Testing made easy
Direct-from-lab medical results can give patients more power, but they might also harm the unwary
Connie Wainwright wants to save time. Rinah Levine is trying to save money. Tina McKee didn't trust her doctor. A cancer patient in Texas is worried about his privacy. Four people, four different reasons, but they all made the same decision: to order their health tests directly from a lab and avoid going through a doctor.
It's not hard to do. "Order any of 5,600 blood tests and save 40-70 percent! Click here to see how!" blares Health-Test Direct's Web site. "Why test with DLS?" asks Direct Laboratory Services on its Web site. "A simple inexpensive blood test could save your life." And even the nation's largest chain of medical labs, Quest Diagnostics, recently jumped into the direct access act with QuesTest. The direct medical testing field is booming. Thyroid, cholesterol, allergies, liver enzymes, cancer markers, blood sugar, hormone levels--tests for all are on the market. Just click, phone, or fax any of these companies with your credit card at the ready, pick a test, and head to an office to have your blood drawn. Within days, the results will be mailed to your home. "This gives me more power," says Levine, 43, a rancher from Coni-fer, Colo., who used HealthcheckUSA to get a complete blood count and a sophisticated thyroid test. "I wasn't getting the answers or tests I needed from my doctor. Plus it's economics. The thyroid panel ordered by my endocrinologist in Boulder cost me $210. The same test through Healthcheck costs $75." Unless your insurance will cover both the doctor visit and lab costs--it won't cover direct testing--this is a bargain.
False security? Quick, confidential, affordable, and service on demand--the opposite of everything we've come to dislike about American healthcare. What could be wrong with that? In many cases, nothing, if you're careful with what you order. But if you're not, you could end up with useless tests, incomprehensible results (do you know whether it's good or bad that your HBG is 15.5?), and literally taking your life in your own hands. False security from an inappropriate test could lead a do-it-yourselfer to avoid needed care. "I worry about someone who orders a cholesterol test when his real problem is hypertension," says James Martin, a family physician in San Antonio. "Cholesterol isn't going to tell him anything about that." But used properly, acknowledges Martin, direct testing can do everything its clients and companies claim.
The recommendation from doctors is simple: Don't go it alone. Doctors, ideally, know a patient well, know the family history, and are familiar with how various drugs and medical conditions can skew lab results. Tests alone don't add up to a good diagnosis. That's why the California Department of Health Services has begun cracking down on direct access. Karen Nickel, the state's chief of Laboratory Field Services, wrote HealthcheckUSA that she was "disturbed to see the full menu of tests offered at your Web site" and that providing many of these tests without using a California physician violates state law. (HealthcheckUSA has, under protest, ceased its California operations.) "You need someone who knows you, who can put all the puzzle pieces together," says Martin.
Patient complaints. The trouble is this sort of doctor-patient relationship hasn't really existed since Marcus Welby, M.D. went off the air. "HMOs are only allowing certain tests and limiting how often you can be tested," complains McKee, 58, of Santa Ana, Calif. "I was feeling bad, and I hadn't seen my doctor in a year. He never listened to me." Wainwright, 42, of Searcy, Ark., adds, "You know how many times you ask a doc for a specific test and he says, `Oh, you don't need that.' " She has dangerously high blood pressure, uncontrolled by the medication her doctor prescribed, and she wanted more tests. So she used a test from HealthcheckUSA, "which will even come to where I work to draw blood, and they listen to what I want." And the Texas cancer patient used a direct access company for his prostate specific antigen test because he didn't want his insurance company to know he had cancer. "I was afraid they would drop me or raise my rates."
The trick, then, is to get the best of both worlds: quick, convenient, confidential tests, plus the benefit of a doctor's knowledge to interpret them. Services like HealthcheckUSA and QuesTest push doctor consultations hard in their literature. "We certainly tell customers to see a doctor," says Holt Vaughan, executive vice president of HealthcheckUSA. But simply saying it may not be good enough; services vary in how deeply they involve a doctor in providing results. Physicians not only review customer requests of QuesTest but also look at the results and sign off on them. They will call a customer if a lab result appears unusual. At HealthcheckUSA, the doctor's role is more removed. The physician signs a paper authorizing the test in order to comply with state laws, says Vaughan. And that physician won't necessarily review the results; they might be evaluated by a lab technician.
To get her tests and expert advice, Levine has reached an agreement with her doctor: She talks to her physician, they agree on the tests she should order, she does it, and she shows the doctor the results.
Then there's the matter of ordering the appropriate test. Many thyroid patients, Levine and McKee among them, have become convinced that they need a free T3 test to detect a specific thyroid hormone. They've dumped doctors who order only a more general test for TSH, or thyroid stimulating hormone. Free T3 is available from HealthcheckUSA as part of a $75 test. Yet it may not be worth ordering, says Hossein Gharib, a thyroid specialist at the Mayo Clinic in Rochester, Minn., and president of the American Association of Clinical Endocrinologists. "Hey, we live in a free world, but it's not a `free T3' world. TSH is the gold standard for thyroid function," he says. "T3 tests are not very reliable. And you would only try one if the TSH is abnormal." Yet patients with normal TSH who still feel lousy insist a further test can pinpoint their problem.
More straightforward are arguments against getting a cancer test called CA-125. Direct Laboratory Services markets it to forewarn of ovarian cancer. But doctors don't think that it can reliably detect cancer--despite the ads, it's used only to monitor treatment after cancer has been diagnosed.
To check whether a test is appropriate, one useful resource is the Web site at www.labtestsonline.org. It offers reliable information on an exhaustive array of lab tests in plain English, telling you what the tests are used for.
Understanding your specific results is another headache. That HGB result, by the way, is a measure of hemoglobin in your blood, and 15.5 means nothing unless you know that normal HGB, or what's called the "reference range," is between 12 and 18. So make sure your direct testing company provides a clear explanation. QuesTest is good about this, providing a custom printout of results. Any value outside the reference range is highlighted, and further details about what the value might mean are printed right alongside it.
QuesTest is limited, however, offering 24 tests compared with the dozens and hundreds that other companies provide. And while you get complete service, it costs you. Its cholesterol test costs $40, for example, while HealthcheckUSA is $10 less. Repeat that several times a year, and it adds up. The cost-versus-benefit calculation is one that all healthcare consumers must make for themselves--without a doctor's help.
Test cases
Here are some of the most popular health tests you can get without visiting the doctor's office. The best advice is to use these tests in consultation with a physician.
ANEMIA: iron status and complete blood count
DIABETES: glucose levels and hemoglobin A1C test
HEART: HDL, LDL, and total cholesterol; triglycerides
THYROID: thyroid stimulating hormone; free T4 hormone (if needed)
PSA: prostate specific antigen to indicate prostate cancer
LIVER: series of liver enzymes, bilirubin, and total protein
NUTRITION AND VITAMINS: B12, folate, calcium, and iron, as well as cholesterol, triglycerides, and glucose
STD: sexually transmitted disease tests for chlamydia and gonorrhea
FOOD ALLERGY: the 10 most common food allergies
HORMONES: estradiol, progesterone, and estrogen
CA-125: ovarian cancer monitoring
HEMOCHROMATOSIS: hereditary iron-overload disease screening
This story appears in the May 19, 2003 print edition of U.S. News & World Report.