There was a time when patients would see their personal physician only when they were sick. Then came preventive medicine and now many patients only see their doctor when they are well. When they are sick, the doctor has no openings and they are forced to go to walk-in care.
If a doctor has 1,500 – 2,000 patients and works 2,000 hours per year, more than half their time is probably spent on routine exams (for commercially insured patients) or Annual Wellness visits (for Medicare patients).
Commercially insured patients generally get a free physical, which is often cursory, and random bloodwork, often referred to as “routine”. The reimbursement for such visits is generous.
The US Public Health Service Taskforce on Prevention declared long ago that neither the exam nor the blood tests have any proven value from a prevention or early detection point of view. Choosing Wisely says the same thing.
The Medicare Wellness Visit is also called an exam, but the only thing that is more or less hands on is the mandatory blood pressure recording. Other than that, it is a talk visit. The first one of these includes a Mickey Mouse eye chart test, like the one at the Bureau of Motor Vehicles, and a baseline EKG, another test of no proven value. Every Wellness Visit pays more than a commercial insurance physical, but if you skip over offering frail 90 year olds testing for HIV, Hepatitis C or anything else on Medicare’s agenda, they might take their money back.
The cruel irony here is that sick people have deductibles and copays for their visits and testing. This can discourage patients from seeking care and getting new problems diagnosed in a timely manner.
According to The Motley Fool, a third of American families have trouble coming up with $400 to cover an emergency expense. And that’s an improvement compared to a few years ago. Yet, the typical annual deductible for commercially insured patients is several thousand dollars. So, many people hesitate to seek medical care they really would like to have.
Is that an ethical and sustainable way to provide health care coverage for hard working Americans?
It is time to consider a different copayment structure as a temporary way to humanize health care until we join the rest of the world in providing government financed universal basic health care for all:
– Provide free but voluntary mass screenings for proven things like blood pressure, blood sugar, cholesterol and mammograms.
– Cover a couple of doctor visits per year without cost for things each patient prioritizes. For some, that might be their hypertension or diabetes care, for others, their annual sinus infection or asthma/COPD flareups.
Like lawyers, we should at least be able to provide one or two free initial consultations. And, speaking of lawyers, the value of our time should not be restricted to face-to-face encounters.
But that’s a different pet peeve of mine.
A Country Doctor Writes: 
That is exactly why I left my practice in 2015. It was like practicing in Alice and Wonderland.
Rosemary Sherman M.D. 1973
Great wisdom, far to simply to adapted, medicine is no longer a healing art.
Well stated, Hans. Thanks for the post.
You describe a lot of the reason I left the practice I loved to build the business I am in.
The US health care system provides the lowest value care in the economically developed world. Though we have great diagnostic and treatment technology, and great care is available, health care is poorly distributed and often inaccessible.
We can do a much better job. There is plenty of money in the system. We have enough work force. Part of Better is to learn techniques that have long been in use in other service industries. Another part is to break habits firmly established in tradition, regulation, and expectation by patients, providers, payers, and regulators.
The main reason I see my pcp for annual physical is to stay active on his panel, because our HMO requires a pcp referral for any specialty referral from ophthalmology to derm to orthopedics.
It was a nightmare when my husband was in a serious accident, needed prompt ortho f/u after the ED, but had fallen off his pcp’s panel due to being healthy thus not checking in for over 2 years (during which time the pcp who’d known him forever retired & was replaced by a newbie). The practice said they couldn’t get him in for a new pt appt for a month. So I spent 2 days on the phone getting him hooked up with a new practice with a new pcp who could see him that week – all to get the urgent ortho appt made & covered by insurance.
Moral: useless as it is medically if you’re healthy, if you’re an HMO member make sure you’re seen by pcp every 2 years or less.
USA should follow other first world countries(Canada, Australia, New Zealand , England) in every systems, specially health system…..
I’m a healthcare consultant, not a clinician, but I try to advise ambulatory practices on regulatory compliance and quality management with the two primary goals of effective health care for patients and practices succeeding as a business, to keep their doors open. This is a great article and an eye-opener on the siren call of “preventive care” competing against what patients want and need. It is yet another example of the “tail wagging the dog” in US healthcare, with reimbursements and payer plans overriding the needs of patients as well as the judgement of physicians. Thank you for this informative and well-written perspective from a doctor!
Are you out of your mind? Many primary care doctors are going under, quitting, looking for a way out and are grossly underpaid. And you want free consultations? And you think exams are overpaid? I agree with you about the Medicare annual wellness. That was never about patient care, only acuity documentation so health plans can get more $$. But the rest of your argument falls flat.
Free to the patient, paid by insurance. I certainly don’t work without compensation. Reason primary care doctors are quitting is that we are asked to do the wrong things instead of what matters the most.
I disagree. I am a primary care internal medicine doctor and I find the annual physical and wellness exam to be invaluable. It keeps me in touch with what’s going on with that patient so I know the latest developments in their healthcare and it allows me to be sure that they are keeping up with preventive services that can make a difference. I do a comprehensive physical exam, “routine lab work“, directed lab work, and over the years during that exam I’ve discovered multiple breast cancers, prostate cancers, colon cancers, liver disease, kidney disease, diabetes and other previously unknown conditions that needed attention. If I keep this up with a regular exam every year and the patient comes down with something acute I have a baseline to compare their new exam to. I can address disease at an early stage before it has a chance to progress. With the help of a physician assistant I am able to see any patient with an acute problem within 1 to 2 days. Now, my patients may be more complex than yours, and maybe that’s why this model works so well for me. But don’t rule out the benefits of a regular physical exam on the patient with chronic illnesses.
This is SPOT ON. We get crushed by “ annual physicals “ which are never just about preventative care – rather a list of things the patient did not want to make separate appointments for. The Medicare wellness – while well intended takes so long that one cannot possibly address all the items required- not to mention the very important code status- advanced directives section. Patients cannot get seen urgently an more and end up in urgent care/ ED instead.
The current system of American Healthcare needs to completely collapse before people realize we would be better off with single party payer.
So very true! I can speak also from the pt’s point of view. Recently I had my annual check up. Apart from answering stupid questions like : do you wear seat belts or a helmet when riding a bike. I had a health issue that needed to be addressed. “Not now. This is your wellness physical. You need to make a separate appointment for that!” I was told. Well I never did because I would have had to take another day off from work. The American health system is set up to make patients sick since sickness makes a lot of money for too many “providers” like hospitals, health insurance and above big pharma.
My experience: If you turn 65 and are fortunate to be healthy, it doesn’t matter. When you go in to see a new, very very young primary care doctor for the first time, they will virtually hurl statins, SSRIs, and CPAP machines at you before looking up from their Epic screen.