By Anthony Ellis, WCI ColumnistFor better or for worse, the evolution of preventive care has progressed to the point of “direct-to-consumer” advertising and screening services that do not require a clinician’s orders. Since about age 40, my primary care doctor has ordered a set of “screening laboratory tests” every year with my routine physical. They are stored in the company's “app,” facilitating the comparison of previous results and spotting trends.
As time passed, insurance practices have changed. This annual preventive care has become harder to get without out-of-pocket expenses for copays and deductibles—or even the ubiquitous “prior authorization” or research as to “in-network” status. As I write this, my “PCP” is a nurse practitioner for the first time in my life. We moved to a new state, and she had the first opening when I called for my routine checkup appointment. The waiting times for routine appointments in our area can be 4-6 weeks for a PCP and up to six months for a specialist. To get an appointment for yearly labs and a checkup has, at times, been a bother, and it is now always an expense.
In 2024, I saw a Facebook advertisement for a direct-to-consumer service that offered access to a battery of blood tests, a U/A, an extended lipid panel, and other screening labs for a yearly fee. Of course, this “more than 100 biomarkers” was described as more comprehensive than most people usually get at their PCP. No doctor’s order or visit was required, and the fee was less than other bundles of labs I had seen. The fee for the service and their report interpretation was $499 yearly, and it is HSA-approved. I thought I would try it. There is no obligation to continue unless you see value.
Here’s what I learned.
Trying Something New
My current HDHP PPO suggests preferred providers to reduce copays and deductibles, but it still involves paying notable amounts for both. The “preferred providers” near us are mostly at the local city health clinic. My part-time employer is in Michigan, and the out-of-state coverage defaults to Aetna. Woe be to your wallet for any “out-of-network services.” I have also been billed for lab studies that were “not covered.” We are all healthy, and we have minimal care needs. In fact, none of us (except me) have sought treatment for symptoms in the two years since I dropped to half-time work. For many, getting yearly labs done involves a PCP appointment with a preferred provider and then paying plan deductibles. Even though most insurance covers a “wellness visit,” this may not include comprehensive labs, and it rarely includes a preventative care approach.
The usual “routine or preventive” labs that a PCP orders can vary widely, as can the approved insurance payments for these labs. In my current psychiatry position, we order a yearly CBC, Chem 20, Lipid profile, HbA1C, TFTs, Vitamin D level, and other labs individually based on medication regimens or comorbid conditions. These are the basic labs on the yearly profiles that my PCP has ordered in the past, along with a screening PSA test.
There are CEOs and VIPs who have yearly blood test screens that look for DNA markers for over 50 cancer types. If you want to add this Galleri cancer screening, you can for an additional $899. If you want other add-on labs, you can pay for them based on your individual or family history. For example, I paid for a genetic assay of my ApoE allele status due to a notable family history of Alzheimer’s disease (an extra $129). This type of “preventative screening” is becoming more commonly available. There are longevity centers and concierge clinics that offer many types of assessments with testing that include labs, a physical exam, a nutritional evaluation, a cognitive screening test, whole body imaging exams, cardiac stress tests, and coronary artery calcium scoring. I read about one recently that a wellness journalist chose, and the appointment and tests were all done in five hours at one visit.
The service I chose for $499 (plus the extra bit for my ApoE allele status) used a national laboratory service (Quest Diagnostics), and the appointment was set in the app for the service with two appointments a week apart. The lab was within a half hour of my house, and I was familiar with the lab company. I was given detailed instructions to follow in the days before the blood draw for stopping supplements, fasting for eight hours, and hydrating adequately.
I am not saying that these services replace routine follow-up care or chronic disease management. I have no new symptoms and very few chronic medical issues. I tend to get all the recommended screening labs or studies to maximize my chances of living a long, healthy life. I eat a healthy diet. I had a coronary artery calcium scan that was ordered by my PCP in 2020 when I was 56. Like many retirees looking to live long enough to spend some of their savings, we hike to stay fit. I swim two or three days a week and do body weight strength training two days a week. My weight is within 10% of my weight at age 35, and I do not smoke.
Fortunately, I do not have HTN, DM, or a known familial lipid disorder. I am simply trying to prevent or detect what I can on the list of health issues that can ruin my quality of life or kill a fortunate, healthy retiree like me.
More information here:
Don’t Push Your Luck (Physically or Financially)
Functional Longevity: What Use Is Retirement If You Can’t Move and Think?
Was It Worth It?
Is an ounce of prevention worth a pound of cure? Are any of these services effective in preventing or reducing illness sequelae, detecting cancer, or finding coronary issues before the widow maker MI, like one of my coworkers had? Are these services “worth it” for a healthy person, or are they better for someone with more health issues? Do they provide actionable data? If not, why are CEOs lining up for them? Do they cause more harm than good with “false positives” that require follow-up testing? Do they provide any peace of mind? Does one really need LDL fractionation, or is this mostly a way to get your hard-earned dollars?
These are good questions with few data-driven answers.
In my case, I avoided one or two PCP appointments where I would try to convince the clinician to do more extensive testing than the norm. Going to the doctor takes time, and I always have copays. The labs are not always covered. It can easily add up to $500 unless I pick the “in-network provider,” obtain “covered lab services,” and take multiple trips and hours of time. There may be little discussion of labs beyond “they were generally normal.” Some clinicians do not always cover nutrition or discuss useful supplements. In fact, based on the resident forums I read, it seems the “rich patients eating Chia seeds, drinking green smoothies, and taking a handful of supplements” are routinely mocked.
Asking for specific assessments can step on the clinician’s toes a bit and brings up the adage: “The doctor who has him or herself as a doctor has a fool for a doctor.” I have never been offered all these labs at once. I was never told to get an ApoE phenotype test despite my family history. I have also had clinicians find it humorous or off-putting when I tell them I love my life and simply do not want to die prematurely and leave my family, retirement savings, and maximum Social Security benefits on the table.
The “biomarker” results were available in about two weeks, and they came with a detailed, fairly cookie-cutter discussion of recommendations and actions to take based on the out-of-range values. Prior to the tests, I predicted my ApoE allele status as E3/E4 based on allele prevalence and family history. Mine turned out to be E2/E3. This is in the lower risk quartile where the rare E2/E2 phenotype sits. In fact, E2/E3 is the next best at ~11% of the population. The worst phenotype is E4/E4, and it's present in about 2% of the population.
The six possible APOE genotypes are: E2/E2 (1%), E2/E3 (11%) (this was my result), E2/E4 (2%), E3/E3 (61%), E3/E4 (23%), and E4/E4 (2%) (the worst).
ApoE4 increases Alzheimer’s risk. Having at least one ApoE4 gene doubles or triples the risk of developing Alzheimer's disease. A rare group has two ApoE4 alleles. Having two copies of ApoE4 increases the risk of getting Alzheimer's disease even more—about eight- to twelve-fold.
In one meta-analysis of pre-clinical amyloid deposition, the ApoE phenotype was correlated with age of accumulation: “The age at which 15% of the participants with normal cognition were amyloid positive was approximately 40 years for APOE ε4ε4 carriers, 50 years for ε2ε4 carriers, 55 years for ε3ε4 carriers, 65 years for ε3ε3 carriers, and 95 years for ε2ε3 carriers.”
My standard lipid profile results (Total Cholesterol, HDL, LDL, and Triglycerides) were about the same as always. This service included an LDL fractionation to look at particle size, ApoB, and LP(a). The new data here was that my “LDL small particle” number was high, and other LDL fractionation levels were abnormal. I had 90/106 markers “in range.” My Hb and Hct were slightly elevated, a consequence of currently living at 2,900 feet elevation. I had normal HDL, Lipoprotein (a), High Sensitivity CRP, and Triglycerides, and I do not have a family history of CAD or early MI. One new finding was that I have notable levels of anti-thyroid antibodies. This had never been checked before.
More information here:
Health Insurance in Early Retirement
How to Save On Healthcare Costs
My Response to the Lab Results
Overall, the added peace of mind from the ApoE allele and the overall assessment were worth the money spent. I think I may have spent a similar amount on copays and deductibles had I gone the usual PCP route.
What did this change for me? Well, I now know to monitor T4 and TSH across time for signs of clinical Hashimoto’s. I know that my Alzheimer’s risk is low with my phenotype (E2/E3), especially given my lifestyle, diet, and exercise levels. I know that, despite healthy HDL and normal LDL and Triglycerides, I may have unquantifiable cardiovascular risk from LDL small particles, elevated ApoB, and elevated homocysteine levels. I looked back on old labs, and I noticed an elevated homocysteine level from five years ago. But I received no recommendations from my PCP on this. I read that lowering this by 20% (with B Vitamins) has not proven to correspond to any lower cardiac or stroke risk, another “fascinoma” like LDL fractionation. It is not entirely clear that “managing” these will do anything spectacular.
Still, I decided to further reduce my red meat intake, increase my intake of non-peanut nuts, and eat even more vegetables. I also decided to try the “top supplements” suggested by the service based on my results. I looked them up and read about each of them. A two-month supply of all of them was about $125. One can look up each supplement and read any available research on its effectiveness. In my experience, it is rare to get specific recommendations based on your “biomarkers” and then have follow-up labs to determine if target values change. My labs will be checked again in six months. At the least, it is interesting, even if it is a bit neurotic. For the next six months, I am one of those “rich people who want to live forever,” but at least it is not “by supplements alone.”
Of course, I will keep swimming, hiking, doing body weight exercises, reading, solving the New York Times daily word puzzles, and writing for an audience. My wife and I also signed up for a “vacation half marathon” in the Great Smoky Mountains in September 2025. We will continue to hike all our local favorite trails that were not damaged or closed by Hurricane Helene’s rampage. We took vacations to hike Sedona, Arizona, and we hiked 80 kilometers of the Amalfi Coast of Italy in 2024. Hiking trips are more fun than vitamins and supplements.
Good luck to me and my LDL fractionation and homocysteine levels. I will still see a PCP yearly, but I am still looking for one like my prior PCP in Michigan. She was excellent, and I miss her.
Would you or have you ever tried a service that offers expanded labs? What conclusions did you reach? Did anything in your life change?
What was the test you ordered? Can you provide a link?
Certainly, but if you use my link, I will get a $100 referral fee. The company gave me a link connected to this referral gimmick, but I think you can go directly to their website via a search.
Hi – Function Health offers 100+ lab tests & insights from top doctors. Sign up here: https://my.functionhealth.com/signup?code=AELLIS13&_saasquatch=AELLIS13
I am not sure how old you are, but with those results, it sounds like you would be fine just checking your labs once a year.
Thanks for an interesting summary of your experience.
I was sixty-one in April. These tests can be done yearly. I’m likely to keep the service. The supplements…not so much. I took them for a few months and faded back to Vit D, Fish Oil, and a multivitamin and I don’t even take those daily.
I’m a big fan of diet and exercise. In addition, as I mentioned, I’m not sure the lipid fraction results are worth addressing. I have no personal or family cardiac history.
You spend $$$, but complain about the copay and deductible that amounts to significantly less than $$$ spent on testing that provides data, but little less behind the actual results aside buying expensive supplements which have little robust evidence on its benefits beyond corporate profits.
Do the tests if you would like AND get a PCP that you build relationship with to go over results and what they mean and options available.
Or you can keep throwing good money at more testing data for the sake of looking at data. ..
These tests are most often taking advantage of folk least needing them. Like ITOT mobile devices on gym rats looking at their VO2 max and worrying about all that data.
Those who would benefit from getting them dont get past 2000 steps a day
I addressed all these points in the article.
I’m still going to see my PCP…I lost the one I had in Michigan after a fifteen year relationship. I need to find another good one.
My HDHCP has an $1800 deductible per person and about $5000 for the family. My healthcare costs for copays and deductibles routinely runs thousands per year for minimal care.
The supplements are widely known, for example, fish oil, Vit D, and similar. There are data sets for many.
I found out new data and used HSA money for the testing. I also found out that I have subclinical Hashimoto’s and a favorable Apo E profile.
I’ve spent this much money at the vet in the past two years for routine canine care.
Great article with so much useful information. Thanks for being so insightful.
Thank you. For me, it was worth the $$ from my HSA. Best wishes for a healthy retirement.
What you fail to address in this article is that a significant number of these lab tests are affected by pretest probability. Ordering them in a vacuum (direct to consumer) is very low yield and potentially harmful. You have the education to interpret the results. Many people do not. I am a PCP, and I cannot tell you how many people come to me asking me to interpret the results of some test that they had done through a third party. These tests cause significant anxiety and often lead to further unnecessary testing. The problem only worsens when you include incidentalomas found from direct-to-consumer “life scans.” I once had a patient come to me asking for a chest CT because the radiologist reading his “screening” chest xray found nodules in each lung placed symmetrically apart which “could be” the nipples, but follow up imaging was recommended. We lament the cost of healthcare in the U.S. but at the same time tend to champion shotgun approaches to care. Without a clear understanding of statistical concepts like prevalence, pretest probability, sensitivity, and specificity, “screening” can do more harm than good.
Fair points.
Remember the target population for this post: White Coat Investors.
It is not meant to be applied to, or be distributed to the general population.
I was going to write something similar. These tests are often being used for purposes they were not designed or tested for, in populations they were not intended for. When you apply testing to a population with a low incidence of the condition you’re testing for, you end up with a bunch of false positives and trivial findings that lead to further testing. When they lead to procedures, biopsies, etc they can actually lead to morbidity stemming from the testing itself. You know darn well Galleri testing is going to lead to increased radiologic testing and biopsies.
I am retired FM and have practiced through debates about PSA and CAC for 30-35 years, Vitamin D for at least 20 years, etc, etc and those debates still go on. Those are labs that have been heavily studied and often there still is no consensus.
For many of the labs in this article the evidence they should be used for screening just isn’t there.
I too had to deal with patients holding abnormal labs I didn’t order. Often they were ordered by NPs specializing in “wellness” that had no idea how to manage the results.
I have no fondness for insurance companies that often made my job miserable, however they should not be expected to pay for things when the evidence isn’t there.
i would add Dr Ellis, you seem like a standup guy and I applaud your responding to the comments. We just disagree on this one.
The tests were fairly basic other than lipid fractionation, anti-thyroid antibodies, and the add on ApoE test.
My other “abnormals” had been evident on prior labs from my PCP.
Luckily, most physicians can manage the results, especially in the age of “Chat GPT”. Most of the time I query Chat GPT, it is pretty useful. In fact, the last two times a friend asked me a detailed psychiatry question, I answered, and then put the clinical scenario in ChatGPT and the AI duplicated my answer to large degree. It was a little surprising.
Thanks for sharing. I’ve been considering one of these services too. I hope you’ll share a follow up over time.
I will get the included follow up test in August and come back with an update.
I have to admit I found the supplements to be a bit of a pain and dropped down to Vit D, Fish oil, and a multivitamin after about four months….so if my labs improve…it won’t likely be due to the supplements.
Some of the live long Gurus are taking a few dozen…
I enjoyed this post. I appreciate your diligence. You’re taking responsibility for your health. We live in a disease management model of healthcare. I personally am not surprised that so many patients with the means are looking for alternatives to maintain a healthy lifestyle. I think more physicians need to invest in our own health so that we can live long enough to fulfill our calling.
Thank you. I’m glad. Have a great summer!
Good article, I actually went so far as to start Cologuard this year (42). I cash paid it and had to change my age to get it done even with cash pay. That said as a General Surgeon I’ve diagnosed and treated enough people who get a stage 3/4 diagnosis at their first screening colonoscopy so it is well worth the price to me to start early with noninvasive testing.
I know dozens of doctors, friends, relatives, and people from my high school class that have had a stage 3-4 cancer diagnosis. My best friend from childhood died at age 55. Had he been aware of his CAD and coronary calcium score, he might have had a chance at retirement.
I think some enhanced screening might be useful for some people?
What you are describing sounds like a “cancer cluster”, similar to testicular cancer in firefighters and chimney sweeps or prostate cancer from Agent Orange exposure, or lead poisoning in poor community with older houses… or that you are more biased to hear about the cancer cases but in fact your high school cohort is no different from any other HS cohorts in the country. Routine cancer screening accounts for family history, but it cannot account for local exposures unless a sharp eye epidemiologist or environmental warrior in the health department dig deep into the data, in retrospect, like Erin Brokovich.
On most days, I now share with my patients that “obesity is a pre-cancer”. What do you think most patients do with this new information from their PCP? They roll their eyes and demand more screening or diagnostic tests to find an illusive cancer, instead of managing their obesity to prevent all cancers and heart disease equivalent. That is essentially the misguided premise of more screening as described in this article.
https://www.cdc.gov/cancer/risk-factors/obesity.html
Thanks for writing. Reminds me of Peter Attia’s book Outlive. After I read it, I worked with my primary care on getting more testing, many of which he’d never heard of. I love the approach of locating markers for disease decades before they develop into true disease instead of just waiting for a disease to occur. .
I read and liked that book. Given my genetics (FH of a lot of glandular cancers), age (61), and my good fortune to have been able to work and invest for 30 years, I’m trying to miss out on the odd cancers that go undetected until you become a chemotherapy candidate.
I had a negative total body PET scan after my stage 1 melanoma diagnosis in 2021. I’d pay for a total body MRI every few years if there was proof it was a useful screening method.
You can bet some CEO’s and the “big yacht owners” of the world are getting screened. Most of the 60 year old WCI docs have a notable amount of cheese on the table after working hard for thirty years. It would be a shame to leave it there.
Whether your Apo E result was high or low risk, how can you manage your life differently beyond what you ordinarily would do? We already know that controlling standard cardiovascular risk factors like blood pressure has a great impact on development of dementia. Until some treatment comes along that Modifies genetic risk beyond what we already have, I fail to see the value of knowing your genetic testing beyond intellectual curiosity.
Fair point. I already “don’t smoke, eat a healthy diet, exercise a lot, don’t have HTN, don’t have DM (type 2), use my brain, reduce stress, maintain a healthy social network, and use word puzzles.”
So it was mostly for intellectual curiosity and possibly to worry a bit less given my family history. But, seriously, if it came back E4/E4, you don’t think that provides some rocket fuel to keep up the good work? As it is, I’m not likely to slack off , gain 30 pounds, and eat more bacon, but I think it’s worth price of a nice dinner out to know my ApoE risk is below average.
I’m not a physician. I’ve been using a similar service, but I get blood draws every 90 days (50+ biomarkers) and I meet with a clinician via Zoom after each blood draw. They also provide a health coach to help me implement any diet or workout recommendations. They recommend proprietary supplements, but don’t push them (and I don’t take them). I decided to explore this service because I was looking for something a little more “high touch” than my PCP. Things seemed to change after his practice was acquired by a large regional health system. Having said that, I still see him for my annual physical or any immediate health problems. I have a family history of ASCVD, diabetes, HBP, and kidney disease, so as a healthy middle-aged person who cares about health and longevity, the price is worth it for me as it helps me stay accountable with my diet and health plan. I haven’t explored this feature yet, but you can now connect a wearable device to your dashboard (Whoop, Oura, Fitbit) and the data will populate for analysis by your clinician. I pay $129 per month for this service, but I think new members pay $149. I looked at Function, but membership costs are higher in my state due to state regulations that prevent direct billing, so I would pay the $499 plus an additional estimated $500 lab charge.
Sounds like you get some peace of mind from the testing services and use the data to inform your health and wellness plan. Why not?
You may like “How Not to Die” by Dr. Michael Greger, it’s a simple approach to longevity. Spoiler: eat whole Foods, plants > animals, keep moving. Sounds like you’re mostly there. Genetic profile loads the gun, diet/lifestyle pulls the trigger.
I think you’re on to something there.
💊🏥 Doctors still despise the ” worried well”. The worst veterinarian I ever had was 10 times better than the BEST M. D. I ever had. And by far the most dismissive, rude, asinine physicians I have had the misfortune to encounter were… Psychiatrists !! 💵⏰… Sorry 😔, Doc…!! ?? 💊🏥😔
I’m going to leave that comment alone. Best wishes for a great summer!
Sorry 😔 4 unloading like that !! ?? It was therapeutic though. Today the veterinarians charge more ( unreimbursed) than physicians do. They 💵💰 take ” defensive medicine 💊💉” to a 🆕 level 🎚️. Dogs 🐕 and cats 😹 can’t really be called ” worried well”. But they don’t 🦜 talk back, thus being ideal patients !! 😹🐕
Our vet bills for the past two years were more than this lab and interpretation service. Veterinary care has gotten really expensive. Our dog had a skin tag between her toes and was licking it all the time. To get it removed (under anesthesia) was $1100. 😳
We really do need evidence to help us understand the value of Multicancer Detection Assays. Fortunately, the NCI is studying this. The vanguard study is now enrolling and will randomize patients to one of 2 different MCDs or a control group. The folks Randomized to the MCDs will get them free.
https://www.fredhutch.org/en/research/institutes-networks-ircs/cancer-screening-research-network/the-vanguard-study.html#accordion-6cc3761bd9-item-c173a6b8c9
One more thing to keep in mind: normal test values are arbitrarily defined, “normal” being within two standard deviations from the mean. This means that 5% of healthy individuals will have a positive screening result on any given test. As more tests are ordered, the likelihood of a false positive increases: a “simple” panel of 20 independent lab tests in a patient with no disease will yield at least one abnormal result in over 60% of the time.
True enough. When I look at my own test results, I’m concerned with trends and with clearly abnormal results.
For example, my Hb was slightly elevated, but I live at 3000 feet of altitude which can push it up a bit.
Given that I have biannual sets to look at since about 2010, I can spot trends and new outliers.
As a 1st gen immigrant turned PCP with 28 years spent in the military, I have a vested interest in healthcare equity and medical literacy. In the U.S., most adults read and comprehend at a 6th to 8th grade level, the prime reason that military training materials (and UpToDate Basics) are written at these levels. Medical literacy is further limited by literacy level accordingly per one’s education and socioeconomic status. I seldom order some of the tests that are mentioned in this article as a PCP. Some patients will fall into a coma at the mention of A1C and diabetes.
What I do mentioned repeatedly:
1. Diagnostics is not the same as prevention or treatment. We can check the gas tank five times a day; at the end we need to put gas in it.
2. I Google “healthy heart diet” and “typical American diet” in the clinic, so my patients can see the difference. No vitamins or supplements, I explain, can replace or cancel out the excess “American diet” that we eat every single day. Taking vitamins, understandably, is easier than quitting the addiction of irrational, emotional eating.
3. We can’t change our genetics and family tree. Test all we want, but what are we going to DO with the new information of ApoE alleles or whatever? As such, we PCP screens per evidence based clinical guidelines. Shot gun approach is great for concierge medicine, whose cohorts are already healthier and can afford the luxury of time and money of a health club membership.
4. For the masses that neither have time nor money, I invite these patients to take a picture of everything they eat for a 10 day period, and compared them to the Google pics in item 2 above. That’s my diagnostics; with that information, what can my patients DO to change for the better?
In summary, when I walk into an exam room, even before I get into charts, I assess the patient’s level of literacy and medical literacy. I ask what they do for a living and guesstimate what financial or other obstacles they may have in reaching their in healthcare goals. For the lucky few, we are our own obstacle, for we stand at the shore of what we don’t know and yet look backward to find brilliant solutions to non-existent problems.
I could not agree more with everything you said. The overwhelming portion of our health outcomes are determined by our diet, smoking habits and socioeconomic status. Everything else will move the needle by a percentage point or less. Your patients are lucky to have you.