Jeff Bezos Hear My Plea

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.

The EMTALA Paradox

I wanted to add a post here about EMTALA or Emergency Medical Treatment & Labor Act.  The definition can be found  on the CMS web site:

"In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented."


There are numerous links on the web site about what that all means.  From a practical standpoint in many states the law has been disruptive to psychiatric care for persons going to an emergency department with a psychiatric emergency.  The law in effect makes it seem like there are plenty of resources to treat anyone with a serious problem, but on the other had the receiving services are seriously rationed.  There is no better example than psychiatric services where most hospitals have no inpatient services and practically no hospitals have psychiatrists working in their emergency departments (ED).  That results in a triage system based on dangerousness and the two pronged deficiencies of no treatment unless you are dangerous and a frequently contentious determination of dangerousness.  Dangerousness here is basically a managed care term to facilitate discharges in patients who have been partially treated and still symptomatic.  A person can be determined to be ready for discharge if they are no longer saying that they are having suicidal or aggressive thoughts that day.  That means at the time of admission there can be a lot of dishonesty by others to get people in the hospital and in many cases a desperate person who is not able to function will say they are "suicidal" when they are not.  The main problem is people who are uncertain for one reason or another and end up on legal holds for psychiatric assessment.  In the state of Minnesota that hold is for 72 hours excluding weekends and holidays.

The EMTALA law generally creates a massive backlog of patient in the ED waiting to be admitted for psychiatric indications. If they cannot be admitted to the hospital they initially present to, they can be transferred to any hospital in the state.  Transfers of several hundred miles are common.  The receiving hospital is at a disadvantage because they have no records and any transferred electronic health records (EHR) are typically devoid of useful information.  They also no longer have access to psychiatrists who know them and their family has to travel much greater distances to see them.  The combination of rationed inpatient services, rationed housing and residential services, and EMTALA basically keeps a large population or partially stabilized people with psychiatric disorders rotating in an out of the ED, inpatient units, shelters, and in many cases local jails.  EMTALA makes it seem like politicians are doing something while they are allowing insurance companies to ration services and make money.

In health care policy discussions, there has been an excessive focus on ED services.  I have heard many people say that we don't need wider access to health care because of EMTALA: "Whether I have any insurance or not - I can always go to the ED and get treated." That is a rather naive statement about the evaluation and treatment of most medical problems.  

What about the situation where patients have reached American healthcare nirvana and are insured?  In this case rather than getting default rationed treatment because of an inadequate system they have the opportunity to receive proactively rationed care for the sake of maintaining their insurance company's profits.  To make matters worse quality of care in both scenarios is very poor.  Since these scenarios are only obvious to psychiatrists working in either acute care or residential care settings - I will provide a few examples of how being insured works against the patient.  The outcomes are factual, the case specifics are not.

Case 1:  36 year old man admitted with alcohol use disorder and a recent suicide attempt.  He requires detoxification and during that process it is discovered that he is also taking alprazolam 2 mg bars - 4 -5 a day that he acquires off the street.  The detoxification is difficult for many reasons with poor response to benzodiazepines and on day 5 the decision is made to change the detox agent to phenobarbital.  The patient remains depressed, hopeless, and is non-disclosing about suicide potential despite continuing on high doses of two antidepressants, one of which (venlafaxine ER 150 mg/day) was effective prior to escalating alcohol and benzodiazepine use.  A managed care company reviewer calls on day 3 and 4 and says the patient must be discharged by day 5.  When provided with the new data about the change in detox protocol - he says the patient can take the medication with him and complete it as an outpatient.

Case 2: 75 year old man with diabetes mellitus Type II, hypertension, and atrial fibrillation.  He has an alcohol use problem but was admitted because of cognitive concerns and declining cognitive function.  The family doubts that he is taking any of his ten medications accurately due to the cognitive problems.  They are also concerned about the number of empty vodka bottles found at his home and the fact that he has numerous firearms.  The managed care company reviewer calls the day after admission and states that the patient is not covered because there is no "dangerousness" - translation - he is not making any suicidal remarks or threatening to harm other people. He must leave the hospital or pay for his own treatment.

Case 3:  22 year old man with depression and heroin addiction.  He was dropped off outside the ED following an accidental overdose.  The ED staff are familiar with the patient because this is the fifth overdose he has had in the last 3 months all from excessive use of intravenous heroin.  During the interview he says: "Look I am not trying to kill myself, I just get  to the point when I am trying to get high that I don't care if I live or die."  The plan is to detox the patient and get him on buprenorphine-naloxone in a controlled setting to reduce the risk of another overdose and provide the additional counseling necessary to do that.  The managed care reviewer calls on day 2 and says the patient must be discharged and the buprenorphine-naloxone can be started on an outpatient basis.      

These are a few of the many examples of people with insurance who are denied emergency psychiatric care based on the subjective impression of a managed care reviewer.  The reviewer has clear conflict of interest since they are charged with saving the company money.  In all of the examples there is a clear need for the patient to be in a protected environment until effective and maintenance treatment can be established.  There is a clear need for the patient to be detoxed on an inpatient unit.  Why would anyone think that giving a large supply of addictive medications to a person with an addiction to managed their own detox would be a good idea?  In all cases the managed care reviewer does not care.  There used to be an appeal process, but it was to another reviewer hired by the same company.  There is no appeal to anyone who is neutral and there has not been for 20 years.  The system has worsened in the past ten years.  Now the hospitals being reviewed by these managed care companies have their own internal case managers who pressure physicians to make the same low quality decisions. 

The result is clear.  Very poor quality of care.  Burned out physicians scrambling to pull together very shaky discharge plans for unstable patients.  Politicians and regulators making it seem like they are doing something and bragging how they are improving access and quality of care while containing costs.

That is the real product of the EMTALA paradox.

George Dawson, MD, DFAPA