The case against an annual physical
March 5, 2024
Doctors, and often employers, have been recommending ‘annual physicals” for decades, and most health plans impose no cost sharing for an annual examination visit with a doctor or advanced practice clinician (APC) like a physician assistant or a nurse practitioner. But there is little convincing evidence that adult annual physical exams improve health or lower future health care costs.
This pains me, because when I practiced primary care, I was enthusiastic about the opportunity to coach my patients to stop smoking, exercise, wear seatbelts, and get age-appropriate cancer screening. But multiple research studies have failed to show health benefits from annual exams, and the Wall Street Journal published an article last week entitled “The Case Against the Annual Physical.”
In my mind the biggest problem with encouraging annual examinations is that we simply don’t have enough primary care practitioners (PCPs). If a PCP with a panel of 2000 patients did 30-minute annual examinations on every one of their patients, this would take 1000 hours a year. Primary care clinicians generally do ~34 hours of patient encounters about 44 weeks a year (considering vacation, holidays, and sick days), which means that these physicals would take up two-thirds of their office time. This leaves little room to schedule visits for those with ongoing chronic diseases, and even less room to schedule patients with acute illnesses, who will have to seek care at emergency rooms and urgent care centers. The Association of American Medical Colleges projects a shortage of 48,000 primary care physicians by 2034.
The case for annual visits was stronger in the past. For instance, women were recommended to have annual pap smears, but at this point screening for cervical cancer with HPV testing is usually recommended only every 3-5 years. We can remind people about vaccinations and cancer screening without annual visits. Annual examinations are not recommended by the US Preventive Services Task Force. Scheduling annual visits can also be more difficult for lower wage workers to arrange since they often have less flexible schedules and might not have advance notice of when they will be working.
We can say “everyone should get an annual” all we want, but my friends and colleagues have a hard time finding a physician with an open panel when their physician retires or moves on. Many adult primary care physicians are booking these annual visits 6 or 12+ months in advance.
Happily, the pediatricians serve children much better. Children absolutely should have periodic pediatric or family medicine preventive care visits, to assess developmental milestones when they are young, to provide vaccinations throughout childhood, and to evaluate mental health and provide proactive counseling for teens. Here’s a link to recommendations from the American Academy of Pediatrics.
Many adults benefit from a periodic preventive visit with their physician or advanced practice clinician. Those with chronic disease need to have periodic check-ins to be sure that their medical regimen is appropriate, and as we get older most of us accumulate enough medical conditions that we benefit from a therapeutic relationship with a primary care physician. I see my primary care physician about once a year, and I self-monitor my blood pressure and arrange to get my fasting lipid profile done in advance so we can review the results. The Society of General Internal Medicine does not recommend an annual adult physician visit “unless patients are likely to benefit.”
Some primary care physicians, as the WSJ reported, are reinventing the periodic preventive visit on their own. They encourage patients to complete pre-visit questionnaires, so they can focus on a patient’s most pressing concerns. They spend more time talking, and less time poking and prodding. Virtual care providers offer preventive care visits, too, with no need for commuting, parking, and sitting in a waiting room. That’s not appropriate for people who have concerns that require a physical examination and might not be right for those who are older and have chronic diseases. But virtual care and APCs will help meet our growing primary care needs. In the meantime, not every adult needs to see a doctor once a year.
Implications for employers:
The Affordable Care Act requires coverage without cost sharing for preventive visits.
Employers can encourage preventive care, including cancer screening and vaccinations, even for adults that do not choose to have an annual provider visit.
Employers should consider the PCP shortage, the lack of proven efficacy, and potential equity concerns of requiring annual physician visits for premium discounts or other incentives.
Thanks for reading. You can find previous posts in the Employer Coverage archive
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Illustration by Dall-E
Tomorrow: More teens and young adults prescribed antidepressants