Heroin now kills more people than guns:

[smilesammich 10,727]

14 minutes ago, bcking said:

Ya that is the study I was talking about. I thought we had a thread about it a couple months ago.

 

I can go into detail again, but it'll have to be later. In a conference now and just started service today so I'm busier than usual.

 

Reimbursement for therapies is a different issue from that CNN study. I completely agree that insurance reimbursement for it is horrible. Even in my patients, private insurance can be very difficult to cover therapies for premature infants. Medicare is even worse.

 

I don't think the reimbursement issue is because insurance companies want to pay for opioids, or they are "in" with big pharma. It's just because coverage if medications tends to be easier to manage. Outpatient  services in general are undersupported compared to medicines and hospitalizations. That is a huge issue with our healthcare system as a whole, not just for this topic.

here's the story, i thought it was relatively new..https://www.cnn.com/2018/03/11/health/prescription-opioid-payments-eprise/index.html

[bcking 3,157]

4 minutes ago, smilesammich said:

here's the story, i thought it was relatively new..https://www.cnn.com/2018/03/11/health/prescription-opioid-payments-eprise/index.html

Ah that is new. There was something very similar about pharma payments to doctors published in 2017. I must have confused the two.

 

I'll look at this one later when I get a chance.

[smilesammich 10,727]

8 minutes ago, yuna628 said:

Same here. In fact, in order for her insurance to approve and authorize her spinal op, my sister had to first receive injections and PT to see if it 'helped' even though it was the opinion of her surgeon, the doctor who administered the injections, and the therapist that she was in urgent need of surgery. They also gave her Tramadol which prompted an allergic reaction. The insurance was happy to keep her 'maintained' on pills instead of just giving her surgery. After waiting far longer than needed, she had her surgery and they sent her home with heavy painkillers. She took one tablet and felt so freaked out she never touched it again, and went through the rest of her recovery without meds. Medicare has refused any further PT for my mom, but is still happy to provide pills.... I mean she's improved from looking like a stroke victim to being able to move more, but I think if they had stuck it out, perhaps she'd be in an even better place physically.

it's sad, in my experience doctors are more than happy to prescribe a bandaid instead of solving the root problem. i don't think that doctors necessarily do this purposefully, i think the insurance companies have been calling the shots for so long that doctors just prescribe because they know that's all insurance will pay for. 

[bcking 3,157]

1 hour ago, smilesammich said:

here's the story, i thought it was relatively new..https://www.cnn.com/2018/03/11/health/prescription-opioid-payments-eprise/index.html

I'm reading through the methodology link now (the actual results I care less about, I tend to spend 90% of my time reading a paper's methodology, and 10% reading the results). Some thoughts as I go:

 

1. I tried looking myself up on the open payments database and I'm not there. My hospital is, but not myself or any of my colleagues. I'm not that familiar with the database so I'm wondering what exactly it is missing. Myself and my colleagues are all generally inpatient providers, so perhaps this is just for outpatient providers? If so, it's missing a ton of data
2. They searched for all payments from "opioid manufacturers", not just payments tied to opioids. They explain their methodological problem (many payments didnt' list an associated drug), but they essentially trade one problem with another. Let's take Purdue Pharma, which is a major opioid manufacturer. The majority of their prescription work is for opioids, but even they also make a sleep aid (Zolpidem). So they will be including payments marketing the use of Zolpidem, in addition to opioids. There are several prescription options for sleep aids, so I'm sure they try to get the word out on Zolpidem since it is (relatively) new sleep aid. That is just one pharma company, but I would assume every manufacturer makes things other than opioids, which muddles their data. They did a subgroup analysis to look into this by just looking at pain management specialists and found the relationship between payments/prescribing to be similar, but I still think this is a methodological limitation. Even a pain management specialist would have a reason to prescribe a sleep aid, and so Zolpidem may be marketed to them.

I realize it's a news article pretending to be a "methodology" section in a paper, but it is quite sparse. Now if we actually look at some of the results -

 

1. 10th percentile of prescribing behavior had an average payment of 125 dollars (median), 90th percentile had an average of 455 dollars. So the more you prescribe, the more gifts/payments you receive.
   1. Even the 90th percentile is a pretty tiny amount. This is data over a year. 455 dollars in a year is peanuts. I'm not trying to brag about physician salaries but it's just not that significant spread over time. Say I work in a pain management clinic. We prescribe lots of opioids, because our patient population is disproportionately made up of people who need them. It would make sense for a pharma company focusing on opioids to have a relationship with my practice. They may come up with a deal to provide us lunch once a week. The lunch payment say is 10 dollars. If I attend each of those free lunches, they will have "paid" me 520 dollars in a year, 480 dollars if you subtract 4 weeks vacation. It's free food, in my workplace, so why would I miss it? As I've already said, these lunches are not talks from the pharma company, they just sponsor the food. They may spend 5 minutes talking to everyone at the beginning (when, lets be honest, everyone is focused on eating their food because they are all starving). We have these sorts of meals. I just smile and nod when they try to chat with me because I'm not their for their 15 second sell, I'm there for free food.
   2. Embedded in my first point is another more simple point - Pharma companies will target prescribers who prescribe their medication. They want to maintain business. That IS NOT the same thing as saying that because a pharma company targets you, you are going to prescribe more. The question is what comes first. Based on my interactions with pharmaceutical companies it seems like the former. They are there because you are already business for them. We get formula companies, companies for cardiac medications (more rarely), companies for some expensive medical devices (ventilators, iNO) because that is what we use and they want our business. We didn't suddenly start using iNO because the pharma company started buying us lunch. They mention the "seek out and reward" option, but I still think that language biases people's opinions. It isn't necessarily rewarding, it may just be maintaining business. 
2. 31,417 doctors received payments of more than 1,000 dollars (I'm not going to talk about the <1,000 dollars for reasons mentioned above - that is a fairly minor amount in the grand scheme of things)
   1. There are over 1 million physicians in the USA. So that is roughly 3% of physicians. Even if we assume that all of those physicians that accept more than 1,000 dollars are all being influenced by their payments (and I'd argue that isn't true), that is a fairly minor impact on our opioid crisis. We don't have the issues we have currently because 3% of physicians are over-prescribing opioids. The issues are much bigger than that
   2. There are ~3,900 doctors who received >15,000 dollars - Well there are roughy 3,000 pain medicine specialists, so that fits reasonably well. Most of those payments are going to be "pooled" from their practice as a whole (no one really works individually these days). 
3. Opioid manufacturers are more likely to pay physicians who write more opioid prescriptions
   1. Similar to the first point - That is just business. That pain medicine clinic is going to write a ton of opioid prescriptions, so of course if they want to send a rep somewhere they are going to send them to their clinic. Same with an outpatient ambulatory surgery center etc... You didn't need this study to know that this is true. It's common sense. 

 

One interesting thing to do would be to compare this study with a similar study looking at say Cardiac medications, or some other class of medications. I'm sure you'd find similar relationships. Those who prescribe more, get paid more. Specialist groups that manage it, get the vast majority. Large dedicated specialist groups probably receive what seems like quite large sums of money. Are we abusing Cardiac medication prescriptions? Perhaps, but not to the same degree as opioids. 

 

I'm not saying payments from pharmaceutical problems aren't an issue...but I don't think they are as big of an issue as people want to make them out to be. The problems are massive and multi-factorial. They are just one of many. 

[bcking 3,157]

1 hour ago, smilesammich said:

it's sad, in my experience doctors are more than happy to prescribe a bandaid instead of solving the root problem. i don't think that doctors necessarily do this purposefully, i think the insurance companies have been calling the shots for so long that doctors just prescribe because they know that's all insurance will pay for. 

It's a combination of

 

1. What will insurance pay for?

2. What do I (the doctor in question, I don't see people in clinic) have the time and resources to manage? Prescribing a medication and having them come back to see how it's going is relatively painless. More complex methods for treating pain (that involve a combination of therapies etc...) are harder to coordinate, and harder to follow-up

3. How much time to have to uncover the root problem? It's not that doctors don't want to get to the "root problem", but in many cases that could take hours. If gave every patient as much time as they truly "needed", you'd be waiting years to see a doctor. Even for me to schedule a doctor with  my PCP it has to be a couple months in advance (if it's not an acute issue). If every appointment received the actual amount of time required for that patient, some would list 5 minutes and some would last 2 hours and doctors wouldn't be able to keep up with the number of patients they need to see.

[The Nature Boy 7,659]

25 minutes ago, bcking said:

It's a combination of

 

1. What will insurance pay for?

2. What do I (the doctor in question, I don't see people in clinic) have the time and resources to manage? Prescribing a medication and having them come back to see how it's going is relatively painless. More complex methods for treating pain (that involve a combination of therapies etc...) are harder to coordinate, and harder to follow-up

3. How much time to have to uncover the root problem? It's not that doctors don't want to get to the "root problem", but in many cases that could take hours. If gave every patient as much time as they truly "needed", you'd be waiting years to see a doctor. Even for me to schedule a doctor with  my PCP it has to be a couple months in advance (if it's not an acute issue). If every appointment received the actual amount of time required for that patient, some would list 5 minutes and some would last 2 hours and doctors wouldn't be able to keep up with the number of patients they need to see.

So what you are saying is most doctors are over loaded and dont have much spare time ?

[smilesammich 10,727]

5 minutes ago, bcking said:

It's a combination of

 

1. What will insurance pay for?

2. What do I (the doctor in question, I don't see people in clinic) have the time and resources to manage? Prescribing a medication and having them come back to see how it's going is relatively painless. More complex methods for treating pain (that involve a combination of therapies etc...) are harder to coordinate, and harder to follow-up

3. How much time to have to uncover the root problem? It's not that doctors don't want to get to the "root problem", but in many cases that could take hours. If gave every patient as much time as they truly "needed", you'd be waiting years to see a doctor. Even for me to schedule a doctor with  my PCP it has to be a couple months in advance (if it's not an acute issue). If every appointment received the actual amount of time required for that patient, some would list 5 minutes and some would last 2 hours and doctors wouldn't be able to keep up with the number of patients they need to see.

#3 angers me. the entire purpose of visiting a person educated in medicine is to get to the root problem. in the year 2018 it's hard to coordinate medical needs? i mean, there certainly isn't any issue coordinating billing and payment. and collections.

 

i never go to the doctor, i'm lucky that i don't have to cause i'm rarely sick (knock on wood). but i went for my yearly checkup last year and the doctor comes in, goes over my paperwork with me verbally and then asks me if i have anything i need to discuss. i didn't even get out a full sentence and she tells me, i don't mean to cut you off but this is an annual and if you're having additional issues we're going to have to bill you for another visit. i was like, um - you asked and never mind. i get that doctors are busy and they have other patients but at the same time - i don't care. i spent twice the time in the waiting room and with the nurse than i did an actual doctor. the nurse that i saw asked me how to spell endometriosis. doctors shouldn't be pushing people out the door and hollering next and they certainly shouldn't be prescribing addictive substances to people in chronic pain if there are other options because 'it's hard'. insurance coverage shouldn't in any way dictate treatment. doctors should dictate treatment. i just read an article on npr (can't get to it right now) talking about how many women die or come close to death directly after giving birth for exactly this reason..their doctor tells them their pain/excessive bleeding is normal, finding the cause or source would be too time consuming and then oops.poor woman is knocking on heaven's door. npr called it denial and delay. i don't get it. if a patient requires 2 hours then a doctor should give 2 hours - thought there was an oath or something involved in all this? not to unload on you but you just listed three reasons why patients should accept and get over why they get sub-par care that doesn't address their root issues.

 

 

5 minutes ago, Nature Boy Flair said:

So what you are saying is most doctors are over loaded and dont have much spare time ?

tough beans. jeez.

[bcking 3,157]

8 minutes ago, smilesammich said:

#3 angers me. the entire purpose of visiting a person educated in medicine is to get to the root problem. in the year 2018 it's hard to coordinate medical needs? i mean, there certainly isn't any issue coordinating billing and payment. and collections.

 

i never go to the doctor, i'm lucky that i don't have to cause i'm rarely sick (knock on wood). but i went for my yearly checkup last year and the doctor comes in, goes over my paperwork with me verbally and then asks me if i have anything i need to discuss. i didn't even get out a full sentence and she tells me, i don't mean to cut you off but this is an annual and if you're having additional issues we're going to have to bill you for another visit. i was like, um - you asked and never mind. i get that doctors are busy and they have other patients but at the same time - i don't care. i spent twice the time in the waiting room and with the nurse than i did an actual doctor. the nurse that i saw asked me how to spell endometriosis. doctors shouldn't be pushing people out the door and hollering next and they certainly shouldn't be prescribing addictive substances to people in chronic pain if there are other options because 'it's hard'. insurance coverage shouldn't in any way dictate treatment. doctors should dictate treatment. i just read an article on npr (can't get to it right now) talking about how many women die or come close to death directly after giving birth for exactly this reason..their doctor tells them their pain/excessive bleeding is normal, finding the cause or source would be too time consuming and then oops.poor woman is knocking on heaven's door. npr called it denial and delay. i don't get it. if a patient requires 2 hours then a doctor should give 2 hours - thought there was an oath or something involved in all this? not to unload on you but you just listed three reasons why patients should accept and get over why they get sub-par care that doesn't address their root issues.

 

 

tough beans. jeez.

A lot of this is why I don't work in outpatient medicine. I completely agree with you, and I generally avoid bringing issues up with "my doctor". The visits are 10 minutes and get really nothing done. I'd rather just take care of myself to the best of my ability. So I totally hear you.

 

I wasn't saying to just accept it and I wasn't justifying the reasons. I was just listing them. Our healthcare in the USA is of very poor value, and it's an area that I study and work in (but within my specific field). A lot needs to be fixed.

 

18 minutes ago, Nature Boy Flair said:

So what you are saying is most doctors are over loaded and dont have much spare time ?

Most outpatient doctors have horrible schedules during the day. I do not envy them. I partly chose my career so I could do more shift work. I'm either on service or I'm not. It's not my whole life.

 

Though even when I am on service I can be very efficient

 

 

[yuna628 9,712]

3 minutes ago, smilesammich said:

#3 angers me. the entire purpose of visiting a person educated in medicine is to get to the root problem. in the year 2018 it's hard to coordinate medical needs? i mean, there certainly isn't any issue coordinating billing and payment. and collections.

 

i never go to the doctor, i'm lucky that i don't have to cause i'm rarely sick (knock on wood). but i went for my yearly checkup last year and the doctor comes in, goes over my paperwork with me verbally and then asks me if i have anything i need to discuss. i didn't even get out a full sentence and she tells me, i don't mean to cut you off but this is an annual and if you're having additional issues we're going to have to bill you for another visit. i was like, um - you asked and never mind. i get that doctors are busy and they have other patients but at the same time - i don't care. i spent twice the time in the waiting room and with the nurse than i did an actual doctor. the nurse that i saw asked me how to spell endometriosis. doctors shouldn't be pushing people out the door and hollering next and they certainly shouldn't be prescribing addictive substances to people in chronic pain if there are other options because 'it's hard'. insurance coverage shouldn't in any way dictate treatment. doctors should dictate treatment. i just read an article on npr (can't get to it right now) talking about how many women die or come close to death directly after giving birth for exactly this reason..their doctor tells them their pain/excessive bleeding is normal, finding the cause or source would be too time consuming and then oops.poor woman is knocking on heaven's door. npr called it denial and delay. i don't get it. if a patient requires 2 hours then a doctor should give 2 hours - thought there was an oath or something involved in all this? not to unload on you but you just listed three reasons why patients should accept and get over why they get sub-par care that doesn't address their root issues.

 

 

tough beans. jeez.

I totally understand your perspective here, and agree. However it all comes down to logistics. My sister has been a part of a busy practice for over 30 years. Many doctors at one time, tons of patients coming in. In the old days you even had procedures done in house (but not anymore). This all takes time. A huge amount of time. Patients are scheduled every day in an estimated block of time. If the doctor elects to spend greater time with a patient (and some do) this ultimately keeps other patients in the room waiting longer. You won't believe how some people will simply just explode and lay into staff. I have seen many good doctors that are willing to spend time with patients and listen carefully, and those that simply do not care one bit. But there has to be some give and take on all sides. There are not enough doctors to accommodate everyone in a day, and I can tell ya the patient may come in for one specific issue but then begin rambling about a whole battery of other unrelated issues, including their life problems, psychological state, personal issues, everything. They then repeat the same process to my sister at the counter or on the phone. The doctors try to oblige calmly, but there have been times security need to be involved if they begin behaving belligerent. The part that bothers me these days about doctors, is the fact we are actually seeing the primary doctor less and less, and are being pushed to see PAs and RNs. Not that there is anything wrong with them, but I have seen some that do not fill me with confidence. The staff these days can also be pretty terrible and not very caring about patient needs.

[bcking 3,157]

It's also not all on the doctors. The reality is convincing insurance to reimburse for an hour-long visit just to "get to the root of the problem" is going to be an uphill battle. Even the most "complex" appointments are still thought of as 20 minute time slots.

 

Now yes a doctor could say "hey I'm here for the patient, I don't care what the insurance reimburses" and that would be noble of him/her. Applying that to one patient, you would probably be fine. Applying that to all of your patients? You may end up seeing only 5 patients in a day that you're expected to see 20-30. Your reimbursements aren't just paying for you, they are paying for essentially the whole practice. 

 

It's a horrible reality, if you ask me. It's why I kept away from that area. I guess you could say I was too selfish and I wanted a good life for myself with relatively lower stress levels. It's a little ironic though because I find the idea of an outpatient clinic more stressful than attending the delivery of a 24 week infant. 

[Póg mo 1,749]

4 hours ago, bcking said:

It's also not all on the doctors. The reality is convincing insurance to reimburse for an hour-long visit just to "get to the root of the problem" is going to be an uphill battle. Even the most "complex" appointments are still thought of as 20 minute time slots.

 

Now yes a doctor could say "hey I'm here for the patient, I don't care what the insurance reimburses" and that would be noble of him/her. Applying that to one patient, you would probably be fine. Applying that to all of your patients? You may end up seeing only 5 patients in a day that you're expected to see 20-30. Your reimbursements aren't just paying for you, they are paying for essentially the whole practice. 

 

 

That's just it. Clinics don't really need all the staff, they tend to have. In other countries you have doctor offices staffed by a doctor and his secretary. They don't have nurses weighing, measuring how tall you are, and taking blood pressure etc every single time you go see have an appointment. The doctor will take your blood pressure, listen to your heart, and hopefully even get to know you a little. 

[Voice of Reason 10,298]

8 hours ago, yuna628 said:

Can you find an official list of reasons what the primary reasons are in Japan? Again, your ideas about suicide are largely going to be based on personal reasons yes, but also the western culture we live in. It is vastly different in other countries. You'd need to study their history to see why suicide can be seen to be honorable. It may be truly strange and horrific to you, but not to others.

 

Pretty sure I never said I though suicide was horrific nor strange.  It’s actually quite easy to understand... someone feels overwhelmed, and thinks that dying is the answer.  I do question why youth today are killing themselves more and more.  It’s not like they have the same life pressures that a parental unit does, not worried about paying the mortgage, putting food on the table, etc.

 

Women who are abused by their spouse may find it an easy to be rid of the problem, without involving the world around them.  But why would a college-aged man or woman choose to kill themselves?  I cannot fathom what could be so traumatic during high school nor college, but aside from that, I get why suicide is a go-to form of escape.

 

Suicide in Japan happens about 1.5~2X the rate in the US, and Korea is even worse, at almost 2.5X.  One reason for that may be the cultural view of honor in committing suicide to save face; but I doubt that extends to the other countries (Belgium, Hungary) where people are offing themselves at high rates.  At one point just a few years ago, suicide was the #1 cause of death in males aged 20-44 in Japan.  That’s pretty darn huge, if you ask me.  (Still better than Korea, to be sure)

 

Reasons for Japanese suicides: http://wasa-bi.com/topics/2199

 

Coutries in rank order of suicide committed:  https://en.m.wikipedia.org/wiki/List_of_countries_by_suicide_rate

[TBoneTX 46,067]

Val and Brian and Yuna are dead-nuts accurate with their observations and objections.  See here:

 

https://www.ncbi.nlm.nih.gov/pubmed?term="Texas+Heart+Institute+journal"[Jour]+AND+Fred[author]&cmd=detailssearch

 

The author of all is a doctor who spent 62 years in medical education and who remembers the importance of patient-centered care.

 

Within the above are many (highly readable) articles relevant to the discussion of what's wrong with Medicine today, touching on several of the issues being discussed in the last part of this thread.

 

Click the box near top right for "PMC full text."  You can then read the online text or click again at upper right to see a PDF.

 

I like #53, #59, #26, #34, #14, and #41.  You might like these and others in addition.  The articles' titles largely suggest their content.

 

Interspersed among the editorials are some pretty neat articles about specific conditions, including topics in adult cardiology.  I might not understand all the medical stuff, but the author makes things as readable as possible.

[Ban Hammer 13,512]

[Póg mo 1,749]

48 minutes ago, Ban Hammer said:

a) nobody is expecting you to this arm. 

b) where do criminals get all there guns?