Thou Shalt Do More Physicals

Not long ago, I wrote a piece about the futility and waste of annual physicals. Soon after that, I suddenly saw the light. Or, rather, my CEO and COO educated me about why so many people still want physicals so badly: Obamacare is still with us.

When the Government regulates health care, medical sense is often disregarded and Medicine is replaced by Metamedicine.

Medicare has it own sets of parallel realities, and in my type of clinic Medicare is the largest health insurer we deal with.

Medicare covers a talk session they call the “Annual Wellness Visit” but doesn’t pay for physicals at all, except the HMO-like “Medicare Advantage” plans that survive through rationing diagnostic tests and also through extra reimbursement from the Government. They pay us a fee every year for providing them with a list of the specifics of our patients’ diseases and disease complications. This is what helps them get the extra money from the Government to cover their patients’ health care costs.

All the commercial insurances, like Anthem, Aetna, Cigna and the Obamacare companies put together, make up a smaller piece of our practice than Uncle Sam’s insurance for older Americans.

Those are the people that call for physicals and the people my bosses want me to provide them for.

This is why, and I kind of missed this ten year old fact:

Many people have lousy insurance with high deductibles, but under Obamacare “Annual Physicals” and many tests that can be construed as “screening” are FREE. So I have to pay more attention to the realities of health insurance today.

If a patient with newly diagnosed extremely high blood pressure and exertional chest pain needs lots of blood work, stress testing and imaging, he or she may pay thousands of dollars out of pocket. Or if a patient has abdominal pain, weight loss and severe diarrhea and needs a colonoscopy, it is considered a “diagnostic” test and potentially quite costly to the patient.

If, on the other hand, a healthy person with no symptoms wants a baseline electrocardiogram (proven useless and not recommended by the US Public Health Service Taskforce on Prevention), a PSA test (not recommended), breast, testicular or digital rectal exam (not recommended), an annual instead of biannual mammogram (not proven more effective) or random blood panels (of unproven value), there is no cost. I have read, in business literature, that the most powerful word in marketing is FREE. In American healthcare, very few things are.

After I was spoken to by my superiors about how people want physicals, how they bring in more revenue than sick visits and how doing them is often counted as a “Quality Indicator”, I realized I can’t live in my Evidence Based bubble any longer. I now understand that the realities of practicing medicine trump science and clinical judgement. How could I have been so blind as to think otherwise?

I did some research. The key issue is what constitutes “Prevention”.

There is great confusion about what “prevention” means. I always thought the word referred to not smoking, not eating junk food or drinking dirty water, not being permanently parked in front of the television and so on.

Anthem says 85% of illnesses can be prevented, inferring that the Annual Physical accomplishes that. This is of course total garbage, unless you believe that the only opportunity to get people to eat right and exercise is by having their Annual Physical.

But there are several types of prevention. Listening to a lecture recently, my own sense of prevention has sharpened. I always thought of it as PRIMARY (not smoking) or SECONDARY (stopping after you get diagnosed with COPD). But there is more to it. Here is what I learned about the World Health Organization’s definition of prevention :

PRIMARY PREVENTION is, for example, not smoking. It is also taking aspirin just beacause you are a male over 50.

SECONDARY PREVENTION is, for example, finding asymptomatic disease through screening, like low dose chest CT for lung cancer or cardiac CTs to demonstrate coronary atherosclerosis.

TERTIARY PREVENTION is treatment to minimize the effects and progression of symptomatic disease, like taking aspirin or Lipitor because you already had a heart attack.

I just never thought of screening as a form of prevention. I guess I took the word too literally.

So right now, we are working on my schedule and patient “panel management”: How many physicals can I do in a year, how many patients am I responsible for and, if the numbers don’t match, should I relinquish some physicals or some sick visits? Where is my 30+ year experience best utilized – by screening and motivating the well or caring for the sick?

I used to know the answer…

5 Responses to “Thou Shalt Do More Physicals”

  1. 1 P Miller MD February 18, 2018 at 1:03 pm

    The problem as I see it is that we’re working in an antiquated system, fee for service run by accountants in the interest of stockholders. In the long run, preventive care pays for itself. Plus the Hippocratic Oath; let us practice medicine.

  2. 2 SGwock February 18, 2018 at 8:01 pm

    see this article from NYTimes last week:

  3. 3 Laurence Bauer February 19, 2018 at 7:23 pm

    Many practices I’ve learned use NPs or PAs or clinical pharmacists to do the annual visit. The doc does not need to participate. Let me know if you want details.

  4. 4 Christine Segatti April 27, 2018 at 2:12 am

    Hi. I found your blog in a mad search for discussions on the value of a hands-on physical. A week ago, I saw a new doc. His practice is a PCMH, of which he’s very proud. The practice provides elder care only. I thought this would be great for me. Bloodwork was ordered the week before by his CRNP. My visit, although lengthy, consisted of a review of the results. Period. My complaints of areas of chronic pain were shrugged off–“Google videos of exercises for seniors.” He never touched me. I feel ripped off!!! Your thoughts, please?

    • 5 acountrydoctorwrites April 27, 2018 at 2:16 am

      Physicals are aimed at finding stuff that could shorten your life or maim you. What you are looking for is problem solving of your symptoms or limitations. If we only did that, pneumonia shots and colonoscopies wouldn’t happen.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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