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The American Journal of Managed Care October 2016
Cost-Effectiveness of a Statewide Falls Prevention Program in Pennsylvania: Healthy Steps for Older Adults
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Periodic Health Examinations and Missed Opportunities Among Patients Likely Needing Mental Health Care
Ming Tai-Seale, PhD; Laura A. Hatfield, PhD; Caroline J. Wilson, MSc; Cheryl D. Stults, PhD; Thomas G. McGuire, PhD; Lisa C. Diamond, MD; Richard M. Frankel, PhD; Lisa MacLean, MD; Ashley Stone, MPH; and Jennifer Elston Lafata, PhD

Periodic Health Examinations and Missed Opportunities Among Patients Likely Needing Mental Health Care

Ming Tai-Seale, PhD; Laura A. Hatfield, PhD; Caroline J. Wilson, MSc; Cheryl D. Stults, PhD; Thomas G. McGuire, PhD; Lisa C. Diamond, MD; Richard M. Frankel, PhD; Lisa MacLean, MD; Ashley Stone, MPH; and Jennifer Elston Lafata, PhD
Among patients likely needing mental health care, two-thirds had no discussion or perfunctory discussion of mental health during periodic health exams.
Given that one of the undisclosed agendas for patients scheduling a PHE was to discuss mental health topics, physicians could be more purposeful about eliciting, uncovering, and prioritizing the patient’s agenda. As it is often the case that the most important issues affecting patients’ well-being isn’t always the first topic discussed in a visit, negotiating around time and topics to be discussed becomes critical.42 Agenda setting is difficult; even in a sample of psychiatric encounters, the evidence showed that 2 of every 3 patients were not asked if they had any concerns to discuss.43 Physicians fear that eliciting a complete agenda will be too time-consuming,9 and many physicians also feel unprepared to handle mental health problems.40 Fully eliciting patient concerns adds less than a minute to the visit, however, and teaching these agenda-setting skills requires as little as 3.5 hours to learn and implement.43-45 Encouraging patients to fully voice their concerns, and preparing physicians to address difficult and potentially uncomfortable topics, can yield more effective consultations9 and mental health discussions, as shown in this study.

The annual costs of PHEs exceeded $10 billion per year, similar to the annual costs of all lung cancer care in the United States.46 Many individuals have called for eliminating annual physicals,46-48 based on systematic reviews and meta-analyses showing no reduction in morbidity or mortality.49 This study revealed that some patients came to their PHEs with mental health concerns, yet only one-third of patients likely needing mental health services had an evidence-based mental health discussion. Combined with findings of limited application of the 5As (assess, advise, agree, assist, and arrange) in colorectal cancer screening in PHEs,23 this study contributes to the body of evidence that reveals suboptimal quality of care delivered in PHEs. Policy makers should revisit the ongoing challenges of asking primary care physicians, who often are not trained in evidence-based counseling approaches, to deliver this care under increasing time pressures. Doing this poorly is likely a waste of a scarce resource: physician time. We should consider means to offer support outside of the ambulatory encounters so that it is possible to extend the office visit conversation—that often falls short—beyond the visit so that it approaches recommended counseling content.

Because the Affordable Care Act mandates one “free” PHE per person per year, it is important that PHEs be effective, including identifying patients with mental health needs.  Improving the quality of PHEs may require reimbursement for longer visits, training, and rewards that enable physicians to more fully elicit patients’ agendas and to listen more attentively. Without significant improvement in the quality of PHEs, eliminating them may do more to improving value in healthcare for the nation.46

Limitations

This study included older and privately insured patients in a single integrated delivery organization. The generalizability is not known. An additional limitation is the proxy measure of patient activation (ie, patient bringing a list of issues to the visit). We didn’t have information regarding what topics were on the list. A more specific measure of patient activation related to mental health would have been helpful to understand if mental health was on patients’ agendas. It would have been informative had we been able to document what was on patients’ lists, as it would enable us to understand if there were competing demands for the time with physician. Lastly, the study did not address health literacy training of the physicians and the patients’ ability to be highly verbal. Future research efforts should take account of these important factors.

CONCLUSIONS

The cup is one-third full, or two-thirds empty. PHEs could fill an important role for some patients to raise mental health concerns without directly stating that they are having these problems to the scheduling staff. Physicians should be on the look-out to uncover these potential issues and use the time to assess and evaluate mental health (a high-value service), rather than on performing extensive physical exams (low-value activities) during PHEs. Graduate medical education should spend at least as much time on training the next generation of physicians on how to ask open-ended questions, fully elicit patients’ agendas, and listen attentively as on how to listen for heart murmurs. 

Author Affiliations: Palo Alto Medical Foundation Research Institute (MT-S, CW, CS, AS), Mountain View, CA; Harvard Medical School (LH, TM), Boston, MA;  Memorial Sloan-Kettering Cancer Center (LD), New York, NY; Indiana University (RF), Indianapolis, IN; Wayne State University (LM), Detroit, MI; University of North Carolina at Chapel Hill (JEL), Chapel Hill, NC.

Source of Funding: National Institute of Mental Health (NIMH R01MH081098) and National Cancer Institute (NCI R01CA112379).

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MT-S, JEL, TM, CW, LD, RF, AS); acquisition of data (MT-S, JEL, TM, AS, CS, CW); analysis and interpretation of data (MT-S, LH, TM, CS, CW, LD); drafting of the manuscript (MT-S, LH, JEL, AS, CW, LD, RF, CS); critical revision of the manuscript for important intellectual content (MT-S, LH, JEL, RF, AS, CS, CW); statistical analysis (MT-S, CW, LH); provision of patients or study materials (JEL); obtaining funding (MT-S, JEL, TM); administrative, technical, or logistic support (MT-S, JEL); and supervision (MT-S).

Address Correspondence to: Ming Tai-Seale, PhD, MPH, 2350 W El Camino Real, Rm 446, Mountain View, CA 94301. E-mail: tai-sealem@pamfri.org.
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