The High Cost of Free Checkups

A predictable irony of the never-ending Affordable Care Act (ACA) debate is that the one provision that the Republicans should be attacking -- free "checkups" for everyone -- is one of the few provisions they aren't attacking.
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A predictable irony of the never-ending Affordable Care Act (ACA) debate is that the one provision that the Republicans should be attacking -- free "checkups" for everyone -- is one of the few provisions they aren't attacking. Why should they attack them? Simple -- checkups, on balance, are worthless. Why provide a 100 percent subsidy for a worthless good? Where is the GOP when you need it?

How worthless are checkups? Dr. Ezekiel Emanuel -- one of the architects of the ACA and its "free" checkup centerpiece -- recently recommended not getting them. As if "free" is not cheap enough, the ACA also pushes ubiquitous corporate wellness programs, which often pay employees to get checkups -- or fine them if they don't. This policy establishes a de facto negative price for millions of workers, making checkups the only worthless service on earth that one could get paid to utilize.

Those economics of a "negative price" trump Dr. Emanuel's advice, and have made preventive care the fastest-growing component of employer health spending. Though hard statistics on checkups themselves are elusive, Dr. Emanuel estimates about 45-millon adult checkups are conducted each year, the equivalent of roughly 8 percent of America's PCPs doing nothing but checkups, a curious use of their time when experts say the country could soon face a shortage of PCPs.

Shortage or not, subsidies and incentives might make economic sense if checkups improved health. However, when generally healthy adults go to the doctor for no reason, just the opposite is true: the Journal of the American Medical Association (JAMA) supports Dr. Emanuel assertion that annual checkups for asymptomatic adults are at best worthless, saying that additional checkups are "not associated with lower rates of mortality" but "may be associated with more diagnoses and more drug treatment."

At worst, checkups are counterproductive. The British Medical Journal adds to JAMA's conclusion that "important harms [of checkups] were not reported." Overtreatment following overdiagnosis is the most common harm: Canada's former prime minister spent six weeks in the hospital due to complications of a biopsy investigating two spots on his lung that, like most apparent abnormalities, proved completely harmless. No wonder Slate concluded: "If you're not sick, don't go to the doctor." (One could also make the argument that the people who most need to have checkups are disproportionately the ones least likely to get them no matter what the economics.)

None of these findings discourage workplace wellness vendors, who -- empowered by ACA provisions encouraging financial incentives for all preventive care -- want physicians to order "biometric screens" during these checkups, or spend time discussing the screens performed at the employee's worksite. As with the visits themselves, most of this screening has no value, and literally no one in health care other than wellness vendors and consultants who make their money off the practice defends annual screening. By contrast, there is no blood-based test that the United States Preventive Services Task Force (USPSTF) recommends be done annually on healthy people.

So checkups driven by an overzealous corporate screening agenda, for patients who participate largely due to the incentives or penalties, exacerbate the worthlessness of the entire endeavor by crowding out the most useful part of any patient-provider interaction, relationship-building, in favor of signing off on a screening report card allowing employees to get their money.

The solution to this orgy of overscreening and overdoctoring is remarkably simple: remove the ACA provision that makes annual checkups automatically immune from deductibles and copays; if they are going to be free at all, it should only be every few years. The proposal could still allow employers to override this provision -- and even to attach money (incentives and penalties) to checkups -- if they are willing to summarize the above-cited clinical findings for their employees.

If the only way they can continue the subsidy is by summarizing the literature, corporate human resources departments would predictably and immediately curtail this expensive corporate medical campaign. That would free up PCP time to work with patients who actually need medical care, while reducing counterproductive and costly healthcare utilization by those who do not.

Perhaps, even in this polarized political environment, there is still a HuffPost reader or two out there who actually knows a Republican. If so, could you pass this along? Point out that this is the first time in the history of the ACA that the GOP has had a chance to do something easy and useful and ask them to please not blow it.

(Note: Just to show the bipartisanship of this proposal, this posting was written in collaboration with my Surviving Workplace Wellness co-author , Vik Khanna, who could never be confused with a Democrat.)

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