The New England Journal of Medicine recently ran a Pro -vs- Con op-ed debate on the merits of well-patient visits in primary care. Like other such discussions, wellness visits were conflated with physical exams, the operative words are wellness and physical exam, not annual. Wellness visits and physicals are 2 completely different things, different processes, different goals, and thus it is unreasonable (if not a completely misguided use of the research literature) to address them as one entity.
Annual Wellness Visits
The annual wellness visit (AWV) has been around for some time, though widespread implementation is a recent innovation - Medicare started in 2012 and all non-grandfathered health plans started in 2014 under the Affordable Care Act. Almost all health plans now provide an annual benefit of a no-copay, no-deductible visit with a primary care physician (PCP) for the purposes of assuring appropriate vaccinations, cancer screenings, and cardiometabolic risk factor measurements are up-to-date.
Further, the AWV should include a forward-looking 5-10 year personalized prevention plan (PPP), so that these preventive factors stay current. In theory, a PCP and low-risk patient might agree to do AWVs less frequently than once a year, though that should be a decision between a patient and his or her doctor.
More important, the PPP should refer a patient, if appropriate for his or her situation, to community-based risk reduction intervention services. Section 4103 (b)(2)(F) of the Affordable Care Act specifically delineates that patients who have primary, secondary or tertiary prevention needs should receive:
The furnishing of personalized health advice and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
By my rough math, with about 1-in-5 patients having hypertension, 2-in-3 being overweight or obese, 1-in-4 being completely sedentary, 1-in-11 being diabetic and 2-3 times that many being pre-diabetic...uh, that’s a lot of folks who should be referred to these programs!! Accounting for co-morbidity among these diagnoses, probably ½ of all people are “appropriate” from a medical perspective. Yes, about ONE HALF, give or take.
In contrast, the annual physical exam (APE) is mainly a physical exam and screening tests - often the very same tests that are part of an AWV. The AWV does not include a physical exam, though an astute physician might well do a limited exam if, for example, the patient said they didn’t walk much because his or her knees hurt after they walk. The purpose of the exam there would be to see if physical therapy or some other evaluation / treatment might help the person walk without having pain.
Annual physicals have been around for a really, really long time - maybe even as long as there have been doctors. The head of student health services at my medical school was very interested in their value, as it’s been known for over 30 years that physical exams on asymptomatic individuals don’t provide much return on investment. In some cases they may even be more bother than benefit. Nonetheless, it's easy to find old-tyme doctors who will vouch for the few times that they found a melanoma or other badness, but on balance the meta-analyses are against annual physicals.
It is worth reading the fine-print of those meta-analyses, though, because the Cochrane review(1) included 16 studies in their primary analysis while excluding 124 studies. In particular, they excluded the kinds of studies that might have been more like an AWV, or that attempted to help patients thrive (as opposed to living longer). Thus, it is scientifically inaccurate to discard AWVs based on the meta-analyses of APEs. The truth is that we don’t yet know the merits and demerits of the AWV as they are currently configured.
Quality-of-Life: Does Our System Really Care?
Now you know the truth about APEs and AWVs, but that was not the discussion in the New England Journal of Medicine, nor was it the discussion by Ezekiel Emanuel(2) in the New York Times earlier this year. It is worth noting that most of the American medical system, particularly academia, is dominated by specialists who financially benefit from people who are not healthy. American physicians are trained to manage disease, not to produce health and well-being to keep patients thriving. So when one reads an op-ed by a physician opposed to preventive services, it is worth bearing their bias in mind.
I'm not saying physicians want people to be sick, having worked with them for nearly 30 years I don't think they do. Still, specialists, clinics and hospitals make money by treating people who aren't well. Following this rationale as the value of physicians to society, Mehrotra and Prochazka(3) subscribe to a medical culture that views the physician's "top of license" as the diagnosis and management of disease. They have a point, and in an era where we have a shortage of doctors, there is much merit to employing physicians in this way and letting allied health professionals do "wellness".
Others, such as Goroll(4), hold a view that physicians should go beyond mere medical outcomes, that we should also address well-being. In this perspective, true healers try to minimize the burden of chronic disease, helping patients maintain their quality-of-life and liberty to pursue happiness. Also, it is worth stating that, in contrast to other professionals, physicians are conferred a level of moral imperative on health matters that our society holds in unique esteem. Whether or not we agree or follow the advice, we all want to know what our doctor thinks is best for us.
It may or may not provide much return-on-investment, but there is value for having a visit with your doctor where he or she isn't burdened with difficult diagnostic or management decisions, and can just tell you what he or she thinks about improving your health and well-being. All too often, physicians don't start addressing quality-of-life until there is little left to offer a patient. This is mostly a consequence of trying to help patients to the end of our medical ability, but in a fee-for-service world one must also make the uncomfortable acknowledgement that a doctor's financial incentive is to keep treating until they can't do any more, and then bring up quality-of-life.
Why does our system not put a high value on quality-of-life before the end-of-life?
Is medicine solely about prolonging survival, or do physicians also have a duty to help patients thrive despite chronic conditions?
Investing in Well-Being
Such is the noble purpose of wellness visits, which is why it is an abomination to conflate them with annual physicals. Those who advocate throwing out well-patient visits overstate the evidence, improperly using it to support their bias towards a culture of disease care and that under-values quality-of-life.
The Affordable Care Act tasks physicians and employers with investing in health and well-being. Health care administrators who speak against wellness visits have lost sight of the humanitarian need to help heal, superseding patient needs with poorly-applied “evidence-based” policy(5).
The plain truth is that there aren’t enough lifestyle intervention staff to handle half of all Americans, mainly because health care policies won’t cover their services with compensation sufficient to sustain their businesses. I've met many people who have a master's degree in exercise science, but who quit their careers and went to work for a Big Pharma company because they couldn't support their families on what an exercise physiologist is paid.
People need help being more active, but what our system pays for is prescribing a pill. Better yet, get a procedure done by a highly-paid specialist, using an expensive high-tech gizmo that requires taking a pill a day forever. All the high-tech and specialists are wonderful resources that are welcome innovations, but health plans need to pay for the lifestyle intervention professionals too. The 3 most under-paid and under-valued allied health care staff are social workers, nutritionists and exercise physiologists. We must make better use of their training.
Some years ago, I had a patient who had spent 9 months in the hospital waiting for a heart transplant, at a cost in excess of $2M, and who then in the year after transplantation needed valve replacement surgery on the transplanted heart (a most unusual outcome, and the only such case I know of). His insurance denied him coverage for cardiac rehabilitation. I wrote the medical director of his health plan, noting that this was penny wise and pound foolish, and as I recall we eventually got approval for 12 sessions.
Long ago, Francis Peabody taught us that the secret of patient care is in caring for the patient. He must be rolling over in his grave(6).
1) Krogsboll LT, Jorgensen KJ, Gronhoj Larsen C, Gotzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2012; 345:e7191-e7191.
3) Mehrotra A, Prochazka A. Improving Value in Health Care — Against the Annual Physical. N Engl J Med 2015; 373:1485-1487. DOI: 10.1056/NEJMp1507485
4) Goroll AH. Toward Trusting Therapeutic Relationships — In Favor of the Annual Physical. N Engl J Med 2015; 373:1487-1489. DOI: 10.1056/NEJMp1508270
5) Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (ed). The Mid Staffordshire NHS Foundation Trust Public Inquiry. London; 2013.
6) Davidson CS. The Caring Physician: The Life of Dr. Francis W. Peabody. N Engl J Med 1993; 328:817-818. DOI: 10.1056/NEJM199303183281123
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