Do you need an annual exam?

The yearly reminder

The other day I received in the mail a form letter from my physician’s office reminding me that I am due for my annual “well woman” visit. The letter also pointed out that if I have an ACA-compliant health insurance plan, the cost for the exam would be 100% covered as a preventive benefit.

I have three problems with this letter.

  1. Although my current physician is part of my new insurance plan’s network, the hospital she works out of is not. What if I needed to have surgery or be hospitalized? My care would then be given over to a different set of physicians in a different hospital system using a completely different electronic medical records system. Continuity of care would be non-existent. So, I still haven’t decided if I want to keep my physician or establish care with a new one.
  2. I’m not convinced that annual exams are necessary for healthy adults. And I’m a healthy adult.
  3. Although in theory annual exams are a covered benefit, the reality is that they open a window to further expensive and often unnecessary screening tests. Not every test the physician considers “preventive” or “screening” is covered by the ACA.

The myth of the annual exam

One of the signature provisions of the Affordable Care Act (ACA) was the creation of a list of preventive care health services to be covered without any cost sharing by the patient.

The crafters of the ACA assumed, I suppose, that if everyone were encouraged to see their physicians at least once a year, diseases such as cancer, diabetes and high blood pressure could be detected and treated early. Everyone would be more healthy, and health care costs would go down over time.

It’s a good theory, but evidence does not support the benefits.

Studies have shown that annual exams or wellness visits or health checks do not decrease morbidity (illness) or mortality (death) rates. A meta-analysis (looking at several smaller studies) published in 2012 concluded:

General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although they increased the number of new diagnoses. Important harmful outcomes were often not studied or reported.

The Society of General Internal Medicine, in its Choosing Wisely list of “5 things patients and physicians should question,” flatly states: Don’t perform routine general health checks for asymptomatic [healthy] adults.

Routine general health checks are office visits between a health professional and a patient exclusively for preventive counseling and screening tests. In contrast to office visits for acute illness, specific evidence-based preventive strategies, or chronic care management such as treatment of high blood pressure, regularly scheduled general health checks without a specific cause including the “health maintenance” annual visit, have not shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing.

Both of these sources underscore the true outcome of these annual exams—increased tests, screenings and diagnoses with the potential to incur not only greater costs, but harm from overtreatment.

The high cost of the annual exam

We all know there is no such thing as a free lunch, and there is no such thing as free preventive care. It is pre-paid and subsidized, but not free.

One writer summed up the problem very neatly:

Insurance is an institution for dealing with risks. It is a costly and counterproductive way to pay for things that are not risks — such as annual checkups, which are known in advance to occur every year.

Your annual checkup does not cost any less because it is covered by insurance. In fact it costs more, because the person who is insured must pay premiums that cover not only the cost of the checkup itself, but also the costs of insurance-company paperwork.

Related story: Free preventive care can still cost 

A commentary by a physician in the New England Journal of Medicine explains:

Laboratories have learned that one easy way to increase revenue is to make it easy for clinicians to order more tests… Costly tests that once would have required physicians to submit multiple collection vials and specimens can now be ordered with the Pap smear simply by clicking a single box in the electronic medical record. Nothing at any point along the way alerts either the clinician or the patient to the high costs of these tests or to the fact that there is little medical evidence to suggest that they are useful for most patients.

Related post: Check and check again

And if the main purpose of the “adult wellness visit” (AWV) is to check boxes and order tests, wouldn’t it be more cost efficient to have it done by a nurse practitioner or a physician’s assistant instead? That’s what one doctor is predicting:

A time will come when AWVs are brief visits done by assistants, and the patient will have to come in for a physical on another day (which will not be covered at 100%, as the AWV is). I suspect many patients won’t like this.

It’s all better than being un-insured, but don’t be surprised when your doctor tells you that your yearly physical isn’t your yearly physical.

A few years ago my annual exam lasted about an hour, and my physician listened to my lungs and heart, looked into my ears, eyes and mouth, checked my skin for moles, gave me a breast exam and a pelvic exam. It was thorough. I also had time to discuss several small concerns, none of which was urgent or, I thought, worthy of its own visit. Overall, it was an opportunity to bond with my doctor.

But now doctors don’t like that. If you come to your “annual exam” armed with a laundry list of complaints, no matter how small, they will tell you to make another appointment.

My exam last year lasted less than 10 minutes, and included only a cursory physical exam. Like the physician above suggested, my yearly physical was no longer my yearly physical. For that I will have to reschedule and pay.

So here I am, reminder letter in hand, wondering whether to change physicians and whether to schedule an annual exam.

Most likely I will keep my doctor but ditch the annual exam.

Sláinte,

Frugal Nurse

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