Can we control costs through checkups and wellness programs for the healthy?
General Health Checks in Adults for Reducing Morbidity and Mortality From Disease
By Allan V. Prochazka, MD, MSc; Tanner Caverly, MD
JAMA Internal Medicine, January 14, 2013
The concept of general health checkups to identify disease at a stage at which early intervention could be effective has been promoted for nearly 100 years. Both patients and primary care physicians are interested in such examinations, which can include detailed history taking, physical examination, extensive laboratory testing, and imaging.
General health checks do not improve important outcomes and are unlikely to ever do so based on the pooled results of this meta-analysis spanning decades of experience. We should be clear about what a general health check is. A general health check is a visit dedicated solely to preventive counseling and screening tests. Other names, such as annual physical, preventive health examination, or periodic health evaluation, are often used. These terms exclude preventive care that occurs during visits for other reasons, such as during chronic care or acute care visits. In other words, we are talking about screening and counseling in addition to the prevention measures that occur during routine medical care.
General health checks are one of the most common reasons adults seek medical care, with an estimated 44 million seeing a physician for this reason each year from 2002 through 2004. During these health checks, an estimated $322 million is spent annually on laboratory tests that no guideline groups recommend. The costs of downstream testing and overtreatment are likely to be much larger. For example, the costs of mammography might be $4 billion a year assuming biennial screening. The cost of follow-up biopsies of normal breasts triggered by false-positive mammogram results alone is probably in the range of $14 to $70 billion annually. It is likely that follow-up testing from general health checks substantially contributes to the estimated $210 billion in annual spending on unnecessary medical services.
Is It Time To Re-Examine Workplace Wellness ‘Get Well Quick’ Schemes?
By Al Lewis and Vik Khanna
Health Affairs Blog, January 16, 2013
Virtually unheard of thirty years ago, workplace wellness is now embedded in large self-insured companies. These firms pay their workers an average of $460/year to participate in worksite wellness programs. Further, wellness is deeply enough engrained in the public policy consciousness to have earned a prominent place in the Affordable Care Act, which allows large employers to tie a significant percentage of health spending to employee health behavior and provides direct subsidies for small businesses to undertake these workplace wellness programs.
Yet the implausible, disproven, and often mathematically impossible claims of success underlying the “get well quick” programs promoted by the wellness industry raise many questions about the wisdom of these decisions and policies. In this post, we lay out the evidence demonstrating that the industry consistently mis-measures and overstates the direct healthcare cost savings. We suggest several strategies to prevent this and to re-allocate wellness dollars from “get well quick” schemes to the much more challenging, but ultimately more rewarding, task of truly creating a culture of wellness, a workplace that can attract and retain healthier, presumably more productive, people than competitors do. There is no guarantee that strategy would work and no easy way to implement it, but clearly the easy approach isn’t working.
While we do not believe that employers need to adopt military-style standards, we do propose that it is illogical to expect sustainable reductions in medical care spending if corporate leaders treat their environments, personnel policies, practices, and procedures with the insouciance of people who believe that they can just wish something into existence.
HR departments need to reconfigure their benefits consulting relationships, since with few exceptions the latter have not provided critical thinking about wellness (and other “value-added” programs) on a par with that of insurers, who have universally shunned these programs for their fully insured members. (Most insurers will happily sell them to self-insured employers even so, because they clearly understand that “invalid” is not the same as “unprofitable,” especially when you do not bear risk for the outcomes and the customer’s consultants are demanding the service.)
By Don McCanne, M.D.
In discussions of our exorbitant health care spending, we frequently hear that we need to change from a system that treats disease to a system that promotes prevention and wellness, as if prevention and wellness programs would displace disease and injury.
First, let's be clear that the benefits of effective prevention programs are undeniable. But much of prevention is out in the community at large and not so much within the health care delivery system. Examples are public health services, community planning for safety and to promote physical activity, the promotion of healthy food choices, industry design of safer products such as automobiles, public policies to reduce hazards such as the ubiquitous accessibility of firearms, and innumerable other measures that are or should be promoted through both public and private efforts.
So what about routine preventive health checkups? The comprehensive meta-analysis published in the current JAMA Internal Medicine reveals that "general health checks do not improve important outcomes and are unlikely to ever do so," but "it is likely that follow-up testing from general health checks substantially contributes to the estimated $210 billion in annual spending on unnecessary medical services."
However, specific examples of preventive care that are a part of and integrated within the provision of care for acute and chronic disorders have been shown to be of some benefit and should not be abandoned until new evidence demonstrates that there are compelling reasons to do so. Nevertheless, we cannot look to the medical practice environment to find the health care paradise that will displace sick care with well care.
Which brings us to employer-sponsored wellness programs. Simply stated, they fall into the spectrum between naivete and outright fraud. As stated in the Health Affairs Blog article briefly excerpted above, "Even the iconic Safeway story of achieving a zero medical cost trend through wellness - the inspiration for the wellness provisions in the Affordable Care Act - turns out to be made up."
If you wish to know the shocking truth on wellness programs (yes, shocking), you should read the entire article available at the link above. The fact that insurers promote these programs, but only for their non-risk bearing contracts with self-insured employers, certainly is revealing.
Pretending that we can control health care spending with checkups and wellness programs no longer cuts it. We need to tackle costs with proven methods that would ensure quality care for everyone. We should begin by enacting an improved Medicare for all.