Science marches on

Or maybe the title should be 'welcome to another revenue stream.'

I got to experience a new-to-me preventive medicine screening procedure yesterday. A few weeks ago I had my annual wellness meeting with my primary care practitioner, the encounter I always refer to as the 'yes, I'm still breathing' encounter because it's not a physical exam in the old-fashioned sense of an annual exam. It's a question-and-answer session that doesn't go much beyond the practitioner demonstrating that yes, she does still know how to use a stethoscope to make sure you have a heartbeat. 

Anyway, as part of the Q & A, my PCP ascertained I had managed to dodge the tits-in-a-vise for over five years, had never been tested for Hepatitis C, couldn't remember the last time I'd gotten a tetanus booster, and had never even heard of being screened for an abdominal aortic aneurysm, let alone had that screening done. When did routinely doing ultasounds of geezers' guts become a thing? 

I do like to feel like I'm getting my money's worth out of my insurance premiums, though, so when I got told it was a covered procedure under Medicare, I said sure, schedule it. It's summer. I don't mind the drive from the ranch up to Portage Health in Hancock when the weather is good. I acquiesced on the tits-in-a-vise, too. I figured it's a waste of time, but didn't feel like arguing it. 

Then I started Googling abdominal aortic aneurysms. No surprise -- they're pretty common in the elderly. Not super common, but of all the age groups, old people are the most likely cohort to end up with blood vessel problems. You get old, stuff starts wearing out, including major arteries. And arteries don't come any more major than the aorta. If you think of the aorta as analogous to a rubber hose that is being repeatedly inflated and deflated multiple times per minute day after day, month after month, decade after decade, it's not surprising that it's doing to develop some odd bulges as it fatigues. Eventually the bulges can get bad enough, the tissues thin enough, that leaks develop. Or, worst case scenario, blowouts. 

So when did screening for potential blowouts become a routine procedure? As far I could tell, it goes back to 2015 and the recommendations of the United States Preventive Services Task Force. The USPSTF is an independent organization, a panel of experts that evaluates findings in scientific medicine, and comes up with recommendations for improving preventive care. Seven years ago the Task Force reviewed the extant research on abdominal aortic aneurysms and decided screening older persons who presented certain risk profiles would be a good idea. 

Who fit that profile, you ask? Overweight elderly men with a history of long-term smoking and high blood pressure. How did the Task Force feel about screening old ladies? Probably not beneficial for women. So why did I, a woman who has normal blood pressure and quit smoking over 40 years ago, end up getting referred for a screening? See the subtitle suggested above: revenue stream. 

In a Facebook post where I mentioned the screening, I described the experience as the hospital trolling for surgery patients. After all, that is the fix: treat the aorta like a bad tube on a tire by patching it. It can be patched in a minimally invasive way (insert a stent by slicing into the femoral artery and sliding a stent up to reinforce the aorta from the inside, a procedure that's still going to require a general anesthetic and no stair climbing for a few days) or you can slice the patient open and work directly on the bad section. So, yes, I'm still thinking trolling for candidates to slice and dice is an accurate assessment. The more old people you screen, regardless of whether or not they fit the high-risk patient profile, the more likely you are to reel in a few potential occupants of a surgery suite.

Am I likely to be one of those candidates? Based on the statistics I saw, this is a case where the odds are in my favor. Geezers might be the most likely group to experience abdominal aortic aneurysms, but even among geezers aneurysms are pretty rare. And then when you get into just how many people who have been diagnosed with an aneurysm, the numbers who experience actual ruptures isn't especially high. Yes, it's a risk, but in the overall scheme of things that might kill a geezer, it doesn't make the top ten. 

As for how I'd react if I did get told to consult with a surgeon, my feelings on medical interventions once a person hits their sell by date (or is close to it) have been documented elsewhere. Watching my mother age did a good job of convincing me I have zero desire to be a centenarian. She actually aged pretty well (no cognitive decline, for example) but it's still depressing as hell to become increasingly frail while watching everyone in your age cohort drop dead before you. Involuntary tontines suck; being the oldest person in the audience at someone else's funeral doesn't seem like much of a pay-off.

Hey, Medicare geezers, when was the last time your doctor saw you naked?

 The S.O. and I were chatting the other day, talking about doctor appointments and the annual "wellness" visit with one's primary care physician, and we started wondering just when was the last time either of us had an actual full-blown annual physical. In my case, it was probably in Atlanta. Might be the same for the S.O. In any case, it was before passage of the Affordable Care Act. 

One of the provisions of the ACA is that Medicare will pick up 100 percent of the tab for an annual wellness visit with your primary care physician. No co-pay like there always was (and still is) with an actual physical exam. And, yes, young folk, Medicare has co-pays just like every other insurance plan in the U.S. The stuff it covers (and there's a lot it simply doesn't cover, just like . . .) Medicare reimburses providers 80 percent of what they (Medicare) has decided is a reasonable rate. The patient is on the hook for the other 20 percent, although there are providers who are happy to just get the 80 percent -- they treat it like full payment and never bill the patient for the rest. Those providers are rare.

Anyway, the purpose of the wellness visit is supposedly to just chat with your PCP about your health, raise any concerns you may have, and decide if "further research is needed." This is actually the visit that had right wingers foaming at the mouth because it was originally framed as the moment when your doctor would ask you about care directives, the infamous living will. It got redefined as a time to talk with your doctor without getting naked. An office visit where the doctor and you would talk about your health in general and decisions could be made about what to do next. You know, do you need to actually take your clothes off for a thorough exam? Or maybe get a referral to a specialist? It was quite explicitly not meant to be an actual annual physical exam. 

Except, of course, it gets treated like one. You make an appointment for an 'annual' with your PCP and by default it becomes the wellness visit. Or, as I tend to refer to it, the "yes I'm still breathing" chat. You get your temperature and blood pressure checked, the nurse or technician reviews your record (any new medications? Been to any other doctors since the last time you were in?), and that's about it. Your doctor comes in, asks if you have any concerns, reminds you (if you're a woman) you're overdue for a mammogram, and life moves on. The guy I see will usually get out the stethoscope and listen to me breathe (confirming, I guess, that I'm not a revenant), he'll ask a few ADL-related questions* (e.g., can I still tie my own shoelaces), we'll make small talk about infectious disease (he went to Africa as part of a team responding to one of the Ebola outbreaks a number of years ago, I worked on the journal Emerging Infectious Diseases at the CDC), and we go our respective ways. No feet in the stirrups and an ice cold metal implement being inserted into a very personal space, no quick manual boob exam, no doing a quick scan of exposed skin for odd looking growths. None of the stuff that used to be a routine part of an "annual."

I see this as typical of the Law of Unintended Consequences. The intent of the wellness visit provision was to improve elderly person's health by giving them an opportunity to talk with their doctors. It was meant to be a complement to other routine care, like an actual annual physical. It was not supposed to replace it. But inevitably it did -- a wellness visit takes a lot less time than a full-blown physical, which means more patients can be scheduled in a physician's day, which in turn means more money and reduced expense for the provider. It may seem kind of minor, but when patients keep their clothes on you don't have to worry about providing gowns for them to change into, there's no time being wasted while waiting for patients to undress, there are no supplies like gloves or lube being used, cleaning the exam room between patients is a lot faster and easier. It adds up. 

It also makes perfect sense that in the profit driven model that is the American health care system that the wellness visit would morph into the primary visit. Next step, as we've already seen during the pandemic, is going totally to telemedicine. Health care delivered via telephone and Zoom meetings. We're all really close to being able to list WebMD as our PCP. 

Which, in an odd way, is rather comforting. Back when the annual was truly an annual, I swear every year found me with a new comorbidity. Since it became the 'are you still breathing' visit, no new pre-existing conditions have emerged. I am apparently a heck of a lot healthier now than I was ten years ago. Ignorance can be bliss.

 *ADL - activities of daily life. Questions about ADLs are meant to determine if you're still capable of living independently or do they need to start getting a bed ready for you at the local nursing home.