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Crashrat posted:Latuda has a far narrower set of pharmacokinetics than Geodon. If you read the post I made above the one you quoted you'll see where I explain how specifically with migraine patients Latuda is pretty much the only option because it doesn't interact with 5HT-1B or 5HT-1D at all, which means it doesn't have to compete for affinity with the triptan-class drugs that are used for migraines. I guess if you’re a migraine specialist you’ll run into more people that will have migraines and a psychiatric condition that requires an antipsychotic. I have rarely encountered a situation where it would be my go to drug over a mood stabilizer / AED or another antipsychotic. Loxapine looks like it would work comperably Latuda at not doing the HT1A/D stuff.
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Nov 8, 2017 22:25
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So I saw a while back that Trump was planning on an EO to destroy the individual mandate and basically nobody's talked about it since then. Is that still a thing? Can he not do that? Am I just crazy?
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Nov 8, 2017 22:28
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Spiritus Nox posted:So I saw a while back that Trump was planning on an EO to destroy the individual mandate and basically nobody's talked about it since then. Is that still a thing? Can he not do that? Am I just crazy? The IRS has issued a statement saying it was going to enforce the mandate, contrary to Trump's announcement earlier this year that people could leave the question blank as to whether they were insured and not be questioned further or have the penalty levied. But I think the IRS commisioner's term is nearing its end, which means a Trump nominee who likely will not enforce the mandate. Trump's also trying to get no-mandate language inserted into the tax-reform bill currently before Congress.
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Nov 8, 2017 22:56
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Spiritus Nox posted:So I saw a while back that Trump was planning on an EO to destroy the individual mandate and basically nobody's talked about it since then. Is that still a thing? Can he not do that? Am I just crazy? https://www.cbo.gov/publication/53300 This came out today. Using an EO to repeal the individual mandate, if it worked as intended, would reduce the deficit by $338 billion but increase the number of uninsured by 13 million over the same timeframe.
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Nov 8, 2017 23:01
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Dumb gently caress wants to make the hardship exempation broader is what the EO will be about, which will be wonderful to see cause cascade effects if it even is possible to change. Reminder congress is talking of putting a full mandate repeal in the tax cut bill to pay for the death tax repeal. And implode every insurance market in the country in under a year because of a cascade effect of healthy people leaving the market and only the sick and people that are going for surgery actually buying insurance. Can you say death spiral in the insurance market for all policies from individual to employer?
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Nov 9, 2017 02:57
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Spiritus Nox posted:So I saw a while back that Trump was planning on an EO to destroy the individual mandate and basically nobody's talked about it since then. Is that still a thing? Can he not do that? Am I just crazy? I think we're all just hoping if nobody talks about it he'll forget
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Nov 9, 2017 03:20
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UCS Hellmaker posted:Dumb gently caress wants to make the hardship exempation broader is what the EO will be about, which will be wonderful to see cause cascade effects if it even is possible to change. Voters in Virginia, while handing the GOP their rear end, just said that healthcare was their biggest issue when it wasn't mentioned at all during the campaign. Congress would have to be suicidal to try any funny business with the insurance markets from now on because voters know exactly who would be responsible for wrecking things.
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Nov 9, 2017 05:16
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Nocartax posted:I guess if you’re a migraine specialist you’ll run into more people that will have migraines and a psychiatric condition that requires an antipsychotic. I have rarely encountered a situation where it would be my go to drug over a mood stabilizer / AED or another antipsychotic. Foremost - there is no way in hell anyone should be reaching for a typical antipsychotic as a treatment for a patient that has any hope of being treated with an atypical. I've seen NMS and TD. I'm not going to put someone in their 20s at risk for NMS - or especially TD - unless there's literally no other way to treat them because long-term use of a typical is a serious gamble with developing TD. No way should a younger person be treated with a typical unless everything else has failed - and I mean a long period of testing and failing not "welp that didn't work - here's some haloperidol gl;hf!" Not to say that NMS and TD can't happen with atypicals, but it's far less likely. Beyond that - Loxapine acts on 5HT-1B & 5HT-1D. The whole point of what we're talking about here is the issue of migraines with concomitant psychiatric condition; Latuda is a drug that allows you to successfully treat both. Second - Loxapine is outright discouraged for any patient with a cardiovascular disorder. Which just so happens to be a massive chunk of psych patients - especially bipolar. I actually wrote up a really long thing about first-gen antipsychs and the dangers of them that I've come across, but I get a feeling people are sick of me writing walls of text. Suffice to say I've seen way too much horrible poo poo like a patient showing up at the ER with DRESS because they never realized they had a Hep A infection (because they were homeschooled and never had to get the vaccine - because their parents are loving morons) and the valproic acid someone prescribed them to handle their bipolar just made things bad. Would have almost certainly never happened with an SGA - it's still possible, but not even close to the same risk level. For people that don't care about this granular stuff This idea that just because a drug is expensive means we shouldn't use it is just ridiculous. If there is a safer more tailored drug that a patient can be given to treat their condition that's precisely what that patient should be given. This concept of "well the PT has X so what's the cheapest thing I can do about that" rather than "what's the most safest thing I can do about that" is mindboggling. Crashrat fucked around with this message at 06:28 on Nov 9, 2017 |
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Nov 9, 2017 06:25
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Agree to disagree. I treat a very different patient population where migraines aren’t on the radar. I get that it’s good for what you want to do, but I can’t really incorporate it into my practice. Also, I would be very hesitant to go to Latuda alone over a mood stabilizer. There aren’t head to head comparisons, and it’s way too early to go all in on the Latuda train.
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Nov 9, 2017 10:02
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I'm an inpatient pharmacist (clinical if you want to call it that), and I didn't realize that the basic interaction checkers (LexiComp and the like) ignore the serotonin nuances between antipsychotics. I'll keep that in mind going forward, at the very least. I think I've seen like one patient on lurasidone thus far.
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Nov 9, 2017 16:37
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Nocartax posted:Agree to disagree. I treat a very different patient population where migraines aren’t on the radar. I get that it’s good for what you want to do, but I can’t really incorporate it into my practice. Fair enough. Don't get me wrong. I'm not saying "all new expensive drugs are better drugs" but so far Latuda has really proven to be an actually better drug. The number of interaction problems is significantly less. Though the lactation issue with higher doses seems to pop up more often, which rightly freaks out women, but from what I've seen that's largely an issue of an inexperienced doctor thinking they just need to increase the dosage of lurasidone until the problem is solved. As you know it's more like finding the right cocktail and which thing behave better together or not - and then being willing to accept that everything you thought was right turns out to be wrong for a patient and just working through adapting. reagan posted:I'm an inpatient pharmacist (clinical if you want to call it that), and I didn't realize that the basic interaction checkers (LexiComp and the like) ignore the serotonin nuances between antipsychotics. I'll keep that in mind going forward, at the very least. AFAIK every single typical and atypical antipsych acts on 5HT-1D and 5HT-1B except lurasidone. This is really more of a problem in neurology rather than psychiatry. There's no shortage of bipolar people on an antipsych and a mood stabilizer, they get migraines, and they get sent to a neurologist who has no idea why the triptan-class drugs aren't working. I just see it as a psych problem because ultimately if the migraines are bad enough their condition will need to be managed differently. Honestly I think I can count on one hand the psychiatrists and pharmacists that actually knew about the serotonin interaction issue. I don't know a lot on the pharmacy software spectrum, but I know that whatever software Walgreens, CVS, and WalMart use it doesn't catch that the triptan-class migraine abortive will be competing with the antipsych. Which makes no sense. And the problem is that patients are suffering, doctors are confused, and no one understands why. I'm not claiming I have some magic truth here. It's just a glaring issue in the whole sector. Crashrat fucked around with this message at 06:25 on Nov 10, 2017 |
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Nov 10, 2017 06:20
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The interaction programs that I have access to just trip the generic NMS/SS interactions between antipsychotics and triptans. No mention of the specific receptors, as you stated. My current hospital uses Cerner, and my previous hospital used Meditech. I don't recall in depth analysis of the receptors in either of those on the pharmacist verification side, which is probably because they are both pulling their info from First Databank. As an aside, in my personal experience as a younger patient 15+ years ago, many neurologists aren't the greatest when it comes to pharmacology, either. I'm a migraine sufferer myself, and this is certainly information that I will use in my practice going forward. Thanks. reagan fucked around with this message at 08:12 on Nov 10, 2017 |
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Nov 10, 2017 07:16
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I get some expensive eczema drugs per month so I was curious to see on what the process could be. Who Actually Is Reviewing All Those Preauthorization Requests? Milton Packer thinks you should know how the system works quote:Several months ago, I was invited to give a presentation about heart failure to a group of physicians who meet every month for a lunch meeting. Don't worry. No company sponsored the talk, and I did not receive any payment. I accepted the invitation, because it seemed like to good thing to do. However, the audience was a bit unusual for me. Among the 25 physicians in the room, nearly all were in their 70s and 80s. All were retired, and none were actively involved in patient care. I guess that explains why they had time in the middle of the day for an hour-long presentation. I gave my talk, but there were no questions.I had a few moments afterwards to speak to my audience.
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Nov 10, 2017 10:57
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CheeseSpawn posted:I get some expensive eczema drugs per month so I was curious to see on what the process could be. Burn it down Burn it all down
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Nov 10, 2017 15:33
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CheeseSpawn posted:I get some expensive eczema drugs per month so I was curious to see on what the process could be. quote:The physicians agreed. "Yes, you were very convincing. But the drugs are too expensive. So we typically reject requests, at least the first time. We figure that, if doctors are really serious, then they should be willing to make the request again and again."I was astonished. "If the drugs will help people, how can you say no?" Then I got the answer I did not expect. "You see, if it weren't for us, the system would go broke. Every time we say yes, healthcare becomes more expensive, and that isn't a good thing. So when we say no, we are keeping the system in balance. Our job is to save our system of healthcare." I responded quickly. "But you are not saving our healthcare system. You are simply making money for the company that you work for. And patients aren't getting the drugs that they need." Reik, this is literally the argument you keep trying to make, do you see why it comes across as sociopathic? "But without insurance existing, how would people have healthcare?" wonders man who works for insurance company, unable to cut the Gordian Knot.
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Nov 10, 2017 16:14
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WampaLord posted:Reik, this is literally the argument you keep trying to make, do you see why it comes across as sociopathic? What do you think is a bigger problem, pre-authorization and step therapy in formularies or pharmaceutical reps courting physicians to affect their prescribing patterns? As long as healthcare is for profit things like this will be a necessary part of the system. The answer is not to remove this from the current system but to change the system from the bottom up. Reik fucked around with this message at 17:31 on Nov 10, 2017 |
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Nov 10, 2017 17:28
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Reik posted:What do you think is a bigger problem, pre-authorization and step therapy in formularies or pharmaceutical reps courting physicians to affect their prescribing patterns? All of it, it's all a big problem. And that's not going to happen while people like you sit there and claim that everything's peachy keen and insurance companies are just doing their best.
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Nov 10, 2017 17:33
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WampaLord posted:All of it, it's all a big problem. I wouldn't call saying that we need to go to a universal health care system because for-profit healthcare fails at a fundamental level is claiming everything's "peachy keen" but that's your business. Think of the US healthcare system as a car broken down on the side of the road. You get in, push the gas pedal and the car doesn't go so you blame the gas pedal because as a car consumer that's the part of the car you interact with. "Usually when I push the pedal the car moves forward and it's not moving forward so obviously the gas pedal is broken." A mechanic that works for the gas pedal manufacturer shows up and says the transmission is ruined and no matter how much you press on the gas pedal you won't get any power to the driveshaft and the car won't move. You tar and feather the mechanic and call him a shill for the gas pedal manufacturers. Reik fucked around with this message at 18:00 on Nov 10, 2017 |
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Nov 10, 2017 17:36
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Reik posted:I wouldn't call saying that we need to go to a universal health care system because for-profit healthcare fails at a fundamental level is claiming everything's "peachy keen" but that's your business. This. It's hard to fault insurance companies for doing what the system tells them to do. We need either universal health care, or to fundamentally change the incentives for insurance companies such that they make more money by ensuring good treatment decisions and outcomes for patients. I'm in favor of a government-run healthcare solution because trying to weasel out all the loopholes from private corporations would be nearly impossible.
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Nov 10, 2017 18:41
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Dirk the Average posted:This. It's hard to fault insurance companies for doing what the system tells them to do. We need either universal health care, or to fundamentally change the incentives for insurance companies such that they make more money by ensuring good treatment decisions and outcomes for patients. We also need better data. There has been a rash of microscandals in the last few years because it turns out that new therapies were worse than existing ones but cost a gently caress load more. Does anyone know if the EBM initiative as part of the ACA ever got off the ground? I assume it was smothered in the cradle.
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Nov 10, 2017 18:48
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Xae posted:We also need better data. If that's the same thing as PCORI that made it through. https://en.wikipedia.org/wiki/Patient-Centered_Outcomes_Research_Institute quote:It is a government-sponsored organization charged with investigating the relative effectiveness of various medical treatments. Medicare may consider the Institute's research in the determining what sorts of therapies it will cover.
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Nov 10, 2017 18:49
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Xae posted:We also need better data. Going back to my migraine schtick here... Treximet is a "microscandal" of sorts because it's a super-expensive brand name drug that does nothing but combine Aleve and Imitrex. Aleve (naproxen sodium) is stupid cheap. Imitrex (sumatriptan) isn't stupid cheap, but it's still pretty cheap as a generic. So you get the immediate response from pretty much every insurer that they're not going to cover the drug. The average person looks at what I just wrote and says "yeah that makes sense - just take the two separate ones." Except that's not the full story. Treximet has GSK's "RT Technology" which makes the tablet dissolve up to 350% faster. Anyone that's dealt with abortive migraine drugs knows that speed is the whole point. This is why the nasal sprays became so popular because they get the drug into your brain pretty damned fast. The problem, though, is that most of the time you want to combine an NSAID with whatever triptan you're giving. Naproxen sodium is the usual go-to. You want both drugs to be hitting the PT as quick as possible. So that's the void Treximet hits - you get rapid uptake of both the triptan and the NSAID, and for some patients that's the only abortive that will work. And it's pretty damned obvious when a migraine patient has a serious migraine. You can test for it if you wanted to though there's no reason to do it unless you're just a dick. It's not like these drugs have any street value even though in the case of sumatriptan you're taking a synthetic analog of psilocybin mushrooms (albeit a very sub-psychotropic dose). So if you have a PT that only responds to an NSAID and a triptan (that's common) and they're non-responsive to those being taken separately the next step up - and honestly the last step - is Treximet because it solves the speed issue. Treximet pretty much treats ever PT the neurologists I've seen talk about that were otherwise treatment resistant. But, again, no insurer will cover it. Why? 9 tablets is $1100 at cash price. A typical dose for a migraine abortion is assumed to be 2 pills (one taken, and another 2 hours later if necessary). Assuming a PTs migraines are otherwise controlled that script should last a month. But since insurers won't cover it GSKs response has been to let patients buy it directly from them. Those same 9 pills cost as little as $20 for PTs with commercial insurance but low income. No that's not a typo. GSK sells it at $1100 unless you can prove your insurer won't cover it, and then you can buy it at for as low as $20 (plus shipping). They don't even require the doctor or PT to send in a bunch of proof like some (coughcough Takeda wants the PTs full tax return cough) TL;DR This is all kinds of hosed. Foremost GSK should have some kind of reward for their "RT Technology" because it honestly seems to have made a major difference for patients that were otherwise untreatable. Making a drug that didn't work start working is nothing to scoff at. I have no idea how that process works for GSK. It's patented. Insurers could at least go to bat for their clients here and realize that Treximet isn't just two off patent drugs stuck together and called a new patent drug. I doubt GSK would let everyone buy it at $20, but I'm sure something reasonable could be agreed on. Instead this whole thing is up in limbo. Insurers just tell the PTs to take the two drugs separately. GSK doesn't advertise that they have the patient assistance program - the drug rep can't tell the doctor either...the doctor has to ask the drug rep to make it happen. In what world is any of this loving sane?
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Nov 11, 2017 07:19
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Crashrat posted:Going back to my migraine schtick here... Do you have any information about the pricing /availability in countries with universal health care?
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Nov 11, 2017 07:55
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Dirk the Average posted:Do you have any information about the pricing /availability in countries with universal health care? No idea whatsoever. AFAIK the entire world of "what we actually pay for this" is a complete and total black box worldwide. If I'm wrong there I would love for someone to point it out and show me where I can look at the information. I'm sure my friends and family will love me even more when I start ranting and looking up how much cheaper their medication would be if they lived in the UK or Norway.
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Nov 11, 2017 08:23
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Crashrat posted:No idea whatsoever. AFAIK the entire world of "what we actually pay for this" is a complete and total black box worldwide. Sadly, that's by design. I suspect that also has to do with why the $20 patient thing isn't advertised, if it were, it might reduce the amount they can charge in countries where the drug is prescribed and covered.
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Nov 11, 2017 08:46
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Crashrat posted:Foremost GSK should have some kind of reward for their "RT Technology" Do you work in pharmaceuticals or something?
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Nov 11, 2017 15:51
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Sounds like they just developed some kind of dissolvable matrix that allows more of the drug to be dissolved concomitantly rather than as one big chunk that is dissolved from the inside out. Good idea? Sure, but not worth the price they are charging IMHO. Pharmacists as a whole roll their eyes at these sorts of combination products. It's a racket.
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Nov 11, 2017 18:03
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Nov 11, 2017 18:04
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PerniciousKnid posted:Do you work in pharmaceuticals or something? Nope. I don't get a dime from anyone. I just have seen a lot of treatment resistant patients and chatted about them with neurologists since I tend to bring up migraines a lot re: psychiatric medication. reagan posted:Sounds like they just developed some kind of dissolvable matrix that allows more of the drug to be dissolved concomitantly rather than as one big chunk that is dissolved from the inside out. Good idea? Sure, but not worth the price they are charging IMHO. Pharmacists as a whole roll their eyes at these sorts of combination products. It's a racket. I'm not claiming that they should be making over $100 per pill for that faster dissolving time. It's likely a process they've applied to a lot of their tablets, and thus they can recoup the cost across the whole spectrum. But that being said it's not something to scoff at. I work with a neurologist that actually had both a walk-in clinic for infusions for migraines AND standing ER orders the patients carried with them for their specific IV infusion to abort their migraines. Not my wheelhouse but it's generally a lot of magnesium and then a cocktail of medications that has been worked out for those patients that works - I've just chatted about it because sodium valproate is on that IV med menu for migraine patients and that's definitely not an option for psych patients that have a separate steady regimen unless there's no other choice. These are PTs that have debilitating migraines - basically a step below cluster headaches - and their lives are hell. Some of those patients are tension migraine so they're already on Botox for migraines, which does work apparently, but they still need abortives...and nothing worked. TL;DR (sort of) My point here is that for a decently sized population of migraine patients the abortive medications just don't work. The only remaining option was either (a) Being lucky enough to have a neurologist with a walk-in migraine infusion clinic AND your migraine happens while they're open (b) Taking your infusion orders and going to the ER to have it administered under observation of people who tend to treat migraine patients pretty poorly. Those are the patients that tend to end up on Treximet. For whatever reason that fast dissolving time makes the drug work for them. They're DEFINITELY prescribed the two drugs separately first to see if it will work. No one's purposefully trying to pick the most expensive option. So contrast the above. Option 1: A stupidly overpriced pill - plenty of argument that it shouldn't cost that much and I agree with them - but it works. Option 2: Tell those patients they can't have the pill and instead treat them as outpatient or ER patients, which no matter how you slice is FAR more expensive. With the above in mind which route do you think the system should go?
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Nov 11, 2017 21:14
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Improved Inhaled medication formulations are a real bitch to get covered by insurance. For example, Spiriva is a pretty typical LAMA that has been around forever which is one of the must have meds in anyone with COPD Stage II-IV. If/When a patient's pulmonary function deteriorates to the point where their FEV1 is in the 10-30% range, the Spiriva Handihaler (basically you crush a capsule in a device and suck on the device real hard to get the dose) becomes less effective because the patient often doesn't have the capacity to inhale deep and fast enough to get the full dose. There is a Spiriva Respimat device on the market which generates a mist that is much much easier to inhale but costs more. Too bad it often requires a prior auth and documented "failure" from "side effects" before insurance will pay out and trial of other dry powder inhalers similar to the Spiriva Handihaler in formulation such as Tudorza. And a patient's inability to use or receive the full medication dose from the Handihaler device is NOT an "approved" reason that can get a Prior Auth apporved. The next option is to just switch the patient over to an inhaled nebulizer LAMA, nebulized LABA/LAMA, nebulized LABA/LAMA and ICS, etc. Insurance will also try to deny Prior Auths for that as well as again the "other dry powder meds" must be tried first. gently caress you assholes. Patient's with severe COPD either off of their meds from insurance fuckery or not getting the full dose of their meds again from insurance fuckery can exacerbate, end up in the hospital really fast, and not leave alive. It's complete bullshit that insurance companies are now dictating patient care and continue to deny coverage for specific med formulations even though there are often completely valid medical reasons for the more expensive formulation of a particular drug. Hell, I should receive a kickback from the insurance company as I'm saving them money by helping to keep the patient from a $15000/day ICU hospitalization. I guess a more visible analogy of the absurdity of all of this would be a hypothetical situation where a double lower extremity amputee is denied coverage for artificial limbs: Insurance: "No sorry. We won't cover prosthetic fitting or the prosthetic devices themselves even though the patient has no legs. The patient must first try and fail to run a 5k, half-marathon, and full marathon, demonstrate an average of 7 falls during each event, and must run at least 25% of each event and fail or else it won't count as a failure. Also, all of these results must be submitted to us within the next 72 hours or we will automatically deny the prior auth request." You know what the recourse healthcare providers have for all of this? Nothing. There's no regulatory agency we can complain to. There's nothing we can do to make sure that the insurance company is honoring their contract with the patient. We can encourage the patient to sue their insurance company but good luck with that in the day and age of arbitration clauses, dissolution of class action suits, and the little man going against an army of corporate lawyers. We could "maybe suggest hint hint wink wink nudge nudge but not really because it's kind of illegal" that the patient obtain their needed meds from a pharmacy Canada or Mexico. We can also clean out the drug sample closet and stock up the patient as much as we can on free samples given to us by drug reps. And that's about it. There's also ways you can answer the prior authorization questionnaires to get the meds covered almost every time and maintain plausible deniability, integrity, and some degree of honesty but I will say no more. For a physician to fully abide by the Hippocratic Oath in this day and age, he or she basically has to commit borderline fraud and violate multiple drug laws. Personally, I don't believe in following rules made up by Nazis that result in people getting hurt at the very least or even dying years to decades before their time.
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Nov 11, 2017 23:08
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Crashrat posted:I work with a neurologist that actually had both a walk-in clinic for infusions for migraines AND standing ER orders the patients carried with them for their specific IV infusion to abort their migraines. Not my wheelhouse but it's generally a lot of magnesium and then a cocktail of medications that has been worked out for those patients that works - I've just chatted about it because sodium valproate is on that IV med menu for migraine patients and that's definitely not an option for psych patients that have a separate steady regimen unless there's no other choice. Yeah, my previous hospital had quite a few patients who would arrive at the infusion clinic - oncology/rheumatology patients for the most part - like clockwork once or twice per month for their migraine cocktail. High dose magnesium, ketorolac, hydromorphone, and ondansetron were the most common. I don't think I saw anyone with valproic acid, but I'm sure they use it on some patients. Clearly oral is the way to go if at all possible, and yeah, a triptan/NSAID combination with a novel dosage form falls into that category, even if it is ridiculously expensive for what it contains. I don't even want to know how much a visit like that to the infusion clinic would cost, especially when I'm sure the hospital is billing the labor costs using the same formula they use for patients with cancer or other illnesses that require regular infusions. Inpatient/outpatient distinction matters as well. poo poo is so broken that I think that it all needs to be torn down and rebuilt from scratch, rather than trying to fix it piecemeal. Avalanche posted:Improved Inhaled medication formulations are a real bitch to get covered by insurance. I'm convinced that a large number of handi-haler patients end up ingesting the capsules rather than actually use the inhaler. The tiotropium capsules look just like every other capsule out there. The respimat design is nice, and I do like that companies seem to be adopting it for a large number of inhalers. Consistency across the board would go along way to easing use and improving compliance. I thought maybe it would take over the market, but then the ellipta inhalers started to show up. I don't have enough experience with those to judge them quite yet. You still do samples? In my area of the country most of the big health systems have scrapped them almost entirely. Patient assistance programs have taken up a lot of the slack, but often those are only good for a set amount of fills/months before the patient or their insurance must pay the cost. Which begs the question, as was previously mentioned, if the company can essentially give this stuff away for free, how the hell do they get off charging an arm and a leg for most patients? Oh, and the last time I helped with a prior-auth, the person at the insurance company told me that the ICD-10 diagnostic code that I was giving her was not available for her to choose from her dropdown box. I know 100% that it was the correct code, so I was just dumbfounded at how they managed to find another way to make the process even more difficult.
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Nov 12, 2017 00:56
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reagan posted:Yeah, my previous hospital had quite a few patients who would arrive at the infusion clinic - oncology/rheumatology patients for the most part - like clockwork once or twice per month for their migraine cocktail. High dose magnesium, ketorolac, hydromorphone, and ondansetron were the most common. I don't think I saw anyone with valproic acid, but I'm sure they use it on some patients. The one critique of the respimat device is that it is sort of a pain in the rear end to initially setup and have the patient use correctly without getting confused. You first have to take the clear plastic outer housing off, load the cartridge containing the med into the bottom of the device, and then replace the clear plastic housing. To remove the housing, you have to hold down on a plastic button and slide it off. To get the cartridge to fit properly, you literally have to jam the device into the cartridge on a hard counter top. Rheumatoid patients are screwed. Once that's ready you then have to prime it by first doing a twist with the green cover cap closed, open the cap, press the button, and have some mist come out. Then close cap, twist, open cap, up to mouth, breathe in while pressing the button, close cap, rinse repeat for second dose. If you twist with the green cap open, the device will shoot out a dose which is completely wasted. There's just a ton of convoluted steps of "Do this, then this, but don't do this and never do that, but do this!" Every patient gets an extensive training session with this med and they do not leave the office until they can demonstrate in front of us how to do all of the above steps themselves. Even then, we recommend having the pharmacist go over it with them again when they get their script filled and even having the pharmacist pre-load the cartridge for them so patients with RA don't have to stress over that part. If the patient is too cognitively impaired and is in a hosed up home situation where there typically isn't anyone around to help with administering meds, then they get the nebulizers instead. And there have been patients where when they first started the respimat, they had no problem and did just fine but some adverse advent like a random fall leading to a broken hip, leading to an extensive hospitalization, leading to a gnarly hospital acquired infection, extensive ICU stay, inpatient rehab, outpatient rehab, back to us eventually. The patient and person you knew before is still there, but they are cognitively off, are exacerbating, and have some coordination issues indicating a good probability that they are no longer using the device correctly. You have them demonstrate in front of you and they screw up multiple steps. gently caress. Referral for a home health RN is an option, but the home health outfits around here are absolutely terrible and never do half of the poo poo they should be doing (probably due to some poor overloaded RN driving across town to see different patients 15 times a day because hiring more RNs just can't happen cause "we gotta think of the bottom line and our shareholders!"). Nebulizers are an option as most patients have had a nebulizer for years for emergencies, have the motor memory of how to use the thing ingrained just like how they can still field strip and put back together an M16 as they could back in Vietnam. We still do samples via calling drug reps directly, ask if they want to do a presentation for us during lunch time about whatever drug we're running low on, and then basically strong arm them into giving us samples because "Oh, well we REALLY want to PUSH your new PRODUCT as it would significantly benefit our patients and we tell them ALL about it, but it's just so popular and we just don't have anymore samples is there something you could do to get us more please?" Yea, it's manipulation and it's really hosed up. I don't give a poo poo because 2/3rds of the reps are scumbag drones just following orders, present very flawed research by their company with huge holes in design, and get really defensive if you challenge them on it. The other third sometimes are decent human beings, know the game we're playing, think it's kinda funny, will have constructive conversations about their companies study limitations, and will pull strings to get us what we need. Those ones typically have seen the light and are already on the path to looking for a different job though. As far as private insurance goes, if you try to bill a Spirometry under ICD 10 J44.9 (COPD unspecified), they will typically not pay for it. The ICD 10 code MUST BE something like R06.00 for dyspnea or R06.02 for shortness of breath. So what about a COPD patient just coming in for a routine check-up and med refills? We need to see their god drat current spirometry OBJECTIVE DATA to see if their lung disease is currently controlled or not. The patient telling us "Oh everything's fine" is a huge pitfall as many people with mild-moderate COPD have a really hard time noticing when they are in an active flare vs. at their baseline. So again insurance dictates care and is essentially stating: "If you want to get paid for a Spirometry, the patient has to be short of breath. If they are not, then you shouldn't do it and won't get paid because we are a bunch of loving morons that don't understand what objective data is and the importance of tracking data and interpreting trends" A few weeks ago we had a patient come in with 3+ pitting edema lower extremities with a known coagulation disorder and prior history of DVT come in. gently caress. Ok, we're calling your cardiologist NOW, and we're also going to order labs and a LE ultrasound done to check for clots to save the cardiologist and the patient some time. Insurance denied the patient's claim for the bilateral LE ultrasound to check for clots because apparently "coagulation disorder" and Z codes like "personal history of other venous thrombus or embolism" are not "valid codes" for this type of study. The patient almost refused to get the study done because of the out of pocket cost until one of us gave him the old "Come to Jesus" talk about how this poo poo is life threatening and you could very likely DIE if this is indeed present and not managed ASAP, and we will call your insurance company and chew them a new one. The patient got the ultrasound done and lo and behold there was a loving clot. gently caress you assholes. Wanna know what puts a person at a significantly elevated risk for blood clots especially with positive clinical signs and patient symptoms? A history of having a prior blood clot. That should be a no-brainer. Again, there are 'ways' around this but all of us like being really accurate and honest and charting things exactly as we see them and giving very logical and concrete rationales for everything we do and order. This never matters because insurance drones just check for "Uhhhh, is the special cheat code there? No it isn't. Ok claim denied". If you escalate it higher up, you end up having to do a "peer to peer" video teleconference bullshit phone call with some retired 70-80 year old MD who still thinks 1970s practice guidelines are still valid. Trying to explain your logic to him about why something should be covered in this special circumstance is like trying to explain to your 80 year old father/grandfather that yes, there's lots of LGBT people in the world, the vast majority of them are good people, and there's nothing wrong with them. You're treated like some dumbshit hotshot kid who still needs to learn a thing or two "about how medicine really works" and needs to be put in his place CLAIM DENIED. So "how medicine really works" means selling your patients out, violating the Hippocratic Oath, and being a narcissistic Ayn Rand rear end in a top hat? "Well it sucks that our patient died because he had a massive stroke resulting from an underlying clot that was never worked up due to insurance denial, but he really should of done the test we ordered, and him not getting the test done because of money was HIS problem and NOT MY PROBLEM NOT MY PROBLEM EVERY MAN'S AN ISLAND I DID MY JOB I AM STILL A GOOD MEDICINE PERSON LALALALALALALALALALAALLA."
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Nov 12, 2017 03:18
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reagan posted:You still do samples? In my area of the country most of the big health systems have scrapped them almost entirely. Patient assistance programs have taken up a lot of the slack, but often those are only good for a set amount of fills/months before the patient or their insurance must pay the cost. Which begs the question, as was previously mentioned, if the company can essentially give this stuff away for free, how the hell do they get off charging an arm and a leg for most patients? Avalanche posted:Nebulizers are an option as most patients have had a nebulizer for years for emergencies, have the motor memory of how to use the thing ingrained just like how they can still field strip and put back together an M16 as they could back in Vietnam. The neurologists I know that handle Treximet do *precisely* this. They'll get the drug rep in and they cajole them into handing over a shitload of samples. They've gotten to the point of literally just asking the rep to say the box fell out of the back of their car because they forgot to close their hatch before driving off. Because loving GSK gives out Treximet samples in a bigass bottle that has ONE pill. A standard abortive treatment requires the patient to have at least two of them. The neurologists office just has brown paper sacks sitting in their supply closet with 6 bottles in it to give out for patients that are trying to get the patient assistance program part working. Apparently it can take 3-5 months before they'll be able to order the meds from GSK over the phone. In the meantime? Just loving suffer...or have a neurologist who's willing to push to get a drug rep that understands the game and is willing to "lose" supplies. The only way I think it makes any sense is that GSK knows precisely what's happening and turns a blind eye to it. There's no other way I can reconcile it. Avalanche posted:You know what the recourse healthcare providers have for all of this? Nothing. There's no regulatory agency we can complain to. There's nothing we can do to make sure that the insurance company is honoring their contract with the patient. We can encourage the patient to sue their insurance company but good luck with that in the day and age of arbitration clauses, dissolution of class action suits, and the little man going against an army of corporate lawyers. We could "maybe suggest hint hint wink wink nudge nudge but not really because it's kind of illegal" that the patient obtain their needed meds from a pharmacy Canada or Mexico. We can also clean out the drug sample closet and stock up the patient as much as we can on free samples given to us by drug reps. And that's about it. This has come up for me with Provigil (modafinil) and Nuvigil (armodafinil). It's no secret that psychiatric medications tend to make patients feel tired. Typically excessive daytime sleepiness would be fielded off to pulmonology / sleep doctors, but unsurprising a loving LOT of pulmonologists / sleep doctors are literally only doing the job so they can also run their own DME company to sell CPAP machines. They want bread and butter. They want an overweight / obese PT to come in, do a study, get atleast 16 events per hour, and then sell them supplies for life. They get to bill a few thousand for the study - which was run by a minimum wage worker and the interpretation might as well have been copy/pasted - and then sell thousands and thousands of dollars in supplies. Insurance tells you to put the PT on a stimulant - methylphenidate is their preferred - because it's cheap. Oh sure let me just put a person with bi-polar and general anxiety disorder on a loving amphetamine. THAT'LL GO WELL. So instead you try to get them on Provigil or Nuvigil. That means a prior auth almost 100% of the time. It will be denied unless the PT has shift-work sleep disorder / sleep apnea (requires sleep study) / or daytime sleepiness (requires even more expensive sleep study). Otherwise they'll tell you to get lost. Because even though modafinil and armodafinil are generic now they don't give a gently caress. So you beg the PT to get a sleep study. Well they can't afford it, unsurprisingly, and even if they could afford it they can't get it scheduled in because [insert myriad excuses here]. Nevermind they probably have sleep apnea and need a CPAP irrespective of the psychiatric meds making them more tired. So what's that leave them with? The winkwinknudgenudge of "I just can't believe how many people end up buying these medicaitons, for not much money, online. I mean they sell them in the exact same packaging from the pharmacy. It's totally not a legal thing to do so it just amazes me how cheap these are online. On the internet...just google it...but don't because that's not legal. But if you're curious about how common this is you can definitely learn about it by googling it." The system is totally hosed. Avalanche posted:Nebulizers are an option as most patients have had a nebulizer for years for emergencies, have the motor memory of how to use the thing ingrained just like how they can still field strip and put back together an M16 as they could back in Vietnam. Completely unrelated, but I'm stealing this analogy and there's nothing you can do to stop me. Crashrat fucked around with this message at 11:00 on Nov 12, 2017 |
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Nov 12, 2017 08:39
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Crashrat posted:
Sleep studies are good to get with general daytime fatigue and sleepiness even if it's probably medication induced because there's a chance of undiagnosed OSA also contributing significantly to even the psych symptoms. If your sleep quality is absolute poo poo due 40-50 apneas an hour then that will contribute significantly to exacerbating any underlying psych issues. SSRIs also tend to suppress REM sleep and it probably doesn't hurt to know to what degree in each individual patient to better help manage dosing. Just order them from academic institutions like Stanford where you don't have to deal with poo poo like non board certified sleep physicians running garbage sleep labs. Also, a lot of the DMEs out there are really really shady and will do things like bill a patient monthly for the cost of their CPAP machine but then charge a re-occurring "maintenance fee" of $100-$200 a month even after the machine has been fully paid off. That, and marking up the cost of PAP supplies to absolutely insane levels (100% markup) even after insurance has fully paid out what they actually billed and then stiffing the patient with the remainder phony charge. We recently got a local DME shut down for doing poo poo like the above and the owners are looking at some serious jailtime for Medicare fraud. It feels good to know that sometimes the system kinda sorta works if you bark up the right tree enough times but then again why the gently caress do providers even have to get involved in this kind of poo poo in the first place? No one went to med school or pharmacy school or nursing school or whatever to play Paralegal all day. Also, correct me if I'm wrong but you can sometimes get prior authorizations approved with Provigil and Nuvigil without a sleep study if you use something like G47.14 "Hypersomnia due to medical condition" or G47.26 "Circadium rhythm sleep disorder shift work type". If they fire back with "Patient must try methylphenidate first unless contraindicated for reason: x" then just be very very blunt about the significant cardiovascular side effects, psych side effects, significant interactions with psych meds, and how they may be legally on the hook if something goes wrong since they are now essentially dictating patient care and playing doctor. Yea, that's not true, but the call center "executive customer prior auth claims associate specialist" with a GED typically doesn't know that.
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Nov 12, 2017 11:41
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Avalanche posted:Sleep studies are good to get with general daytime fatigue and sleepiness even if it's probably medication induced because there's a chance of undiagnosed OSA also contributing significantly to even the psych symptoms. If your sleep quality is absolute poo poo due 40-50 apneas an hour then that will contribute significantly to exacerbating any underlying psych issues. SSRIs also tend to suppress REM sleep and it probably doesn't hurt to know to what degree in each individual patient to better help manage dosing. Just order them from academic institutions like Stanford where you don't have to deal with poo poo like non board certified sleep physicians running garbage sleep labs. Also, a lot of the DMEs out there are really really shady and will do things like bill a patient monthly for the cost of their CPAP machine but then charge a re-occurring "maintenance fee" of $100-$200 a month even after the machine has been fully paid off. That, and marking up the cost of PAP supplies to absolutely insane levels (100% markup) even after insurance has fully paid out what they actually billed and then stiffing the patient with the remainder phony charge. Oh I'm an absolute believer in sleep studies. When my wife had one scheduled I went ahead and asked to get one at the same time, just to be safe. I barely met the indicators for it and was told it may or may not be necessary (I'd rather be safe), and I loving love my CPAP. Best sleep of my whole life. The point I'm homing in on is that while sleep studies are absolutely the gold standard, and patients should get them, there's plenty of patients who just won't do it. Primarily because of cost. If all they have is some low-level bronze coverage because they didn't want to fork over $200 a month for insurance then their deductible is in the thousands. That deductible will stop them from doing pretty much any procedure unless you can convince them that it's life or death (like you did for the DVT PT). That deductible is doing precisely what the insurer hoped it would do - stop people from utilizing their insurance. And you can definitely use a shift work sleep disorder diagnosis to skip the sleep study (I mentioned that), but I'm afraid if every doctor starts doing that all the time that it's going to cause a problem as insurers remove it from the approved list. So now the people who legitimately are in a shift-work situation are hosed because they're not going to have sleep apnea or have excessive daytime sleepiness (or atleast not enough to fail a MLST). There's no good solution here short of the whole approach changing.
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Nov 12, 2017 19:49
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Avalanche posted:There's also ways you can answer the prior authorization questionnaires to get the meds covered almost every time and maintain plausible deniability, integrity, and some degree of honesty but I will say no more. Sit next to the coding department when they take their lunch break for some fun conversations. But actually the reason why payers don't trust providers is that there are actually a lot of malicious actors provider-side and this fucks with providers who are actually trying to care for patients. Since we're payer/provider we actually get to fire them if they're in our network, but re: CPAP machines, about three years ago we had a few GPs in the big regional physicians group who ~mysteriously~ had >70% of their pts on CPAP machines because they had a nice little racket going on with a sleep study clinic and a small DME provider in the area. poo poo like that just increases healthcare costs for everyone. e: Also, enforcement of criminal laws in the health care system needs to be stepped up. There's a provider in my region who has a deservedly lovely reputation (it's a teaching hospital that is unaffiliated with either of the two major provider chains in the region) with ridiculously poor patient outcomes and it took one of their clinicians loving selling organs on the black market for the state to even look into what was going on there. The Phlegmatist fucked around with this message at 20:45 on Nov 12, 2017 |
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Nov 12, 2017 19:58
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What happens if the Republican tax bill removes the individual mandate, but also requires that insurers cover pre-existing conditions?
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Nov 14, 2017 20:56
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Twerk from Home posted:What happens if the Republican tax bill removes the individual mandate, but also requires that insurers cover pre-existing conditions? The individual market collapses.
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Nov 14, 2017 20:58
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As if the dilemma over drug prices and pre-existing conditions wasn't bad enough, under brand new guidelines from the American Heart Association nearly half of the U.S. population now has high blood pressure. The cutoff for stage 1 hypertension has been lowered to 130/80 and the previous stage 1 threshold of 140/90 is now stage 2.
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Nov 15, 2017 18:48
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I'm sorry but starting blood pressure meds at a loving 81 diastolic pressure is stupid as hell
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Nov 15, 2017 19:31
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