What’s the Value of an Annual “Checkup”?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Are annual checkups all they’re cracked up to be?

Remember Cigna’s “Doctors of America” ads?

“We are the TV Doctors of America,” says McDreamy.

“And we’re partnering with Cigna to help save lives,” says Dr. John Carter.

“By getting you to a real doctor for a checkup,” chimes in Cuddy.

But to put our “Devil’s Advocates of America” hats on: what if this annual checkup business isn’t all it’s cracked up to be?

It is reasonable to hold any potential medical test or treatment to one of three standards:

  1. It makes the patient feel better. This includes hundreds of treatments, like using medications and physical therapy for pain, prescribing inhalers for asthma, giving antidepressants and therapy for depression, and replacing knees, for starters. It could even apply to things like bone mineral density screening, sometimes referred to as “DXA,” which linked with osteoporosis treatment may make no difference in the risk of death, but clearly prevents hip, wrist, and spine fractures.

  2. If it does not make the patient feel better, the test or treatment should make the patient live longer. This applies to everyday things like checking and treating high blood pressure and high cholesterol (neither one of which make most patients feel any better or worse today) to surgery and chemotherapy for cancers (most of which make patients feel much, much worse at least in the short-term, but prolong many lives).

  3. Finally, if a treatment makes no difference in how the patient feels and makes no difference in how long the patient lives, it should at the very least save money. The best example of this may be diabetes screening. As far as we can tell, screening for diabetes does not prolong life, at least not in the two or three trials that have specifically addressed the question. But diabetes screening linked to preventive measures like the Diabetes Prevention Program clearly saves money [disclaimer: the KBGH is closely linked to Health ICT through the Medical Society of Sedgwick County, which receives CDC funding to promote things like blood pressure control, cholesterol management, and diabetes prevention].

Many of the tests and treatments medicine offers do not live up to that rubric. This may be why the Cochrane Review, which many consider the highest level of evidence in medicine, published a review in 2018 stating that “Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.” So when the TV Doctors of America say you need an annual checkup, what they surely mean is not that you need an old-fashioned sit-down with your doctor where, at the end of the visit, she gives you a “clean bill of health.” No. What I hope they mean is that you need to have access to a primary care provider. Investigators in 2019 found that every 10 additional primary care physicians per 100,000 people was associated with a 51-day increase in life expectancy, which doesn’t sound like much, but is pretty big by medical standards. Some estimate that a doctor practicing at the top of his license adds about 4.5 net years to the average patient’s life. Not too shabby.

“Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.”

What actually improves or extends someone’s life?

What the TV Doctors of America really mean is that you should have certain preventive services like immunizations and periodic screenings for health conditions that, if left untreated, can profoundly shorten your life. Most of these aren’t sexy. Probably the most effective preventive medical intervention, for example, is a simple periodic blood pressure check with medications if your blood pressure is too high. Sexier things like cancer screenings tend to have a “disease-specific” benefit, meaning they prevent you from dying of colon, prostate, cervical, breast, or lung cancers specifically, but they may not make people live longer as a whole.

If there is doubt in your company about what services you should be providing, a good place to start is with the United States Preventive Services Task Force (USPSTF), a rotating group of doctors that follows very specific rules to evaluate the risks and benefits of specific screening. Their opinion holds a lot of weight because any test given a “B” or better rating is mandated to be covered by your insurance. Examples of “A” rated services are things like tobacco use counseling and interventions, blood pressure screening in adults, and screening for cervical and colon cancers, which are all strategies that easily conform to our rubric. Cholesterol testing in people without diabetes or heart disease gets a “B.” Screening for prostate cancer in men aged 55-69 with a prostate specific antigen (PSA) test is a good example of a “C” rated service, since it has no overall mortality benefit and its disease-specific mortality benefit is largely offset by the harms that screening can cause (prostate biopsies and surgeries can cause bladder leakage and erectile dysfunction, among other things). PSA screening for prostate cancer in men aged 70 or older gets a “D” rating because it appears, in the hive mind of the USPSTF, to cause more harm than it prevents; that is, it violates rules #2 and 3.

What does this mean for employers?

How do you apply this to your workforce? Start by being an informed shopper for any workplace wellness services being offered to your company. Whenever a wellness provider tries to charge you a lot of money for offering annual “wellness checks” or “health risk assessments,” check their recommendations against the opinion of the USPSTF (or have us at KBGH check them for you). If the amount of testing they’re charging far exceeds what the experts recommend, ask them why.

Second, work on the health literacy of your employees (we can help with this). It’s hard as a patient to turn down testing or treatment your doctor offers if you don’t have the background to know what works and what doesn’t. I’m a doctor myself, and even I’ve felt vulnerable being squeezed through the gears of the medical-industrial complex.