Last week I wrote about doctors who order unnecessary tests, and the excuses they give. Then I ran across an example that positively flabbered my gaster. A friend’s 21-year-old son went to a board-certified family physician for a routine physical. This young man is healthy, has no complaints, has no past history of any significant health problems and no family history of any disease. The patient just asked for a routine physical and did not request any tests; the doctor ordered labwork without saying what tests he was ordering, and the patient assumed that it was a routine part of the physical exam. The patient’s insurance paid only $13.09 and informed him that he was responsible for the remaining $3,682.98 (no, that’s not a typo). I have a copy of the Explanation of Benefits: the list of charges ranged from $7.54 to $392 but did not specify which charges were for which test. It listed some of the tests as experimental and not covered at all by the insurance policy, and one test was rejected because there was no prior authorization.
The tests were done by Health Diagnostic Laboratory, Inc., a company that offers an advanced comprehensive menu of biomarkers. Here’s a list of the tests they did on this young man:
- Lipids: total cholesterol, LDL-C, HDL-C, Triglycerides, Non-HDL-C
- Lipoprotein Particles and Apolipoproteins: Apo B, LDL-P, sdLDL-C, %sdLDL-C, Apo A-1, HDL-P, HDL2-C, Apo B: aApo A-1 Ratio, Lp(a) Mass, Lp(a)-P
- Inflammation/Oxidation: Fibrinogen, hs-CRP, Lp-PLA, myeloperoxidase
- Myocardial Structure/Stress/Function: Galectin-3, NT-proBNP
- Platelets: AspirinWorks (urine) Ppg/mg of creatinine
- Lipoprotein Genetics: CYP2C19*2*3, CYP2C19*17
- Coagulation Genetics: Factor V Leiden, Prothrombin Mutation, MTHFR (C677T), MTHFR (A1298C)
- Metabolic: 25-hydroxy-Vitamin D, Uric Acid, TSH, Homocysteine, Vitamin B12
- Renal: Cystatin C, Estimated Glomerular Filtration Rate, Serum creatinine
- Electrolytes: sodium, potassium, chloride, CO2, calcium
- Liver: ALT/GPT, AST/GOT, ALP, Total bilirubin
- Renal: Creatinine, BUN
- Thyroid: TSH
- Others: Albumin, Total protein, Ferritin
- Omega-3 fatty acids: ALA, DPA, EPA, DHA
- Omega-6 fatty acids: Omega-6 total, Arachidonic acid, Linoleic Acid
- Other fatty acids: cis-monosaturated total, saturated total, trans total.
They did not report hemoglobin, hematocrit, blood glucose, or hemoglobin A1C, but they nevertheless commented:
- Glucose and hemoglobin A1c are in the normal range and are consistent with normoglycemia
- There may be some evidence of insulin resistance. There is evidence of adipose tissue insulin resistance.
- There is evidence of hyperinsulinemia, suggesting beta cell strain. There is evidence of beta cell dysfunction. Elevated Proinsulin to C-peptide ratio has been associated with beta cell failure and beta cell dysfunction.
At the end of the lab report there is a long list of comments explaining the associations of various factors with various health consequences. Helpful information, like the fact that the patient’s genotype shows that he would be a normal metabolizer of the drug clopidogrel. Finally, the patient is encouraged to contact the lab to set up an appointment with a Clinical Health Consultant to discuss his exercise needs at no charge.
According to most published guidelines, a routine physical on a 21 year old male should include BP, weight, updating immunizations (and offering HPV vaccine), inquiring about risk factors, and counseling, as appropriate, about lifestyle issues like safe sex, smoking, alcohol, diet, exercise, etc. NO lab tests are recommended except for possibly checking lipids or HIV status, which most guidelines do not advise in the absence of risk factors.
I will not comment further, as I feel incapable of moderating my language.
Addendum: August 7, 2014
The young man in question called the doctor’s office to complain about the charges. They referred him to the billing department. The billing department said there was nothing they could do and he should call the lab that did the tests. He called Health Diagnostic Laboratory and they told him to just forward the check for $13.09 that his insurance company had sent to him. They told him he would not be billed for the rest of the charges. I don’t know how they can do business this way, but at least he doesn’t have to pay.
In response to a fraud alert issued by the Inspector General, Health Diagnostic Laboratory has recently dropped the “reimbursement for shipping and handling” kickback to doctor’s offices.
This is all very reassuring, but my flabber remains gasted at the doctor ordering all those tests on a healthy young man.