My latest excursion into direct-to-consumer lab testing concluded about an hour ago (2:30 PM) and it was an unequivocal bust. I wanted to check three different endocrine parameters that I thought might be important for asthma control - so I went online looking for a way to do that. I am not a novice in the area. About 10 years ago I found a local health care system that offered a limited menu of direct to consumer testing. In other words, you just walk into the lab, check off what labs you want, pay them, and they do the tests. No calls to a doctors office and the endless telephone queues, no discussions with staff who treat you like you are a demanding patient, no waiting for a call back from the doctor, and no waiting for the staff person to talk with the doctor and then call you back. That is exhausting and a clear impediment to medical care. The electronic health record (EHR) "fixes" for this problem are not much better. I find myself either looking at a list of fairly simple lab tests and visits or signing off on a possible $45 fee for an email if I have not seen the doctor within a certain interval. That is equally exhausting, especially when I end up clicking on "other" and typing an essay on what I really want.
About 10 years ago, the first direct to consumer labs became available in the Twin Cites - a metro area of just over 3 million people. There was a very limited menu, but I found it useful to follow Vitamin D levels and discovered that my wife probably did not need to take Vitamin D. I occasionally checked a few other tests - maybe a total of 5 times in the 10 years. This time I needed more esoteric tests than were on the list and hoped there was another lab. I did find it but there were several problems. The first was test selection and payment. It suggested that I do it online, collect all of my tests in a cart and check out. When I did that I discovered that the company collecting my credit card information was not the lab, but some other company I had never heard of. Was it safe to give them that information? There was an online chat staff - but she just gave me an 800 number to confirm the company was who they said they were. I shut it down at that point.
The next step was calling the nearest lab about 9 miles away. I called several times and left my number. Nobody bothered to call me back. I finally decided to just drive down there. They were located in an industrial strip mall - nothing unusual for durable medical goods companies. I walked into a packed waiting room of about 20 people. There was a reception window that was never inhabited during the 90 minutes I was there. Any new customer needed to figure out that they needed to enter their name, birth date, and phone number on an electronic tablet in order to get into the queue. A phlebotomist came out every 5-10 minutes to call the next customer. The place had an industrial feel - not unlike an old hospital past its prime. It seemed like everyone else was bringing in paper work. My expectation was that it ran like the other place. Just check off the boxes, pay, and get the blood drawn. The real conversation went something like this:
Phlebotomist: "Do you have any paper work?"
Me: "No I thought from the web site that I could just tell you what I want and pay here."
Phlebotomist: "No - here you need a doctor's order or an account."
Me: "Well I am a doctor can I just give you the order?"
Phlebotomist: "Do you have a prescription pad?"
Me: "No I thought I could just check a form and pay you."
Phlebotomist: "No we can't take any payments here - you have to pay online."
Me: "OK - sorry for wasting your time."
Phlebotomist: "You're not wasting my time. I'm here until 4 o'clock."
It was a total wash. No lab test and about 2 1/2 hours wasted.
This is where a company like Amazon can really revolutionize health care. Healthcare companies are doing everything they can to monopolize lab and imaging services. They have oversold the EHR to patients like everybody else. I have argued with some of these unfortunate souls that believe the EHR is really going to help them maintain their own private healthcare information and portability. My description above indicates otherwise. I also ask them if they still have any healthcare information that they stored on a computer in the 1990s.
The news about Amazon, Berkshire Hathaway and JP Morgan news about their healthcare initiative has fueled a lot of speculation about how that will play out. My speculation is that Amazon has the current data handling infrastructure to aggregate healthcare just like they aggregate everything else. The question is what will be aggregated, how will it be aggregated, and what will the regulatory burden be on the aggregation. Consumers are now considering their personal healthcare information to be their own property. That is not how the laws are written, but it is a selling point for health care products. If Jeff Bezos is listening, the low hanging fruit in health care are high margin lab tests, imaging studies, and medications. Those are the best products to aggregate based on price comparisons and how easily they are available. On the back end, there is the question of getting the results to the attending physician and the medicolegal implications of giving abnormal results back to a patient with no commentary. In Minnesota, the first company I used here got around that by saying that any abnormal tests were run by the laboratory pathologist for comment.
As a physician and consumer, this is the revolution that is necessary. Many people are perfectly capable of getting maintenance labs or labs of interest when necessary and call their doctor about the results. They are less likely to keep coming in and seeing a doctor for the sake of routine labs and lab interpretations. They are less likely to go to traditional hospital and clinics that adhere to inconvenient hours. This approach would shift some of the cost to the consumer, but the trade off would much better cost and convenience. An example is the three endocrine tests I was ready to order cost about $230 and they have been available for decades. For the same price, I can get my entire genome analyzed. Lab margin estimates in the news are 10-20%, but I would guess that is on the low side.
All of the current major Internet companies are capable of these changes. They should also be very competent in producing a much better EHR that works for physicians. I think that health care regulation and business models are what has been holding them up. Hopefully Amazon's move will get the rest of them involved and move health care management and funding as far away from the insurance industry and pharmaceutical benefit managers as possible.
I may still end up walking into an industrial strip mall lab to get my blood tests done - but at least I would know that everything on the front end would have been handled flawlessly and my credit card will take less of a hit.
George Dawson, MD, DFAPA
Graphics Credit:
The Amazon sign was downloaded as an image from Shutterstock per their licensing agreement. I have no connection with Amazon and am not a stockholder. I have no conflict of interest to declare in this area.
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