Posted by: notdeaddinosaur | March 11, 2012

Defining the “Routine Physical”

I got a call the other day from a disgruntled patient. The source of his displeasure:

I got a bill from the lab for $84.75 for the blood work you did as part of my routine physical last week. Since the blood work is an intrinsic part of the physical and since annual physicals are free, why should I have to pay the lab separately?

Oy.

Where to start? How about with some definitions. What exactly is a “routine physical”? Real answer: there isn’t any such thing. Let’s be more precise and recognize that the term “annual physical” is used as a synonym for a “periodic preventive care visit.” What, precisely, should that mean? What services are indicated? What is the correct periodicity, for that matter? Is it always “annually”?

Turns out there is a group of people whose job is to evaluate objective evidence to answer those very questions. They’re known as the United States Preventive Services Task Force (USPTF), and they’ve done quite a thorough job sifting through actual evidence about the efficacy of all kinds of things, from mammograms to PSAs, from colonoscopies to stress tests.

It turns out that there is no screening intervention recommended annually for all adults. Got that? Not mammograms; not PSAs; not listening to heart and lungs; not a complete skin exam; even the frequency of screening for high blood pressure isn’t specified. Granted there’s been some bad press lately over the recent update of mammography recommendations, but when you look closely at who’s screaming the loudest, it’s the people making the most money from annual mammograms (radiologists, mammography machine manufacturers) plus those who participate in the over-diagnosis and treatment of breast cancer (surgeons, radiation therapists, oncologists). A recent article even mathematically deconstructed the “Mammography Saved My Life” testimonial.

What about heart disease? Isn’t coronary artery disease the leading cause of death in the US? Surely an annual EKG or stress test is an important bulwark against this terrible killer of Americans? Nope:

  • The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening with resting electrocardiography (ECG), exercise treadmill test (ETT), or electron-beam computerized tomography (EBCT) scanning for coronary calcium for either the presence of severe coronary artery stenosis (CAS) or the prediction of coronary heart disease (CHD) events in adults at low risk for CHD events.
    Grade: D Recommendation.
  • The USPSTF found insufficient evidence to recommend for or against routine screening with ECG, ETT, or EBCT scanning for coronary calcium for either the presence of severe CAS or the prediction of CHD events in adults at increased risk for CHD events.
    Grade: I Statement.
  • The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to assess the balance of benefits and harms of using the nontraditional risk factors* discussed in this statement to screen asymptomatic men and women with no history of CHD to prevent CHD events (select “Clinical Considerations” for suggestions for practice when evidence is insufficient).
    Grade: I Statement.
  • *The nontraditional risk factors included in this recommendation are high-sensitivity C-reactive protein (hs-CRP), ankle-brachial index (ABI), leukocyte count, fasting blood glucose level, periodontal disease, carotid intima-media thickness (carotid IMT), coronary artery calcification (CAC) score on electron-beam computed tomography (EBCT), homocysteine level, and lipoprotein(a) level.

But what about labs? Wouldn’t it make sense to check a cholesterol level at least once a year? Nope. Here’s their official statement about screening for lipid disorders:

Screening Men
  • The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 and older for lipid disorders.
    Grade: A Recommendation.
  • The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease.
    Grade: B Recommendation.
Screening Women at Increased Risk
  • The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease.
    Grade: A Recommendation.
  • The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease.
    Grade: B Recommendation.
Screening Young Men and All Women Not at Increased Risk
  • The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease.
    Grade: C Recommendation.

So what are we left with?

Even though the USPTF never came out and specifically addressed the “annual physical”, there are enough specific recommendations for (and against) so many diseases and conditions that it makes some sense to sit down with a patient on a regular basis just to review which of those myriad recommendations apply to that particular person.

Finally, the idea that “annual physicals are free” is disingenuous, to say the least. “Covered in full, 100%, with no co-pay, deductible, or co-insurance”, ie no money out of pocket at the time of service, is not “free”. Trust me: if you’re not paying for it in your premiums, then you’re paying for it with your taxes. It’s definitely not “free”. Excessive utilization of preventive services is a significant waste of health care resources. Somehow, though, the idea has spread that the “annual physical” — including whatever screening tests the patients may insist upon — ought to be free.

It’s not. So yes, you owe the lab $84.75; pay up, and let’s just be more explicit next year about what preventive care services you really need.

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Responses

  1. It doesn’t help that Medicare promotes the “welcome to Medicare” ‘physical”, which doesn’t include what most patients think it does.

  2. Does the Medicare Physical include *ANYTHING* that anyone thinks a physical is? There is no requirement to actually touch the patient or really even ask them how they’re doing except to ask if they are depressed/falling/able to pay their bills.

  3. One point appearing in JustADoc’s comments rung a bell. More than once have I seen a doc (not Dr.Dino, to be sure) who, during an exam, looked at paper work, Xrays, MRIs, etc, but who never touched me or even looked at me other than when saying hello and goodbye. I felt cheated in a way because the exam was not of me but of paper and pictures and could have been done by phone without my having been in the doc’s office. This, to be sure, might adversely have affected the doc’s ability to collect money from the patient or from an insurer but still, I felt that for what was done and accomplished, I need not have visited the doc in person. (The C in COG is not for nothing.)

  4. The Medicare “physical” is a bad joke: inadequate for new patients, and redundant for established patients, a waste of time for everyone involved. I did one and said never again.

  5. The Medicare “physical is a bad joke: inadequate for new patients, as well as redundant for established patients, a waste of time for everyone involved. I did one as well as said did not once more.


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