RE: Value of an Annual Physical Exam

[Guest guest]

Dr.

Frame, a Family Physician in Upstate New York, studied the “Annual Physical

Exam” issue a number of years ago and published a number of articles about it

that could be accessed by a literature search. The basic conclusion was that almost all of the history and

exam items in the “traditional” PE were not cost-effective, considered in the

sense of both false positives and false negatives. (The current preventive-care guidelines of the U.S. Preventive Services Task Force and

the Canadian Task Force on Preventive Health

Care were based on such studies.)

To be

effective medical interventions, “H & P” items must satisfy all of the following

conditions: (1) common in the relevant population or sub-populations, (2)

non-symptomatic until discovered by the examiner, (3) capable of reliable

detection by the standard screening exam (considering the consequences of both

false positives and false negatives), (4) having an effective intervention

available for a detected condition, and (5) the intervention is likely to make

a significant difference in the patient’s health, function or longevity.

Blood

pressure, pap, mammogram, and now-days cholesterol screen are some of the few actions

that satisfy the above screening effectiveness criteria, and usually at longer intervals

than every year. A simplified

history (even by phone!) could accomplish most of the other cost-effective screening

needed. These studies were done several

decades ago when the “Executive Physical” for $500 to $1000 was popular for the

well to do, a total waste of money for those with money to burn. The annual physical idea started in the

early 20th century when medicine was much more primitive and

virtually “veterinary medicine” with almost no history obtained, when people

believed in “doctor’s orders” without questioning. It was observed that advanced cancers were often seen at

such visits, where earlier visits might have allowed surgical cures. This was before anyone thought of

placing responsibility on the patient for watching for the “seven signs of

cancer” and then coming in to get them checked, and before the population was

taught to ask for those few modern cancer screens we have now like paps and

mammograms.

My

conclusion: The “Annual Physical” on healthy non-symptomatic patients is useful

primarily to become acquainted with the patients and encourage establishing a primary

care “medical home”. The screening

guidelines should be reviewed whenever the patient comes in for other purposes

(ideally having enough visit time to address all needed issues at the time of

that visit), and the EMR (or EHR now) should be programmed to suggest appropriate

preventive interventions automatically during the visit. A special “routine physical” visit would

then be needed in a healthy non-symptomatic patient only if there is no other visit

over a specified interval. (This

is the rationale behind the reluctant Medicare and insurance coverage of the non-symptomatic

PE.)

Wes

Bradford

-----Original

Message-----

From: Tom

Sent: Friday, December 03, 2004

8:01 AM

To:

Subject:

Value of an Annual Physical Exam

This brings

up two issues I have struggled with.

What is the value in an annual physical exam? And how does it mesh with our

goal of treating the whole patient at a visit (and not just a single

complaint)?

I understood our model to be one in which we have the time to address *ALL* of

our patients' concerns at the time of a visit. This presumably includes

preventive health issues. Doing this is how we justify all those 99214s

and (for some members of the group) 99215s to the insurance companies.

This is opposed to the traditional model, where a patient is seen for a single

complaint or several complaints, these are addressed, and that's that. Any

preventive health issues require the patient to schedule another visit (ie

annual physical). The reason for doing this is that the traditional model is so

time constrained that we have to limit what we do at any given visit.

But we have (presumably) structured our practices differently. When a patient

comes in for a complaint or blood pressure followup, we not only address that

issue, but also can review other things (so Mrs. , when was the last time

you had a mammogram? etc). So really, a review of preventive health

issues should be part of every patient encounter we have.

Many patients are seen routinely for followup of chronic problems, such as

diabetes or hypertension, and are seen maybe 3-4 times over the course of a

year. If we address even only one or two preventive health issues per visit,

over the course of a year we have addressed everything we would review in an

annual physical.

Granted, an annual physical may have value for a patient who does not come in

for routine followup.

Which brings up the second issue. Why should a complete physical exam be done

annually (as opposed to every 2,3,4, whatever years?) Are there any studies to

support the 'annual' frequency? My sense is that an 'annual' exam

recommendation is just a old tradition. I am actually surprised that so many

insurance plans allow it at all. (Of course, Medicare doesn't, although it does

allow one initially).

So, if anyone out there can provide some POEMS or other data to support the

value of an annual physical exam, I'd love to see it. I think before we

'market' an annual physical, we better have some good data to support its

value, both medical and financial.

So what does the group think?

Tom

With that said, I wonder if this is more of a

marketing problem than anything else. If informed consumers, which I would hope

include many with HSAs, are regularly bombarded with the facts about preventive

medicine, including that these types of evaluations SAVE them money in the long

run, I believe many would show up for their annual exam. The real problem for

us is to market it effectively (remember the Fram oil filter you can pay me

now or pay me later commercial?) and to really have a consensus on what the

preventive exam should entail.

·

F. Mydosh,

M.D.

1160 Chili Ave.

Suite 102

Rochester, New York 14564

(fax)

[Guest guest]

Wes:

This would then lead itself into an age appropriate H & P which does not need a comprehensive physical exam. So for a preventive H & P would you truely just ask age appropriate screening questions or include the medical school complete review of symptoms, perform targeted physical exam based on symptoms, and conclude the visit with recommendations.

I am often tempted to just perform what is needed based on medical literature, but find it difficult to charge patients for $135 for an hour of history and counseling when they may have been just as well served with a "sports" physical and a minute on healthy exercise, not smoking, and protective sexual relations.

I believe to maintain medical practice we all see the worried well and perform more physical and history examinations than truely benefits patients. However, the revenue stream to my clinic would not supprt me let alone a staff if I just treated acute visits. Perhaps marketing to hypertensive , diabetic, syndrome X, smokers, depressed, and obese patients would help fill the ranks and provide true interventions that make a difference.

I think I would need to expand my screening for medical disease to a broader patient population than just my patients. Marketing to businesses while providing counseling for those found to have disease, may be a differnent line of business than regular primary care.

I am interested to hear what others believe to be scope of primary care in the "" model. If we develop a model of care that meets needs, and has documented benefit, we could market these services to business, insururers, and patients. Could we dare to come up with a unit cost for preventive services?

"Wesley G. Bradford" wrote:

Dr. Frame, a Family Physician in Upstate New York, studied the “Annual Physical Exam” issue a number of years ago and published a number of articles about it that could be accessed by a literature search. The basic conclusion was that almost all of the history and exam items in the “traditional” PE were not cost-effective, considered in the sense of both false positives and false negatives. (The current preventive-care guidelines of the U.S. Preventive Services Task Force and the Canadian Task Force on Preventive Health Care were based on such studies.)

To be effective medical interventions, “H & P” items must satisfy all of the following conditions: (1) common in the relevant population or sub-populations, (2) non-symptomatic until discovered by the examiner, (3) capable of reliable detection by the standard screening exam (considering the consequences of both false positives and false negatives), (4) having an effective intervention available for a detected condition, and (5) the intervention is likely to make a significant difference in the patient’s health, function or longevity.

Blood pressure, pap, mammogram, and now-days cholesterol screen are some of the few actions that satisfy the above screening effectiveness criteria, and usually at longer intervals than every year. A simplified history (even by phone!) could accomplish most of the other cost-effective screening needed. These studies were done several decades ago when the “Executive Physical” for $500 to $1000 was popular for the well to do, a total waste of money for those with money to burn. The annual physical idea started in the early 20th century when medicine was much more primitive and virtually “veterinary medicine” with almost no history obtained, when people believed in “doctor’s orders”

without questioning. It was observed that advanced cancers were often seen at such visits, where earlier visits might have allowed surgical cures. This was before anyone thought of placing responsibility on the patient for watching for the “seven signs of cancer” and then coming in to get them checked, and before the population was taught to ask for those few modern cancer screens we have now like paps and mammograms.

My conclusion: The “Annual Physical” on healthy non-symptomatic patients is useful primarily to become acquainted with the patients and encourage establishing a primary care “medical home”. The screening guidelines should be reviewed whenever the patient comes in for other purposes (ideally having enough visit time to address all needed issues at the time of that visit), and the EMR (or EHR now) should be programmed to suggest appropriate preventive interventions automatically during the visit. A special “routine physical” visit would then be needed in a healthy non-symptomatic patient only if there is no other visit over a specified interval. (This is the rationale behind the reluctant Medicare

and insurance coverage of the non-symptomatic PE.)

Wes Bradford

-----Original Message----- From: Tom Sent: Friday, December 03, 2004 8:01 AMTo: Subject: Value of an Annual Physical Exam

This brings up two issues I have struggled with.What is the value in an annual physical exam? And how does it mesh with our goal of treating the whole patient at a visit (and not just a single complaint)?I understood our model to be one in which we have the time to address *ALL* of our patients' concerns at the time of a visit. This presumably includes preventive health issues. Doing this is how we justify all those 99214s and (for some members of the group) 99215s to the insurance companies.This is opposed to the traditional model, where a patient is seen for a single complaint or several complaints, these are addressed, and that's that. Any preventive health issues require the patient to schedule another visit (ie annual physical). The reason for doing this is that the traditional model is so time constrained that we

have to limit what we do at any given visit.But we have (presumably) structured our practices differently. When a patient comes in for a complaint or blood pressure followup, we not only address that issue, but also can review other things (so Mrs. , when was the last time you had a mammogram? etc). So really, a review of preventive health issues should be part of every patient encounter we have.Many patients are seen routinely for followup of chronic problems, such as diabetes or hypertension, and are seen maybe 3-4 times over the course of a year. If we address even only one or two preventive health issues per visit, over the course of a year we have addressed everything we would review in an annual physical.Granted, an annual physical may have value for a patient who does not come in for routine followup.Which brings up the second issue. Why should a complete physical exam be done annually (as opposed to every 2,3,4, whatever years?) Are

there any studies to support the 'annual' frequency? My sense is that an 'annual' exam recommendation is just a old tradition. I am actually surprised that so many insurance plans allow it at all. (Of course, Medicare doesn't, although it does allow one initially).So, if anyone out there can provide some POEMS or other data to support the value of an annual physical exam, I'd love to see it. I think before we 'market' an annual physical, we better have some good data to support its value, both medical and financial.So what does the group think?TomWith that said, I wonder if this is more of a marketing problem than anything else. If informed consumers, which I would hope include many with HSAs, are regularly bombarded with the facts about preventive medicine, including that these types of evaluations SAVE them money in the long run,

I believe many would show up for their annual exam. The real problem for us is to market it effectively (remember the Fram oil filter you can pay me now or pay me later commercial?) and to really have a consensus on what the preventive exam should entail.

· F. Mydosh, M.D.1160 Chili Ave.Suite 102Rochester, New York 14564 (fax) __________________________________________________

[Guest guest]

this is a real interesting topic.

i am seeing several types of patients:

healthy patients, those "worried well" or who just want reassurance that they are doing the right things,

required/regualtory exams: commercial drivers license, FAA medical certificate, school physicals; where they may or may not have a problem; and who will, with all other patients, fall into the following categories:

those who are at the beginning stage of a problem, often patients new to me, and if they had a previous doctor, were not screened appropriately, and where intervention now will prevent a disease;

those who have a problem who had no idea; often patients new to me, and if they had a previous doctor, were not screened appropriately, and where intervention now will prevent serious consequences of the disease;

those who have a problem(s) who are treated appropriately;

those who have a problem(s) who aren't being treated appropriately;

those who have an acute problem, not the result of an exacerbation of a chronic problem;

those who have an acute problem, the result of an exacerbation of a chronic problem, which may or may not have been treated appropriately, if they were even aware that they had a problem.

i agree and believe that the key lies not so much in the physical examination, but in the history. When i see new patients, most of the about an hour (usually more) i spend are spent on the history: review of systems, past medical/surgical history, social history and family history; significantly less time on the examination, and depending on the history, time for education, "anticipatory guidance" (yes, adults benefit from that, too) and recommendations, including additional screenings (pap, DRE with stool guiaic), and if appropriate, referrals for specialty screenings (mammo, colonoscopy) in addition to screening labs (cbc c diff, cmp, lipid profile (if >25), tsh, others as indicated, eg fsh, psa). i see a lot of elevated fasting sugars and am picking up huge numbers of pre-diabetics.

my assistant tries to get new patients to come in for blood and to sign a release prior to their initial visit. that way, i have all the sources of information at hand together: the patient, the screening lab work, and the old chart.

i believe there is tremendous value for the annual, or at minimum, initial history and physical examination and review in the "moore model" style of practice. for one, we get a thorough baseline. for another, we are better equipped to catch problems and concerns and address them before they become diseases. still another, when we do find a problem or disease, we can get patients into treatment earlier, with hopefully less morbidity and possibly less mortality-- we'll have to wait some time before we can run the numbers. additionally, and unfortunately, we catch "misses" by other doctors, who don't take the time and care that we can and do.

we have the time to ask the questions; we take the time to ask the questions. it's not just good for the drug companies--it's important to ask patients about sexual functioning, incontinence, constipation, quality of life issues. by asking, we make it ok to talk about hopefully anything.

patients also need to hear from us doctors (orthographically from the equine oropharynx) recommendations regarding diet, exercise, salt and fat intake, to take a daily multivitamin/multimineral, no straining with bowel movements, stop risky behavior like smoking, sexual promiscuity, no drinking more than one etoh equivalent/day and they don't roll over, to stop completely if indicated, go to AA if they need help, to stop methamphetamine use, to go to the local drug treatment program and when they're clean to return, the works. patients want to know what we think and will listen to us if we provide them with the recommendations and the tools to carry them out. "just don't smoke" is insufficient; give them the tools. i give patients a specific method, and i am tied to no specific method, because i want them to stop, however it takes. i give them specific information on what to eat and what not to eat, and tell them i don't expect them to

eat cardboard and drink water, nor do i want them to feel deprived, however i want them to make some significant changes, and encourage them to do so, and then follow them up.

the moore model is good medicine: individual attention to patients, listening carefully to them, putting the puzzle together, with appropriate screening, based on the USPHTF guidelines, along with patients hearing straight from us on an individual basis what we recommend and how to do it. it's actually what we are taught in medical school, and then de-learn in residency.

i remind patients that with inflation, the ounce of prevention in now worth far more than the pound of cure.

so how much is that worth? we know we're underpaid. insurance companies will never pay us what we're worth. sure, lobby for better pay.

to answer your question, kevin, i have plenty of work, my patients appreciate my care, and they send me their friends, co-workers and family members.

larry lyon

Egly wrote:

Wes:

This would then lead itself into an age appropriate H & P which does not need a comprehensive physical exam. So for a preventive H & P would you truely just ask age appropriate screening questions or include the medical school complete review of symptoms, perform targeted physical exam based on symptoms, and conclude the visit with recommendations.

I am often tempted to just perform what is needed based on medical literature, but find it difficult to charge patients for $135 for an hour of history and counseling when they may have been just as well served with a "sports" physical and a minute on healthy exercise, not smoking, and protective sexual relations.

I believe to maintain medical practice we all see the worried well and perform more physical and history examinations than truely benefits patients. However, the revenue stream to my clinic would not supprt me let alone a staff if I just treated acute visits. Perhaps marketing to hypertensive , diabetic, syndrome X, smokers, depressed, and obese patients would help fill the ranks and provide true interventions that make a difference.

I think I would need to expand my screening for medical disease to a broader patient population than just my patients. Marketing to businesses while providing counseling for those found to have disease, may be a differnent line of business than regular primary care.

I am interested to hear what others believe to be scope of primary care in the "" model. If we develop a model of care that meets needs, and has documented benefit, we could market these services to business, insururers, and patients. Could we dare to come up with a unit cost for preventive services?

"Wesley G. Bradford" wrote:

Dr. Frame, a Family Physician in Upstate New York, studied the “Annual Physical Exam” issue a number of years ago and published a number of articles about it that could be accessed by a literature search. The basic conclusion was that almost all of the history and exam items in the “traditional” PE were not cost-effective, considered in the sense of both false positives and false negatives. (The current preventive-care guidelines of the U.S. Preventive Services Task Force and the Canadian Task Force on Preventive Health Care were based on such studies.)

To be effective medical interventions, “H & P” items must satisfy all of the following conditions: (1) common in the relevant population or sub-populations, (2) non-symptomatic until discovered by the examiner, (3) capable of reliable detection by the standard screening exam (considering the consequences of both false positives and false negatives), (4) having an effective intervention available for a detected condition, and (5) the intervention is likely to make a significant difference in the patient’s health, function or longevity.

Blood pressure, pap, mammogram, and now-days cholesterol screen are some of the few actions that satisfy the above screening effectiveness criteria, and usually at longer intervals than every year. A simplified history (even by phone!) could accomplish most of the other cost-effective screening needed. These studies were done several decades ago when the “Executive Physical” for $500 to $1000 was popular for the well to do, a total waste of money for those with money to burn. The annual physical idea started in the early 20th century when medicine was much more primitive and virtually “veterinary medicine” with almost no history obtained, when people believed in “doctor’s orders”

without questioning. It was observed that advanced cancers were often seen at such visits, where earlier visits might have allowed surgical cures. This was before anyone thought of placing responsibility on the patient for watching for the “seven signs of cancer” and then coming in to get them checked, and before the population was taught to ask for those few modern cancer screens we have now like paps and mammograms.

My conclusion: The “Annual Physical” on healthy non-symptomatic patients is useful primarily to become acquainted with the patients and encourage establishing a primary care “medical home”. The screening guidelines should be reviewed whenever the patient comes in for other purposes (ideally having enough visit time to address all needed issues at the time of that visit), and the EMR (or EHR now) should be programmed to suggest appropriate preventive interventions automatically during the visit. A special “routine physical” visit would then be needed in a healthy non-symptomatic patient only if there is no other visit over a specified interval. (This is the rationale behind the reluctant Medicare

and insurance coverage of the non-symptomatic PE.)

Wes Bradford

-----Original Message----- From: Tom Sent: Friday, December 03, 2004 8:01 AMTo: Subject: Value of an Annual Physical Exam

This brings up two issues I have struggled with.What is the value in an annual physical exam? And how does it mesh with our goal of treating the whole patient at a visit (and not just a single complaint)?I understood our model to be one in which we have the time to address *ALL* of our patients' concerns at the time of a visit. This presumably includes preventive health issues. Doing this is how we justify all those 99214s and (for some members of the group) 99215s to the insurance companies.This is opposed to the traditional model, where a patient is seen for a single complaint or several complaints, these are addressed, and that's that. Any preventive health issues require the patient to schedule another visit (ie annual physical). The reason for doing this is that the traditional model is so time constrained that we

have to limit what we do at any given visit.But we have (presumably) structured our practices differently. When a patient comes in for a complaint or blood pressure followup, we not only address that issue, but also can review other things (so Mrs. , when was the last time you had a mammogram? etc). So really, a review of preventive health issues should be part of every patient encounter we have.Many patients are seen routinely for followup of chronic problems, such as diabetes or hypertension, and are seen maybe 3-4 times over the course of a year. If we address even only one or two preventive health issues per visit, over the course of a year we have addressed everything we would review in an annual physical.Granted, an annual physical may have value for a patient who does not come in for routine followup.Which brings up the second issue. Why should a complete physical exam be done annually (as opposed to every 2,3,4, whatever years?) Are

there any studies to support the 'annual' frequency? My sense is that an 'annual' exam recommendation is just a old tradition. I am actually surprised that so many insurance plans allow it at all. (Of course, Medicare doesn't, although it does allow one initially).So, if anyone out there can provide some POEMS or other data to support the value of an annual physical exam, I'd love to see it. I think before we 'market' an annual physical, we better have some good data to support its value, both medical and financial.So what does the group think?TomWith that said, I wonder if this is more of a marketing problem than anything else. If informed consumers, which I would hope include many with HSAs, are regularly bombarded with the facts about preventive medicine, including that these types of evaluations SAVE them money in the long run,

I believe many would show up for their annual exam. The real problem for us is to market it effectively (remember the Fram oil filter you can pay me now or pay me later commercial?) and to really have a consensus on what the preventive exam should entail.

· F. Mydosh, M.D.1160 Chili Ave.Suite 102Rochester, New York 14564 (fax)

__________________________________________________

[Guest guest]

& Larry both present good observations. Larry’s age- and individual-specific medical

and psychosocial history is a much more valuable use of medical resources than

the old medical school H & P with ROS (which was based mostly on a

traditional internal medicine undetected chronic disease model). Questionnaires and computer-driven interviews

are available, including “Instant Medical History” (http://www.medicalhistory.com/) of

which I have heard enthusiastic reviews and which can be integrated with any

EHR. Paper or computer questionnaires

completed by patients & /or ancillary staff can do most of the

screening. As Larry says, the relevant

exam items take a very small proportion of the visit. If our EHRs are programmed to present us specific relevant

questions and recommend specific relevant preventive history/test items, we can

pick up much more than the traditional H & P in less time.

I remember an interesting study of Family Practice medical

liability suits that was published a number of years ago, in which 2 subsets of

doctors were selected from doctors in practice at least 10 years – those sued 2

or more times, and those never sued.

All characteristics of these 2 subgroups (gender, age, and other

demographics, practice model, type of community and type of payment) were identical,

except that those sued 2 or more times averaged 15 minutes per visit (the upper-limit

traditional primary care standard of the “efficiency” gurus), while those never

sued averaged almost 20 minutes per visit.

That time-pressure issue is the essence of the Gordon

model! I actually do better

averaging 30 minutes per visit, and more for a new patient. If my revenue averages $70 per half

hour, and I keep expenses low (rent reduced 80% and employee expense reduced

100%) and minimize other hassles and friction, then I don’t lose money with a

slower practice, but patients love it!

Counseling and teaching at the end of the visit also need enough time to

be effective. The “bean counter

efficiency experts” think we’re nuts, because they don’t understand the link

between effective chronic disease prevention/management and PCP E & M time. Documenting the actual number of

minutes spent in each visit, plus documenting the counseling done (over 50%)

are easily done on a good EHR, and are vital for proof of a higher level visit

(actually a bargain for the insurance company for the additional services

provided and for future visits and problems avoided).

Wes Bradford

-----Original

Message-----

From: lawrence lyon

Sent: Wednesday, December 08, 2004

10:42 AM

To:

Subject: RE:

Value of an Annual Physical Exam

this is a

real interesting topic.

i am seeing

several types of patients:

healthy

patients, those " worried well " or who just want reassurance that they

are doing the right things,

required/regualtory

exams: commercial drivers license, FAA medical certificate, school

physicals; where they may or may not have a problem; and who will,

with all other patients, fall into the following categories:

those who are

at the beginning stage of a problem, often patients new to me, and if they had

a previous doctor, were not screened appropriately, and where intervention now

will prevent a disease;

those who

have a problem who had no idea; often patients new to me, and if they had

a previous doctor, were not screened appropriately, and where intervention

now will prevent serious consequences of the disease;

those who

have a problem(s) who are treated appropriately;

those who

have a problem(s) who aren't being treated appropriately;

those who

have an acute problem, not the result of an exacerbation of a chronic problem;

those who

have an acute problem, the result of an exacerbation of a chronic problem,

which may or may not have been treated appropriately, if they were even aware

that they had a problem.

i agree and

believe that the key lies not so much in the physical examination, but in

the history. When i see new patients, most of the about

an hour (usually more) i spend are spent on the

history: review of systems, past medical/surgical history, social

history and family history; significantly less time on the

examination, and depending on the history, time for

education, " anticipatory guidance " (yes, adults benefit from

that, too) and recommendations, including additional screenings (pap, DRE with

stool guiaic), and if appropriate, referrals for specialty screenings (mammo,

colonoscopy) in addition to screening labs (cbc c diff, cmp, lipid profile (if

>25), tsh, others as indicated, eg fsh, psa). i see a lot

of elevated fasting sugars and am picking up huge numbers of pre-diabetics.

my assistant

tries to get new patients to come in for blood and to sign a release prior

to their initial visit. that way, i have all the sources of

information at hand together: the patient, the screening lab work, and

the old chart.

i believe

there is tremendous value for the annual, or at minimum, initial history and

physical examination and review in the " moore model " style of

practice. for one, we get a thorough baseline. for another, we are

better equipped to catch problems and concerns and address them before they

become diseases. still another, when we do find a problem or disease, we

can get patients into treatment earlier, with hopefully less morbidity and

possibly less mortality-- we'll have to wait some time before we can run

the numbers. additionally, and unfortunately, we

catch " misses " by other doctors, who don't take the time and

care that we can and do.

we have the

time to ask the questions; we take the time to ask the

questions. it's not just good for the drug companies--it's important

to ask patients about sexual functioning, incontinence,

constipation, quality of life issues. by asking, we make it ok

to talk about hopefully anything.

patients also

need to hear from us doctors (orthographically from the equine oropharynx)

recommendations regarding diet, exercise, salt and fat intake, to take a daily

multivitamin/multimineral, no straining with bowel movements, stop risky

behavior like smoking, sexual promiscuity, no drinking more than one

etoh equivalent/day and they don't roll over, to stop completely if indicated,

go to AA if they need help, to stop methamphetamine use, to go to the

local drug treatment program and when they're clean to return, the

works. patients want to know what we think and will listen to us if

we provide them with the recommendations and the tools to carry them out.

" just don't smoke " is insufficient; give them the tools. i give

patients a specific method, and i am tied to no specific method, because i want

them to stop, however it takes. i give them specific information on what

to eat and what not to eat, and tell them i don't expec! t them to eat

cardboard and drink water, nor do i want them to feel deprived, however i

want them to make some significant changes, and encourage them to do so, and

then follow them up.

the moore

model is good medicine: individual attention to patients, listening

carefully to them, putting the puzzle together, with appropriate screening,

based on the USPHTF guidelines, along with patients hearing straight from us on

an individual basis what we recommend and how to do it. it's

actually what we are taught in medical school, and then de-learn in residency.

i remind

patients that with inflation, the ounce of prevention in now worth far more

than the pound of cure.

so how much

is that worth? we know we're underpaid. insurance companies will

never pay us what we're worth. sure, lobby for better pay.

to answer

your question, kevin, i have plenty of work, my patients appreciate my care,

and they send me their friends, co-workers and family members.

larry lyon

Egly

wrote:

Wes:

This would

then lead itself into an age appropriate H & P which does not need a

comprehensive physical exam. So for a preventive H & P would you truely

just ask age appropriate screening questions or include the medical school

complete review of symptoms, perform targeted physical exam based

on symptoms, and conclude the visit with recommendations.

I am often

tempted to just perform what is needed based on medical literature, but find it

difficult to charge patients for $135 for an hour of history and counseling

when they may have been just as well served with a " sports " physical

and a minute on healthy exercise, not smoking, and protective sexual relations.

I believe to

maintain medical practice we all see the worried well and perform more physical

and history examinations than truely benefits patients. However, the

revenue stream to my clinic would not supprt me let alone a staff if I just

treated acute visits. Perhaps marketing to hypertensive , diabetic,

syndrome X, smokers, depressed, and obese patients would help fill the ranks

and provide true interventions that make a difference.

I think I

would need to expand my screening for medical disease to a broader patient

population than just my patients. Marketing to businesses while providing

counseling for those found to have disease, may be a differnent line of

business than regular primary care.

I am

interested to hear what others believe to be scope of primary care in the

" " model. If we develop a model of care that meets needs,

and has documented benefit, we could market these services to business,

insururers, and patients. Could we dare to come up with a unit cost for

preventive services?

" Wesley G.

Bradford " wrote:

Dr. Frame, a Family

Physician in Upstate New York, studied the Annual Physical Exam issue a

number of years ago and published a number of articles about it that could be

accessed by a literature search.

The basic conclusion was that almost all of the history and exam items

in the traditional PE were not cost-effective, considered in the sense of

both false positives and false negatives.

(The current preventive-care guidelines of the U.S. Preventive Services Task Force and

the Canadian Task Force on Preventive Health

Care were based on such studies.)

To be effective medical

interventions, H & P items must satisfy all of the following conditions:

(1) common in the relevant population or sub-populations, (2) non-symptomatic

until discovered by the examiner, (3) capable of reliable detection by the

standard screening exam (considering the consequences of both false positives

and false negatives), (4) having an effective intervention available for a

detected condition, and (5) the intervention is likely to make a significant

difference in the patients health, function or longevity.

Blood pressure, pap,

mammogram, and now-days cholesterol screen are some of the few actions that

satisfy the above screening effectiveness criteria, and usually at longer

intervals than every year. A

simplified history (even by phone!) could accomplish most of the other

cost-effective screening needed.

These studies were done several decades ago when the Executive

Physical for $500 to $1000 was popular for the well to do, a total waste of

money for those with money to burn.

The annual physical idea started in the early 20th century

when medicine was much more primitive and virtually veterinary medicine with

almost no history obtained, when people believed in doctors order! s without

questioning. It was observed that

advanced cancers were often seen at such visits, where earlier visits might

have allowed surgical cures. This

was before anyone thought of placing responsibility on the patient for watching

for the seven signs of cancer and then coming in to get them checked, and

before the population was taught to ask for those few modern cancer screens we

have now like paps and mammograms.

My conclusion: The Annual

Physical on healthy non-symptomatic patients is useful primarily to become

acquainted with the patients and encourage establishing a primary care medical

home. The screening guidelines

should be reviewed whenever the patient comes in for other purposes (ideally

having enough visit time to address all needed issues at the time of that

visit), and the EMR (or EHR now) should be programmed to suggest appropriate

preventive interventions automatically during the visit. A special routine physical visit

would then be needed in a healthy non-symptomatic patient only if there is no

other visit over a specified interval.

(This is the rationale behind the reluctant M! edicare and insurance

coverage of the non-symptomatic PE.)

Wes Bradford

Value of an Annual Physical Exam

This brings up two issues I have struggled with.

What is the value in an annual physical exam? And how does it mesh with our

goal of treating the whole patient at a visit (and not just a single complaint)?

I understood our model to be one in which we have the time to address *ALL* of

our patients' concerns at the time of a visit. This presumably includes

preventive health issues. Doing this is how we justify all those 99214s

and (for some members of the group) 99215s to the insurance companies.

This is opposed to the traditional model, where a patient is seen for a single

complaint or several complaints, these are addressed, and that's that. Any

preventive health issues require the patient to schedule another visit (ie

annual physical). The reason for doing this is that the traditional model is so

time constraine! d that we have to limit what we do at any given visit.

But we have (presumably) structured our practices differently. When a patient comes

in for a complaint or blood pressure followup, we not only address that issue,

but also can review other things (so Mrs. , when was the last time you

had a mammogram? etc). So really, a review of preventive health issues

should be part of every patient encounter we have.

Many patients are seen routinely for followup of chronic problems, such as

diabetes or hypertension, and are seen maybe 3-4 times over the course of a

year. If we address even only one or two preventive health issues per visit,

over the course of a year we have addressed everything we would review in an

annual physical.

Granted, an annual physical may have value for a patient who does not come in

for routine followup.

Which brings up the second issue. Why should a complete physical exam be done

annually (as opposed to every 2,3,4, whatever ye! ars?) Are there any studies

to support the 'annual' frequency? My sense is that an 'annual' exam

recommendation is just a old tradition. I am actually surprised that so many

insurance plans allow it at all. (Of course, Medicare doesn't, although it does

allow one initially).

So, if anyone out there can provide some POEMS or other data to support the

value of an annual physical exam, I'd love to see it. I think before we

'market' an annual physical, we better have some good data to support its

value, both medical and financial.

So what does the group think?

Tom

With that said, I wonder if this is more of a

marketing problem than anything else. If informed consumers, which I would hope

include many with HSAs, are regularly bombarded with the facts about preventive

medicine, including that these types of evaluations SAVE them money in the !

long run, I believe many would show up for their annual exam. The real problem

for us is to market it effectively (remember the Fram oil filter you can pay

me now or pay me later commercial?) and to really have a consensus on what the

preventive exam should entail.

·

7 F.

Mydosh, M.D.

1160 Chili Ave.

Suite 102

Rochester, New York 14564

(fax)

__________________________________________________

[Guest guest]

Wes, Larry, Tom:

All great points. Wes comes closest to putting a price on the value we generate for patients. $70 per half hour. It appears Larry has put a description to the many encounters we see each day. But, could we possibly start to get a patient's perspective of what that 30min visit is worth and how to deliver targeted, evidence based care, that meets the patient's expectations?

Back to the first point: my overhead is expected to be about $60 - 70K next year. I can expect to distribute that across 34hours/week times 48 weeks times 1.5 providers=2448 hours seeing patients. So 70K/2448= $28.60/hour $140-28.60= $111.40/hr as income "theoretically." 111.40 * 34 *48 =$181,804. I do not think I could manage to see 34 hours worth of patients without additional staff and I don't expect my wife to perform the business functions I am performing right now. The time it takes to collect insurance has come down since I started electronic billing, but I think it would be easier to attempt to copy what the insurance companies do already. They get patients, employers, and us to agree to contracts. They then just collect the contractual amount monthly and try to spend it appropriately.

If we could shift focus from traditional healthcare then somewhere between 250 and 365 dollars per year per patient would cover overhead and expenses. No billing nightmares from insurance companies!

I believe that in the future as people shift to high deductible plans it will be our jobs to sell the managed costs of our clinics to patients. This is only 10% of the $4000 deductible mentioned in an earlier post. Still worth about a dollar a day to patients. For many of my patients this is less than one of their medications for just part of the year. Certainly more than the $7-$12/month the local IPA wants me to see HMO patients. Then we would not need to play any games with coding, physicals, counseling, but could offer access, service, targeted healthcare, and even appropriate phone call service. I cannot help but think what a large part we play in the diagnosis and treatment of the remainder of health care expenditure $9900/year for afamily of four.

$365/$9900

I strongly believe that patients must be educated on the value we provide for about a dollar a day. Ultimately, I also believe it will be a bitter struggle to progress from $10/month to a dollar a day as clinicians wrentch the primary care dollars out of insurance companies control. Concierge is too fancy a word for good quality primary care. It is a fight we will face as a Michigan BCBS has taken 1% of physician fees for the year and set it aside. They are working out quality of care issues that they will implement and distribute only to groups of physicans based on their measure of quality. We control the health care costs with each prescription, test, order, and admit H & P we write. It is time to fight for the control of how our patients resources are being spent. We need structure in our words, actions, and clinics to offer a sound alternative to the fear that drives the nature of insurance of catastrophic health

events. Primary care is not a catastrophic financial event. It is a reasonable, calculated, and measured expense. Insurance premiums of $600 - 1400 per month are certainly the"catastrophic" events of modern healthcare.

That was my 10 cents on the issue.

A penny for your reply, please.

Now if I could just find someone who knows the value of anothe 66 cents per day.

Thanks for reading my thoughts.

I anxiously await your reply

P.S. my hourly goal is $135 set at actual medicare rates for a traditional practice. I will see if a "" practice can exceed the goal.

"Wesley G. Bradford" wrote:

& Larry both present good observations. Larry’s age- and individual-specific medical and psychosocial history is a much more valuable use of medical resources than the old medical school H & P with ROS (which was based mostly on a traditional internal medicine undetected chronic disease model). Questionnaires and computer-driven interviews are available, including “Instant Medical History” (http://www.medicalhistory.com/) of which I have heard enthusiastic reviews and which can be integrated with any EHR. Paper or computer questionnaires completed by patients & /or ancillary staff can do most of the screening. As Larry says, the relevant exam items take a very small proportion of the visit. If our EHRs are programmed to present us specific relevant questions and recommend specific relevant preventive history/test items, we can pick up much more than the traditional H & P in less time.

I remember an interesting study of Family Practice medical liability suits that was published a number of years ago, in which 2 subsets of doctors were selected from doctors in practice at least 10 years – those sued 2 or more times, and those never sued. All characteristics of these 2 subgroups (gender, age, and other demographics, practice model, type of community and type of payment) were identical, except that those sued 2 or more times averaged 15 minutes per visit (the upper-limit traditional primary care standard of the “efficiency” gurus), while those never sued averaged almost 20 minutes per visit.

That time-pressure issue is the essence of the Gordon model! I actually do better averaging 30 minutes per visit, and more for a new patient. If my revenue averages $70 per half hour, and I keep expenses low (rent reduced 80% and employee expense reduced 100%) and minimize other hassles and friction, then I don’t lose money with a slower practice, but patients love it! Counseling and teaching at the end of the visit also need enough time to be effective. The “bean counter efficiency experts” think we’re nuts, because they don’t understand the link between effective chronic disease prevention/management and PCP E & M time. Documenting the actual number of minutes spent in each visit, plus documenting the counseling done (over 50%) are easily done on a good EHR, and are vital for proof of a higher level visit (actually a bargain for the insurance company for the additional services provided and for future visits and problems avoided).

Wes Bradford

-----Original Message-----From: lawrence lyon Sent: Wednesday, December 08, 2004 10:42 AMTo: Subject: RE: Value of an Annual Physical Exam

this is a real interesting topic.

i am seeing several types of patients:

healthy patients, those "worried well" or who just want reassurance that they are doing the right things,

required/regualtory exams: commercial drivers license, FAA medical certificate, school physicals; where they may or may not have a problem; and who will, with all other patients, fall into the following categories:

those who are at the beginning stage of a problem, often patients new to me, and if they had a previous doctor, were not screened appropriately, and where intervention now will prevent a disease;

those who have a problem who had no idea; often patients new to me, and if they had a previous doctor, were not screened appropriately, and where intervention now will prevent serious consequences of the disease;

those who have a problem(s) who are treated appropriately;

those who have a problem(s) who aren't being treated appropriately;

those who have an acute problem, not the result of an exacerbation of a chronic problem;

those who have an acute problem, the result of an exacerbation of a chronic problem, which may or may not have been treated appropriately, if they were even aware that they had a problem.

i agree and believe that the key lies not so much in the physical examination, but in the history. When i see new patients, most of the about an hour (usually more) i spend are spent on the history: review of systems, past medical/surgical history, social history and family history; significantly less time on the examination, and depending on the history, time for education, "anticipatory guidance" (yes, adults benefit from that, too) and recommendations, including additional screenings (pap, DRE with stool guiaic), and if appropriate, referrals for specialty screenings (mammo, colonoscopy) in addition to screening labs (cbc c diff, cmp, lipid profile (if >25), tsh, others as indicated, eg fsh, psa). i see a lot of elevated fasting sugars and am picking up huge

numbers of pre-diabetics.

my assistant tries to get new patients to come in for blood and to sign a release prior to their initial visit. that way, i have all the sources of information at hand together: the patient, the screening lab work, and the old chart.

i believe there is tremendous value for the annual, or at minimum, initial history and physical examination and review in the "moore model" style of practice. for one, we get a thorough baseline. for another, we are better equipped to catch problems and concerns and address them before they become diseases. still another, when we do find a problem or disease, we can get patients into treatment earlier, with hopefully less morbidity and possibly less mortality-- we'll have to wait some time before we can run the numbers. additionally, and unfortunately, we catch "misses" by other doctors, who don't take the time and care that we can and do.

we have the time to ask the questions; we take the time to ask the questions. it's not just good for the drug companies--it's important to ask patients about sexual functioning, incontinence, constipation, quality of life issues. by asking, we make it ok to talk about hopefully anything.

patients also need to hear from us doctors (orthographically from the equine oropharynx) recommendations regarding diet, exercise, salt and fat intake, to take a daily multivitamin/multimineral, no straining with bowel movements, stop risky behavior like smoking, sexual promiscuity, no drinking more than one etoh equivalent/day and they don't roll over, to stop completely if indicated, go to AA if they need help, to stop methamphetamine use, to go to the local drug treatment program and when they're clean to return, the works. patients want to know what we think and will listen to us if we provide them with the recommendations and the tools to carry them out. "just don't smoke" is insufficient; give them the tools. i give patients a specific method, and i am tied to no specific method, because i want them to

stop, however it takes. i give them specific information on what to eat and what not to eat, and tell them i don't expec! t them to eat cardboard and drink water, nor do i want them to feel deprived, however i want them to make some significant changes, and encourage them to do so, and then follow them up.

the moore model is good medicine: individual attention to patients, listening carefully to them, putting the puzzle together, with appropriate screening, based on the USPHTF guidelines, along with patients hearing straight from us on an individual basis what we recommend and how to do it. it's actually what we are taught in medical school, and then de-learn in residency.

i remind patients that with inflation, the ounce of prevention in now worth far more than the pound of cure.

so how much is that worth? we know we're underpaid. insurance companies will never pay us what we're worth. sure, lobby for better pay.

to answer your question, kevin, i have plenty of work, my patients appreciate my care, and they send me their friends, co-workers and family members.

larry lyon

Egly wrote:

Wes:

This would then lead itself into an age appropriate H & P which does not need a comprehensive physical exam. So for a preventive H & P would you truely just ask age appropriate screening questions or include the medical school complete review of symptoms, perform targeted physical exam based on symptoms, and conclude the visit with recommendations.

I am often tempted to just perform what is needed based on medical literature, but find it difficult to charge patients for $135 for an hour of history and counseling when they may have been just as well served with a "sports" physical and a minute on healthy exercise, not smoking, and protective sexual relations.

I believe to maintain medical practice we all see the worried well and perform more physical and history examinations than truely benefits patients. However, the revenue stream to my clinic would not supprt me let alone a staff if I just treated acute visits. Perhaps marketing to hypertensive , diabetic, syndrome X, smokers, depressed, and obese patients would help fill the ranks and provide true interventions that make a difference.

I think I would need to expand my screening for medical disease to a broader patient population than just my patients. Marketing to businesses while providing counseling for those found to have disease, may be a differnent line of business than regular primary care.

I am interested to hear what others believe to be scope of primary care in the "" model. If we develop a model of care that meets needs, and has documented benefit, we could market these services to business, insururers, and patients. Could we dare to come up with a unit cost for preventive services?

"Wesley G. Bradford" wrote:

Dr. Frame, a Family Physician in Upstate New York, studied the Annual Physical Exam issue a number of years ago and published a number of articles about it that could be accessed by a literature search. The basic conclusion was that almost all of the history and exam items in the traditional PE were not cost-effective, considered in the sense of both false positives and false negatives.

(The current preventive-care guidelines of the U.S. Preventive Services Task Force and the Canadian Task Force on Preventive Health Care were based on such studies.)

To be effective medical interventions, H & P items must satisfy all of the following conditions: (1) common in the relevant population or sub-populations, (2) non-symptomatic until discovered by the examiner, (3) capable of reliable detection by the standard screening exam (considering the consequences of both false positives and false negatives), (4) having an effective intervention available for a detected condition, and (5) the intervention is likely to make a significant

difference in the patients health, function or longevity.

Blood pressure, pap, mammogram, and now-days cholesterol screen are some of the few actions that satisfy the above screening effectiveness criteria, and usually at longer intervals than every year. A simplified history (even by phone!) could accomplish most of the other cost-effective screening needed. These studies were done several decades ago when the Executive Physical for $500 to $1000

was popular for the well to do, a total waste of money for those with money to burn. The annual physical idea started in the early 20th century when medicine was much more primitive and virtually veterinary medicine with almost no history obtained, when people believed in doctors order! s without questioning. It was observed that advanced cancers were often seen at such visits, where earlier visits might have allowed surgical cures. This was before anyone thought of placing responsibility on the patient for watching for the seven signs of cancer and then coming in to get them checked, and before the population was taught to ask for those few modern cancer screens we have now like paps and mammograms.

My conclusion: The Annual Physical on healthy non-symptomatic patients is useful primarily to become acquainted with the patients and encourage establishing a primary care medical home. The screening guidelines should be reviewed whenever the patient comes in for other purposes (ideally having enough visit time to address all needed issues at the time of that visit), and the EMR (or EHR now) should be programmed to suggest appropriate

preventive interventions automatically during the visit. A special routine physical visit would then be needed in a healthy non-symptomatic patient only if there is no other visit over a specified interval. (This is the rationale behind the reluctant M! edicare and insurance coverage of the non-symptomatic PE.)

Wes Bradford

-----Original Message----- From: Tom Sent: Friday, December 03, 2004 8:01 AMTo: Subject: Value of an Annual Physical Exam

This brings up two issues I have struggled with.What is the value in an annual physical exam? And how does it mesh with our goal of treating the whole patient at a visit (and not just a single complaint)?I understood our model to be one in which we have the time to address *ALL* of our patients' concerns at the time of a visit. This presumably includes preventive health issues. Doing this is how we justify all those 99214s and (for some members of the group) 99215s to the insurance companies.This

is opposed to the traditional model, where a patient is seen for a single complaint or several complaints, these are addressed, and that's that. Any preventive health issues require the patient to schedule another visit (ie annual physical). The reason for doing this is that the traditional model is so time constraine! d that we have to limit what we do at any given visit.But we have (presumably) structured our practices differently. When a patient comes in for a complaint or blood pressure followup, we not only address that issue, but also can review other things (so Mrs. , when was the last time you had a mammogram? etc). So really, a review of preventive health issues should be part of every patient encounter we have.Many patients are seen routinely for followup of chronic problems, such as diabetes or hypertension, and are seen maybe 3-4 times over the course of a year. If we address even only one or two preventive health issues per visit, over the

course of a year we have addressed everything we would review in an annual physical.Granted, an annual physical may have value for a patient who does not come in for routine followup.Which brings up the second issue. Why should a complete physical exam be done annually (as opposed to every 2,3,4, whatever ye! ars?) Are there any studies to support the 'annual' frequency? My sense is that an 'annual' exam recommendation is just a old tradition. I am actually surprised that so many insurance plans allow it at all. (Of course, Medicare doesn't, although it does allow one initially).So, if anyone out there can provide some POEMS or other data to support the value of an annual physical exam, I'd love to see it. I think before we 'market' an annual physical, we better have some good data to support its value, both medical and financial.So what does the group think?TomWith that said, I wonder if this is more of a marketing problem than anything else. If informed consumers, which I would hope include many with HSAs, are regularly bombarded with the facts about preventive medicine, including that these types of evaluations SAVE them money in the ! long run, I believe many would show up for their annual exam. The real problem for us is to market it effectively (remember the Fram oil filter you can pay me now or pay me later commercial?) and to really have a consensus on what the preventive exam should entail.

· 7 F. Mydosh, M.D.1160 Chili Ave.Suite 102Rochester, New York 14564 (fax)

__________________________________________________