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Rhesus Pieces posted: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. Definitely not just a way to sell more blood pressure lowering drugs, no sir.
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Nov 15, 2017 19:38
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Reik posted:Definitely not just a way to sell more blood pressure lowering drugs, no sir. The NHS has considered prescribing statins to everyone over 50.
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Nov 16, 2017 01:20
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Statins are a little bit different because, aside from the fairly common side effect of muscle weakness, they don't appear to cause harm to people who don't need them. Anti-hypertensives, though... the big-rear end Canadian polypill study posted:There were significant trends toward a lower risk of events at higher baseline systolic blood pressure for the two coprimary outcomes and for the first secondary outcome, with risks that were nominally significantly lower by 24 to 28% in the subgroup for the upper third of systolic blood pressure (>143.5 mm Hg; mean, 154.1±8.9 mm Hg). By contrast, no benefit was observed in participants who had a baseline systolic blood pressure of 143.5 mm Hg or less and a suggestion of harm for those in the lower-third subgroup (131.5 mm Hg; mean, 122.2±7.5 mm Hg). And this excludes participants who dropped out because of hypotension. But open up the candesartan floodgates anyway, I guess.
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Nov 16, 2017 01:41
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The Phlegmatist posted:Statins are a little bit different because, aside from the fairly common side effect of muscle weakness, they don't appear to cause harm to people who don't need them. Did that study include beta blockers? Or was it just Angiotensin II receptor blockers? I know beta blockers are no longer the fashionable method of controlling hypertension, but they still have some effect on BP, and further are commonly prescribed for essential tremor and anxiety. Hell I know people that started taking 20mg propranolol bid starting in med school and just never stopped as a means to keep their hands steadier during procedures and to help with the anxiety of it.
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Nov 16, 2017 06:35
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One big issue is doctor time. Even if treating these individuals is beneficial, we already have a shortage of primary care physicians, and it's a zero sum problem. Every hour a physician meets with patients who have mild hypertension is an hour they don't have to meet with patients who may have more urgent issues.
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Nov 16, 2017 06:39
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Crashrat posted:Did that study include beta blockers? Or was it just Angiotensin II receptor blockers? The latter. The group was on candesartan + HCTZ. I very rarely see people on beta blockers anymore except as an anxiolytic. There's been a bunch of polypill studies done because pharma companies really really want to prove the need to market something that's basically a statin and an ARB and a blood thinner all in one.
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Nov 16, 2017 08:32
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Konstantin posted:One big issue is doctor time. Even if treating these individuals is beneficial, we already have a shortage of primary care physicians, and it's a zero sum problem. Every hour a physician meets with patients who have mild hypertension is an hour they don't have to meet with patients who may have more urgent issues. Hence the steady rise in nurse practitioners and physician's assistants. Hell if someone is *wanting* to practice primary care I'd almost encourage them to just go to PA school anyways. Most private practices I've seen are more than happy to hire a PA that earnestly wants to do primary care work because they have no shortage of patients that call in and know they don't need to see the MD/DO - they've got an ear infection, a tickle in their throat, a swolen ankle after they stepped off a curb wrong, etc - and just need to get the situation assessed on a basic level. That lets the old war horse MD that's seen loving everything a primary care doc can see - and probably somethings a primary care doc wishes they could unsee - focus on the patients that need that extra attention. Last time I saw my PC was actually in the hall (came in for some minor thing and saw the PA because I wanted an appointment that day, not next week) and he mentioned how much time he's spent trying to talk patients out of getting spine surgery for their mild back pain...but it's loving hard to compete against nonstop TV advertising. Of course that whole "low back pain" blackhole's likely solution is in the physical therapy department that is a complete pain in the rear end to get insurance to cover long term. Even generous insurance plans don't want to cover it for long, and especially do not want to cover it for something they deem chronic. Which is how you end up with patients taking absurd levels of opioids, which aren't all that useful (arguably useless) against chronic back pain, because they hunt around till they find the cheapest path forward they've convinced themselves will work. Poor PC is on a one-man crusade to stop spine fusion for low back pain and save prostates more-or-less. --- But in the broader primary care world everything I've seen points to that lack of availability slowly being filled in by the NPs and PAs. I imagine in the coming years the restrictions on prescribing - and the requirement to have supervision - will continue to wane for both. Not saying someone should walk straight out of their PA school's clinical rotations and open up a shop. But rather that someone who's been a PA for a decade in primary care probably doesn't need the training wheels and supervision anymore. Controversial opinion to some, but it feels like the market forces alone are going to force everyone's hand on the subject regardless of their opinion.
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Nov 16, 2017 09:46
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I'm fine with PAs/NPs replacing GPs. They certainly can handle like 90% of PCP work. The problem comes with patient expectations; most patients are fine with being seen by a PA/NP unless they are misdiagnosed or the PA misses something. Then they quickly start grumbling about "well I shoulda seen a real doctor" even though GPs make mistakes too. Patients are just real weird in general though, especially older patients in rural areas. You have some of them hoovering up all the healthcare they possibly can get for every little thing and others will walk out of the ER AMA in the middle of having a heart attack because it doesn't hurt that bad (this has happened here like three times to my knowledge.) Some of them will refuse to be seen by anything but an MD (or, particularly with older patients, a male MD) and will complain otherwise. Providers don't like to make patients feel responsible for making the determination on whether or not they should seek healthcare because there are both extremes out there. So even though a lot of PCP and ER visits are completely unneeded, it's best to just let people come in if they feel like they need to. The trouble with this is that it does increase healthcare costs for everyone, but there are very few good ways around it. Most "well I have a sore throat and a fever can you give me some antibiotics" PCP visits are unneeded, but then you miss one where the patient has bacterial meningitis and whoops they're dead now.
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Nov 16, 2017 18:38
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The Phlegmatist posted:Most "well I have a sore throat and a fever can you give me some antibiotics" PCP visits are unneeded, but then you miss one where the patient has bacterial meningitis and whoops they're dead now. I consulted a phone nurse once and stayed home with what turned out to be atypical symptoms of a burst appendix that almost killed me, so now I probably see the doctor for more stuff than I really need to. 
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Nov 17, 2017 06:41
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On the regulatory approvals side of things, disbar the members of the Washington Legal Foundation, grant FDA indication oversight again (with a suitably long runup for regulation, think 20 years), and increase their funding by a factor of 10. Many of the problems and uncertainty in insurance, care, prescription and cost have to do with the intentional destabilization and ultimate destruction of the information base that used to be the core of approvals.
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Nov 17, 2017 17:09
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Reik posted:Definitely not just a way to sell more blood pressure lowering drugs, no sir. I dunno, they'll likely point out that lifestyle changes are always the first-order therapy of choice and the fact that the new guidelines are still ok with <140/90 for those with no other cardiovascular risk factors. Still, they just moved the goalposts to a point that's even harder to achieve with diet and exercise alone, which will definitely result in more prescriptions and diagnoses in people's charts, which will affect premiums and insurability if the GOP ever gets their way and brings pre-existing conditions back.
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Nov 17, 2017 17:35
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I'm really enjoying reading all the stuff from the medical practitioners itt. It's really useful and helpful. So my story about why insurance is hosed up is as follows. I've been going to therapy for a year to work out a whole host of anxiety/depression issues that have been untreated for a decade+. Treatment seems to be going well, but my provider isn't in any network. I'm not sure why but I think it's because then insurance has too much control over treatment. Well, hey no problem, my insurance is pretty good and I get paid back 70% of my out of pocket expenses for mental health treatment. Sounds good, so that's what I've been doing since last year and I've seen some real improvement but still have a host of things I need to work on. In my provider's words, the last year was mainly about stabilizing me so I wouldn't hurt myself, now we're working on developing skills so that I can keep my anxiety/depression in check. It's been tough but the weekly check-ins help. Except now my insurer is claiming my case "isn't severe enough" for weekly sessions and said they'd no longer reimburse me for every session, instead they'd only do at max 2/month. At $160/session this is a pretty big deal (~$4,000/year) and so as a result, even though my therapist didn't think I was ready to go bi-monthly (she's concerned I may have SAD and wanted to keep up monitoring this winter), we had to do it because otherwise I'd be going broke. Surprise, surprise, since they did this a lot of my old symptoms are coming back and my provider thinks it could be SAD that needs treatment but we can't make any kind of determination because she can't see me often enough to make a call one way or the other and even though she thinks I should probably come in every week, I can't afford it and my insurance won't cover it unless she lies and changes my diagnosis code. Fun times! 
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Nov 17, 2017 18:20
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axeil posted:I'm really enjoying reading all the stuff from the medical practitioners itt. It's really useful and helpful. Call up your state department of insurance and say you think your insurer is violating Mental Health Parity. If they don't have a written policy for limiting other therapies like rehab/speech/occupational to twice a month based on severity of diagnosis they are probably in violation. What state is this? Also insurer if you don't mind me prying. Might be able to find some info on their medical policy.
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Nov 17, 2017 19:10
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Reik posted:Call up your state department of insurance and say you think your insurer is violating Mental Health Parity. If they don't have a written policy for limiting other therapies like rehab/speech/occupational to twice a month based on severity of diagnosis they are probably in violation. What state is this? Also insurer if you don't mind me prying. Might be able to find some info on their medical policy. Virginia and UnitedHealthcare. My provider said "oh poo poo" as soon as I said United because apparently they've hosed around with her patients before.
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Nov 17, 2017 19:43
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axeil posted:Virginia and UnitedHealthcare. My provider said "oh poo poo" as soon as I said United because apparently they've hosed around with her patients before. I've worked with multiple actuaries who refuse to work for United. They have a pretty bad reputation even within the industry. I think it's reasonable to suspect they are violating the Non-quantitative Treatment Limitations of mental health parity. quote:Nonquantitative Treatment Limitations http://www.scc.virginia.gov/boi/co/health/check/mhsudbene.pdf I'd file a complaint. I've never heard of depression not being "serious" enough to only warrant bi-weekly visits. Reik fucked around with this message at 20:00 on Nov 17, 2017 |
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Nov 17, 2017 19:52
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Rhesus Pieces posted:Still, they just moved the goalposts to a point that's even harder to achieve with diet and exercise alone, which will definitely result in more prescriptions and diagnoses in people's charts, which will affect premiums and insurability if the GOP ever gets their way and brings pre-existing conditions back. This is a big fear of mine with everyone being screened for prediabetes, with its ~40% incidence rate and huge amount of comorbidities. And of course screening for it is free due to the ACA; it's going to be some sort of horrifying dark irony if your free preventative screenings of today wind up being a barrier to care if ACA ever gets repealed. e: There's also going to be a problem with the rise of genetic screening if ACA ever goes down, too; GINA has a loophole where it doesn't allow insurers to discriminate based on genetic testing but that protection stops if you actually come down with the disease you're screening for. So they can't deny you if you have the BRCA1/BRCA2 mutation...unless you have breast cancer! The Phlegmatist fucked around with this message at 20:59 on Nov 17, 2017 |
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Nov 17, 2017 20:54
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The Phlegmatist posted:This is a big fear of mine with everyone being screened for prediabetes, with its ~40% incidence rate and huge amount of comorbidities. This is no joke one of the reasons I still never bothered getting checkups even while insured.
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Nov 17, 2017 21:15
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Did anybody listen to the latest Freakonomics podcast? I thought it was pretty interesting—it was about the primary care shortage and how expanding the roles of nurse practitioners and physician assistants could be a good solution to the problem. They talked quite a bit how doctors’ political lobbies are blocking legislation in many states which would give nurse practitioners and physician assistants more autonomy. The link to the podcast is here: http://freakonomics.com/podcast/nurses-to-the-rescue/ Does anybody have any thoughts on the subject?
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Nov 20, 2017 13:07
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silence_kit posted:Did anybody listen to the latest Freakonomics podcast? I thought it was pretty interesting—it was about the primary care shortage and how expanding the roles of nurse practitioners and physician assistants could be a good solution to the problem. They talked quite a bit how doctors’ political lobbies are blocking legislation in many states which would give nurse practitioners and physician assistants more autonomy. I was absolutely floored that Medicaid isn't allowed to pay for retail clinic services. A cash-strapped program won't allow people to get early cheap intervention, and instead winds up sending more people to the ER instead of using the lowest-cost and lowest-overhead form of American healthcare.
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Nov 20, 2017 16:10
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It was never about cost, it was about punishing people for using it.
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Nov 20, 2017 17:37
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Twerk from Home posted:I was absolutely floored that Medicaid isn't allowed to pay for retail clinic services. A cash-strapped program won't allow people to get early cheap intervention, and instead winds up sending more people to the ER instead of using the lowest-cost and lowest-overhead form of American healthcare. Uhh...maybe ten years ago. Most of them take Medicaid now. It took time for them to negotiate with state Medicaid agencies.
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Nov 20, 2017 22:04
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A question for Esquilax or others with some perspective on how plan provisions affect enrollment / pool characteristics: How much protection, if any at all, do open enrollment periods provide to avoid death spiral conditions relative to a mandate? Presumably you still lose the youngest and healthiest potential participants, but for those a bit further along who may feel a general need for insurance, could the temporal limitations on access (and hence the inability to enroll only upon negative diagnosis or condition) be expected, in some measure at least, to replace the incentive that the mandate provides? I seem to recall some speculation about this when the ACA was originally being structured and debated, but I can't recall any metrics or projections, or whether it was seriously discussed, etc.
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Nov 20, 2017 22:14
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Annual Prophet posted:A question for Esquilax or others with some perspective on how plan provisions affect enrollment / pool characteristics: How much protection, if any at all, do open enrollment periods provide to avoid death spiral conditions relative to a mandate? Presumably you still lose the youngest and healthiest potential participants, but for those a bit further along who may feel a general need for insurance, could the temporal limitations on access (and hence the inability to enroll only upon negative diagnosis or condition) be expected, in some measure at least, to replace the incentive that the mandate provides? I seem to recall some speculation about this when the ACA was originally being structured and debated, but I can't recall any metrics or projections, or whether it was seriously discussed, etc. Those limitations are pretty much already in place. Limited open enrollment periods are currently the norm for health insurance (public and private) and are generally seen as important. I'd be surprised if the adverse selection impact on premiums from year-round enrollment was double-digits huge though - not even close to the selection impact of hypothetical "no-mandate" or "no-subsidies" changes. Despite the "low" impact, the practical impact on people who are doing what they should by staying continually insured is so minor that you'd be pretty irresponsible not to limit the length of open enrollment periods. There's probably a lower bound though, shortening the ACA enrollment period beyond the current healthcare.gov six-week window would probably not have a material impact on premiums. Side note: one interesting type of time-sensitive enrollment limitation are the ones used by Medicare. If you don't enroll when you first get the chance, you get a percentage penalty that lasts for the rest of your life. The longer you go without Medicare, the higher your penalty gets. I'm mostly speculating on the effects, there are probably others who are more qualified to answer specifically about pieces of these
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Nov 20, 2017 23:16
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The Phlegmatist posted:Uhh...maybe ten years ago. Most of them take Medicaid now. It took time for them to negotiate with state Medicaid agencies. The podcast linked was in New Jersey where they aren't allowed to take Medicaid.
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Nov 21, 2017 00:39
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Twerk from Home posted:The podcast linked was in New Jersey where they aren't allowed to take Medicaid. I'm not listening to the podcast since Freakonomics irks me but did they explain what the rationale was? Retail clinics barely make a dent in Medicaid costs at all they aren't placed in low-income areas The Phlegmatist fucked around with this message at 02:12 on Nov 21, 2017 |
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Nov 21, 2017 02:05
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Annual Prophet posted:A question for Esquilax or others with some perspective on how plan provisions affect enrollment / pool characteristics: How much protection, if any at all, do open enrollment periods provide to avoid death spiral conditions relative to a mandate? Presumably you still lose the youngest and healthiest potential participants, but for those a bit further along who may feel a general need for insurance, could the temporal limitations on access (and hence the inability to enroll only upon negative diagnosis or condition) be expected, in some measure at least, to replace the incentive that the mandate provides? I seem to recall some speculation about this when the ACA was originally being structured and debated, but I can't recall any metrics or projections, or whether it was seriously discussed, etc. The issue with the open enrollment periods as far as preventing a death spiral is that it still relies on a future economic pain to try and change behavior. That is, people would enroll in order to cover potential losses in the future, as opposed to enrolling to cover a known penalty that is happening roughly now.
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Nov 28, 2017 17:48
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In fact, my sister did without health insurance until she decided to get pregnant, then got it. Which is stupid, but some people are.
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Nov 28, 2017 19:21
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Reik posted:The issue with the open enrollment periods as far as preventing a death spiral is that it still relies on a future economic pain to try and change behavior. That is, people would enroll in order to cover potential losses in the future, as opposed to enrolling to cover a known penalty that is happening roughly now. I was naively thinking/hoping that the individual mandate would make enrollment periods obsolete, and the industry would move to contracts like leases or cell phones with one year minimum commitments. Because administering enrollment periods is a goddamn pain in the rear end, and the sooner they can go away, the better. Oh yeah, and it really fucks over people who need healthcare. Who for some reason don't understand a business practice that doesn't exist in any other industry, or any other country, in the entire loving world.
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Nov 30, 2017 05:46
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So in the context of health care costs, I constantly hear talk of going to the Mexican border for dental stuff or Singapore for surgery. However I rarely see any resources about how people set this up or do research to make sure they're not going to wake up in a bathtub full of ice with a tube in their side. Does anyone have any legitimate information on medical tourism?
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Dec 1, 2017 01:55
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Does anybody have thoughts on Christian health share plans? My unemployed uncle is considering it as an option.
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Dec 1, 2017 02:35
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They can deny nearly any claim one makes on some very bullshitty grounds. To elaborate, they are not beholden to pre-existing conditions protections, or lifetime benefit cap bans, and additionally can deny claims for injuries or illnesses that resulted from a lifestyle lacking in sufficient virtue. Highbrow Slick fucked around with this message at 02:46 on Dec 1, 2017 |
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Dec 1, 2017 02:39
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PerniciousKnid posted:Does anybody have thoughts on Christian health share plans? My unemployed uncle is considering it as an option. If he's unemployed have him get on Medicaid if he can. As far as Christian health share plans go, they don't cover preexisting conditions like ACA-compliant plants do (there's usually a waiting period before they're covered) but they are generally okay if you don't have any preexisting conditions and comply with the sign-up regulations. Any actuary would love the risk pool that signs up for those. They're a complete pain in the rear end to bill provider-side but they pretty much always get charity care rates.
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Dec 1, 2017 05:23
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The Phlegmatist posted:If he's unemployed have him get on Medicaid if he can. This is Missouri, so no, but I believe his pension income from a prior long-term job is barely sufficient for subsidies. If I'm wrong about that, then he pretty much had to do the health share for affordability reasons.
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Dec 1, 2017 05:43
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PerniciousKnid posted:This is Missouri, so no, but I believe his pension income from a prior long-term job is barely sufficient for subsidies. If I'm wrong about that, then he pretty much had to do the health share for affordability reasons. Did he look at the marketplace? Barely sufficient for subsidies because it's too low or because it's too high? In the former case he should definitely be on the marketplace since health share ministries don't have APTCs and in the latter case it might be an okay choice for him if he has no preexisting conditions.
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Dec 1, 2017 05:48
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Ganson posted:So in the context of health care costs, I constantly hear talk of going to the Mexican border for dental stuff or Singapore for surgery. However I rarely see any resources about how people set this up or do research to make sure they're not going to wake up in a bathtub full of ice with a tube in their side. Does anyone have any legitimate information on medical tourism? The arbitrage opportunity is so dramatic for medical tourism from the U.S. that the only reason it's not a multi-billion dollar industry is american anxiety about foreigners. IMO the way you do correctly it is to do it in conjunction with your local doctors. Some HMOs actually have partnerships with vetted doctors in other countries now because the insurance companies have given up on the US system too and realize that buying a plane ticket will save everyone money. Anyhow, get the diagnosis/treatment plan/check-ups/follow-ups/etc from your local doctors. Tell them you're going abroad to get the expensive poo poo done. Then reach out to 2-3 medical tourism outfits who have vetted doctors and compare what they tell you. Throw out the stupid cheap bid if you get one (alternative cheap option, reach out to local U.S. embassies and see who they send their embassy staff to for medical.)
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Dec 1, 2017 10:25
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Re: medical tourism, it probably doesn't help that you really need to fall in the bracket of "wealthy enough to do it in the first place, but not wealthy enough to just get it done in the US". It's quite a middle class option and if there's no middle class there's no medical tourism.
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Dec 1, 2017 10:51
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The Phlegmatist posted:Did he look at the marketplace? Barely sufficient for subsidies because it's too low or because it's too high? In the former case he should definitely be on the marketplace since health share ministries don't have APTCs and in the latter case it might be an okay choice for him if he has no preexisting conditions. I don't know if he's looked at the marketplace, he just mentioned offhand that he was considering health share and that caught my attention. His pension is like 16-18k I think, and he probably has some small investment income. Mainly I just want to know if I need to call him and yell at him not to make a Terrible Mistake.
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Dec 1, 2017 16:31
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PerniciousKnid posted:I don't know if he's looked at the marketplace, he just mentioned offhand that he was considering health share and that caught my attention. His pension is like 16-18k I think, and he probably has some small investment income. Missouri radio has been pushing this poo poo hard --- he should apply ASAP through the Marketplace (like, today). It will automagically tell him if he qualifies for Medica*
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Dec 1, 2017 18:35
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PerniciousKnid posted:I don't know if he's looked at the marketplace, he just mentioned offhand that he was considering health share and that caught my attention. His pension is like 16-18k I think, and he probably has some small investment income. Don't worry! Liberty Health Share has a FAQ, and one of the questions is "Will my Bills Be Paid?" https://www.libertyhealthshare.org/faq#q14 The answer is a video, rather than text like the previous questions, which I think is a really good sign. I'm not at all worried that the answer isn't a simple "Yes of course", but rather an elderly man gesticulating a lot. Edit: Jesus, the answer to that question is terrifying
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Dec 1, 2017 19:15
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Highbrow Slick posted:To elaborate, they are not beholden to pre-existing conditions protections, or lifetime benefit cap bans, and additionally can deny claims for injuries or illnesses that resulted from a lifestyle lacking in sufficient virtue. This is actually legal now on employer-provided plans. My company just changed its insurance offerings this year and explicitly says that any claims filed for injuries or illnesses "resulting from drug or alcohol abuse, or other lifestyle choices" will not be covered.
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Dec 2, 2017 17:15
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