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BLOG biotech : Aug 26, 2011
Improving Healthcare Delivery: Over the Counter and Under the Radar
YMMV: Your Mileage May Vary
Ask for help on the right internet forums, and you'll probably receive a useful reply of what worked for the author, with the disclaimer, "YMMV." Whether you're discussing how to install Linux on your home thermostat, trying to get a discount on a new TV, or figuring out what that rash is, the YMMV tag emphasizes how even minor differences can throw a wrench in the diagnosis or solution.
Even so, anecdotal information and informal advice form a large portion of forum traffic, and this extends to medical information. With the widespread adoption of the internet, it should come as no surprise that people are using the internet to exchange anecdotal evidence regarding illnesses and healthcare.
Internet advice has a number of advantages over professional medical care:
--It will arrive faster than doctor's appointments or even ambulances. The recent earthquake on the East Coast is a perfect example; NY users could read posts about furniture shaking in Washington before the shockwaves reached NYC as tweets outran the tremors they described.
--It is completely anonymous and faceless. Even with doctor-patient privilege, many patients don't feel comfortable discussing their medical issues in person. Perhaps they fear disapproval, disgust, or humiliation. Maybe they fear compulsory medical care, as in the case of some infectious diseases.
--It comes in a familiar format. It's totally natural to refer to Wikipedia, search engines, or internet forums on all matters of interest, so why should healthcare be any different? YMMV disclaimers abound, and there are plenty of cases of "it looks like a bug bite and probably is, but it could also be cancer."
--It is free. The biggest impediment isn't the diagnosis, it's that getting the diagnosis could be a waste of time and money. Perhaps it's the visit or that the visit may require additional tests.
These are advantages that would be present regardless of insurance status but when insurance is added to the mix, the situation becomes even more complicated.
FUD: Fear, Uncertainty, and Doubt
With over 50 million Americans without health insurance, that's one in six, there is a significant market that is very, very concerned about cost. Even those with health insurance may find themselves in the same boat as the uninsured if the practitioner is out-of-network, if the service code is not covered, if coverage is dropped, or if pre-authorization is not completed.
Being uninsured carries more than just higher prices at the point-of-service. When I needed a blood test at a local hospital, I discovered that it was not in-network. Since the "financial manager" had taken a day off, I couldn't even find out what the price of the blood test was.
Imagine that—a simple, well-defined procedure with no chance of complications, and they wouldn't even tell me up front what the cost would be! I had to sign forms that essentially said I would pay whatever they asked. They actually reminded me of forms I signed to get a tire replaced—pay for whatever the services turn out to be ... except with the mechanic I got an estimate that was actually precisely the final bill. With the blood test, I didn't know if the cost would be $20 or $200 or more (it was closer to $200).
The immense cost uncertainty associated with receiving healthcare prevents many consumers, insured and uninsured, from seeking preventative and diagnostic care as well as minor treatments.
The system is what it is, but there are ways to work within the system to satisfy an unmet need: The most common alternative to medical care is self-help. Patients will self-diagnose on the internet and purchase over-the-counter treatments or use home remedies. How many times have you heard "take some ibuprofen and see if it still bothers you in the morning?"
Over-the-counter options have many of the same advantages as internet diagnosis: They are much more convenient and their cost is certain and fairly cheap, regardless of insurance status. Internet diagnosis and OTCs are serving an underserved patient group: patients who need inexpensive, commodity-level healthcare.
Look around Walgreens—what tests and services are already available there? Pregnancy, ovulation, and urinary tract infection tests. Cholesterol, steroid, and illegal substance tests. Breathalyzers and glucose meters. HIV and paternity tests. Services such as vaccinations, skin treatments, and mild infection control also exist.
Until the FDA objected, a few companies such as 23andMe had packaged kits to allow the public to inexpensively profile their genes and the potential consequences while generating a large dataset for further study of the relationship between gene and phenotype.
There's plenty of room for improvement in commodity care. The majority of Americans have internet access, which makes general-access telemedicine feasible. If people can ask unqualified forums for medical advice, surely they could ask a pool of doctors through a web service? Together with electronic health records, the barriers between patients and medical help will shrink.
There's no reason not to allow consumers direct access to approved diagnostics. It shouldn't always be necessary to schedule a doctor's visit or play phone tag just to order a test.
These tests could also be improved and made OTC-compatible, either by having mail-in samples or test them on the spot. There are many common diseases that don't have OTC tests—from staph and strep to anemia, heart disease, and stroke.
The technologies that power many OTC tests are becoming mature: Binary tests for presence of some protein can rely on an enzyme immunoassay, which can be manufactured inexpensively, retailing for $8–16 per test, and stored in room temperature conditions. These also give near-instant results.
Similarly, advances in automation could allow a barcoded sample to receive the appropriate preprocessing and storage before transfer to a lab, permitting a sort of "Redbox" for lab tests.
Common or emergency tests could have equipment for processing on the spot; fixed wavelength spectroscopy is not difficult, and microfluidic sample analyzers have grown in maturity in recent years. Products such as DxNA's GeneSTAT have shown how nucleic acid test samples can be analyzed in the field with a prepackaged PCR system.
With simple sample collection and low-volume, technician-free automated tests, a testing kiosk could allow patients to check for serious conditions on their own schedule and take the appropriate actions, if necessary. Often, it's difficult for people to distinguish the normal pains of daily life from the symptoms of a serious disease—chest pain could be a heart attack or indigestion. A test to probe the middle ground, where the pain isn't so serious but does warrant concern, would be excellent.
Earlier diagnosis of a serious condition has numerous benefits in treatment, while a false negative would simply result in the patient going to the emergency room on the grounds of later symptoms; they would have went to the ER anyway when the situation became unbearable and something was definitely wrong.
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