Consumer-Driven Health Care: The Changing Role of the Patient
Table of Contents
How Patients Are Managing Their Care
Americans have a powerful new tool with which to educate themselves and manage their own health care needs: the World Wide Web.46 The Internet is a portal to medical libraries and Web sites with disease-specific information, and it gives patients direct access to prescription drugs, direct laboratory testing services, and therapeutic alternatives.
“Two-thirds of people who seek health information on the Internet search for data on specific diseases.”
Obtaining Information on Conditions and Treatments. The Internet allows access to medical information that was unavailable to ordinary Americans only a decade ago. And people are responding. In 1997 the National Library of Medicine eliminated fees to search its “MedlinePlus” Web site, the world’s largest medical library,47 and the number of searches rose from about seven million a year to 180 million — about 60 million of which were by the general public rather than medical professionals.48 The American College of Physicians Foundation encourages doctors to send patients to MedlinePlus,49 a practice referred to as writing prescriptions for “information therapy.”50 Although physicians have been slow to embrace the trend, patients who obtain information from the Internet potentially save physicians time when they arrive for an office visits more fully informed.51
Two-thirds of people who seek health information on the Internet search for information on specific diseases. A survey indicates the information sources they are using.52
- Most people (83 percent) search for medical studies
- Seventy-one percent go to the Web sites of medical societies.
- About 39 percent go to the Web site of nonprofit organizations, such as patient advocacy organizations and disease research groups.
- Thirty-eight percent search Web sites for information about clinical trials for new therapies.
- Almost one-third (32 percent) go to commercial health Web sites, such as product-specific sites maintained by drug companies.
Obtaining Advice from Physicians. Most patients with Internet access (90 percent) would like the ability to consult their physician by e-mail, according to a Harris Interactive poll.53 However, only a few doctors offer patients the ability to request services or prescriptions by e-mail.54 According to a 2001 survey, only about 14 percent of patients exchange e-mail with their physicians and only a tenth of these do so on a frequent basis.55 [See Figure IV.]
“About 14 percent of patients exchange e-mail with their physicians.”
One obstacle to e-mail consultations is that few insurance companies will reimburse physicians for this service.56 Some health plans will not compensate doctors for e-mail exchanges unless the patient has first been examined in an office.57 Other insurers reimburse less for e-mail exchanges than for in-person visits.58 However, this is changing. For example, Blue Shield of California pays physicians the same for an e-mail consultation ($25) as it does for an office visit.59 Furthermore, in January 2004, the American Medical Association created a reimbursement code for online consultation patients, making it easier for physicians to get paid.60
Physicians who exchange e-mail with their patients find it often replaces telephone consultations. But patients who send e-mail messages tend to spend more time composing their thoughts and create more focused messages than they do for phone conversations.61 An example of this new paradigm is Alan Dappen, M.D., who practices medicine almost entirely by telephone and e-mail contact. His time is billed in 5-minute increments and ranges from $25 for in-office visits to $15 phone consultations with patients who have set up prepaid accounts.62
Obtaining Diagnoses. Patients have access to an increasing number of medical tests to assess the state of their health and diagnose their ailments. They can now order a variety of tests directly that were once exclusively available only at a physician’s request. But they often have to pay for these tests of pocket. Many tests are offered by pharmacies and other retailers over the counter.63 Sales of self-diagnostic over-the-counter tests64 tripled from $750 million in 1992 to $2.8 billion in 2002.65 [See Figure V.]
Home pregnancy-testing kits have been available for years. In fact, they have become so ubiquitous that they are sold in grocery stores everywhere. In some cases, they can be purchased at inexpensive “dollar stores” for $1 a piece.66 High quality pregnancy test strips are available in bulk on eBay.com for 50 cents apiece. Pregnancy tests were followed on to retail store shelves by ovulation predictor tests.
“Sales of self-diagnostic over-the-counter tests more than tripled from $750 million in 1992 to $2.8 billion in 2002.”
Do-it-yourself tests are proliferating, making self-diagnosis easier than ever before.67 These include tests for HIV, prothrombin time (clotting) for bleeding disorders and hepatitis C infections.68 For example, ear infections are the number one reason children see a doctor — accounting for 20 million office visits annually.69 The EarCheck Middle Ear Monitor is a home testing device for inner ear infections that uses sonar to check behind the eardrum for fluids that may indicate ear infection.70 The monitor costs about $50, an amount roughly equal to the fee for a single office visit. Likewise, children often get sore throats —which usually don’t require a physician visit. Families can buy a QuickVue Strep Test, which costs $90 for 25 tests. Each test helps differentiate strep infections (that require a physician visit) from viral infections (that do not require physician care). The test is simple to use — swab the back of the throat with the applicator, then add a reagent. The color change determines the diagnosis.71
The FDA recently approved a Menopause Home Test as the newest entrant into the field of OTC home diagnostics. The kit contains two pads for measuring the serum FSH level (which indicates the onset of menopause). The test is designed to make women aware of the possible onset of menopause without the inconvenience and cost of a physician visit. (Some physicians question the benefit of this test, mostly because they don’t understand how much patients value this knowledge.72)
“Patients can order a blood work up for about $95.”
Numerous tests can now be done on blood, and many of these are readily available to patients without a doctor’s prescription. Another option that may soon be available to patients is screening storefronts or kiosks that offer lab tests in a convenient setting and provide results quickly, without consulting a physician. The results of a typical physician-ordered blood test are delayed at least a day when they are sent out to a lab. Follow up consultations and/or playing “phone tag” can add more time. However, a Culver City, California-based company (Careside, Inc.) sells a much smaller blood testing machine that can provide results for the 36-most commonly-ordered blood chemistry tests in about 15 minutes.73 It costs about $10,000, a fraction of the price of most laboratory testing machines, making it affordable for testing centers or individual physician practices.
“Over-the-counter drug products account for 60 percent of drugs used by Americans.”
One firm, Quest Diagnostics, has aggressively moved into the field of patient-ordered medical testing.74 The Web site QuesTest.com features a health library that patients can use to learn more about the tests Quest offers. Another medical testing laboratory, HS Labs (BloodWorksUSA.com), allows patients to pay a fee online, then stop by one of a nationwide network of collection points where a lab technician can draw a blood sample. HS Labs offers a complete blood work special for about $95 that examines numerous metrics.75
A competing laboratory service, Direct Laboratory Services, Inc. (DirectLabs.com), offers a similar battery of tests priced at $89.76 This blood profile provides a thorough biochemical assessment of health based on more than 50 individual tests including blood count, thyroid profile, lipid profile, liver profile, kidney panel, profile of minerals and bone, fluids and electrolytes and tests on diabetes. The company works with more than 5,000 labs so the service is available in most parts of the country.
“Patients can order genetic tests to determine their risk for cancer or heart disease and diagnostic imaging to discover if disease is present.”
Patients can also order genetic tests to determine their risk for cancer or heart disease and diagnostic imaging to discover if disease is present. Prices for patient-ordered genetic testing for susceptibility to breast and ovarian cancer range from $586 for a single point mutation to $3,312 for a complete sequence.77 Patients can also order “virtual exams” using MRI or PET technologies to detect cancer, heart disease and other conditions.78 Many physician groups oppose the use of patient-ordered body scans in asymptomatic patients because these often yield ambiguous results that require patients to spend money on follow-up tests.79 However, medical societies support doctor-ordered preventive screening tests for various conditions at ages called for in medical protocols. Patients who are aware of the recommended screenings can order many of those tests themselves, for less than a doctor would charge. The difference: Patients typically have to pay for scans they seek out themselves out of pocket, whereas doctor-ordered tests are more likely to be reimbursed by insurers.80
Self-Treatment. According to an article in the British Medical Journal, only one out of every 40 symptoms results in a patient making an office visit for a medical consultation.81 For example, it has been estimated that, at some point in their lives, between 15 percent and 40 percent of the general population experiences gastrointestinal symptoms such as rectal bleeding, irritable bowel syndrome, and dyspepsia (chronic indigestion). Yet only a quarter to a third of people experiencing these symptoms ever consults a practitioner.82 The information they obtain on the Internet often allows patients to make their own decisions about which symptoms require consultations.83
For most medical conditions, people initially self diagnose and treat symptoms, usually with OTC drug remedies. OTC drug products account for 60 percent of drugs used by Americans.84 [See Figure VI.] Estimates vary, but according to Rottenberg, Americans buy OTC drugs about 12 billion times a year. If only two percent of them sought professional care, rather than treating themselves, the increase in office calls would require 50 percent more primary care physicians than are currently available. If everyone using OTC drugs sought the advice of a physician, the number of primary care physicians needed would be 25 times greater than the number we currently have.85
“Eighty-nine prescription drugs, including specific strength doses of some drugs, have been switched to over-the-counter since 1975.”
Eighty-nine prescription drugs, including specific-strength doses of some drugs, have been switched to over-the-counter since 1975.86 Millions of Americans use these drugs. For example, first generation antihistamines are a popular class of drugs sold over the counter with 14 different formulations available since 1975.87 It is estimated that 20 million allergy suffers were self-treating with OTC (sedating) antihistamines in 2002, almost half of the total number of Americans suffering from allergies.88 Claritin, a second-generation antihistamine, one of the best-selling allergy medications, was moved to the OTC market in December 2002.89 Claritin is an improvement over earlier allergy drugs due to its nonsedating characteristics. The 20 million that were treating themselves with other OTC remedies (and the millions whose symptoms go untreated) are candidates for Claritin or its generic equivalent Loratadine.90 Virtually all patients on a second-generation prescription antihistamine are candidates for OTC Claritin. Prescription antihistamines generated about $4.7 billion in sales in 2002.91
“A patient with a prescription can find a range of prices by clicking on a few Internet pharmacy Web sites.”
Another example of a popular prescription drug recently moved to the OTC market is the antiulcer drug Prilosec — which was the second best-selling drug in 2001.92 When it became available over the counter in the fall of 2003, it sold for around 70 cents per capsule compared to almost $4 for the prescription version. Access to popular prescription drugs, such as Claritin and Prilosec, make it both easier and cheaper for consumers to obtain treatment. Not only are these two drugs top sellers, they are both from classes of drugs that have been among the most widely sold. Patients taking any of the other prescriptions drugs in their respective classes might be able to switch to the OTC version of Prilosec or Claritin and save a bundle. [See Figure VII.]
Giving consumers access to medical technology also helps patients since doctors may not be readily available when patients need them. For instance, about 70 percent of heart attacks occur in the home. Philips Electronics now offers a FDA-approved defibrillator for home use that does not require a doctor’s prescription.93 For less than two thousand dollars, consumers can be prepared to treat a cardiac emergency themselves.94 (See the discussion below on Monitoring and Treating Chronic Conditions.)
“Seniors can reduce the cost of some common drug therapies by more than 90 percent with the same techniques they use when shopping for other goods and services.”
Shopping. Consumers have never had more opportunities to obtain price information about drugs. A patient with a prescription can find a range of prices by clicking on a few Internet pharmacy Web sites. The Internet makes it easy to look up information on government and private programs to assist elderly, low-income and disabled patients. Additionally, Web-based services help patients find comparable medications that are cheaper than their current prescriptions. Patients can cut costs substantially by becoming aggressive consumers. In fact, seniors can reduce the cost of some common drug therapies by more than 90 percent if they use the same buying techniques they routinely use when shopping for other goods and services.95
Case Study: Cardiovascular Drugs. Patients prescribed 50mg of Tenormin daily can save money by comparison shopping for the best price and quantity. [See Table I.] For instance:
- Our survey found that the price of 100 (50mg) doses of Tenormin ranged from $149.93 at Drugstore.com to $130.49 RxUSA.com.
- But patients could save at least 75 percent over the lowest cost brand-name drug by switching to the generic alternative Atenolol.
- One hundred doses of the generic drug ranged $21.67 at RxUSA.com to $7.99 at Costco.com.
- Finally, consumers could save another 45 percent (from $12.50 to $6.87) by buying larger pills (100mg) and splitting them in half.
Smart buying of this drug lowered the potential overall cost by 95 percent — from a high of $149.93 to a low of $6.87.