Having an annual exam and preventive screenings is the key to good health — or is it?
The answer may depend on who you ask and what you’re trying to achieve. Experts have become so divided on the annual exam that the New England Journal of Medicine’s October 2015 issue addressed it with two articles written by physicians: one article supporting the annual physical and one advising against it.
Likewise, some preventive screenings have been in debate in recent years. While many preventive screenings can identify health problems early, that’s not always the case. Studies have shown that some screenings have doubtful value, while others can lead to unnecessary treatment and some may even cause harm to some patients. Consumer Reports notes that “Many Common Medical Tests and Treatments are Unnecessary” and offers examples such as giving EKGs to patients without risk factors during routine exams.
This “insights” publication aims to help employers:
- Sort through conflicting opinions.
- Offer a list of screenings that experts agree are worthwhile and so may be worthy of incentives.
- Use a to offer incentives for the annual physical or preventive screenings.
Why Some Employers Encourage Annual Physicals
Some employers want everyone covered by their health plans to get an annual physical. They want to meet these goals:
- Encourage employees and family members to have an ongoing relationship with a primary care doctor.
- Encourage employees and family members to get preventive screenings that are recommended for early detection of chronic or potentially life-threatening conditions.
Unfortunately, employers cannot assume that every doctor’s office already offers patients all their recommended preventive screenings. A study published in January 2012 in the American Journal of Preventive Medicine showed that patients were typically due for five to six preventive services when they visited the doctor, but received only three. The study examined care for patients ages 50 to 80 who made nearly 500 visits to Michigan family-practice and internal-medicine doctors.
Some employers may use incentives to encourage annual physicals, preventive screenings or both. Appendix A provides a form adapted from Monroe Truck and Equipment, Monroe, Wis., which offers a financial incentive of to employees who get an annual physical plus recommended screenings. Employers can revise this form to require only the annual exams, only preventive screenings, or both the exam and screenings.
Where the Annual Exam Falls Short
When the annual exam identifies a significant health problem, there’s no doubt it’s a “win.” But what if it leads to a “false positive” test result that requires more testing or treatment, even if there’s nothing actually wrong with the patient? Or it identifies a problem that is sometimes linked to unnecessary treatment, such as thyroid nodules?
“There have been many studies of the effects of these annual checkups,” states The Choosing Wisely publication on “Health Checkups: When You Need Them and When You Don’t.” “In general, they won’t help you stay well and live longer. And usually they don’t help you avoid hospital stays or keep you from dying of cancer or heart disease.” Choosing Wisely is sponsored by the American Board of Internal Medicine (ABIM) Foundation. It works with specialty medical associations to help patients and doctors have conversations about unnecessary care.
One issue with the annual physical is that its components can differ significantly from one provider to another. In some cases, this means that having an annual physical results in unnecessary tests. The U.S. health system spends $300 million a year on unnecessary tests ordered in annual physicals, according to Choosing Wisely.
Another issue is the organization of modern physician offices, which may support a primary care doctor’s practice with physician assistants or nurse practitioners. Patients who call for an appointment may not see “their” primary care doctor and will instead have an appointment with the physician assistant or nurse practitioner. So while an initial physician visit will create a relationship with a specific physician office, it can be argued that subsequent visits are unlikely to extend that relationship since the patient might see a different health professional at each visit.
The availability of medical staff could make scheduling routine physicals more difficult in the years ahead, when primary care physicians are expected to be in short supply. Approximately 10 percent of primary care visits are for annual physicals, according to “Improving Value in Health Care – Against the Annual Physical,” published Oct. 15, 2015 in the New England Journal of Medicine. As fewer physician appointments are available, more appointments may be reserved for patients with urgent issues, making it more difficult to schedule an annual physical.
Benefit/Risk Characterization Theater Approach
Dr. Andrew Lazris and Erik Rifkin, PhD, summed up the debate about the annual preventive exam in their book, Interpreting Health Benefits and Risks: “The annual exam is a forum to look for problems about which the patient may be unaware…But by fishing for problems, we may uncover false positives: abnormal results that are not reflective of real disease.” They also noted that there is another danger: “false negatives, where tests or exams are normal in the face of real disease, a situation that sows a sense of false security.”
Lazris and Rifkin developed the Benefit/Risk Characterization Theater (BRCT) approach to help engage patients in shared decision making about tests and treatments. As part of this process, they use an illustration of a theater with 1,000 seats to illustrate the benefits and risks. Lazris and Rifkin shared the BRCTs for the annual exam and annual blood tests at The Alliance Annual Seminar on May 16, 2017.
Finding Middle Ground
There may be middle ground in this debate. An employer who wants to use an evidence-based approach to encourage employees to seek appropriate preventive care can create a program with three components:
- Encourage employees to have an initial visit with a primary care physician so they have a relationship in place when problems arise.
- Help employees understand when health checkups are useful. Choosing Wisely’s “Health Checkups” guide notes eight times when a checkup may be needed:
- When you are sick
- When you have a symptom that could mean illness
- To manage chronic or ongoing conditions
- To check on the effects of a new medicine
- To help with risk factors like smoking or obesity
- For prenatal care, if you are pregnant
- For lifestyle issues like family planning, sexually transmitted disease (STD) prevention and healthy eating, especially if you are a young adult.
- For other reasons based on your individual needs.
- Base rewards for preventive screenings on evidence-based information. The U.S. Preventive Services Task Force (USPSTF) provides guidelines on preventive screenings. Choosing Wisely and Consumer Reports are also reliable sources for evidence-based information about preventive screenings.
The Role of Plan Design and Time-Off Policies
Employers who self-fund their health benefits often have the flexibility to use plan design and incentives to encourage preventive screening. Under a value-based benefit design approach, an employer may choose to cover high-value services and screenings at 100 percent. The Affordable Care Act (ACA) also requires 100 percent coverage for immunizations and evidence-based screenings for adults that currently have an “A” or “B” rating from the United States Preventive Services Task Force (USPSTF). The USPSTF is an independent panel of clinicians and scientists that works under the Agency for Healthcare Research and Quality. It is unknown whether this requirement will be removed or revised as part of health reform.
If the ACA requirement is revised or removed, employers may choose to continue to offer 100 percent coverage as an incentive for employees and dependents to pursue evidence-based screenings.
Time-off policies can also play a role in determining whether employees get preventive screening. One study showed that employees who had paid sick-leave had “significantly higher” rates of participation in mammography or colorectal cancer screening, which typically require several hours or even a full day off work to complete. Some sources suggest that employees may be more likely to have tests if they receive an additional time-off benefit – that is not charged against accrued sick time or other paid time off – to use for specific cancer screenings.
Preventive Services Covered by Private Health Plans under the Affordable Care Act, The Henry J. Kaiser Family Foundation, Aug. 4, 2015, accessed on March 20, 2017.
Getting Started: Eight Tests You Need
Consumer Reports’ recommendation of “Eight Cancer and Heart Tests You Need” can be a good starting point for a preventive screening program that links to a monetary or time-off incentive. But even for these eight tests, there are exceptions based on age, gender and health history. Only the first item on the list – blood pressure – applies to everyone. And two items on the list – screenings for osteoporosis and abdominal aortic aneurysm – are recommended only for people above age 65, which means they may not be useful for the general population at many workplaces.
Here’s the full list:
- Blood pressure. Good for everyone, this test gives you a reading of your systolic (upper) and diastolic (lower) number. It should be done at least every two years and annually if your readings are at or above 120 over 80.
- Cervical cancer. This consists of two tests recommended for women ages 21 to 65.
- A pap smear, which analyzes cervical cell samples. Women should have a pap smear every three years, but can go five years between tests if they have an HPV test at the same time they have the pap smear.
- A human papillomavirus (HPV) test to detect the HPV virus, which can cause cervical cancer.
- Cholesterol. This test is recommended at least every five years for men ages 35 and older and women age 45 and older when they have other risk factors. Examples of risk factors are high blood pressure or smoking. The test measures levels of three types of cholesterol: LDL (the “bad” kind), HDL (the “good” kind) and triglycerides, which can clog arteries with fat.
- Diabetes. A diabetes test measures your blood glucose level. The test is needed every three to five years for anyone with one or more of these three risk factors:
- Systolic blood pressure over 135 or diastolic pressure over 80.
- Obesity, indicated by a body mass index of 30 or higher.
- LDL cholesterol over 130.
- Breast cancer. Women ages 50 to 74 should have a mammogram every two years. Women who are in their 40s or age 75 or older should talk to a doctor to see whether a mammogram is recommended based on their individual risk factors.
- Colon cancer. Tests for colon cancer are recommended for people ages 50 to 75 (see The Alliance’s “Insights on Colorectal Cancer Screening” for more information). When you should have the test differs based on which of these three types of tests you choose.
- A colonoscopy every 10 years.
- A sigmoidoscopy every five years, when combined with a stool test every three years.
- A stool test every year.
- Osteoporosis. Women age 65 and older should have the dual-energy X-ray absorptiometry (DXA) scan to measure bone density once, with additional tests based on the results of the initial test. Men age 70 and older should check with the doctor to see if the test is recommended.
- Abdominal aortic aneurysm. An abdominal ultrasound is used to look for a ballooning of the main artery that carries blood from the heart to the rest of the body, which can be a fatal condition. This test is for men ages 65 to 75 who smoked at some point in their lives. Unless the first test reveals an abnormality, the test is only conducted once.
Source: Eight Heart Tests and Cancer Tests You Need, Consumer Reports
An Employer Checklist
Here are seven steps to help you create a preventive care strategy that meets the goals of your company.
- Decide what goals and information will guide your decisions. Relying on evidence-based guidelines is always the “gold standard.”
- Choose the behavior you want to reinforce. Do you want employees to get an initial visit or an annual visit? Or do you want to emphasize preventive screenings? Be specific as you develop your program.
- Determine whether plan design plays a role. Under the ACA, employers were guided by the ACA’s requirement to cover screenings at 100 percent. Health reform could change that requirement. If it does, will your company change its benefit plan?
- Consider other factors that might encourage or discourage employees from getting preventive screening, such as time off policies.
- If you decide to offer a financial reward, figure out how to make the reward pay off for your company. Issues to consider include:
- Deciding how to notify employees that a reward is available.
- Creating a method to verify that employees received the targeted care, which will trigger payment of the reward. Appendix A offers one option, but your TPA or broker may have more ideas.
- Telling employees how often the reward has been used. While you must never share personal health information, you can tell employees that 12 employees have already received a check for getting preventive screening, for example. People hate to “lose out” on a financial reward that others are getting.
- If you decide to encourage or reward the annual physical, help patients prepare to use the time with the doctor wisely. The Better Health Care Consumer booklet and presentation from The Alliance provide information that “coaches” employees about questions to ask and how to talk with doctors and other health professionals.
- Stay current. Guidelines for preventive screenings evolve over time, so periodically check to make sure your program is still in line with the evidence that supports preventive screenings.