As a health economist, I try to keep abreast of new trends in health care insurance. One trend I have found is that consumers can now purchase short term health insurance policies that will pay for doctor visits if the patient is sick, but they will not pay for the standard “complete physical” associated with an initial visit. Some primary care doctors will not see a new patient unless the doctor can bill insurance for $350 – $500 for a comprehensive visit. If you search on the Internet for “head-to-toe physical” and “outdated,” you will find many web pages that provide arguments and evidence that the complete physical is indeed not necessary but may be reassuring for some patients. In contrast, the blood tests are ten times more important than a complete physical for new patients.
We often hear the argument that a good baseline physical exam with lab work is important and can help engage the patients in their own care as well as identify those patients at risk for heart disease, diabetes, and other problems. The patient centered medical home model is built on coordination of care, not sick care. For standard health insurance policies (those polices other than short term policies), at least one annual “physical exam” or wellness visit is covered 100% by insurance and no cost to the consumer.
I am looking for a new primary care physician and will be seeing one at the end of the month. This appointment is for a new patient and will be coded for insurance as “wellness visit, physical exam” even though there will be little or no physical exam. Instead, I plan to use the time to tell the doctor what blood tests I want on this visit to establish a baseline, and in the process of explaining why I want them, he will learn about my medical history. I doubt there will be any time remaining in the appointment for even a limited physical exam, but we shall see.
My cholesterol numbers are not simply excellent, they are outstanding. The same is true for my C-reactive protein (a measure of heart attack risk) and homocysteine (a measure of stroke risk). I have not had a complete physical exam in over 20 years and have not missed them one bit. I find it appalling that any physician would palpate my abdomen and then tell me I don’t have any tenderness there, as if I did not already know that. I am all in favor of preventive health care, but I agree with the U.S. Preventive Health Task Force that the complete physical exam has not been shown to be cost effective at preventing disease. Blood testing, on the other hand, is critical to monitoring overall health and critical to formulating a strategy to prevent diseases and medical conditions.
I have been asking primary care docs for several years now if they have ever found an abnormality on physical exam in an asymptomatic patient that was not picked up as part of standard screening (PAP smear, colonoscopy, lab testing, etc.) There have been minimal positive responses. (One doctor found an oral cancer). Standard screening could be done much more effectively and efficiently by non-physicians as part of a public health campaign: think of the Polio vaccination campaigns of the 1940s and 1950s.
Having said that, a consultation with the patient/client for health planning purposes — identifying what is important to him/her and the impact of health issues on those things that are important and then coming up with a mutually acceptable plan on how to achieve those goals — is probably invaluable, especially if the physician has no financial interest in the choices that are made.
Yet we find an amazing lack of evidence to support “annual physicals exams” leading to early detection of health problems. I invite the proverbial interested reader to click on the link at the bottom of this article to find the reference for the National Institute of Health’s pubmed link related to annual physicals.
In examining a population of junior high and high school student athletes who were required to get “participation physicals” in order to play on sports teams, one study found of 1268 students, 5% were referred to specialists, but only 0.2% were disqualified from playing the sports activity. The author concludes that the majority of those disqualified would have been discovered by obtaining a detailed medical history alone. Another study of 763 student athletes found 3 positive referrals total. Factoring in the cost of all the health workers involved, each of these three findings came at a cost of $4563. In addition, a total of 16 medical problems were found during the course of the 763 student physicals, BUT 15 of the 16 problems were, and could have been identified, from taking the patient’s medical history alone.
How do you think most primary care physicians would react if a new patient went over his medical history but declined more than a cursory physical exam in favor of getting his desired blood tests? Would the typical primary care doctor simply note “patient declines complete exam” and move on, or would he/she badger the patient into getting a complete physical, because that the way the doctor always handles new patients? One problem with health care is that patients are generally obsequious and fall into lockstep patterns of getting certain exams or tests even though they have little to no benefit on overall health.
I frequently hear from foreign-born and foreign-trained medical doctors that “here in the US, doctors spend too much time on treating people after they get ill and not enough time of preventing the illness from occurring.” But what does this mean in practical terms? (1) doctors should be ordering more blood tests to determine average glucose levels (HbA1C test) such that all patients know their HbA1C numbers and whether they are inching towards diabetes. Other helpful blood tests would include a hormone panel for all middle-aged or older patients, and then the doctors need to learn about optimal levels for these hormones, rather than ignorantly dismissing results that fall in the “normal average” range but may be sub-optimal. (2) doctors need to have staff who can answer patients’ health questions, e.g., whether the patient should start taking magnesium, without placing a burden on the doctor to answer all these questions. (3) patients need to be given targets for HbA1C, HDL, total cholesterol/HDL ratio, cortisol, etc., to achieve through their own proactive, informed selection of food choices.
I can’t think of any blood test that would be ordered solely to make a patient aware. As a general rule, no physician would be able to estimate the results from a blood test, e.g., no physician can estimate HDL cholesterol or total cholesterol just from talking to a patient and getting his medical history. When insurance companies stress preventive health, they always emphasize doctor exams over laboratory tests. But again, no doctor exam can reveal 3-month average glucose, or iron deficiency, or elevated liver enzymes. It sounds like some insurance companies want to do preventive health on the cheap, and with that attitude, they should not be surprised that the limited type of preventive care they support is next to worthless.
To say that the annual physical is worthless without reinforcing to the public that some monitoring of health is necessary probably sends the wrong message. After all, it is hard to argue that monitoring of hypertension, lipidemia and diabetes is not worthwhile. FDA has generally indicated by its refusal to approve OTC versions of the maintenance medications that the public cannot be trusted to monitor or manage these maladies.
I am all in favor of monitoring hypertension, lipidemia, and diabetes. In fact, where the Affordable Care Act recommends diabetes checking for people with hypertension, I would go further to say everyone should know his or her HbA1C number (3-month average of glycated hemoglobin). But why shouldn’t those values be checked in an ordinary preventive health visit, without the need for a head-to-toe physical? None of the articles have said that lab tests are worthless; they tend to question the value of the “annual physical” for an asymptomatic healthy adult. Indeed some doctors have recognized this fact and give patients a more limited and directed physical exam. That approach seems more sensible than the “one size fits all” approach with head to toe exams.
The FDA has generally indicated that the public cannot be trusted to monitor or manage these maladies. I strongly disagree with the FDA and question its motives in preventing cholesterol and hypertension medications from being accessible OTC. I hope in my lifetime that they do become available. An enlightened individual can use the Internet to learn about drugs that lower blood pressure, glucose, and lipids, along with the drug’s side effects. At-home blood pressure devices are more effective in monitoring real-world blood pressure than periodic visits to a doctor’s office. An enlightened patient can precisely individualize dosing of anti-hypertensive medications to bring their blood pressure to optimal levels (below 115/75 mm Hg in most people).
For an expanded version of this article, please see http://www.michaelguth.com