, in many cases, substitute regular office visits — but they would reduce their prevalence. Any savings achieved could be invested in other aspects of primary care, such as remote chronic care management or health coaching — care that's typically not reimbursed but that has been shown to improve outcomes.

Eliminating the annual physical might appear contradictory to our health care system's increased attention to prevention. Indeed, Medicare just began reimbursing for the annual wellness exam in 2011. But it is evidence-based prevention that's key, and the annual physical is not evidence-based: research has demonstrated both its minimal benefit and potential harms. We believe it's time to act on this evidence and stop wasting precious primary care time by having a third of the adult population come in for such visits. Eliminating coverage for annual physicals, shifting our approach to preventive care delivery, and creating and reimbursing for a visit whose sole goal is to establish primary care relationships are key first steps to move us forward.

Source: Ateev Mehrotra MD MPH, and Allan Prochazka MD, Improving Value in Health Care — Against the Annual Physical, N Engl J Med 2015; 373:1485-1487, October 15, 2015DOI: 10.1056/NEJMp1507485.

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Last Updated : Thursday, January 4, 2018