Yes, Democrats have a well-known negative stance about Rh-positive babies. Including A+, B+, AB+, and of course O+(?)
Oooh-kay. For those of you not familiar with basic newborn hematology, if a mom has Rh-negative blood (relatively rare compared at 15% to Rh-positive blood) and the baby has Rh-positive blood, and during pregnancy the mom's blood gets exposed to babies (can happen in car accidents and other placental problems resulting in fetal-maternal hemorrhage - the fetus's blood ends up in mom's circulation) the mom will start to make antibodies against the babies Rh antigens (more specifically, Rh-D antigens - there's more than one - Rhesus is a whole group; the D antigen is the troublesome one). This is one of the reasons couples contemplating marriage used to get blood tests in the United States, before the introduction of the medicine folks like James Harrison made possible.
In the United States, anti-D is typically referred to by its brand name, RhoGAM. It has antibodies to Rh-D - just a small amount, though. You inject this into a mom, her immune system detects them, and then if it sees actual anti-D from the fetus her immune system doesn't freak out and attack the fetal blood cells. Now and then we run into patients who do not like vaccines, which RhoGAM more or less is. The first baby is fine. The second baby to be exposed will often die (NSFW: pictures). In babies who don't die from hemolytic disease of the newborn (where their blood cells are destroyed, by maternal antibodies, among other problems) they can suffer brain damage. Treatment involves exchange transfusion and, in less severe cases, phototherapy, where we shine 460 nm light on them for a few days—hopefully not knocking too many DNA off the strand in the process.
Alternatively, you can take your chances with red raspberry and nettle tea, according to this person who claims to uphold evidence-based wellness, though she doesn't actually cite any evidence.
RhoGAM is made from pooled human plasma, like the gentleman cited in the article. He just happened to have a substantial amount of the antibodies, likely the result of blood transfusion exposure.
Imbruvica is priced at about US$12,000-13,000 for a month's supply (typically dosed as 420 mg daily for leukemias and related diseases, taken as 140 mg cap x 3 at a time once daily until either it or the disease kills you). If you RTFA, you'll find that's $133 a pill. They're going to introduce 3 new tablet sizes —280 mg, 420 mg, and 560 mg, and charge US$400 for each of them, no matter how many mg are in it. Once that's done, they'll make the old 140 mg capsule unavailable.
So some physicians did a trial last year that found 140 mg a day actually works as well as 420 mg for certain cancers. This, however, would cut into profits by 66%, so instead you can get a new 140 mg tablet for $400 instead of the old 140 mg capsule for $133. See, the pharmaceutical companies do understand math: you pay for treatment of the disease, not for the amount of medicine, and if it turns out you can be treated for a disease for a third of the price, they can just raise the price.
Or I suppose you could split the new 420 mg tablet into 3 pieces (carefully!) and pay the same price as before, or quarter the new 560's and get a modest discount. Cancer patients love gambling with a pill splitter for their $12k/month meds! As the drug company puts it, this is "a new innovation to provide patients with a convenient one pill, once-a-day dosing regimen and improved packaging, with the intent to improve adherence to this important therapy.”
So, that's believable - they are increasing the price of the old capsule by discontinuing it and replacing it with one that costs 3 times as much to "improve adherence." It's accurate to say they are correcting a pricing anomaly, I suppose, except it's one that didn't exist until research proved you didn't necessarily need as much of this medicine. You pay for your survival, not the drug.
Most drugs have a bunch of patents, including ones for the active ingredient, the delivery mechanism, the coating, etc. The patents will have staggered expiration dates, which can maximize the time a drug remains on patent. Albuterol inhalers, for example, which used to be generic until they were reformulated to be ozone safe, has 4 US patents for one particular formulation (ProAir). That helps keep this 40 year old drug at $57-$70 an inhaler. Somehow, back when it was generic, it was $4 an inhaler. Albuterol was supposed to be going generic again any minute now for the past 2-3 years, but it's still hung up in court —all for a drug that probably ought to be over-the-counter. IMHO.
Do you have any citations for this? Given the antigenic shift in the viral protein coat of influenza viruses, I'm not aware of evidence that past infections prevent future infection. It looks like there is evidence that natural immunity prevents infection from that same strain, but it doesn't look like there's evidence it provides you with much infection to inevitably drifting isotypes.
Doctors (these days largely through their large, single or multi-speciality practices) in the US negotiate charges with each individual insurance carrier, each in a race to be bigger in order to exact more negotiating power. Or, more precisely, groups and hospitals come up with a "charge master" list of prices which is really just the start of negotiating tactics:
Medical group: We charge $590 for a checkup.
Insurance company: If you want access to the patients in our Sapphire Plus Horizons Extra plans, we'll pay you $80 for a checkup.
Medical group: Your patients will have to drive 20 miles out of their way to see other providers, then, because we won't take anything less than $120
Except in very rural areas, it's not a monopoly in most places in the US — it's more of wrestling giants, with the uninsured getting screwed since they get stuck with the $590 "list price" that is really just supposed to start off the negotiation.
The AMA isn't a trade union (they don't negotiate pay and benefits for physicians, and only 25% of US physicians are members). The AMA contracts with the feds to develop a list of the relative values of chargeable medical procedures (which then get modified by insurance companies, who decided actual remuneration.
The AMA does come up with a code of ethics, but ensuring US physicians meet acceptable standards of competency is up to your state or territorial medical board, which are all quasi-governmental entities.
I enjoyed your comment about the "health insurance pigeon hole." I mean I get everyone hates health insurance, but what about the car insurance pigeon hole, and the fire insurance pigeon hole? The fundamental idea of insurance — spreading out risk — seems like a good one, and all insurance markets are regulated. It's a fascinating question if health insurance needs to be more regulated, or less, or simply standardized like they do in most other industrialized companies so it can be understood by mere mortals.
I agree with most of the foregoing. I am a primary care physician, and when people ask me for the prices of things —even when I'm able to spend 20 minutes downloading their formulary from some terrible website and then figure out the math of their deductible and out of pocket maximums I typically get it wrong. Every individual plan from every distinct insurance provider is structured differently, and the negotiated prices for the different billable procedures I do are considered (as I understand it) trade secrets of the insurance providers between them and each group of health care providers.
The only way of getting a menu of prices like they have posted at the Jiffy Lube is to go to a place that foregoes insurance and lets you pay cash. My group actually has a "price estimating hotline" staffed by a nice group of people who spend all day trying to tell you what your co-pay might be for a given service, but that's only good for figuring what you're in for, and not useful for comparison shopping.
This isn't a conspiracy of physicians to keep prices obscure: we really don't know. It's a side effect of the complex (expensive, inhumane) insurance system in the United States. (The same one that my Canadian colleagues love to roll their eyes at when we go to the same conferences, wondering why we put up with it.)
There's plenty of medical and insurance regulation in this country (resulting in me needing to fill out 8 page forms to get people 3 unpaid days off work for a cold, or a 20 item form to get diabetic test strips for diabetic patients). It would be nice to see more harmonized regulations, though, that didn't assume private enterprise was the perfect cure for all market problems. Health care isn't the same as oil changes and automobile repair. I'm among those who think the Affordable Care Act represented the hopeful breezes for a better future, and that its Swiss-styled system was not the unmitigated disaster my right wing friends claimed it to be.
I think this is a good point: a good primary care clinician should provide a good gatekeeping service for referrals. We should refer you only when it's likely to help, and to a competent specialist. I do think some PCP's refer more than they should because they feel pressed for time and/or think that it's simply easier to send the patient for a specialist to give a more detailed opinion. That opinion can be blinkered, though.
In my mind, competency for specialists includes knowing not just the full range of treatments, but spending time with many patients telling them they should do nothing —no fancy procedures or medications. It's not universal, but there are many specialists out there who are willing to risk making patients unhappy by not waving their magic wand, and who are willing to spend the time (and liability) to do so despite it being to their own economic disadvantage. I'm looking forward to changes in the US health care system that will encourage this, instead of encouraging simply doing as many billable procedures as possible.
It sounds like the GP had Dupuytren's contracture, a common thickening of connective tissue in the palm, with a time course of years that can result in inability fo extend (unbend) one's fingers.
As a primary care physician, I don't think I've yet referred anyone for surgery for this (in 17 years) and instead have people do stretching exercises, but surgery may make sense in severe cases. Collagenase injections (the Xiaflex referred to above)looks like it may be useful for patients who don't do well with stretching, don't want surgery, and don't have severe contractures. It doesn't look totally benign (51% bruising, 37% bleeding, 1% tendon rupture, 0.5% permanent unrelenting pain syndrome) but less invasive than surgery. It looks pretty effective.
That said, I've learned when I do referrals, one needs to be careful of who one refers to. For some specialists, given that they use a hammer a lot, most patients may start looking like a nails. I think pretty much all of these specialists genuinely want to help people, but when you specialize in something there's a risk of tunnel vision. For example, when a patient with annoying (but maybe not disabling) back pain wants to see a specialist —depending on who one sends them to — they've got a good chance of getting surgery done. Most back surgery for common spine conditions isn't clearly better than waiting a year for most patients. It's hard to tell some people you don't want to see a fancy specialist for this: you'd be better off losing weight and exercising more.
That said, though I'm pretty proud of myself for encouraging patients to avoid even seeing a surgeon until I really think it will help, and avoiding brand name medications, and decrying expensive vitamins or supplements with little evidence of effectiveness, this article in the New England Journal of Medicine gave me pause. Sure, Gawande claims with some reasoning that a lot of medical procedures have little benefit, and a lot of money is wasted. But the research leading to those conclusions was somewhat cherry-picked, and there is other research that suggests that higher spending really does improve outcomes. The author notes that "perhaps the most accurate conclusions is that sometimes less is more, sometimes more is more, and often we just don't know." Like a lot of health policy (and a lot of life in general), the issues may be more complex than they first appear.
Face ID seems to work fine in normal daylight in my experience, though bright sunlight is trickier. On the other hand, Touch ID worked for me maybe half the time - no good in the rain, or with sweaty fingers, or gloves on. (When I'm not running in the rain in the not very bright Pacific Northwest, I'm taking pictures of people's moles in a secure app to stick in their medical charts while wearing globes, so I suppose this thing fit my use cases well.) Not having to type my password for Face ID-enabled secure apps 20 times a day has been (effin') worth it.
HPV causes a lot of things (various isotypes are responsible for warts, most head and neck cancer, penile cancer); it is also the (99.7% of the time) cause of cervical cancer. HPV vaccination has been shown to prevent cervical intraepithelial neoplasia (CIN) and carcinoma in situ, the precursor lesions to invasive cervical cancer, in large randomized trials. The current 9-valent HPV vaccine is 97% effective in preventing CIN 2 (moderate) and more severe disease (CIN 3, carcinoma in situ). It also prevents the vaginal equivalent (VIN2/3) - 100% effective, in fact, among HPV naive populations, and 62% among the overall population.
Current cervical cancer prevention strategy involves Pap smears and then biopsies and surgical intervention when we find abnormalities. It's not cheap, and involves women (best case) getting an exam they don't like every 3 years from 21-29 years of age, and every 5 years from age 30-65 years of age. In the worst case, in areas and among populations that don't get Pap screening, people either can try to get to "screen and treat" centers (where we use liquid nitrogen to spots that show up on a cervix swabbed with vinegar), or, more often, simply consign a percentage of women to a miserable death. Cervical cancer is common (17.8 per 100k in countries without screening, with 9.8 of those dying), which amounts to about 266,000 deaths per year. In developed countries, cervical cancer is the eleventh most common type of cancer and ninth most common cause of cancer mortality (3.3 per 100k). In the US, that amounts of 13,000 cases per year, and 4100 deaths.
It stands to reason that HPV vaccine, since it prevents in HPV infection, and advanced pre-cancerous lesions, will likely be shown to prevent incident cancer as well when the vaccine has been around long enough. (The vaccine was first licenses in June 2006; most women get colonized with HPV around sexual debut but the cancer doesn't show up until age 35-55, a 20-40 year delay.) The tragedy of the vaccine, if any, is that it is largely available only in developed countries, where most people can get treatment rather than dying from the disease. That's not nothing: ask any woman who has to have repeated colposcopies and LEEP surgery if she would have preferred to have gotten 2 shots around age 11 and skipped all of the attended pain, expense, and risk of later preterm labor.
In fact, with the introduction of widespread HPV vaccination in the United States proposals are already afloat to change Pap screening—one proposal suggests every 10 year screening for vaccinated persons. Despite the expense of the vaccine ($240 for the two shot series) it's likely to be cheaper and less cruel than the current state of the art.
You are free to consider Gardasil to be a "scare tactic." As a family physician who gets to follow up on plenty of abnormal Paps, and not a particular fan of the pharmaceutical companies, my kids are getting vaccinated
I have plenty of apps on my phone that are essentially websites, that, one I verify my identification by other means (like my password and some other factor like my pre-registered IMEI number or out of band code sent to me) let me log in with my fingerprint. Which isn't transmitted; the phone has an API that tells the app my fingerprint was recognized.
This includes my bank, investment firms, and hospital (that's the one keyed to my specific phone).
In my primary care practice in the US, we’ve been asking about firearms since I started (in the Clinton administration). Not by government mandate or guideline, but suggestions from specialty societies, like the American Academy of Pediatrics and the American Academy of Family Physicians. We sit around in meetings and discuss this sort of stuff a couple of times a month and it gets added to the (ever lengthening) questionnaire.
9. Nephritis, nephrotic syndrome and nephrosis (kidney disease)
10. Intentional self-harm (suicide)
Out of 199,972 injury deaths during the last reporting year (62.6 per 100k population), 51,966 went by poisoning, 33,736 by motor vehicle accident, and 33,594 by firearms, most of that accidental. (Out of 15.872 homicides, 11,008 were by firearms, so two thirds of firearms deaths are accidents.)
So, we ask if you have a gun, and if you do, we ask if you have it properly locked up so no one accidentally shoots themselves (like your kids), just like we ask about seatbelt and carseats and smoke detectors. If it’s toward the top of the list of preventable deaths, we try to ask you about it to see if we have an opportunity to prevent you from dying—simple as that.
My use case is running for 40 minutes 4 times a week while getting my headphones soaked in a combination of sweat, rain, and lately ash blown in from nearby wildfires. I have blown through 3 prior pairs of Bluetooth wireless headphones, all of which suffered from poor reception while running, and all of which died a salt-encrusted death within several months.
My Powerbeats 3 aren't perfect (the cord sticks a bit on the back of my neck) but they are by far the only wireless headphones that ever really worked for me for running. I spent more than $200 with the other 3, which I suppose made the admittedly stiff price worth my while.
1. If I had a nickel for every time I had a heart to heart talk with a patient about improving their diet and exercise regimen to avoid the untoward consequences (reflux, overweight, diabetes, heart disease, feeling like crap in general) I'd have, like, a lot of nickels.
2. Interestingly, a response I get that's more common than you'd think is "I'm not switching from Pepsi to water. I hate the taste of water." We call this "pre-contemplative."
3. Some folks eat quinoa and twigs and still have risky acid reflux (with risks including esophageal cancer, bleeding, and cooking their esophagus sufficiently in acid it narrows - kind of like ceviche). While H2-blockers are first line, if they don't do the trick, sometimes proton pump inhibitors are the least worst thing.
Epinephrine and naloxone are both typically injected in muscles - no need to hit a vein. You can use epinephrine subcutaneously (just under the skin) but IM seems to work better.
I prescribed a vial and syringes a few hours ago. Not an EpiPen; in my case it was for a similar (but less sexy) scenario, naloxone, to use for opioid toxicity, a popular cause of death among opioid addicts and even those prescribed opiates for legitimate use. (The current recommendation is to prescribe an opiate-antagonist for those using over 50 morphine equivalents a day.) I just hope to heck if my patient ends up over-gorked on their meds they can find the syringe and draw up the medicine. (Injecting it is the easy part; you could do it through your pants blam! into the leg.) You can't keep a regular syringe pre-filled safely - the medicine doesn't stay safe. Luckily, naloxone doesn't need to be dosed carefully. Epinephrine does (too much could fry your heart). I suppose it's not so importnat to be precise as it is for insulin, but most people don't need to draw that up in a hurry.
Blowing my mod points for the opportunity to clarify why we screen for diabetic retinopathy:
By the time a diabetic patient has visible diabetic retinopathy, laser photocoagulation treatment cannot always repair the damage. The goal is to find the bleeding before risking significant visual loss, when treatment tends to be more successful. This is why most organizations (like the American Diabetes Association) recommend yearly dilated eye exams for diabetic patients.
Unfortunately, screening can be expensive for underinsured or uninsured patients, or those without access to ophthalmologists or optometrists. As a primary care physician I asked if I couldn't get trained myself to save the cost for my uninsured patients, and got basically a bunch of eye-rolling.
Somewhat like neuropathy, you don't want to be able to self-diagnose it: you want to prevent it before it becomes noticeable, which is awfully close in many patients to the point of also being irreversible. Diabetic neuropathies tend to be easier and cheaper to diagnose currently and don't need a specialist (and could probably be done by patients themselves with monofilament examinations). The same isn't true for the eyeballs —yet.
Good intentions, maybe, and despite the grief there are some advantages. I can see my patient's clinic charts in the hospital - before, I'd have to wait for Monday and a fax machine. I can see what happened to folks in the emergency department. I can figure out my obstetric patients' prior pregnancy history. I can send records to specialists directly, and send requests with an electronic copy of a chart note and pictures of moles and whatnot at no cost to a patient and sometimes save them a visit to another office.
It's not perfect, but it's not a total disaster either.
I like a conspiracy theory as much as anyone, but I really don't think the NSA convinced Congress to pass the not thoroughly thought out HITECH Act to amass statistics about the home addresses of people with pneumonia or which patients with high blood pressure are smoking. Being able to gather anonymized statistics on public health issues may help, however, to figure out how to improve immunization rates or best help diabetics get their blood sugar under control.
To the grandparent poster, our EMR company actually will pay their own way to have their engineers follow us around and see how we work, and our prior vendor was originally a nice internist who wrote his own code (who then sold the thing to a big conglomerate that also makes microwave ovens and jet engines and curling irons and stuff).
Our current EMR does a lot of stuff well, but I'm hopeful for the day it's more usable by clinicians. The basic process of writing progress notes (in some sense, the evidence of my life's work as a physician) is clunky and hard to correct and even less intuitive for my colleagues who don't happen to have fancy computer science degrees like me. Writing good software is hard, and maybe progress notes have had to wait in line behind revenue cycle and privacy and a bunch of compliance issues.
As a physician practicing in a US state (Oregon) where oral contraceptive pills are available behind the counter, I'm all for expanding access to contraception. Nothing quite has made otherwise young, promising women be overwhelmed in my practice than unplanned pregnancy (combined with flaky partners). OCP's are available here without a prescription, but require a consultation from a pharmacist. This isn't free, but where they make sure you don't have any of the various risk factors for having a stroke or blood clot on estrogen-containing contraceptives.
I'm also in favor of expanding access to more effective forms of contraception, like the subdermal implant (sold as Nexplanon in the US), and IUD. I'm pretty puzzled, however, about how one would implement an app to jab the implant in your arm. It's not hard to do (see this video), but clinicians have to get special certification from the manufacturer to do it. (This is to avoid the Norplant debacle of inadequately trained people putting the rods in a little too deep, making eventual removal challenging.) I do love the idea of having etonorgestrel rods and lidocaine hooked up to a smartphone app, however.
Epic is a big suite of applications that run on top of a big iron server - typically Unix (ours is AIX, I think). There's fine-grained user permissions in the application itself. End users do not have shell access or filesystem access or MUMPS prompt access, and everything has an audit trail. A select group of IT nerds get access to a text-based system running as a (Unix) application (with audit trails), and, at least at our organization, next to no one gets MUMPS prompt access or shell access. We have hot swappable servers located on opposing coasts of North America. I can't speak to the implementation at your daughter's site.
There may be examples out of there of hackers breaking into Epic; I'm not aware of any. Since our implementation was modeled after Epic's recommendations my impression is they've got their heads screwed on straight, security-wise.
Good luck getting EMR applications disconnected from the Internet. Every institution I know of has their EMR available behind a firewall, accessible visa Citrix. So we can work on our charts after putting the kids to bed (not uncommon for that to be a 1-2 hour task) and covering our partners during overnight call and answering emergency calls when out of town. And for seeing patients in nursing homes, and home visits (they still happen!). And our EMR's exchange information with one another, so if you go to hospital X in my town and then show up in office Y to follow up with your regular provider we can tell what happened Or, I dunno, I suppose you could keep us (physicians) locked up in the office for 24 hours 2-3 days a week and for 14 hours (instead of 12) on non-call days. I know, boo hoo hoo, but I think this horse has left the barn.
When I worked as a software engineer, typed my password in for various ssh sessions maybe 10 times a day. Now that I'm working as a physician, every time I walk in and out of a patient room (which can be multiple times for visit, fetching the liquid nitrogen and scalpes and where are we keeping the extra large speculum this week anyway). I get to type in my (Active Directory) password with its enforced mixed capitals and numbers that I'm not allowed to change (too many disparate systems, apparently), maybe 50 times a day.
Which doesn't help with the spear-phishing, right? That just requires that I click on the link in the email addressed from my information security department, complete with their logo, saying they need to verify my information. I don't think my clinician colleagues are falling for that much, but the folks who answer the phone, hired out of high school, it's easy enough for them to fall for it.
Or it means you had diabetes (and there are plenty of thin, otherwise people with diabetes) and didn't work for a company that offered health insurance;
Or it means you had a (now illegal) plan that "covered" well child visits, just not more than 2 in the first two years of life (out of the 9 that are the standard of care);
Or it means you fell off a ladder painting your house and broke your back;
Or it means you have congenital heart disease —
SORRY SUCKERS! You shouldn't have had Pacific Islander grandparents/been a kid/painted your house/been born — not my problem! I'm not saying "Your problem, not mine" isn't a valid viewpoint, but I do think that letting people who have treatable medical problems through no fault of their own drop dead in the streets is a bit more individualistic than all but the most libertarian viewpoints in the US. Not to mention every single other developed nation on the planet, that somehow manage to have popular support for their universal health care systems yet still spend about half of what we do.
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Yes, Democrats have a well-known negative stance about Rh-positive babies. Including A+, B+, AB+, and of course O+(?)
Oooh-kay. For those of you not familiar with basic newborn hematology, if a mom has Rh-negative blood (relatively rare compared at 15% to Rh-positive blood) and the baby has Rh-positive blood, and during pregnancy the mom's blood gets exposed to babies (can happen in car accidents and other placental problems resulting in fetal-maternal hemorrhage - the fetus's blood ends up in mom's circulation) the mom will start to make antibodies against the babies Rh antigens (more specifically, Rh-D antigens - there's more than one - Rhesus is a whole group; the D antigen is the troublesome one). This is one of the reasons couples contemplating marriage used to get blood tests in the United States, before the introduction of the medicine folks like James Harrison made possible.
In the United States, anti-D is typically referred to by its brand name, RhoGAM. It has antibodies to Rh-D - just a small amount, though. You inject this into a mom, her immune system detects them, and then if it sees actual anti-D from the fetus her immune system doesn't freak out and attack the fetal blood cells. Now and then we run into patients who do not like vaccines, which RhoGAM more or less is. The first baby is fine. The second baby to be exposed will often die (NSFW: pictures). In babies who don't die from hemolytic disease of the newborn (where their blood cells are destroyed, by maternal antibodies, among other problems) they can suffer brain damage. Treatment involves exchange transfusion and, in less severe cases, phototherapy, where we shine 460 nm light on them for a few days—hopefully not knocking too many DNA off the strand in the process.
Alternatively, you can take your chances with red raspberry and nettle tea, according to this person who claims to uphold evidence-based wellness, though she doesn't actually cite any evidence.
RhoGAM is made from pooled human plasma, like the gentleman cited in the article. He just happened to have a substantial amount of the antibodies, likely the result of blood transfusion exposure.
Imbruvica is priced at about US$12,000-13,000 for a month's supply (typically dosed as 420 mg daily for leukemias and related diseases, taken as 140 mg cap x 3 at a time once daily until either it or the disease kills you). If you RTFA, you'll find that's $133 a pill. They're going to introduce 3 new tablet sizes —280 mg, 420 mg, and 560 mg, and charge US$400 for each of them, no matter how many mg are in it. Once that's done, they'll make the old 140 mg capsule unavailable.
So some physicians did a trial last year that found 140 mg a day actually works as well as 420 mg for certain cancers. This, however, would cut into profits by 66%, so instead you can get a new 140 mg tablet for $400 instead of the old 140 mg capsule for $133. See, the pharmaceutical companies do understand math: you pay for treatment of the disease, not for the amount of medicine, and if it turns out you can be treated for a disease for a third of the price, they can just raise the price.
Or I suppose you could split the new 420 mg tablet into 3 pieces (carefully!) and pay the same price as before, or quarter the new 560's and get a modest discount. Cancer patients love gambling with a pill splitter for their $12k/month meds! As the drug company puts it, this is "a new innovation to provide patients with a convenient one pill, once-a-day dosing regimen and improved packaging, with the intent to improve adherence to this important therapy.”
So, that's believable - they are increasing the price of the old capsule by discontinuing it and replacing it with one that costs 3 times as much to "improve adherence." It's accurate to say they are correcting a pricing anomaly, I suppose, except it's one that didn't exist until research proved you didn't necessarily need as much of this medicine. You pay for your survival, not the drug.
Most drugs have a bunch of patents, including ones for the active ingredient, the delivery mechanism, the coating, etc. The patents will have staggered expiration dates, which can maximize the time a drug remains on patent. Albuterol inhalers, for example, which used to be generic until they were reformulated to be ozone safe, has 4 US patents for one particular formulation (ProAir). That helps keep this 40 year old drug at $57-$70 an inhaler. Somehow, back when it was generic, it was $4 an inhaler. Albuterol was supposed to be going generic again any minute now for the past 2-3 years, but it's still hung up in court —all for a drug that probably ought to be over-the-counter. IMHO.
Do you have any citations for this? Given the antigenic shift in the viral protein coat of influenza viruses, I'm not aware of evidence that past infections prevent future infection. It looks like there is evidence that natural immunity prevents infection from that same strain, but it doesn't look like there's evidence it provides you with much infection to inevitably drifting isotypes.
Except in very rural areas, it's not a monopoly in most places in the US — it's more of wrestling giants, with the uninsured getting screwed since they get stuck with the $590 "list price" that is really just supposed to start off the negotiation.
The AMA isn't a trade union (they don't negotiate pay and benefits for physicians, and only 25% of US physicians are members). The AMA contracts with the feds to develop a list of the relative values of chargeable medical procedures (which then get modified by insurance companies, who decided actual remuneration.
The AMA does come up with a code of ethics, but ensuring US physicians meet acceptable standards of competency is up to your state or territorial medical board, which are all quasi-governmental entities.
I enjoyed your comment about the "health insurance pigeon hole." I mean I get everyone hates health insurance, but what about the car insurance pigeon hole, and the fire insurance pigeon hole? The fundamental idea of insurance — spreading out risk — seems like a good one, and all insurance markets are regulated. It's a fascinating question if health insurance needs to be more regulated, or less, or simply standardized like they do in most other industrialized companies so it can be understood by mere mortals.
I agree with most of the foregoing. I am a primary care physician, and when people ask me for the prices of things —even when I'm able to spend 20 minutes downloading their formulary from some terrible website and then figure out the math of their deductible and out of pocket maximums I typically get it wrong. Every individual plan from every distinct insurance provider is structured differently, and the negotiated prices for the different billable procedures I do are considered (as I understand it) trade secrets of the insurance providers between them and each group of health care providers.
The only way of getting a menu of prices like they have posted at the Jiffy Lube is to go to a place that foregoes insurance and lets you pay cash. My group actually has a "price estimating hotline" staffed by a nice group of people who spend all day trying to tell you what your co-pay might be for a given service, but that's only good for figuring what you're in for, and not useful for comparison shopping.
This isn't a conspiracy of physicians to keep prices obscure: we really don't know. It's a side effect of the complex (expensive, inhumane) insurance system in the United States. (The same one that my Canadian colleagues love to roll their eyes at when we go to the same conferences, wondering why we put up with it.)
There's plenty of medical and insurance regulation in this country (resulting in me needing to fill out 8 page forms to get people 3 unpaid days off work for a cold, or a 20 item form to get diabetic test strips for diabetic patients). It would be nice to see more harmonized regulations, though, that didn't assume private enterprise was the perfect cure for all market problems. Health care isn't the same as oil changes and automobile repair. I'm among those who think the Affordable Care Act represented the hopeful breezes for a better future, and that its Swiss-styled system was not the unmitigated disaster my right wing friends claimed it to be.
I think this is a good point: a good primary care clinician should provide a good gatekeeping service for referrals. We should refer you only when it's likely to help, and to a competent specialist. I do think some PCP's refer more than they should because they feel pressed for time and/or think that it's simply easier to send the patient for a specialist to give a more detailed opinion. That opinion can be blinkered, though.
In my mind, competency for specialists includes knowing not just the full range of treatments, but spending time with many patients telling them they should do nothing —no fancy procedures or medications. It's not universal, but there are many specialists out there who are willing to risk making patients unhappy by not waving their magic wand, and who are willing to spend the time (and liability) to do so despite it being to their own economic disadvantage. I'm looking forward to changes in the US health care system that will encourage this, instead of encouraging simply doing as many billable procedures as possible.
It sounds like the GP had Dupuytren's contracture, a common thickening of connective tissue in the palm, with a time course of years that can result in inability fo extend (unbend) one's fingers.
As a primary care physician, I don't think I've yet referred anyone for surgery for this (in 17 years) and instead have people do stretching exercises, but surgery may make sense in severe cases. Collagenase injections (the Xiaflex referred to above)looks like it may be useful for patients who don't do well with stretching, don't want surgery, and don't have severe contractures. It doesn't look totally benign (51% bruising, 37% bleeding, 1% tendon rupture, 0.5% permanent unrelenting pain syndrome) but less invasive than surgery. It looks pretty effective.
That said, I've learned when I do referrals, one needs to be careful of who one refers to. For some specialists, given that they use a hammer a lot, most patients may start looking like a nails. I think pretty much all of these specialists genuinely want to help people, but when you specialize in something there's a risk of tunnel vision. For example, when a patient with annoying (but maybe not disabling) back pain wants to see a specialist —depending on who one sends them to — they've got a good chance of getting surgery done. Most back surgery for common spine conditions isn't clearly better than waiting a year for most patients. It's hard to tell some people you don't want to see a fancy specialist for this: you'd be better off losing weight and exercising more.
That said, though I'm pretty proud of myself for encouraging patients to avoid even seeing a surgeon until I really think it will help, and avoiding brand name medications, and decrying expensive vitamins or supplements with little evidence of effectiveness, this article in the New England Journal of Medicine gave me pause. Sure, Gawande claims with some reasoning that a lot of medical procedures have little benefit, and a lot of money is wasted. But the research leading to those conclusions was somewhat cherry-picked, and there is other research that suggests that higher spending really does improve outcomes. The author notes that "perhaps the most accurate conclusions is that sometimes less is more, sometimes more is more, and often we just don't know." Like a lot of health policy (and a lot of life in general), the issues may be more complex than they first appear.
Face ID seems to work fine in normal daylight in my experience, though bright sunlight is trickier. On the other hand, Touch ID worked for me maybe half the time - no good in the rain, or with sweaty fingers, or gloves on. (When I'm not running in the rain in the not very bright Pacific Northwest, I'm taking pictures of people's moles in a secure app to stick in their medical charts while wearing globes, so I suppose this thing fit my use cases well.) Not having to type my password for Face ID-enabled secure apps 20 times a day has been (effin') worth it.
HPV causes a lot of things (various isotypes are responsible for warts, most head and neck cancer, penile cancer); it is also the (99.7% of the time) cause of cervical cancer. HPV vaccination has been shown to prevent cervical intraepithelial neoplasia (CIN) and carcinoma in situ, the precursor lesions to invasive cervical cancer, in large randomized trials. The current 9-valent HPV vaccine is 97% effective in preventing CIN 2 (moderate) and more severe disease (CIN 3, carcinoma in situ). It also prevents the vaginal equivalent (VIN2/3) - 100% effective, in fact, among HPV naive populations, and 62% among the overall population.
Current cervical cancer prevention strategy involves Pap smears and then biopsies and surgical intervention when we find abnormalities. It's not cheap, and involves women (best case) getting an exam they don't like every 3 years from 21-29 years of age, and every 5 years from age 30-65 years of age. In the worst case, in areas and among populations that don't get Pap screening, people either can try to get to "screen and treat" centers (where we use liquid nitrogen to spots that show up on a cervix swabbed with vinegar), or, more often, simply consign a percentage of women to a miserable death. Cervical cancer is common (17.8 per 100k in countries without screening, with 9.8 of those dying), which amounts to about 266,000 deaths per year. In developed countries, cervical cancer is the eleventh most common type of cancer and ninth most common cause of cancer mortality (3.3 per 100k). In the US, that amounts of 13,000 cases per year, and 4100 deaths.
It stands to reason that HPV vaccine, since it prevents in HPV infection, and advanced pre-cancerous lesions, will likely be shown to prevent incident cancer as well when the vaccine has been around long enough. (The vaccine was first licenses in June 2006; most women get colonized with HPV around sexual debut but the cancer doesn't show up until age 35-55, a 20-40 year delay.) The tragedy of the vaccine, if any, is that it is largely available only in developed countries, where most people can get treatment rather than dying from the disease. That's not nothing: ask any woman who has to have repeated colposcopies and LEEP surgery if she would have preferred to have gotten 2 shots around age 11 and skipped all of the attended pain, expense, and risk of later preterm labor.
In fact, with the introduction of widespread HPV vaccination in the United States proposals are already afloat to change Pap screening—one proposal suggests every 10 year screening for vaccinated persons. Despite the expense of the vaccine ($240 for the two shot series) it's likely to be cheaper and less cruel than the current state of the art.
You are free to consider Gardasil to be a "scare tactic." As a family physician who gets to follow up on plenty of abnormal Paps, and not a particular fan of the pharmaceutical companies, my kids are getting vaccinated
This includes my bank, investment firms, and hospital (that's the one keyed to my specific phone).
In my primary care practice in the US, we’ve been asking about firearms since I started (in the Clinton administration). Not by government mandate or guideline, but suggestions from specialty societies, like the American Academy of Pediatrics and the American Academy of Family Physicians. We sit around in meetings and discuss this sort of stuff a couple of times a month and it gets added to the (ever lengthening) questionnaire.
This, in turn, is based on . Here’s your top 10 for 2014:
Out of 199,972 injury deaths during the last reporting year (62.6 per 100k population), 51,966 went by poisoning, 33,736 by motor vehicle accident, and 33,594 by firearms, most of that accidental. (Out of 15.872 homicides, 11,008 were by firearms, so two thirds of firearms deaths are accidents.)
So, we ask if you have a gun, and if you do, we ask if you have it properly locked up so no one accidentally shoots themselves (like your kids), just like we ask about seatbelt and carseats and smoke detectors. If it’s toward the top of the list of preventable deaths, we try to ask you about it to see if we have an opportunity to prevent you from dying—simple as that.
My use case is running for 40 minutes 4 times a week while getting my headphones soaked in a combination of sweat, rain, and lately ash blown in from nearby wildfires. I have blown through 3 prior pairs of Bluetooth wireless headphones, all of which suffered from poor reception while running, and all of which died a salt-encrusted death within several months.
My Powerbeats 3 aren't perfect (the cord sticks a bit on the back of my neck) but they are by far the only wireless headphones that ever really worked for me for running. I spent more than $200 with the other 3, which I suppose made the admittedly stiff price worth my while.
Epinephrine and naloxone are both typically injected in muscles - no need to hit a vein. You can use epinephrine subcutaneously (just under the skin) but IM seems to work better.
I prescribed a vial and syringes a few hours ago. Not an EpiPen; in my case it was for a similar (but less sexy) scenario, naloxone, to use for opioid toxicity, a popular cause of death among opioid addicts and even those prescribed opiates for legitimate use. (The current recommendation is to prescribe an opiate-antagonist for those using over 50 morphine equivalents a day.) I just hope to heck if my patient ends up over-gorked on their meds they can find the syringe and draw up the medicine. (Injecting it is the easy part; you could do it through your pants blam! into the leg.) You can't keep a regular syringe pre-filled safely - the medicine doesn't stay safe. Luckily, naloxone doesn't need to be dosed carefully. Epinephrine does (too much could fry your heart). I suppose it's not so importnat to be precise as it is for insulin, but most people don't need to draw that up in a hurry.
Blowing my mod points for the opportunity to clarify why we screen for diabetic retinopathy: By the time a diabetic patient has visible diabetic retinopathy, laser photocoagulation treatment cannot always repair the damage. The goal is to find the bleeding before risking significant visual loss, when treatment tends to be more successful. This is why most organizations (like the American Diabetes Association) recommend yearly dilated eye exams for diabetic patients. Unfortunately, screening can be expensive for underinsured or uninsured patients, or those without access to ophthalmologists or optometrists. As a primary care physician I asked if I couldn't get trained myself to save the cost for my uninsured patients, and got basically a bunch of eye-rolling. Somewhat like neuropathy, you don't want to be able to self-diagnose it: you want to prevent it before it becomes noticeable, which is awfully close in many patients to the point of also being irreversible. Diabetic neuropathies tend to be easier and cheaper to diagnose currently and don't need a specialist (and could probably be done by patients themselves with monofilament examinations). The same isn't true for the eyeballs —yet.
Good intentions, maybe, and despite the grief there are some advantages. I can see my patient's clinic charts in the hospital - before, I'd have to wait for Monday and a fax machine. I can see what happened to folks in the emergency department. I can figure out my obstetric patients' prior pregnancy history. I can send records to specialists directly, and send requests with an electronic copy of a chart note and pictures of moles and whatnot at no cost to a patient and sometimes save them a visit to another office.
It's not perfect, but it's not a total disaster either.
I like a conspiracy theory as much as anyone, but I really don't think the NSA convinced Congress to pass the not thoroughly thought out HITECH Act to amass statistics about the home addresses of people with pneumonia or which patients with high blood pressure are smoking. Being able to gather anonymized statistics on public health issues may help, however, to figure out how to improve immunization rates or best help diabetics get their blood sugar under control.
To the grandparent poster, our EMR company actually will pay their own way to have their engineers follow us around and see how we work, and our prior vendor was originally a nice internist who wrote his own code (who then sold the thing to a big conglomerate that also makes microwave ovens and jet engines and curling irons and stuff).
Our current EMR does a lot of stuff well, but I'm hopeful for the day it's more usable by clinicians. The basic process of writing progress notes (in some sense, the evidence of my life's work as a physician) is clunky and hard to correct and even less intuitive for my colleagues who don't happen to have fancy computer science degrees like me. Writing good software is hard, and maybe progress notes have had to wait in line behind revenue cycle and privacy and a bunch of compliance issues.
As a physician practicing in a US state (Oregon) where oral contraceptive pills are available behind the counter, I'm all for expanding access to contraception. Nothing quite has made otherwise young, promising women be overwhelmed in my practice than unplanned pregnancy (combined with flaky partners). OCP's are available here without a prescription, but require a consultation from a pharmacist. This isn't free, but where they make sure you don't have any of the various risk factors for having a stroke or blood clot on estrogen-containing contraceptives.
I'm also in favor of expanding access to more effective forms of contraception, like the subdermal implant (sold as Nexplanon in the US), and IUD. I'm pretty puzzled, however, about how one would implement an app to jab the implant in your arm. It's not hard to do (see this video), but clinicians have to get special certification from the manufacturer to do it. (This is to avoid the Norplant debacle of inadequately trained people putting the rods in a little too deep, making eventual removal challenging.) I do love the idea of having etonorgestrel rods and lidocaine hooked up to a smartphone app, however.
Epic is a big suite of applications that run on top of a big iron server - typically Unix (ours is AIX, I think). There's fine-grained user permissions in the application itself. End users do not have shell access or filesystem access or MUMPS prompt access, and everything has an audit trail. A select group of IT nerds get access to a text-based system running as a (Unix) application (with audit trails), and, at least at our organization, next to no one gets MUMPS prompt access or shell access. We have hot swappable servers located on opposing coasts of North America. I can't speak to the implementation at your daughter's site.
There may be examples out of there of hackers breaking into Epic; I'm not aware of any. Since our implementation was modeled after Epic's recommendations my impression is they've got their heads screwed on straight, security-wise.
Good luck getting EMR applications disconnected from the Internet. Every institution I know of has their EMR available behind a firewall, accessible visa Citrix. So we can work on our charts after putting the kids to bed (not uncommon for that to be a 1-2 hour task) and covering our partners during overnight call and answering emergency calls when out of town. And for seeing patients in nursing homes, and home visits (they still happen!). And our EMR's exchange information with one another, so if you go to hospital X in my town and then show up in office Y to follow up with your regular provider we can tell what happened Or, I dunno, I suppose you could keep us (physicians) locked up in the office for 24 hours 2-3 days a week and for 14 hours (instead of 12) on non-call days. I know, boo hoo hoo, but I think this horse has left the barn.
When I worked as a software engineer, typed my password in for various ssh sessions maybe 10 times a day. Now that I'm working as a physician, every time I walk in and out of a patient room (which can be multiple times for visit, fetching the liquid nitrogen and scalpes and where are we keeping the extra large speculum this week anyway). I get to type in my (Active Directory) password with its enforced mixed capitals and numbers that I'm not allowed to change (too many disparate systems, apparently), maybe 50 times a day.
Which doesn't help with the spear-phishing, right? That just requires that I click on the link in the email addressed from my information security department, complete with their logo, saying they need to verify my information. I don't think my clinician colleagues are falling for that much, but the folks who answer the phone, hired out of high school, it's easy enough for them to fall for it.
Or it means you had diabetes (and there are plenty of thin, otherwise people with diabetes) and didn't work for a company that offered health insurance;
Or it means you had a (now illegal) plan that "covered" well child visits, just not more than 2 in the first two years of life (out of the 9 that are the standard of care);
Or it means you fell off a ladder painting your house and broke your back;
Or it means you have congenital heart disease —
SORRY SUCKERS! You shouldn't have had Pacific Islander grandparents/been a kid/painted your house/been born — not my problem! I'm not saying "Your problem, not mine" isn't a valid viewpoint, but I do think that letting people who have treatable medical problems through no fault of their own drop dead in the streets is a bit more individualistic than all but the most libertarian viewpoints in the US. Not to mention every single other developed nation on the planet, that somehow manage to have popular support for their universal health care systems yet still spend about half of what we do.