Maximizing Patient Screenings Easier Said Than Done

Ed Rabinowitz

A lot of health services - and similarly a lot of practice revenue - are being left on the table. But fixing it is easier said than done.

American Journal of Preventive Medicine

Almost half (46%) of guideline-recommended preventive health services and screenings are missed during routine visits, according to the results of a recent study published in the (February 2012, Vol. 42, Issue 2).

The study revealed that breast cancer, colorectal cancer and hypertension screenings were the most delivered services, while counseling on aspirin use, vision tests and flu immunization were least likely to be delivered.

If that sounds like a lot of health services being left on the table — and similarly a lot of practice revenue — it likely is. So, the opportunities are readily available for physicians to add to their revenue stream. It’s an easy, quick fix, right? Well, maybe not.

According to Samuel Sandowski, MD, director of the Family Medicine Residency Program at South Nassau Communities Hospital in New York, there are several dozen recommended screenings and services listed on the U.S. Preventive Services Task Force website.

“But it comes down to the bottom line,” Sandowski says. “And the bottom line is time.”

A matter of time

Sandowski explains that even if a physician took two minutes to go over the recommendations, which is really not enough time, a patient visit would take well over one hour if the exam included the history taking, the physical and addressing whatever concerns the patient may have.

Most importantly, he points out, the list of recommendations is not on the patient’s agenda. They’re almost always the physician’s agenda. As an example, Sandowski points to the recommendation regarding alcohol misuse and counseling.

“First, you need to screen someone for alcohol use and then you have to counsel them,” he says. “So that takes time.”

Another recommendation is that any man between the ages of 65 and 75 should have a sonogram of their abdominal aorta if they’ve ever smoked in order to rule out an aortic aneurism. This can be difficult to convince a patient who maybe smoked once and is feeling no pain. And that discussion takes place even before the paperwork, Sandowski says.

“If we’re hitting 50% of [the recommendations], that’s not necessarily a bad thing,” he says. “It may be that 50% of the screenings are not done, but I’m looking at the 50% that are done. It really is a matter of perception.”

Whose recommendation is it?

It’s also a question of who’s making the recommendation. Sandowski says that the U.S. Preventative Services Task Force recommendations tend to be the most lenient — meaning that if the organization makes a recommendation, it’s probably got the best research behind it and probably has the best studies done to substantiate those recommendations.

That being said, there are organizations — such as the American Cancer Society, the American Academy of Family Medicine and the American Academy of Pediatrics — that might have different recommendations than the U.S. Preventative Services Task Force.

“In the past, I believe it was the American Cancer Society that was strongly in favor of screening for prostate cancer with a PSA,” Sandowski explains. “I know that’s starting to change now, but the U.S. Preventative Services Task Force was a little more ambivalent about whether or not the PSA should always be done or should be discussed, as opposed to recommended. And that’s where you need to take a look at who’s making these recommendations.”

Resolving the issue

Sandowski says that it’s important for physicians to recognize that when the patient’s agenda and the physician’s agenda do not match, meeting somewhere in the middle might be the best way to proceed.

“A yearly screening might not necessarily come up every year,” he explains. “So, one year, I may say, ‘Okay, we’ll do the colon screening.’ The next year I’ll say, ‘Okay, let’s do the abdominal aneurism screening,’ if they’re a candidate for that. And if I have discussions with the patient about a PSA and we decide that we’re going to do this on an annual basis, the next time I have to do it, that discussion is not going to be nearly as time-consuming.”

Can the physician-patient relationship benefit by raising the topic of certain screenings? Sandowski says the instinctive answer is, “Yes,” but that introducing certain medical issues can actually be a double-edged sword.

“There are those patients who are not interested in screening; who come to their physician for acute problems only. For instance, recommending HIV screening universally. There are those people who don’t want to have to deal with that subject at all. And if you bring it up, you’re creating a sore spot on the patient.”