There are so many problems with our current healthcare system. The difficulty getting appointments. The rushed visits. The paperwork. The surprise bills. I’ve addressed how Direct Primary Care solves a lot of these in my last post. But there’s another element I haven’t touched on yet, but that’s ultimately even more important: insurance driven care is very standardized, which means that it’s often five, ten, or even twenty years behind the science. 

To illustrate this point, let me give an example. Let’s suppose that tomorrow a new test was developed that could accurately diagnose pancreatic cancer (one of the most lethal types of cancer) years before it could otherwise be detected by current means. You would think it would be adopted right away by the medical establishment and that doctors would be offering it to every patient at their annual physical starting immediately. But it’s almost certain that would not happen. 

First, it would probably be expensive, so the insurer’s would decide they couldn’t afford to offer it widely. Then there would be a big debate about whether the test is actually useful or not – after all, it’s only worthwhile to find cancer early if there is an effective treatment that leads to a cure. Insurers and various regulatory bodies would demand research demonstrating that early detection actually leads to improved outcomes, and it would take years to gather this data. Finally, doctors – who are overworked and can’t keep on top of every new medical development – would have to learn about the test, understand how to order it, and receive training in how to confidently interpret the results. By the time all of the above was done, it could be a decade or two before large numbers of patients started to actually receive the test. 

In the logic of the mainstream healthcare system, in which the need to stretch the healthcare dollar is an imperative, this all makes sense. But it would really suck for the 50,000 or so Americans who died of pancreatic cancer each year while waiting for all of the above to be sorted out. 

Unfortunately, as of this writing I am not aware of any great diagnostic test for pancreatic cancer. But I am aware of a few tests that are really helpful for predicting and preventing disease, that have been validated by good research, and that are even in widespread use in other economically advanced nations but are rarely offered to American patients. 

At Dr. Fischer, MD, I discuss ordering these tests with many of my patients – and even have a deal worked out with a local lab to get them for an affordable cash fee if the insurance balks at paying the cost. While these tests are not appropriate for every patient, they certainly should be in widespread use, and if you join my practice, I’ll look forward to discussing the possible benefits of each of these with you at one of our visits. 

Here then are five (very) under-ordered tests in America that you might want to consider having at some point:

1. Insulin Level – Insulin is the main hormone that lowers sugar in our bloodstream. While doctors conventionally screen for type 2 diabetes by checking a blood glucose level, the fact is that type 2 diabetes is not at its root a disease of high sugar. Rather it is a disease of insulin resistance, meaning that type 2 diabetics often make MORE insulin than the typical person, but their tissues ”ignore” the insulin and don’t respond to it, which eventually leads to the finding of elevated glucose levels in the bloodstream. Typically, people will develop elevated insulin levels years, or even decades, before their blood sugar starts to rise and they get a diagnosis of type 2 diabetes. Therefore, most people – especially young people – should have this level checked periodically, so that they can know NOW if they are heading for an eventual blood sugar issue, and take lifestyle steps to correct it before the problem ever sets in. How much will this useful information cost you if your insurance declines to pay the bill? Dr. Fischer, MD patients can get it for a mere $13.
2. Apo B – While mainstream medicine in this country obsesses about people’s cholesterol levels, many other advanced nations have moved beyond cholesterol testing, and instead routinely check patient’s apolipoprotein B (Apo B) level. I’ll have more to say about this test in a future post, but to briefly summarize, Apo B is a protein that carries cholesterol molecules around the bloodstream. Extensive research has established that it is the Apo B carrier protein, NOT the cholesterol itself, that can damage the artery walls and increase the risk for eventually developing cardiovascular disease. While cholesterol in most people correlates somewhat with Apo B levels (in other words, most people with high cholesterol have a high Apo B level, and vice versa) there are many exceptions and a large minority of the population has discordance between these results (meaning they have high cholesterol but low Apo B, or vice versa). How to know if you should truly be concerned about your cholesterol or not? Cut out the “middleman” and just check an Apo B level. This test typically runs fifty dollars or less.
3. Lp(a) – While Apo B should be checked somewhat regularly (every few years at least), Lp(a) needs to only be checked once per lifetime. What is Lp(a)? It’s basically a “mutant” cholesterol carrying particle that has been shown to dramatically accelerate the risk for coronary artery disease. Why should you care about this? Because approximately 20% of the population carries this mutation, which means there’s a very good chance that you or someone you care about has this. What is the huge cost of checking for this risk factor for early disease and death that is almost never ordered in mainstream medical clinics? $17.50 for Dr. Fischer, MD patients at the time of this writing. 
4. Coronary Artery Calcium (CAC) CT scan – the first three tests I’ve mentioned above are all blood tests that help determine your risk for developing metabolic or cardiac disease. Ultimately, they are all helpful for figuring out if you are more or less likely to develop clogged arteries. By contrast, a CAC lets you know if you actually have any clogged arteries. This is a quick, non-invasive, very low radiation CT scan of the chest that directly looks at the coronary arteries to see if they have any plaque in them or not. Multiple studies have shown that a clean CAC scan infers a less than 1% risk for having a heart attack over the following decade, and I’ve joyfully pulled more than one patient off their cocktail of anti-cholesterol medication after getting this scan and demonstrating to them that they have the arteries of a teenager. Depending on where you go, this test can usually be had for $100-$200.
5. Visceral Fat Test – Not all fat is the same. The subcutaneous fat (that is, the fat right under the skin) may be visually bothersome to many people, but it does not confer any particular risk for disease or early death. By contrast, the visceral fat (that is the fat that is buried deep inside the abdominal cavity and surrounds the internal organs such as the liver, kidneys, and intestines) is linked to a heightened risk for high blood pressure, cholesterol abnormalities, type 2 diabetes, cirrhosis of the liver, heart attack, stroke, chronic kidney disease, and certain cancers, to name just a few. Unfortunately, simply weighing yourself or looking in the mirror tells you nothing about how much visceral fat you are carrying. It would be really helpful to periodically be able to get a scan of your body that tells you how much visceral fat you have so that you and your doctor can partner on a plan to reduce your risk for future disease. It would be even more helpful if that test did not expose you to any radiation or other harmful substances, took only moments, was non-invasive and painless, and cost you nothing. At Dr. Fischer, MD, we are in the process of obtaining a body composition scanner which will tell you all of this information. This will be available to all of our patients for no extra fee as soon as it’s up and running (April or May of 2024, per the company we have ordered it from). 

In sum, direct primary care is about reclaiming the doctor-patient relationship so that you can experience “old-fashioned” customer service, such as prompt replies to texts and phone calls, on-time appointments, and unhurried visits with the doctor. But it’s also about freeing doctors and patients from the constraints of the insurance-run factory style medicine that is typically practiced in this country, so that cutting edge technology can be used to improve your chances of a long and healthy life. This is why one of our slogans at Dr. Fischer, MD is “the future of medicine, practiced the old-fashioned way.”

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