Annual Screening Medicals - who should pay for what?

Colin Alert

Barbados

My experience of 20 years of medical practice tells me that there are many Caribbean persons have no ongoing medical care, and visit the nearest physician when they hurt their back, have some sort of ‘bad’ abdominal pain, are afflicted by H1N1, or are otherwise convinced that work is too stressful and they need a few days sick-leave.

Individuals who work with food, the ‘food handler’,  a diverse group that includes hotel workers, waitresses and barmen, super-market deli workers and others, require an annual certificate to practice their trade, and must have the certificate on hand when visited by the Health Inspector. When the food handler works in a formal institution, often (but not always) the visit to get this medical certificate is organized and paid for by the ‘company’. Since the primary purpose of this medical is to detect (and remove) conditions that may lead to food-bourne diseases, the focus of these medicals is on personal hygiene, looking at length of nails, open sores and wounds, doing stool-sample screening: at one point the VDRL blood test seemed to be an important part of this annual screening.

At an individual level, many workers do not have ready access to medical care. It must be noted that the Government polyclinics (Health Centres) offer free care (and hence ready access) to all locals, but many working individuals are put off by long waiting times, in particular. Having to spend hours in a waiting room for medical attention is often at the expense of a day’s wages, so workers tend to visit only when ‘seriously ill’; screening visits are a luxury under these circumstances.  The individual food handler thus requests that his/her blood pressure and blood sugar be checked when attending for his/her food handling certificate, since 1. These tests are free or cheap; and 2. There are rumors that hypertension and diabetes, the original ‘silent killers,’ are spreading like wildfire in our populations. Further, this is a belief that ‘checking-on’ these conditions is protective in some way, especially if some rudiments of a ‘healthy lifestyle’ are also practiced.

Thus the ‘basic medical’ for food handlers, in addition to the ‘hygiene screen’, would include screening tests for diabetes mellitus and hypertension. [In actual fact, there is no legally defined ‘basic medical examination’, but the U.S. Preventive Services Task Force (USPFTS) make recommendations about which preventive services should be incorporated routinely into primary medical care. See www.ahrq.gov ]. To date the recommendations directed to the Afro-Americans seem to be the most applicable to Caribbean people, as there is significant overlap in the health profile of these groups.

There are many workers for whom an annual medical examination/health certificate is not a legal requirement. A few companies, perhaps spurred on by agreements with trade unions, also organize annual medical examinations for the workers, at least those at the blue-collar level. Again, these examinations are generally at a ‘basic’ level, falling short of the ‘reccomendations’ for annual screening examinations for adults in our countries.

Unfortunately, at a population level, our leading causes of sickness and death include some conditions that can be identified (and offer opportunities for early medical intervention) by simple screening tests: these include elevated cholesterol and breast, cervix, and prostate cancers. Some would also include colon cancer on this list. The tests for these conditions are more costly than the diabetes/hypertension screening tests, and this creates challenges for the individual to pay for these tests, or for companies to pay for the tests for individual workers.

There is some awareness that, in the world of rich business executives, employment contracts include provisions for the company to pay all or a large proportion of an individual’s medical bills. This generally includes an annual screening examination, and as we heard at the 3rd Pan Caribbean CCFP (Caribbean College of Family Physicians) Conference in 2006, can costs as much as $ US 10,000 per person in the Bahamas. The presenter, a cardiologist based in the Bahamas, was quick to point out that the target here was Wall Street Executives, USA; perhaps a few Caribbean companies could afford this.

The ‘culture’ of most Caribbean businesses to date does not include the company paying annually for mammograms, colonoscopies, PSA tests and pap smears, or even treadmills, MRI scans and 24-hour halter monitoring, not for non-executive level workers. Individual workers with personal medical insurance policies can have a large portion of these tests refunded by the Insurance Companies; experience suggests that ‘significant numbers’ of individuals do not (or cannot) avail themselves of these screening tests, and are content with the annual ‘basic medical’.

Thus, when viewed across the entire population and in spite of official National statistics which suggest that 99% of our people have free access to Primary Health Care, in fact a much lower percentage of our people are actually screened annually for the common conditions prevalent in our communities. (This fact seemed to be recognized by the Caribbean Prime Ministers who, in their Declaration of Port-of-Spain following a special meeting in September 2007, promised to have screening programs in place in all Caribbean countries by mid-2008. To date no countries have such a program in place). When screening fails to detect and prevent illnesses in primary health, diseases are allowed to ‘incubate’ and subsequently require tertiary care, which is high-cost and resource-intense care: governments are hard pressed to finance the level of tertiary care that community health profiles dictate. In this context screening programs offer a cost-effective option to dealing with a significant number of our health problems. But should Governments, individuals or employers be responsible for paying to monitor and maintain the health of persons in our communities?