Three trillion dollars. That’s trillion with a t. That’s more money than the annual gross domestic product (GDP) of Canada and South Korea combined. At a rate of spending exceeding more than $8 billion a day, the U.S. healthcare system is a massive behemoth, guzzling and spewing 20% of the U.S. GDP. By comparison, the 2015 Pentagon budget, a paltry $0.8 trillion, is surpassed by healthcare expenditures annually before the end of April. There is no enterprise in the world that remotely approaches the size and scope of American medicine.
Some policy experts applaud the shift of the fiscal burden from insurer to patient, viewing this development as a healthy one. To follow this line of reasoning, forcing patients to become more price conscious alters their purchasing behaviors accordingly. However, one key ingredient is missing in this messy remedy: price transparency. Shouldn’t consumers be able to review a list of charges before they make their decisions? Isn’t that the way commerce normally works?
Overspending on healthcare creates some major heartburn for our economy. First, it chokes off the potential growth of other economic sectors because so much of GDP is consumed by healthcare. Although the annual growth rate has slowed, the total cost of healthcare remains so enormous that just a 3% rise in growth amounts to an additional $100 billion per year. Second, some medical bills are simply insurmountable and account for about 20% of all personal bankruptcies.
It may turn out that the steady shifting of costs to our patients’ wallets may provide the greatest impetus for disruption of the colossal healthcare apparatus. A growing number of patients have quietly moved to the newest frontier in healthcare, best described as do it yourself (DIY) care. DIY care is an effort to provide quality care at reasonable prices that are transparent, two concepts totally alien to the U.S. market. DIY care is teeming with some exciting ideas and not every one of them involves using a smartphone app! Imagine if some forms of DIY care were to gain a foothold in a $3 trillion industry. Their success could force traditional stakeholders to reexamine their costly, and often illogical, ways of doing business. Let’s explore a few of these new ideas.
Bloody Simple
To describe Elizabeth Holmes as an overachiever would be something of an understatement. Even among the high-flying whiz kids of Silicon Valley, her intellect and determination stand out.2 After completing her junior year at Stanford University in Palo Alto, Calif., she conceived a way to perform multiple laboratory tests at once, using the same drop of blood, and to wirelessly deliver the resulting information to a doctor. That summer, she filed a patent for the idea, one that was ultimately granted in November 2007.
Theranos (a combination of the words therapy and diagnosis), the company she founded, aims to disrupt the $75 billion diagnostics industry by using a combination of miniaturization and automation to create a proprietary blood analyzer. Because only two drops are ever needed, the blood can be drawn via finger needle prick rather than from a vein. The sample is shipped to their lab from one of the many test sites that are being opened in thousands of Walgreens pharmacies. The cost savings can be staggering. Consider the blood work that a rheumatologist might order for a new patient presenting with a possible inflammatory arthritis. Let’s guess the cost of a complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein, comprehensive metabolic panel, antinuclear antibody (ANA), rheumatoid factor and cyclic citrullinated peptide. The total cost from Theranos is $39.15 to be exact.3 Doctors could also reassure their lupus patients that a double-stranded DNA antibody test plus the full range of extractable nuclear antigens totals a reasonable $83.39 from Theranos, nearly a 90% discount compared to the charges at many major hospital labs.
How does this menu compare to other current pricing schemes? Googling the terms, lab costs for ANA, ESR and uric acid, I found the lowest charges for each of these tests to be $59, $32 and $49, respectively. Compare this to Theranos, where the combined cost for all three tests was $12.78 ($8.31+ $1.36 +$3.11), and at a major teaching hospital in Boston, where they totaled $230 ($144+$32 +$54).
Once upon a time, inflated paper charges held little meaning for most patients, whose insurers had contracts with labs and hospitals that assured them far lower prices than those posted. But now, with the burgeoning growth of high-deductible healthcare plans, these deep discounts are not routinely passed on to patients, leaving them to cope with some major fiscal obligations.
The implications of miniaturized testing technology are likely to be profound. Investors have already valued Theranos at more than $9 billion, on par with Quest, the largest diagnostic lab in the U.S. The ability to have blood testing done simply, cheaply and close to home will challenge the entire sector.
If these concepts aren’t sufficiently disruptive, there’s a critical facet of the company’s business plan that may truly upend American medicine. As Holmes described it, her aim is “to redefine the paradigm of diagnosis away from one in which people have to present with a symptom in order to get access to information about their bodies to one in which every person, no matter how much money they have or where they live, has access to actionable health information at the time it matters.”2
In plain English, Theranos does not anticipate requiring physician referrals for their tests. Some lab testing may evolve as a direct-to-consumer activity.
Holmes is not alone in her thinking. Delos M. Cosgrove, MD, president and chief operating officer of the Cleveland Clinic in Ohio and a noted expert on U.S. healthcare, predicts that blood tests for many common health issues, including high cholesterol and diabetes, will soon be initiated by patients, as well as by doctors.
“The CVSs and the Walgreens and the Walmarts of the world are going to be taking a lot of things that currently go to primary care physicians,” Dr. Cosgrove said. “The impact of that on our industry will be enormous.”2
Will the Food and Drug Administration sanction consumer-directed testing? Recently, it has approved DIY genetic testing for certain autosomal recessive genes, but it has yet to issue its final ruling on tests for which the results can have immediate effects on patient healthcare choices.4 Stay tuned.
A Trip Abroad
Joint replacement surgery has been one of the truly great advances in medical care over the past 50 years. Paradoxically, despite the more skillful surgical techniques, shorter hospital stays, better-designed implants and rising volumes of patients undergoing these procedures (1 million annually), the cost of joint arthroplasty continues to rise. Why? Orthopedic procedures have been plagued by the common medical malady of “sticky” pricing, where costs remain high or increase over time instead of dropping. For example, the list price of a total hip implant rose nearly threefold from 1998 to 2011.5 This spurs some patients to seek care in fairly exotic locales, such as Thailand, Hungary, India, Singapore and Malaysia, countries that happen to be the most sought-after destinations for Americans looking for less costly options for joint arthroplasty, spinal fusion, bariatric surgery and cosmetic procedures.
Such organizations as Patients Beyond Borders tout the virtues of medical tourism, especially the ability to receive excellent care at substantial cost markdowns compared with American prices.6
Oh yes, getting some travel time is a nice additional perk. But how patients deal with delayed post-operative complications is not easily addressed.
Medical tourism has its limits, but the concept of seeking quality orthopedic care at reasonable cost has spurred some interesting innovations. It may have persuaded several major hospitals to set fixed, discounted prices for joint arthroplasty procedures for some of the nation’s largest employers. Walmart, Pepsico and Lowe’s have created an alliance with four hospitals that will offer no-cost knee- and hip-replacement surgeries for more than 1.5 million employees and their dependents. But wait! Not only will employees receive consultations and treatment without deductibles or co-insurance, their travel, lodging and living expenses, as well as those of their companion, will also be covered.7 Pack your bags. You may soon be traveling to Baltimore or Springfield, Mo., for that total knee replacement.
Does the Crowd Know Best?
Errors in navigation can have fatal consequences. This was especially true in earlier times, when ships were lost at sea at an alarming rate due to an inability of sailors to track a ship’s correct longitude. For this reason, in 1714 the British Parliament passed the Longitude Act, which offered a substantial prize to anyone who could solve the problem of identifying a ship’s longitudinal position.8 Many proposals were submitted from all parts of Europe, and over the years, the prize was awarded to several individuals for their creative solutions. Some consider this nautical challenge to be one of the first examples of effective crowdsourcing.
Crowdsourcing works because it draws on the curiosity & the altruistic impulses of the human spirit. This creative approach will likely cultivate the growth of open source science, allowing investigators to share ideas & resolve many challenging research issues relatively quickly & at low cost.
Nowadays, crowdsourcing research has enabled investigators to engage thousands of people to provide data or perform data analysis. It has been highly effective in solving some critical problems in molecular biology, comparative genomics, pathology and radiology. In one study, trained participants were able to outperform computer-generated algorithms in solving complex protein-structure prediction problems.8 On the clinical side, another study found that participants were able to correctly classify colonic polyps on computed tomography imaging studies and accurately identify red blood cells infected with malaria parasites over 99% of the time.8
Crowdsourcing works because it draws on the curiosity and the altruistic impulses of the human spirit. Participants generally have some expertise in solving puzzles, making them specifically adept, for example, at solving complex protein-folding problems. This creative approach will likely cultivate the growth of open source science, allowing investigators to share ideas and resolve many challenging research issues relatively quickly and at low cost. Perhaps the benefits of lower-cost DIY research will trickle down to DIY care.
Can the crowd be used effectively in our domain, clinical medicine? Can the diagnostic abilities of nonphysicians be tapped for the benefit of patients? A proliferation of online sites that mine the crowd in search of finding accurate diagnoses have recently sprouted, the most prominent being CrowdMed. Patients submit their cases, often offering a monetary reward to incentivize the medical detectives to work on their cases. Medical detectives can be just about anyone; there are no educational requirements.9
The founder of CrowdMed, an economist named Jared Heyman, started the site after his younger sister contracted a debilitating illness that no one could diagnose. After two years of fruitless leads and half a million dollars in tests, she was given a diagnosis and began treatment. Heyman believes that a large group of engaged participants tends to be smarter and their combined wisdom more accurate than any single expert. He claimed that just three days after submitting his sister’s multi-year symptoms, the site’s medical detectives had correctly identified her condition (he does not specify what it was).
Will CrowdMed challenge our practices? Or will it merely serve the needs of those patients with multiple somatic complaints and a paucity of objective findings? Let the crowd decide.
Medical crowdsourcing is popping up in many locations. There are YouTube clips, Facebook postings and tweets describing odd or difficult diagnostic dilemmas in search of answers. Every month, the Diagnosis column of The New York Times Magazine asks readers to try their hand at solving a medical riddle.10 Cases are presented in a fair amount of detail, and readers are asked to e-mail their diagnoses. Recent winners have included a retired bookkeeper who made the diagnosis of postural tachycardia syndrome in a young woman with fainting spells, a layperson with an “interest in hypoglycemia” who diagnosed an insulinoma and a college undergraduate who solved a puzzling case of porphyria.
No doubt, these exercises confirm the considerable general interest in solving medical puzzles. Will rheumatologists be replaced by the crowd? I don’t think we need to fret, at least not yet—or perhaps we should. A recent study surprisingly observed that the mortality rate for patients with advanced cardiac disease who were admitted to teaching hospitals during the days of national cardiology meetings actually fell.11 Yes, patients did better when the doctors were away!
Less is more. The new mantra for medicine.
Simon M. Helfgott, MD, is associate professor of medicine in the Division of Rheumatology, Immunology and Allergy at Harvard Medical School in Boston.
References
- Brill S. America’s Bitter Pill. Money, Politics, Backroom Deals and the Fight to Fix Our Broken Healthcare System. Random House. New York 2015.
- Auletta K. Blood, simpler: One woman’s drive to revolutionize medical testing. The New Yorker. 2014 Dec 15. http://www.newyorker.com/magazine/2014/12/15/blood-simpler.
- Theranos. https://www.theranos.com/test-menu?ref=our_solution.
- Burton TM, Gormley B. FDA signals easier rule on genetic tests. The Wall Street Journal. 2015 Feb 21. http://www.wsj.com/articles/fda-signals-easier-rule-on-genetic-tests-1424468927.
- Rosenthal E. In need of a new hip, but priced out of the U.S. The New York Times. 2013 Aug 3. http://www.nytimes.com/2013/08/04/health/for-medical-tourists-simple-math.html?_r=0.
- Medical Tourism Statistics & Facts. Patients Beyond Borders. 2014 Jul 6. http://www.patientsbeyondborders.com/medical-tourism-statistics-facts.
- Walmart, Lowe’s enter bundled pay deal with four health systems. The Advisory Board Co. 2013 Oct 9. http://www.advisory.com/Daily-Briefing/2013/10/09/Walmart-Lowes-enter-bundled-pay-deal-with-four-health-systems.
- Ranard BL, Yoonhee PH, Meisel ZF, et al. Crowdsourcing—harnessing the masses to advance health and medicine, a systematic review. J Gen Intern Med. 2014 Jan;29(1):187–203.
- Arnold C. Can the crowd solve medical mysteries? NOVA Next. 2014 Aug 20. http://www.pbs.org/wgbh/nova/next/body/crowdsourcing-medical-diagnoses.
- Sanders L. Think like a doctor: Swept off her feet solved. The New York Times. 2015 Feb12. http://well.blogs.nytimes.com/2015/02/12/think-like-a-doctor-swept-off-her-feet-solved.
- Jena AB, Prasad V, Goldman DP, et al. Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during dates of national cardiology meetings. JAMA Intern Med. 2015 Feb 1;175(2):237–244.
Correction
An error was introduced in the editing process to Figure 3 GiACTA Study Schema, in “Giant Cell Arteritis” (The Rheumatologist, March 2015). Tocilizumab should have been represented by the acronym TCZ, and there was a mistake in the dosing schedule. To see the correct version of the figure, visit https://www.the-rheumatologist.org/details/article/7577501/Giant_Cell_Arteritis_Challenging_to_Diagnose_Manage.html. We regret the error.
