THere are weekend/weeklong ECHO courses that primary care docs could take. NPs could be trained to read ECHOs. Costs can be greatly reduced by not sending the procedure to an organologist except for confirmation. Could probably get the cost down to $100 for a screening ECHO.

I doubt the parents who have lost a child at an athletic event would agree that it is cost-ineffective

Dr. Rich: Excellent post!

Let’s see if we can gin up a business model:

Assumption #1: American litigiousness can produce a $1 million lawsuit over an amateur athlete’s death.

Assumption #2: American technical ingenuity can produce a $20,000 box than can identify the thickness of the myocardium at one point, and, at the same time, acquire an electrocardiographic signal from the same point on the chest.

Assumption #3: Computer analysis of these two data streams can reliably (at 90% accuracy) rule in or out HCM. (Note: I am VERY confident of the first two assumptions; not being a cardiologist, I think #3 is possible, but I don’t know.)

Business case:

Market: If we take Dr. Rich’s 1 million athletes, and assume about 100 per sponsoring organization (e.g., school, club, soccer league, etc.), there would be about 10,000 organizations with potential liability. With about 100 deaths per year, the rate is 1% of organizations per year. With $1 million in liability, the annual insurance would be $10,000 (plus profit, risk assumption, etc. for the insurance company).

But this would equal $100 per athlete per year, which would basically cause organizations to close up, or go bare and hope to avoid the suit. However, if the risk (as per Dr. Rich) drops to 2 per year with screening, then the annual risk drops to 0.02% and the raw insurance cost would be about $200 per organization, or $2 per athlete. Clearly in the range or insurability. Insurance companies will only insure organizations where everyone is screened, though, but this provides a very strong incentive for organizations to require screening.

At $1000, or even $100 a pop, though, the number of athletes would drop precipitously, and the market would dry up. Let’s assume the parents would be willing to put up $25, since, in my experience, this is about 10% of what one spends on gear. Total market: $25 million per year (yes, there may be less than annual need, but let’s not make it too complicated for now).

Operations: Clearly, the key to screening at $25 per athlete is rapid, batched processes, with non-physician personnel. Conveniently, athletes are in geographic proximity on a regular basis, e.g., practice, so a mobile lab model could work. Let’s assume 100 vans could cover 80+% of the need from a geographic perspective, so each van would need to screen 8,000 athletes per year. One FTE is 2,000 hours, so the average will have to be one screening every 15 minutes, but since at least 1/3 will probably be travel time, and 1/3 wasted time, our little device will need to be able to screen in about 5 minutes. This will require electronic data capture (e.g., parents would have to fill out ‘bubble cards’) so the tech would not have to spend time entering ID data, etc. All analysis would be done centrally after uploading data at the end of the day. (Back check: tech needs to screen average of 32 athletes per day… seems reasonable).

Financials: Let’s assume a fully loaded full time tech averages $60,000 per year and total van operating expenses are $40,000 per year (40,000 miles at $1 per mile), then each van runs about $100,000 per year; 100 vans would be $10 million per year. One hundred diagnostic devices would be $2 million (one year payback); assume non-field personnel at 20 people at an average of $100,000 fully loaded ($2 million), and assorted other headquarters/computer/etc. expenses are another $2 million. Total first year costs are $16 million; 80% of market is $20 million. Theoretical profit is $4 million (possibly more in out years, because less device expense, or less, because of smaller market with already screened athletes).

Considerations: Niche small business, not going to make anyone rich, but probably both financially and socially satisfying (how many jobs can say you save 100 lives per year!). Not likely to be VC funded, probably best for angel funding. Biggest hurdles are likely to be device development (probably will need some grants, help from an engineering and medical schools), tech training (state support unlikely because of geographically diffuse jobs, but may be attractive to non-profit support since it is a two-fer… benefits both technicians and kids), and penetration (insurance industry cooperation critical). All in all, it seems doable, although it would require the right team with technical skills and both non-profit and insurance industry contacts. Anyone out there up for it?

In reply to SteveSC and pcb:

SteveSC,

I’m thinking more along the lines of a classically disruptive technology rather than an actual business model: a $5,000 hand-held (or laptop-based) machine that does ECG and echo-based HCM screening, that can be used by any family doc or by any of the walk-in clinics now springing up in drug stores across the land. For 40 – 50 bucks, you can get your kid screened for HCM. It doesn’t require vans or anything else. The distribution channels already exist, entirely outside of the current cardiology-echocardiography corridor, and consist of low-end users who just want to be able to do one thing quickly and cheaply. (The current high-end users, following their classic role, would have absolutely no use for this technology, the idea of which will cause them apoplexy.)

pcb:

You make a very good point, which I have chosen to ignore here, because the point I’ve been trying to make has more to do with our dysfunctional healthcare system than the issue of how useful it would actually be to screen healthy young athletes. However, I have written about it elsewhere ( see http://heartdisease.about.com/od/exerciseandheartdisease/a/athlete_screen.htm), and I agree with you. This kind of screening would probably identify relatively large numbers of young athletes who, despite abnormalities on screening sufficient to deny them permission to play sports, are probably in fact at very low risk for sudden death.

While individuals who have HCM and also have symptoms (or a family member with symptomatic HCM) are at a relatively high level of risk, the risk is unknown for athletes without any symptoms and with no family history, whose HCM is discovered on routine screening. Are we to deny these young people the opportunity to compete? The answer is: if we screen them and find them, you’re damned right we will. That’s the whole point of screening, isn’t it?

As DB has pointed out, there are actually many, many layers to the question of whether we ought to screen for things like this. I have intentionally kept my comments to the “easier” part of the question, coward that I am.

DrRich

SteveSC,

This is probably why I went into medicine (where one’s pay is determined by Acts of Congress) instead of business, where the big bucks are.

So: WalMart will buy these screening devices (at a loss if necessary, and with smiles on their faces) in order to draw young athletes and their families into the store, where lots of sporting goods, etc. are sold. WalMart (and some of the drug stores launching these mini-clinics) aren’t planning to make much direct profit, if any, from these clinics anyhow. It’s all about attracting more feet into the aisles, which I think explains why the clinics are usually in the back.

But if you’ve read my response to pcb, you’ll understand why the biggest impediment to any business like this may turn out to be the athletes themselves, who tend to get very angry when they’re told they can’t play football/basketball/soccer any more. Most, if given the choice, would rather just take the odds that they’re not among the 125 in 2.5 million. Since taking odds like that is not irrational, it’s a tough stance to counter with simple logic. We’d probably need regulations to force the screening, which takes us where I for one would not want to go (paying lobbyists, applying for earmarks, cozying up to the ABA, pretending to admire lawmakers, etc.)

Making this into a successful business would require predicting complex, and many layered, human behavior. I would feel safer starting a business that relies on more predictable human behavior such as, say, liking ice cream.

DrRich

Albatross,

You have discovered one of the Dirty Little Secrets of medicine, to wit, every variety of cheap screening test (invariably heralded as a way of reducing cost and saving lives) always leads to false positives; which always leads to MORE (not fewer) aggressive workups, which always leads to more expense, and often to more morbidity if not mortality. Cardiology, my chosen profession, makes its living on this Axiom. What you have not discovered – and which I now graciously point out to you now in order that you may avoid embarrassment in the future – is that this is something we just don’t talk about in polite society. To suggest that widespread screening for hidden medical conditions could ever have negative consequences is simply too politically and medically incorrect for words.

Since you are not a doctor you get one free pass. Just don’t let it happen again.

No need to thank me.

DrRich