Teens With Health Insurance Absent in the Doctors' Offices

Nov. 9, 2010— -- Seventeen-year-old Giulia Bertoli is sure to get her checkup every year. And if she were to forget, her mother would be the first to remind her.

While some of her friends say that an annual physical is a waste of time when they're feeling perfectly healthy, Bertoli thinks differently.

"My father died from liver cancer, so my mom always likes to keep a count with regular blood tests and stuff," said Bertoli, a high school senior from New Jersey. "Plus, I like to know how my body is, if it's OK and I'm in good condition."

The teen years are filled with growing pains, with changes in hormones, moods and emotions. With such transformation, many would think that all teens, like Bertoli, fit an annual physical exam into thier regular routine. But a new study from the HealthPartners Research Foundation found that this is not the case for many adolescents.

The research, published in the Annals of Family Medicine, examined data of 300,000 Minnesota teenagers. Study authors found that one-third of those teenagers did not go to even one routine checkup between the ages of 13 and 17. Forty percent of the teens had only gone to the doctor for preventive care once during those four years. And insurance wasn't a factor -- every teenager in the system had insurance that did not require a deductible or co-pay.

"I was surprised that so few kids are in regularly preventive services," said Dr. James Nordin, lead author of the study and a pediatrician with the HealthPartners Health System in Minnesota. "I think this could be because teens think of themselves as invulnerable and many parents consider this a very healthy period in life."

The American Academy of Pediatrics' Bright Futures' and the American Medical Association currently recommend that teenagers get a routine physical exam once a year. But, some past studies have suggested that 13- to 17-year-olds visit the doctor less than any other age group.

Teens: Absent in the Doctor's Office

"Yes, it's true, teens hate coming to the doctor," said Dr. Carolyn Eaton, a general practitioner in private practice in San Antonio, Texas. "Since they don't need any vaccinations for school after age 11 or 12, there is not much incentive to come in if they do not participate in sports."

"Adolescents disappear after routine child care, usually about age 8 or 9, then occasional visits for sports exams, then nothing until after college," said Dr. Thomas Schwenk, a professor in the Department of Family Medicine at the University of Michigan.

But could the teens' absences from their primary care physician affect their long-term health? Some doctors say yes.

"I would bet that we are falling down on immunizations, tetanus, pertusis, and HPV," said Dr. Daniel McCarter, associate professor of Clinical Family Medicine at the University of Virginia.

Dr. Marcie Billings, a pediatrician at Mayo Clinic, said that it is during these visits where doctors, teens, and their families have the opportunity to talk about more than just acute pain and illness.

"[Teen health issues] that we see and deal with often are risk-taking behaviors such as alcohol use, substance use, and sexual activity, depression and other mood disorders, obesity, eating disorders, and chronic medical illnesses," said Billings.

And while the risk-taking behaviors are important teen discussion points, it is often just as important to involve the parents in the conversation as well.

"By engaging the parent as well as the teen, it increases the chance you may be able to have them return to continue a more in-depth look at issues you may uncover through the initial screening process," said Dr. Ann Budzak, a pediatrician at Gundersen Lutheran Medical Center in La Crosse, Wisc. "Having office hours in the evening and on weekends also increases the chances a teen will come for a routine visit along with a parent."

Dr. Lee Green, a professor in the department of Family Medicine at the University of Michigan, agrees that parents play an important role in the process.

"My experience is that if teens come in for any preventive services, it's their parents' idea, or more often a requirement of the school, camp, or sports team they join," said Green.

"They make the appointments!" said Dr. Caryl Heaton, associate professor and vice chair in the department of Family Medicine at New Jersey Medical School. "You would never hear a teenager say, 'Oh, I better get a checkup.' That's just not the way their brains work."

'No-Missed-Opportunities' Paradigm

On top of parental involvement, study authors suggested the idea of a "no-missed-opportunities" paradigm to solve the dwindling teen presence in preventive medicine. The idea is that every adolescent visit to the doctor, whether for strep throat, a broken bone, or bronchitis, is seen as an opportunity to provide preventive care services, even in busy practices with short encounters with the clinician.

Eaton said the idea of no-missed-opportunities paradigm has already been incorporated into her routine with teenagers.

"[I] discuss weight, diet, activity levels, flu vaccines, etc.," said Eaton. "Generally, mentioning weight issues doesn't take a long time, and [it's] often helpful."

And Schwenk said that many practices and family physicians already ask preventive care questions at each visit. The University of Michigan has already put a plan into place that will answer preventive care issues for any type of doctor appointment with a teen.

"At U.M., we have a sophisticated system that provides all of these prompts and reminders for any services we choose to emphasize, and they show up for all visits," Schwenk said. "We do not differentiate preventive service from chronic disease from acute care visits any more, everything happens at every visit."

A Time Crunch

But Dr. Michael Good said time would continue to be the enemy when it comes to the no-missed-opportunity paradigm.

"I cannot see how one would have time to sneak in a half-hour of preventive counseling in a seven minute double-booked sick visit," said Good, a family practice physician in Middletown, Ct. "In today's world, a primary care practice would run hours behind, patients would storm out of the waiting room, income would be lost and everyone would be unhappy if we tried to hold up all our patients because a delinquent teenager happened to come in with a sore throat."

Would it Make a Difference?

And even with preliminary systems in place, some doctors wonder if the regular visits would really do much good. Green wasn't convinced that the low level of teen preventive care should be a cause of concern.

"Yes, there are 'guidelines,' but they're based on the opinions of well-meaning experts, not on data demonstrating benefit," said Green. "The health risks in the teens are almost entirely behavioral. It may be motherhood and apple pie to want to bring teens in so we can assess and address their behavioral risk factors, but is that actually an effective intervention?"

But lead author Nordin believes it would be effective.

"Obviously there are a lot of physicals that aren't getting done," said Nordin. "Getting the appropriate screening for obesity and other diseases will improve the health of the entire population."