The contracts are really convoluted and the primary care physician often doesn’t really make much money off of seeing his own patients because he’s paid a fixed amount for each patient. That’s why 1) is often an expense for the physician rather than income.

It might be income, it depends on the contract.

Sorry, it’s very complicated!!!

I am not talking about the cost of the DTC tests. Those are paid out of pocket by the consumer. I am talking about the other costs generated when a person gets a DTC test.

If you look here, in the Kauffman data there seems to be some other costs associated with the DTC tests:

http://www.sciencedaily.com/releases/2010/11/101107213820.htm

“Three in 10 study participants indicated that they had shared their results with a doctor or had gotten a follow-up test, and another 18% said that they intended to do so at a future date.”

So I am talking about the costs of 1) The time spent between the doctor and the patient to discuss that test and 2) the cost of the follow-up tests.

I don’t know where that money is coming from but I suspect it is coming out of the managed care pool. I don’t know how much it is either. If it’s a once in a lifetime expense it might be trivial.

But if it’s coming out of the managed care pool it’s coming out of the physician’s pocket and they’re not going to like that.

Have you ever had an MD interpret the basic blood-work tests that you get at a physical? MDs generally ignore them, unless you are about to lose your liver (even then you will not get an interpretation). Have you ever visited an MD and given them a scientific paper? Many MDs don’t read the science. Have you ever asked an MD about the toxicological side effects of the drugs they prescribe? MDs prescribe pills and they often don’t understand how they damage people or how to fix people when they are damaged.

I believe the ~fourth leading cause of death in this country is from prescription medicines. Read the book “Bitter Pills: inside the hazardous world of legal drugs” by Stephen Fried—you might be terrified, appropriately, when you swallow the pills prescribed by your MDs. http://www.stephenfried.com/bitter-pills/bitterpillsbook.html. We need to focus the conversation on the lack of safety from this system not from DTC.

What if DTC told us why some people die and suffer from pills MDs prescribe? This would cut into the profits of the drug industry. MDs would lose authority and law suits. The FDA is a pawn of the drug industry–much of the FDA budget comes straight from industry. Some FDA personnel worked in industry. Many MDs get money from industry (http://projects.propublica.org/docdollars/). Is this FDA panel a pawn of the AMA or of the drug industry or both? Is this “regulation” or is it a money grab? It is not about safety, in my opinion.

Has anyone researched the disclosures of the people pushing this?

I think the rebound you are describing already happened when managed care came in, Omar.

I don’t know how much people know about this, so forgive me if I am stating the obvious:

Some primary care doctors have contracts where they are paid a fixed amount to care for each patients and then all of the costs that the patient incurs during the year come out of that pot. So, for instance, a doctor might get $2000 if you sign up with him as your PCP for the year and then if you incur $300 in medical expenses it comes out of that $2000 pot. So if you have a DTC test that leads you to think you need a $300 follow up test, he will lose $300 if he lets you have that test.

The system is supposed to work where the doctor would say no if the test is not medically necessary. In practice, doctors hate doing this. So they are left in a difficult spot, where they either take a financial hit or they have to upset a patient. I can see where a doc would be mad if this was occurring because the patient took a DTC test from a for profit company, and it is not particularly medically useful.

Not every contract works as directly as this, but I think that under managed care most contracts have some sort of financial incentive where the doctor has to control costs.

For the AMA, I think, if they can avoid this situation by complaining about safety then that is a better place to fight the cost battle than in the doctor’s office.

I am not as cynical as you are about doctor’s motivations, though. I did not find that doctors were particularly motivated by money. If they were, I think we would have done better on our contracts.

Also, I think we do have a moral obligation to keep insurance rates down. When rich people have tests they don’t need, insurance rates go up and then poor people can’t afford insurance.

This is about where I used to work. I don’t know if you’re interested in risk contracting but it explains some of this better than I did:

http://www.pbs.org/wgbh/pages/frontline/shows/doctor/

I think the comments referred to us as sleazy bean counters. Meh. No one wants to be told they can’t have stuff.

I am wondering if there has been much discussion of DTC as a resource allocation issue? I came to bioinformatics with a background in managed care. My (admittedly somewhat knee jerk) reaction to data I saw it that it appears that physicians are becoming involved in the process whether they like it or not because patients are coming to them after they get the tests to ask them questions about their results. This is leading to some additional testing too. And that requires some spending of health care dollars to pay for that. That might be a big expense or a trivial expense. I don’t know if there is enough data yet to figure that out.

If I were still in managed care, I would see this as a spending health care dollars on something without strong evidence that it improves patient health. That in itself is something I would consider a negative outcome, completely outside of any possibility of error or misinterpretation.

I expect that the AMA is seeing DTC in this light. Increasingly, the physician role in the U.S. is to both provide care but also be a financial gatekeeper who rations care so that money is prioritized. Americans don’t like that, but that is the reality.

I can think of several reasons why I would expect that regulation would be a more conservative approach financially. It would, for example, give physicians the option to always recommend the same company for the tests. Using the same company is cheaper because a physician can read the results more quickly without spending the time to educate himself on what the test means, and that also reduces errors.

It appears that physician education is going to be necessary under regulation or not. I expect regulation would shift the cost burden of physician education ont0 the DTCs. If a DTC wanted their test to be “prescribed” they would have to spend money on marketing their tests to the physicians, which would include education (like the model of pharmaceutical drug reps).

The physician could also, of course, talk the patient out of getting the tests in the first place.

But that’s just an off the cuff analysis. I think it would be quite hard to work out a reasonable projection on that given that most variables are unknown, and you’d have to see how well the insurance companies could manage coverage of these expenses. Sometimes it’s cost-effective for them to provide coverage of things that don’t improve health – like gym memberships – because it attracts healthy patients. That can actually lower rates on some plans, though not overall health spending. Though I suspect covering DTC would attract every hypochondriac in town.

Anyway, sorry this is so long and full of speculation but I’d be interested to hear your thoughts.

http://cxlxmxrx.blogspot.com/2011/03/dtc-testing-mailing-addresses-etc.html

Now if I could get robots who I could be sure would really wash their hands before they touched me, I’d trust them more than doctors and nurses, too.

Genetic information about ourselves should be freely available. Its our responsibility as free-willed individuals with capacity to make our own decisions whilst seeking out appropriate information to make them. Basically if we come to any harm conceivably because we did not consult a doctor, that’s our problem. That a doctor would know anything useful we couldn’t find out ourselves is questionable.

That the companies themselves might be subject to minimal ethical truth-telling regulations is reasonable, though how enforceable or feasible any restrictions on this field might make this irrelevant.