How much of your care is planned?

Your doctor should be using “pre-visit” planning to make sure that your care is proactive, not purely reactive. Here’s how the American Medical Association says we should do it:

  1. Your next visit should be set before you leave the clinic at your current visit. This should include scheduling any needed labs or x-rays. Unfortunately, not all electronic health records (EHRs) allow for proactive lab scheduling, so your doctor’s staff may need to use a look backward strategy, where a staff person orders labs according to a protocol based on your medications and diagnoses a few days before the next appointment. Regardless, you should have repeat labs and imaging available when your next appointment comes around.

  2. Before your next appointment, someone from the clinic–often a nurse or MA–should contact other providers you may be seeing to get results of testing or treatments they may have performed. Ideally, copies of these results should be shared with you.

  3. You should have the chance to check your status on preventive health between visits so you know what to ask your doctor about when you arrive at the next visit. This helps to identify “gaps in care,” like immunizations or screenings. Some clinics develop checklists like this one from Better Health While Aging. While this list is geared toward the primary care of aging patients, other providers like orthopedists, oncologists, or cardiologists may have specialty- or disease-specific checklists.

  4. You should get a reminder of any upcoming visits, either by email, text, or phone call, at your preference.

  5. A list of your current medications should be provided to you upon check-in so you can review the medication list for errors. This can be either a paper copy or a copy through the clinic’s “portal.”

  6. A review of your medications may be paired with a pre-visit questionnaire to see if you have new medications, problems, or symptoms that can start to be evaluated even before the doctor sees you. Here’s an example from the American Academy of Family Physicians.

  7. Your clinic’s staff and your doctor should hold a pre-clinic “huddle” to anticipate some of your needs and gaps in care so that the first time they consider these problems isn’t the moment you step into the lobby.

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

When is the last time you taught your doctor something?

An average visit to a primary care doctor addresses about three primary complaints, like back pain, blood pressure, fatigue, cough, and the like. Each of those problems may have a pretty complex workup and therapeutic plan, so it is no surprise that people often leave their doctor’s office with a muddled idea of what they’re supposed to do next. Forty to eighty percent of what is discussed in doctor’s visits is forgotten immediately, and almost half of the information retained is incorrect. To fight this problem, Medicare (CMS) requires that doctors supply a summary of the visit on paper within three business days of the visit, but the summaries generated by many electronic health records are jumbled messes of computer-generated tech-speak gobbledygook. Some patients go so far as to secretly record medical visits, a practice that has been condemned by people within and outside the medical community. But, sensing an opportunity, clever apps to facilitate consensual recordings, like Abridge, have cropped up.

 But less tech-oriented doctors are interested in a more analog method called “teach-back.” You may know this better as how you make sure your teenagers have heard you when you ask them to mow the lawn; the phrase “repeat what I just said” may ring a bell. But don’t be insulted if your doctor uses the same technique with you. Entire websites and continuing medical education enterprises have been built on teaching it.

 Recently, investigators writing in the Journal of Primary Care & Community Health analyzed six years of data on 2,901 patients with diabetes from the Medical Expenditure Panel Survey (MEPS), a data collection of access, utilization, and payments for American patients. They were able to link the MEPS data to data on hospital inpatient stays. They specifically looked for two pieces of information about doctor visits: 1) did the patient receive medical instruction which was easy to understand, and 2) was the patient asked to describe how to follow the instructions given. If both answers were “yes,” the patient was designated as having had a “teach-back experience.”

 To determine the quality of the patient-doctor interaction that went along with these teach-backs, they looked for several questions that looked into patients’ perceptions of the provider’s listening, respect, time utilization, and the patient’s “global satisfaction.” And, if the survey data showed that the provider helped decide between treatment options and showed respect for the patient’s preference, “shared decision-making” was believed to have taken place.

 Finally, patients were asked about their perceived confidence in their diabetes treatment plan, and the likelihood of having complications (like eye, heart, or kidney problems) or hospitalization related to diabetes within two years was calculated.

 What the investigators found was encouraging. Patient teach-back experiences were associated with a lower risk of hospitalization, a higher perceived interaction quality with the provider, more shared decision-making, and a higher likelihood of lifestyle advice having been given. Patients who’d “taught back” to their provider were more confident in their treatment plan.

 So the next time you get a set of instructions from your doctor, take a second and ask her, “Let me repeat that back to you in my own words.” If she affirms that what you just said is true, you’re in good shape. If what you say back to her doesn’t quite match what she intended, you’ll both walk out of the visit having learned something.

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Introducing Advanced Primary Care

In the last couple of years, we’ve tried to drive home a couple key points about the routine medical care of your employees:

First, even though annual “check-ups” may not be that important, steady access to a primary care provider is essential. Access to primary care increases the life expectancy of a community. Primary care visits are declining, being crowded out by visits to retail clinics, urgent care centers, emergency rooms, and specialist visits.

Second, primary care is the most cost-effective form of health care, and to avoid unnecessary costs, most of your care should be coordinated through a primary care provider. American adults who have a primary care physician may have healthcare costs as much one-third lower than the costs of their peers who lack a PCP. Almost two-thirds of Medicare claims for wasteful or unnecessary care are by physicians with no relationship to the patient’s primary care practitioner.

But it’s possible that even with those assertions we’re thinking too small. KBGH is a member of the National Alliance of Healthcare Purchaser Coalitions (say that three times fast), and they have adopted the provocative stance that simple access to primary care isn’t enough. The Alliance has begun advocating for “Advanced Primary Care.”

If you’re a provider, you might cringe at the name. Isn’t the “advanced” part insulting to a seasoned, experienced, competent doctor who does “regular” primary care? Names are tricky. But the name isn’t meant to connote the achievement of a certain score on board exams or the possession of a special skill set. Instead, Advanced Primary Care, as defined by the National Alliance, describes a philosophy and commitment to seven key, sometimes overlapping, attributes in the clinic: 

  1. Enhanced access. Many patients end up in the emergency department simply because they could not access their primary care practitioner during normal business hours or they got frustrated by the time it takes to schedule and complete a visit. Primary care practitioners who offer available appointments on nights or weekends can reduce emergency room utilization.

  2. Increased time with patients. The average fee-for-service primary care physician carries a patient panel of roughly 2,200 patients. In models in which the physician or practice directly contracts with employers, this number may be more like 400-600 patients. This allows additional time with each patient to encourage better engagement, to better identify social determinants of health, and to relationship-build to ensure continuity of care over time.

  3. Realigned payment methods. Much of the current fee-for-service model perversely incentivizes increased care or increased volume without increased quality of outcomes. Advanced primary care, which operates more frequently on a salaried or subscription model, seeks instead to incentivize patient activation, case and care coordination, accountability for health outcomes, and judicious use of downstream referrals.

  4. Organizational and infrastructural “backbone” to support patient-centered leadership, additional training for staff when needed, and commitment to quality improvement over time. This may mean changes in the practice’s staffing and use of information technology.

  5. Behavioral health integration in order to deliver “whole person health,” not just physical health. This can be in the form of a social worker, therapist, or psychologist on site or coordinated via telemedicine.

  6. A disciplined focus on health improvement, not just reactive care, with a deep understanding of population risk factors and a strategy to focus resources within that population to where they will drive the greatest overall improvements. Advanced primary care seeks to anticipate problems like seasonal influenza, not just respond to crises that arise from those predictable problems.

  7. A process of referral management to other providers or services, like specialist physicians, labs, radiology departments, and allied health, that explicitly seeks to maximize quality while moderating downstream cost.

The National Alliance has a good infographic on Advanced Primary Care below. If you’re interested in exploring direct contracting with primary care providers for your employee benefit package, please let us at KBGH know. We would love to help out.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Achieving-Value-Through-Advanced-Primary-Care-Infographic_FINAL-pdf-1024x622.jpg

Center your care on a PCP

If you’ve been to a Kansas Business Group on Health meeting in the last couple of years, you know already that American health care is beset by “low-value” care. We spend inordinate amounts of money doing “executive physicals” that offer almost no benefit. We pay for expensive back surgeries that are sometimes no better, and often worse, than physical therapy. We fail to substitute cheaper generic or bioequivalent drugs for more expensive drugs in spite of evidence that the less expensive drugs work just as well. All these low-value services account for between $75 billion and $100 billion in annual U.S. health care spending. In a $3.5 trillion health care economy, that seems like a rounding error. But it’s a big number! $100 billion is an extra $300 per year on health care per American.

 What do most of these sins against our collective pocketbooks have in common? They mostly happen in specialist offices, not at the hands of primary care providers (PCPs). We’ve extolled the virtues of primary care often here at KBGH (although not necessarily the “annual check-up”). We’ve long known that primary care is the most cost-effective place to get your care. This was reinforced just last week in a new study looking at the sources of low value care.

 The investigators analyzed Medicare Part B claims from a 20% random sample of beneficiaries enrolled between 2007 and 2014. They excluded anyone in a given year who could not be linked to a PCP in the data, and they defined “low value services” as 31 services by various clinical guidelines:

Annals of Internal Medicine

Annals of Internal Medicine

When they looked at who ordered the low-value services, they found that PCPs accounted for a tiny fraction, 14.5%. But since many of the services you see above are not routinely done by PCPs, they looked further and found another 19.8% were performed or ordered by doctors to whom the patient was referred by the PCP, and another 5.6% was done by physicians to whom the patient had been referred by the PCP in the past.

The remaining 60.2% of low-value spending was “for services performed or ordered by a physician to whom the PCP never referred the beneficiary.” That is, almost two-thirds of the low-value spending was by physicians the PCP likely didn’t even know the patient was seeing! It’s possible the patient Googled “chest pain,” or answered a billboard for another service. The data doesn’t say.

This hurts me as a specialist physician. I wonder how many of the 31 low-value care items I’ve over-utilized in my career. Several of the items on the list, from certain thyroid tests to tests of vitamin D and parathyroid hormone, were right down my alley as an endocrine specialist. If it matters, the worst-offending non-primary care specialties for low-value spending were cardiology (27.3%), ambulatory surgical centers (8.9%), internal medicine (7.0%), orthopedic surgery (4.9%), and gastroenterology (4.8%). No endocrinology on that list. Whew!

All this isn’t to say that people don’t benefit from seeing more than one doctor. We’ve reviewed the myriad benefits of second opinions in past posts. But I do think that it reinforces the need for all of us to have a primary care physician directing our care. More than 84 percent of Americans have had contact with a health care professional in the past year, but only about half of those visits were to primary care offices, and only 75% of Americans have a primary care physician, a number that is declining over time.

None of us want to be accused of erecting barriers to good care. But I believe that adopting policies that encourage the use of primary care over, or ahead of, other services will be good for both the health of your employees and the bottom line of your company.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Transparency is Trust

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

In 1963, Stanford economist Kenneth Arrow published the landmark paper “Uncertainty and the Welfare Economics of Medical Care.” He argued presciently that health care was an unfair system in which to bargain due to “asymmetric information.” The doctors, hospitals, and nurses simply know more than the patients, and this imbalance in information keeps the patient from being able to comparison shop or argue for fairer prices. If a doctor tells you you need a stent in your heart, after all, don’t you need it?

Equip patients with information and they usually make the right choice

There is data to suggest that patients, when given the right information to work with in a digestible way, make responsible decisions in health care purchasing. My favorite study on the topic looked at parents of children with appendicitis. Parents were randomized to see one of two videos: one group of parents saw a video that simply went over the difference between old-fashioned “open” surgery to remove the appendix and newer laparoscopic surgery that uses small “keyhole” incisions to put a camera and small instruments into the abdomen to remove the diseased organ. The video seen by the other half of parents explained the differences in the surgeries but also explained the price difference between the techniques (laparoscopic surgery is more expensive). Both videos stated that patient outcomes are similar with either procedure.

The parents who saw the video with the charge estimate were 1.8 times as likely to choose the open procedure. In fact, the effect of simply stating the charges in the video reduced the average price of the surgery from $10,477 to $9,949, a difference of $528, since more parents chose the open procedure when presented with good data. And more than a quarter of the parents choosing the open procedure said cost was the primary factor in their decision-making! This point is worth restating: parents, when confronted with a surgical choice in an emergency situation that, if handled incorrectly, could harm their own child, still took cost into account in their decision-making.

Things we’d hoped would work… but didn’t.

Many hoped the internet would solve the knowledge gap in medicine and empower patients. After all, in the business of buying and selling cars, some argue that information asymmetry is long-gone. If I were to buy a new Chevy Bolt today, I would simply choose my desired features on Edmunds.com, print the price sheet, and offer to pay my dealer a price in the ballpark of what Edmunds suggested was fair. But in spite of efforts from companies like Castlight, CashMD, and others, we haven’t seen a big dent in healthcare costs due to transparency alone. Some of this is due to the fact that doctors themselves–outside of the radical transparency of many Direct Primary Care physicians–aren’t always privy to the price of tests, drugs, or even their own services. And even those DPC doctors can’t necessarily share other outcomes we’re interested in, like rates of screening for cancer and metabolic diseases, mortality rates, and other quality indicators.

So the government has tried to step in. The Trump administration released an executive order in fall of 2019 requiring that by 2021 all hospitals must publish their “standard charges” online in a machine-readable format so that other software can begin to compare prices. This is a good start, but it is unlikely to work. Those “standard charges” are, in most cases, “chargemaster” prices that have little bearing on reality. Medicare, for example, pays about 31% of the chargemaster price. Second, patients mostly care about out-of-pocket payments, not insurance payments. To have an idea of their own liability, patients need the “bundled price” for the entire episode, which chargemaster prices do not provide. Instead, the chargemaster prices are for individual charges for materials and procedures

What CAN we do?

But we can’t just throw our hands up in frustration. As employers we should control what we can control. We can control state and federal policy as voters, but our power may be better wielded locally. We’ve pointed out previously in this blog that a lack of transparency was one of the big drivers of health care costs. That transparency extends beyond the operating room, exam room, or pharmacy. It reaches into the relationship between you and your partners, such as your broker, your PBM, and medical providers you may directly contract with. A good first step, if you weren’t able to attend our recent webinar with Dave Chase of Health Rosetta, is to ask for those partners to disclose all their revenue streams. Their undisclosed revenue streams may surprise you. Once everyone’s revenue is transparent, we believe that partners can work together in a more trusting relationship, to the benefit of both parties.

Note: KBGH works with Team IBX to introduce transparency in the insurance RFP process, but Team IBX was not involved in the writing and did not influence this post.

Will technology save the aging primary care workforce?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The issue we’re facing

The primary care physician workforce in Kansas–family doctors, internists, and pediatricians–is aging. Of the 1,976 primary care physicians in Kansas as of April 2020, 15.6 percent are already over 65, and 39.2 percent are over 55. The simple demographics of this are intimidating: even though they provide the most essential, cost-effective care in medicine, only 43 percent of practicing physicians in the U.S. are primary care providers, similar to the average of eleven Organization for Economic Cooperation and Development countries. But the fraction of graduating students entering primary care is steadily decreasing.  Even more ominously, older physicians are much more likely to be harmed by infectious diseases like SARS-CoV2, the causative virus behind COVID-19, adding to the inevitable workforce turnover caused by death. This all portends an uncertain future for primary care provision in many Kansas communities, since Kansas is already underserved relative to most other states at baseline.

As if that weren’t enough to worry about, physician skills appear to deteriorate over time. A 2017 study in the British Medical Journal found, for example, that elderly Medicare beneficiaries’ hospital adjusted 30-day mortality rates were 10.8% for physicians aged <40 and rose steadily to 12.1% for physicians aged ≥60, a 15% relative increase in risk for patients cared for by older doctors. Not only that, but costs of care were slightly higher among older physicians. This may not simply be due to age-related decline; it could be that younger doctors were trained in a way that improved their care. For example, “evidence-based medicine” is an integral part of medical training in the modern era. Older doctors who were not trained under this philosophy are demonstrably less likely to follow evidence-based care guidelines. This is hard for me to read. Statistically, I am likely a worse doctor than I was fifteen years ago. But I digress.

What can be done about this problem?

The Association of American of Medical Colleges, predictably, has argued for years that the solution is to train more physicians, by two mechanisms: first, the AAMC advocates for increasing the cap on Medicare funding that limits the number of residents at a given institution. Second, the AAMC supports greater incentives such as scholarships and loan repayment for primary care providers working in underserved areas. Examples of this are the Kansas Medical Student Loan Program, which pays for medical school for a limited number of students in return for an agreement to practice primary care in underserved areas in Kansas; and the Kansas Bridging Plan, which gives resident physicians additional funding during their training in exchange for a three-year commitment to practice in a rural community. On the federal level, the AAMC advocates for increased recruitment of international medical graduates, who already represent about a quarter of practicing physicians in America, through programs like the J-1 Visa Waiver program.

Others point toward increased use of non-physician practitioners like physician assistants (PAs) and advanced practice registered nurses (APRNs). This is clearly the preferred short-term option. PAs and APRNs require drastically less training than physicians, which eliminates the seven-year gap between policy and practice that we see in traditional medical training. And the health outcomes of patients seen by non-physician providers seem to be roughly equivalent to those of patients seen by doctors. Another British Medical Journal systematic review of randomized trials and observational studies–one of several such reviews in various journals, all with similar conclusions–concluded that “Patients are more satisfied with care from a nurse practitioner than from a doctor, with no difference in health outcomes.”

But long-term, if the skills of physicians like me decline with age, we can be certain the skills of other providers fall as well. How do we ensure that quality care continues to be delivered over the lifespan of the practitioner?

Automation may be the answer

Let’s look at my specialty, endocrinology. Six years ago, when I left full-time practice, the management of blood glucose levels was mostly an intuitive art/science, driven mostly by the experience of the physician-patient dyad. But in the last few years we’ve seen the emergence of “smart” glucometers that quadruple the likelihood of of a patient controlling their blood sugars while reducing their risk of dangerous low blood sugars. We’ve seen the development of automated insulin devices in the hospital that outperform conventional treatment of blood glucose levels. The FDA approved an artificial intelligence-based device to scan and diagnose the eyes of diabetic patients with diabetic eye changes (the most frequent complication of diabetes) without even having an ophthalmologist or optometrist involved. Newer, even more innovative, devices are in development, such as an app that can allegedly detect the presence of lung disease by the sound of a patient’s cough.

Some of these devices will pan out in the long run, while others won’t. But even a conservative projection is cause for optimism. It is not unreasonable to predict that practitioners with far less training than physicians will have the tools and skills to provide very competent care–elements of both primary care and specialty care–in the near future. Technology must be carefully monitored by humans, but its abilities do not decline with age. On the contrary, a given technology’s performance today is the worst that it will likely ever be. Best Buy will sell faster computers next month than it does today, and faster yet a year from now. And automated devices aren’t resistant to delivering evidence-based care; it is programmed in. I welcome the Rise of the Robots.

Primary care is being crowded out

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The next time you have a minor injury or get sick, will you call your primary care doctor to get a same-day appointment, or will you go to the local urgent care? Now may seem like a strange time to even be asking the question, since many patients aren’t taking the chance on either one. Patient volumes in medicine are down 50% or more as people practice social distancing and hospitals and surgery centers cancel elective procedures. But eventually we all need care. And a recent study in the Annals of Internal Medicine (paywall) found that when we seek that care we’re increasingly likely to seek it from urgent care centers.

Multiple investigators from Harvard, Mount Sinai, and the University of Pittsburgh looked at deidentified claims data for adults aged 18-64 years from a single commercial insurer (they didn’t reveal which one) between January 1, 2008, and December 31, 2016 to determine the rate of primary care visits per 100 member-years. By cleverly using CMS place-of-service codes, National Provider IDs, tax identification numbers, and CPT codes, they were able to further categorize visits as having taken place in a purely outpatient office, the emergency department, an urgent care, a retail clinic, or a commercial telemedicine visit.

What they found was bad news for primary care doctors and, if you believe that primary care saves money and improves outcomes, as most policy makers do, bad news for the people paying for healthcare, like employers. Primary care visit rates declined 24.2% in the eight years of the study, from 169.5 visits per 100 member-years in 2008 to 134.3 in 2016. The proportion of insured patients with no medical visits at all in a given year went up, from 26.1% to 32.5%, as did the proportion with no visits to a PCP in a given year (from 38.1% to 46.4%). This trend held even when gynecologists were re-classified as PCPs, since some women get the bulk of their care from their gynecologist.

An optimist might venture that the population was just healthier in 2016 than it was in 2008. And in patients that had no chronic diagnoses the drop in PCP visits was higher. But overall the insured group did not get healthier or sicker over the time of the study.

So where did the care go? To “alternative settings.” Urgent care visit rates almost doubled, from 4.4 visits per 100 member-years in 2008 to 8.0 in 2016. Retail clinic visit rates more than tripled, from 0.83 visits per 100 member-years in 2008 to 3.0 in 2016. Commercial telemedicine visit rates rose a spectacular 500%, from 0.003 visits per 100 member-years in 2008 to 1.6 in 2016.

The authors posited three possible explanations for this: First, patients may be less likely to seek primary care if they are younger and healthier and comfortable with online self-care or a secure message with a nurse or other non-physician provider when a minor acute need, like conjunctivitis, arises.

Second, those increasing financial barriers such as increased deductibles and co-pays may influence care more than we have previously thought. The average out-of-pocket cost of a visit increased from $29.70 in 2008 to $39.10 per visit in 2016 for “problem-based” visits (that is, visits meant to address a specific complaint). And over the time of the study more PCP visits became subject to a deductible (from 9.2% of visits in 2008 to 25.2% of visits in 2016). The decline in PCP visits in this study was largest in low-income communities. Using some clever economic calculations the authors estimated that this may have explained about a quarter of the decline in PCP use.

But third, and most powerfully, patients appear to simply be replacing PCP visits with visits to specialists and alternative settings. Even though the proportion of patients visiting specialists did not change, many patients saw multiple specialists. And the increase of 9 visits per 100 member-years to alternative settings offset about a quarter of the PCP visit decline. This may well have been a matter of convenience. As we’ve discussed before in this blog, the average physician visit takes more than two hours. Traditional primary care settings are known for their inefficient or inflexible scheduling practices. One study found that patients are so frustrated by scheduling practices that they think nothing of blowing off visits, leading to high no-show rates in the clinic. Visits to alternative venues may simply be more convenient not only in getting a generic appointment, but in getting an appointment after-hours so that no work is missed.

If the convenience argument is correct, doctors may be able to get some of that patient population back by employing “open access” scheduling. In this system, same-day appointments are almost always available. The day’s schedule isn’t full of appointments made weeks or months ago. The doctors preferentially schedule follow-up appointments in the morning, but fill much of their afternoon schedule as the day goes on. Somewhat famously, this is how a Kaiser Permanente clinic in Sacramento reduced their wait for an appointment from 55 days to one day. But the system requires some sacrifice on the part of the doctor, which may be a tough sell in a system where PCPs are already losing market share. Open patient slots, after all, are potentially lost money. It also may require some sacrifice on the part of the system. Open-access scheduling is generally thought to require doctors to carry smaller “patient panels” than they traditionally do, which may in turn lead to a need to train more physicians.

For larger employers there may be other fixes, such as on-site clinics. And with the increased adoption of telemedicine into traditional practices, we may see more patients using that option instead of going to the ER or to urgent care.

If your business has found a way to incentivize increased use of primary care, rather than ever-expanding use of urgent cares and emergency rooms, let us know.

What’s the Value of an Annual “Checkup”?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Are annual checkups all they’re cracked up to be?

Remember Cigna’s “Doctors of America” ads?

“We are the TV Doctors of America,” says McDreamy.

“And we’re partnering with Cigna to help save lives,” says Dr. John Carter.

“By getting you to a real doctor for a checkup,” chimes in Cuddy.

But to put our “Devil’s Advocates of America” hats on: what if this annual checkup business isn’t all it’s cracked up to be?

It is reasonable to hold any potential medical test or treatment to one of three standards:

  1. It makes the patient feel better. This includes hundreds of treatments, like using medications and physical therapy for pain, prescribing inhalers for asthma, giving antidepressants and therapy for depression, and replacing knees, for starters. It could even apply to things like bone mineral density screening, sometimes referred to as “DXA,” which linked with osteoporosis treatment may make no difference in the risk of death, but clearly prevents hip, wrist, and spine fractures.

  2. If it does not make the patient feel better, the test or treatment should make the patient live longer. This applies to everyday things like checking and treating high blood pressure and high cholesterol (neither one of which make most patients feel any better or worse today) to surgery and chemotherapy for cancers (most of which make patients feel much, much worse at least in the short-term, but prolong many lives).

  3. Finally, if a treatment makes no difference in how the patient feels and makes no difference in how long the patient lives, it should at the very least save money. The best example of this may be diabetes screening. As far as we can tell, screening for diabetes does not prolong life, at least not in the two or three trials that have specifically addressed the question. But diabetes screening linked to preventive measures like the Diabetes Prevention Program clearly saves money [disclaimer: the KBGH is closely linked to Health ICT through the Medical Society of Sedgwick County, which receives CDC funding to promote things like blood pressure control, cholesterol management, and diabetes prevention].

Many of the tests and treatments medicine offers do not live up to that rubric. This may be why the Cochrane Review, which many consider the highest level of evidence in medicine, published a review in 2018 stating that “Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.” So when the TV Doctors of America say you need an annual checkup, what they surely mean is not that you need an old-fashioned sit-down with your doctor where, at the end of the visit, she gives you a “clean bill of health.” No. What I hope they mean is that you need to have access to a primary care provider. Investigators in 2019 found that every 10 additional primary care physicians per 100,000 people was associated with a 51-day increase in life expectancy, which doesn’t sound like much, but is pretty big by medical standards. Some estimate that a doctor practicing at the top of his license adds about 4.5 net years to the average patient’s life. Not too shabby.

“Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.”

What actually improves or extends someone’s life?

What the TV Doctors of America really mean is that you should have certain preventive services like immunizations and periodic screenings for health conditions that, if left untreated, can profoundly shorten your life. Most of these aren’t sexy. Probably the most effective preventive medical intervention, for example, is a simple periodic blood pressure check with medications if your blood pressure is too high. Sexier things like cancer screenings tend to have a “disease-specific” benefit, meaning they prevent you from dying of colon, prostate, cervical, breast, or lung cancers specifically, but they may not make people live longer as a whole.

If there is doubt in your company about what services you should be providing, a good place to start is with the United States Preventive Services Task Force (USPSTF), a rotating group of doctors that follows very specific rules to evaluate the risks and benefits of specific screening. Their opinion holds a lot of weight because any test given a “B” or better rating is mandated to be covered by your insurance. Examples of “A” rated services are things like tobacco use counseling and interventions, blood pressure screening in adults, and screening for cervical and colon cancers, which are all strategies that easily conform to our rubric. Cholesterol testing in people without diabetes or heart disease gets a “B.” Screening for prostate cancer in men aged 55-69 with a prostate specific antigen (PSA) test is a good example of a “C” rated service, since it has no overall mortality benefit and its disease-specific mortality benefit is largely offset by the harms that screening can cause (prostate biopsies and surgeries can cause bladder leakage and erectile dysfunction, among other things). PSA screening for prostate cancer in men aged 70 or older gets a “D” rating because it appears, in the hive mind of the USPSTF, to cause more harm than it prevents; that is, it violates rules #2 and 3.

What does this mean for employers?

How do you apply this to your workforce? Start by being an informed shopper for any workplace wellness services being offered to your company. Whenever a wellness provider tries to charge you a lot of money for offering annual “wellness checks” or “health risk assessments,” check their recommendations against the opinion of the USPSTF (or have us at KBGH check them for you). If the amount of testing they’re charging far exceeds what the experts recommend, ask them why.

Second, work on the health literacy of your employees (we can help with this). It’s hard as a patient to turn down testing or treatment your doctor offers if you don’t have the background to know what works and what doesn’t. I’m a doctor myself, and even I’ve felt vulnerable being squeezed through the gears of the medical-industrial complex.