The Doctor Is Out: Consumers Can Order Their Own Tests

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Consumers will soon be able to bypass their doctors by going online to order cholesterol readings, thyroid tests and other blood work from the largest diagnostics company in the United States.

Laboratory Corporation of America will let customers go online to pay for tests, visit a service center to get blood drawn, then view the results on the Web. The company has already been doing back-office lab work for a number of Internet firms that let people order tests without a doctor.

Rapid and at-home diagnostics are a growing segment of the health-care market, with businesses like WellnessFX Inc. and Direct Laboratory Services LLC tapping into demand from patients who want to get sensitive results in private or seek to monitor their health outside of the traditional doctor’s office. Companies like LabCorp are tapping into demand from consumers who want to measure and monitor the effects on their bodies of exercise and healthy living plus learn about their potential risks of disease.

We need to retake that territory for ourselves,” said David King, CEO of LabCorp. “It’s a growth opportunity for us. It’s something consumers increasingly want to have access to, and it’s something we’re doing already and our capabilities are being utilized without us getting the benefit from a branding perspective.”

LabCorp is also facing competition as options emerge for consumers to get tests without visiting a service center. Startup Theranos Inc., founded in 2003, has developed a diagnostic kit available in some Walgreen locations that can provide a range of results, from lipid panels to the presence of HIV, with mere drops of blood.

Drugstore partnership?

LabCorp’s direct-to-consumer business will initially be run online. The company is exploring a partnership with a drugstore chain as well – an idea that Quest Diagnostics Inc. tried and discontinued. The company did not say precisely which tests it will offer or how much it will charge. In some states, the law will still require consumers to get a doctor to order tests.

The consumer appetite for health information is growing as devices like the FitBit and the Apple Watch offer more sophisticated ways to monitor the body, and as companies like 23andme Inc. clash with regulators over the interpretations they provide for genetic information.

“We have entered an era where there’s a lot more patient involvement in their health care,” said Steven Lamm, medical director of the Tisch Center for Men’s Health at New York University’s Langone Medical Center. “The concern is when you want to take control of your health without being properly informed about what you’re actually testing.”

Taking back

Erena DiGonis, a licensed clinical social worker and health coach with a consulting business in New York City and Long Island, decided to order her own blood work online when the specialists she saw would not run certain tests that she wanted for a thyroid condition.

“It makes you feel like you’re taking back your own health by knowing where things stand,” she said of the testing she ordered online via DirectLabs. “It really empowered me and empowered my clients by recommending this service. If you want to get your cholesterol tested an extra time each year to see if your diet is working, it’s nice to see concrete results.”

Many of the tests do not come cheap. WellnessFX, based in San Francisco, charges $988 for its most comprehensive package, which includes biomarkers for omega-3 fatty acids and fibrinogen, a protein produced by the liver. Customers can go to a Quest Diagnostics center to do their blood work, and they can add a 40-minute consultation with a physician to discuss the results.

New revenue

DirectLabs, based in Mandeville, Lousiana, offers more routine tests like a $29 metabolic panel – glucose, kidney, fluids, electrolytes, calcium and liver – and a $49 measure of Prostate Specific Antigen, which the company says can be used to detect cancer.

Lab operators like LabCorp and Quest Diagnostics are looking for new sources of revenue as they contend with lower reimbursement from insurers and Medicare. The recent movement by hospital companies to buy up physician-owned medical practices has also siphoned off some of the lab work that the major providers had traditionally done.

Quest Diagnostics’ 2002 attempt to start a consumer business, offering blood work through CVS stores in Florida and Ohio, fizzled by 2006.

More educated

If LabCorp succeeds now, it’s because people are more knowledgeable and interested in their health data than previously, said William Quirk, an analyst at Piper Jaffray Companies Inc.

“There’s no question that consumers are more educated now than they were 5, 10, 15 years ago – that’s thanks to the Internet, smartphones and other applications,” Quirk said.

The question is what tests consumers really want, and if they’re motivated to seek data without prompting from a doctor, Quirk said.

“This is not like what color of iPhone to choose,” he said. “There’s a reason you get a prescription for lab work to be done because a physician is seeking information to make a diagnosis.”

Running a consumer business will mean LabCorp must navigate the variety of state laws and regulations on online diagnostics – some favorable, some challenging. Arizona, for example, passed a law that will allow residents to get blood tests without a doctor’s order. More than 20 states allow patients to order blood work without a prescription, Quirk said.

Controlling health

“The underlying principle is that people have a right to control their health, so they should be able to find out anything they want about their health,” King said of the movement in Arizona that allows patients to order any test they would like. However, the reality, he warned, is far more complicated.

“When you get into more complex things like thyroid disease, oncology and infectious disease, I’m completely supportive of the idea that a patient should understand and take accountability for their care – but there’s interpretation,” he said.

“LabCorp will make sure protections are in place for some sensitive tests so doctors are involved in explaining what the results mean,” he said. “We want to be sure we’re doing this in a compliant and responsible way.”

Awake And Safe All Night Despite Dementia

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In their Manhattan apartment, Josephina is trying to coax her 84-year-old mother, Brunhilda, to get ready to go out. As she does most nights, Josephina makes up a story to get her mother, who has dementia, to cooperate.

In Spanish, Josephina asks her mother if she would rather go to Miami or the Dominican Republic. Her mother says she wants to go to the Dominican Republic, and then Josephina helps her mother gather her things and escorts her downstairs to a waiting van. The driver will take her mother to the Elderserve At Night program at the Hebrew Home At Riverdale in the Bronx. It’s a kind of day camp – but at night, for people like Brunhilda who suffer from Alzheimer’s disease.

Josephina says her mother was once a proud, hard-working immigrant who raised four children on her own, but she has changed. “Her memory has been totally lost. She’s very disoriented,” Josephina says. “She doesn’t communicate at all.”

For months, Brunhilda would sleep during the day and be up much of the night wandering around the apartment. Her daughter was too afraid to sleep – afraid her mother might fall and hurt herself or even try to leave the apartment.

“She wanted to sweep the floor. She wanted to watch TV. She wanted to clean the bathroom,” Josephina remembers. “She wanted to go out. This is at one, two o’clock in the morning.”

But now Josephina is finally getting some sleep – and her mother is being well cared for, along with about 40 other people, seven nights a week. Activities may include arts and crafts, cooking, yoga or Zumba, and even live performances. On the night we visited, Juan Ortega played American and Spanish favorites on his synthesizer.

Though it looks like entertainment, each activity has a therapeutic benefit for memory-compromised people, says Deborah Messina, who runs the overnight program. She described a common problem among dementia patients known as “sundowning.” It is thought to affect about 20 percent of Alzheimer’s patients.

“Their day is our night and vice versa, and they are confused about it,” Messina says. “It is usually at dusk where an agitation comes, a confusion comes.”

Many people with dementia are more alert at night than they are all day – just when their caregivers need to sleep. Rather than try to alter this mismatch, Elderserve At Night embraces it.

The program is the brainchild of David Pomeranz, the executive director of the Hebrew Home, who opened the program in 1996. He says the idea came to him after hearing heartbreaking stories from struggling families.

“People were sleeping in front of doorways because they were concerned that mom or dad would wander out of the house,” Pomeranz says.

Those families desperately needed a safe place for their loved ones at night – and a decent night’s sleep. And the Hebrew Home set out to meet that need.

It’s a similar philosophy – to meet clients’ needs wherever they may be – held by the therapists and social workers who now staff Elderserve. “Here, their behaviors are normalized,” Pomeranz explains.

“Everything is OK. Activities are structured for them to be successful. They eat, they relax – they can be themselves. To us, this is who they are. We’re not the family members who are dealing with that incredible loss of seeing someone who was and isn’t any more.”

The program is covered by some private insurers and by New York Medicaid, the federal-state program for poor and disabled people. To the extent that it can keep people out of nursing homes, it can save money.

Medicaid pays a typical nursing home in New York about $320 per day versus $200 for the overnight program. But so far, few, if any, other overnight programs exist solely for people with dementia. Pomeranz thinks the idea hasn’t caught on with other nursing homes because it is difficult to find staff who are willing to work the overnight shift. It was also important to get Medicaid and other insurers to reimburse for the program, and that funding has not been pursued in every state.

Elderserve At Night tries to serve its clients even as their conditions worsen. Next door to the room where Brunhilda and others are dancing and enjoying the live music, it feels like another universe. The music is soft, the lights are low and a subtle scent of lavender is in the air. People with more advanced disease spend the evening here. Some are sitting around a table, each with a caseworker, who helps them work with blocks and basic puzzles.

Several other people are slumped in wheelchairs, getting hand massages from the social workers. Though their faces look expressionless, they seem calm. For people with advanced dementia who might otherwise become agitated at night, this room is a sanctuary, says Messina.

“We’re engaging them on their level. And being able to do that might be through touch, it might be through sound, it might be through scent,” she says. “It works for them. It gives them a sense of serenity.”

When the sun comes up tomorrow, all the clients will be given breakfast and everyone here will return home. Brunhilda will take the van back to her apartment in upper Manhattan where she will be greeted by her daughter before she leaves for work. Josephina says she doesn’t know exactly what happens during her mother’s nightly sojourns, but she is grateful.

“She was very weak when she started there. We had to carry her up and down [the stairs]. But now she walks up and down. She walks to Broadway,” Josephina says. “She would not react to any of the conversation. Now she does. She’s a totally new person. I would say she’s 200 percent better.”

Josephina says the program helped to improve her mother’s life and her own life as well. But Brunhilda was battling congestive heart failure, and she succumbed to the disease a few months after we reported this story.

The Boss May Be Able To Force Company Health Insurance

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Under the health law, large employers that are not offering their full-time workers comprehensive, affordable health insurance face a fine, but some employers are taking it a step further. They are requiring workers to buy the company insurance, whether they want it or not. Many workers may have no choice but to comply.

Some workers are not pleased. Many are disgruntled by the fact that their employer is requiring them to purchase health insurance and is automatically taking the premium out of their paychecks even though they don’t want to sign up for health insurance. Is this legal?

The short answer is yes. Under the health law, employers with 100 or more full-time workers can enroll them in company coverage without their permission as long as the plan is affordable and adequate. This means the employee contribution is no more than 9.5 percent of the federal poverty guideline and the plan pays for at least 60 percent of covered medical expenses, on average.

If an employee is offered minimum essential coverage that provides minimum value and is affordable, an employer does not need to provide an opt out, according to a Washington, D.C. law group firm specializing in employee benefits.

If a plan does not meet those standards, however, employees must be given the opportunity to decline those company plans, under the health law.

Experts say they do not expect many employers to coerse their workers to buy health insurance. Those employers that do may be confused about their responsibilities under the health law, mistakenly believing that in order to avoid penalties they have to enroll their workers in coverage.

“Nothing in the Affordable Care Act (ACA) directs employers to make their coverage mandatory for employees,” says a Treasury Department spokesperson. The law requires large employers “to either offer coverage or pay a fee if their full-time workers access tax credits to get coverage on their own.” 

Employer penalties for not offering insurance that meets the health law’s standards can run up to $3,000 per employee.

The practice of automatically enrolling employees in health insurance is not new. Many employers have been doing it for years. Some enroll new employees in the least expensive company plan, for example. But employees have generally had the option to opt out of the coverage if they wish.

Automatic enrollment makes it simple to satisfy the health law’s requirement that most people have health insurance, experts say.

The health law stipulates that employers with more than 200 full-time workers are required to enroll newly hired full-time employees in a plan unless the employee specifically opts out of the coverage. However, the provision won’t take effect until the Department of Labor issues regulations.

Employees who are unhappy about being required to buy into a company plan could complain to the Department of Labor, some experts say. It’s unclear whether such efforts would succeed.

Employment law experts point to a 2008 decision by the Department of Labor dealing with state laws that restrict employers from making deductions from workers’ paychecks without their consent. The department issued an advisory opinion saying that the federal Employee Retirement Income Security Act (ERISA) pre-empted a Kentucky law that required an employer to get an employee’s written consent before withholding wages to contribute to a group health plan. However, that decision does not have the force of law, because it merely suggests how the Department of Labor views such issues