U.S. to make More Drugs Easily Available, Cutting Role Doctors Play | Hacker News Reader

U.S. to make More Drugs Easily Available, Cutting Role Doctors Play

bloombergquint.com

271 pointsmudil294 comments

I live in a country where this scheme is already the norm (Saudi Arabia) and I can say that while it's not necessarily ideal, I much prefer it to the alternative. It plugs some seriously annoying holes in the healthcare experience and frees up doctors' time for more patients.

As it is, the only medications that require a prescription to buy in Saudi are psychotropic ones, narcotics, and most recently, antibiotics. Things like insulin, birth control medications, hypertension medications, even antidepressants and anti-psychotics- they are all OTC. And I think they should remain so, because from what I've seen the damage from misusing those drugs against pharmacists' advice is far less than the damage from going without them due to the difficulties encountered in seeing a doctor.

The reason that this is the norm here is twofold; one, health insurance wasn't much of a thing here until a few years ago. The second reason (and the reason health insurance didn't factor in until recently) is that the socialized healthcare system here was (and still is) stretched thin; seeing a doctor to get prescriptions for every little thing becomes prohibitively difficult, with appointments taking months.

It's asinine to expect someone suffering from, say, an acute athsma attack to try to navigate ERs or try to see a doctor on short notice during a crisis, when a pharmacist would be able to dispense the exact medication needed, leaving the others free for more complex cases that need closer attention.

Edit: this actually created a bit of culture shock for an older friend of mine. He was traveling to an EU country for the first time and didn't do his homework- he thought he he could simply walk into any pharmacy and ask for a pack of his cholesterol medication, as he usually does back home. I don't envy the poor pharmacist that had to keep trying to explain the dispensing system to him and to emphasize that yes, they are aware that it's Lipitor, not morphine, it's just how the regulation is.

I’m not I agree. The first reason is that many medications carry significant risks. For instance you mention insulin. For someone already prescribed insulin, yes it should be easy to access in case they should be able to get more (and that is the purpose of a repeat prescription). However, to provide insulin over the counter to someone never previously prescribed it could be incredibly dangerous, and indeed fatal. This is Similarly true for some cardiac medication.

Second, i think such a system makes pharmacists de facto community doctors, but without the time, training, or patient medical data to function correctly. Community doctors can make better decisions when they see the same patient multiple times, and have access to blood pressure readings, a list of other medical conditions etc. Buying over the counter makes a lot of this difficult and inefficient.

Third, I think it leads to a risk of encouraging patients to manage conditions without valid medical advice. For instance, depression is often treated best with psychotherapy. By buying antidepressives OTC, it prevents patients getting the holistic care needed. Similarly, patients may follow quack medical advice and do themselves significant injury by taking medications not needed (in the short term or long term).

Ultimately doctors offer a lot of value more than just prescribing medication, and often medicines need oversight to ensure the benefits outweigh the risk.

I think it comes down to whether you are comparing to ideals, or regular life.

Yes, medications carry risk. But, "without a doctor's prescription" does not mean randomly. People still take advice from doctors and pharmacists, they just aren't required to have proof that a doctor has decided something. In any case, a pharmacist is a pharmacology specialist and probably more knowledgable about drug risk and safety than anyone.

>> makes pharmacists de facto community doctors.

Again, depends on the ideal you are comparing to. You are implying an ideal community doctoring setup, where a local doctor knows people and is accessible to them. An ideal that exists for maybe 1%-2% of the world. The problem that pharmacist/nurse led care solves is that this ideal does not exist. GPs are inaccessible, cost $75 for 10 minutes or don't have appointments available. A pharmacist probably sees someone every time they're sick. Doctors... only if it's bad.

I feel like this sort of issue comes up often, when discussing primary medicine. The comparison isn't fair. When listing the pros and cons of pharmacist or nurse led care, we get a laundry list of real life issues. When listing pros and cons of doctor led care, we get an idealisation. IRL, most GPs prescribing antidepressives do exactly as much "holistic care" as pharmacists would. Patient asks for ADs. Doctor spends 2-3 minutes going through a checklist. Done. Whether or not that's ideal has little to do with who writes the script.

I practice in the UK. The system is far from perfect, but does to a certain extent work in the idealistic system you propose. It is not true for all GPs, and some don’t practice holistic medicine, but the system is created to allow (and encourage) this method, and in my experience holistic medicine is practiced by GPs. Perhaps things differ in the USA, but this system works well in the UK.

I live in Dublin, so not that far. GPs here are generally private, though kids, older people and lower income people are subsidized or free. Some other parts of the medical system are more like yours. It's an eclectic system.

Anyway, I don't have a problem with the way primary care works here. It works well. I didn't mean any of this as a slight on the job doctors do. But... I also think pharmacists and other trained people can prescribe medication, tests and such. There is value in accessibility. If they can (as I think some of these ideas take as premise) provide walk in service, there is good reason to do it.

I know people prescribed antidepressants from GPs, in the UK as well. 10 minute appointments several times per year.

> i think such a system makes pharmacists de facto community doctors, but without the time, training, or patient medical data to function correctly.

A U.S. Pharma.D is a professional doctorate degree. They don't just study organic chemistry, but also little things like treatment indications and counter-indications, patient management, etc.

Having access to the patient's medical history is a solvable problem. Some pharmacists already have access to and make use of such information.

Regarding patient time, there are more pharmacists in the U.S. than primary care physicians--roughly 290,000 versus 250,000. (See https://www.statista.com/statistics/185723/number-of-pharmac... and https://www.ahrq.gov/research/findings/factsheets/primary/pc...)

The problem today is that we waste our physicians' expertise on trivial stuff. It's an inefficient allocation of resources. Pharmacists have traditionally always been on the front-lines. The past half century in the U.S. has been anomalous in how underutilized are our pharmacists. Fortunately their training is still quite rigorous. They regularly catch physician errors, including a significant portion not related to drug interactions. (See https://www.sciencedirect.com/science/article/pii/S131901641...)

As long as the lines of communication are kept open, what's the issue? An M.D. or O.D. doesn't make one omnipotent. And U.S. pharmacists are better trained than the pharmacists in many other countries who enjoy greater independence and authority. The sky isn't falling in those places, AFAICT.

I was not belittling the pharmacist’s qualification, they often helped advise me and fit a specific role in the health care system. They are however trained for a different role (at least in the uk where I am based). General practioners are trained to deal with long term conditions. These conditions often require patients to be managed over a long period of time, and seem several times, hopefully by the same clinician. They also see them for the majority of their other illnesses. General practitioners allow a patient to develop a long term relationship with a doctor, and allow the doctor to become an expert in the patient.

I agree with you that a pharmacist is capable of dealing with many of these issues, but (at least in the uk) they are not primarily set up to deal with long term health conditions, and don’t develop that expertise in a single patient. If they become like GPs (which they feasibly could), it would work. But why do that when there is already a doctor who specialises in that? Maybe my arguments work less well in America, but my knowledge of that healthcare system is limited.

Ultimately though it seems we agree medications need some form of specialist oversight, rather than being freely available.

It gives me a bit of pause too, but I think things have gone too far in the controlled direction. My wife uses a nebulizer for her asthma, and recently was prescribed an albuterol refill. To her surprise, it came in a form where it has to be mixed with saline. She had to get a prescription for the saline. I'm sorry, that's nuts.

> She had to get a prescription for the saline.

Probably due to people previously being able to buy saline over the counter, and using it to inject themselves with etc. Misuse of things by people generally ends up with knee-jerk responses by regulators.

Isn't saline literally just salt water?

Yes, it's just very clean water with 0.9% of salt.

This is saline that you're going to warm up and then inhale. And you're only going to do this if you're already ill.

I don't think you should need a prescription for saline, but it's a little more complicated than salt water.

Generic insulins are already available over the counter at any pharmacy in the US. The newer insulin variants are significantly easier to use safely, since they require less frequent injections (long lasting insulin) and have a faster response time (short lasting insulin used when ingesting carbohydrates or correcting high glucose). These newer variants require a prescription that is typically only issued by an endocrinologist who will require a visit at least every 3 months. I’ve had type 1 diabetes for 20 years now, and have only had my prescription changed a couple times over the entire period. 100% of my medication-related complications have occurred during times where I was unable to acquire a prescription for these higher quality insulin variants, either due to a change in doctor or insurance. Pre-ACA it was common for people to be locked out of insurance coverage of these drugs for up to a year without covering impossible markup on specialist care, and protections for pre-existing coverage are back on the chopping block as we speak. Even today, travel away from my doctor can result in stressful prescription renewal logistics despite having no change in dosing for over a decade. After seeing a doctor nearly 4 times per year for 20 years with almost every visit boiling down to “ok, here’s your renewal, see you in 3 months”, I’m not sure I understand the value for me personally. If someone wants to abuse insulin (I’m not sure why they would), they already can with a bottle of humulin, available at their local Walmart for about $20.

I’ve absolutely benefited from my endocrinologists over the years, but 80 appointments for 2-3 prescription changes (prompted by my request each time) seems like excessive rent seeking.

I'm a pharmacist, and I completely agree with your assessment. People are waaaaay over-estimating their abilities here.

I think there's a bit of Dunning-Kruger at play here. People think they can make their own judgements based on the drug monograph and simply checklist over the contraindications/interactions and call it a day. And there are others who share their pills with relatives/family members because "its worked for me before". There's another special group of people who think that piecing together a pharmacological narrative will bring about a clinically meaningful result (it works in theory, so it must work in practice!). Others think statistical significance == clinical significance.

The typical community pharmacist is absolutely not equipped with the tools, incentives, and workplace conditions to assume the role of a GP. We are trained in evidence-based drug therapy management, not diagnosis. I'm also deeply concerned about how retail pharmacy corporations will adapt to this. I imagine that there will be a new metric: prescriptions sold/visit that regional directors will be optimizing for. If not a prescription, then you need to sell an OTC product.

A lot of people think they can DIY medicine. It will be a disaster. I've worked in a very high-income area with a very professional clientele (business owners, health care workers, lawyers, finance), and many are completely swayed by false information or "studies" they read online (because they are intelligent professionals, after all).

We need better access to high-quality healthcare, but not through DIY medicine. This proposal is the result of people running out of ideas and giving up.

> A lot of people think they can DIY medicine. It will be a disaster

So, a person having an obvious anaphylactic shock and being denied an epipen (and dying) is not problematic to you because that would be "DIY medicine"

http://www.foxnews.com/health/2013/12/23/girl-dies-after-pha...

I can't imagine safely prescribing anti-hyperlipidemia and anti-hypertension drugs without medical advice. Sure, we can all measure our own blood pressure. But choosing which anti-hypertension drug to use, or which combination, is nontrivial.

> But choosing which anti-hypertension drug to use, or which combination, is nontrivial.

Then why not consult a doctor? It is already an immense legal risk to recommend starting a course of drugs like this without seeking medical advice, I don't see why it would be any different if you could technically self-administer an anti-hypertension drug.

The basic argument is that when you make seeing a doctor to get access to a drug optional, you also make it a luxury; it changes patient expectations and thus behavior.

Most people don't go to the doctor before taking Claritin or Sudafed; when you go to the doctor and get a "script" for Sudafed, that's your signal that you wasted yours and the doctor's time.

You have a very good point about patient expectations. But patients have been trained to expect a prescription for magic pills from the doctor, and the doctors do their best to oblige, even when they ought to recommend a lifestyle intervention... As you note, people think they've wasted their time (and money) if they only get a recommendation that doesn't need a prescription.

The tragedy of the situation is that most prescriptions aren't as effective as marketing campaigns lead people to believe. For example, statins are good for improving patients' cholesterol lab #'s, but make them achey, and only prevent a handful of heart attacks for every 100 patients treated (statins have a poor 'number needed to treat' [0] ratio).

[0] https://en.m.wikipedia.org/wiki/Number_needed_to_treat (the section titled "simple example" says ~98 people had to take the studied cholesterol drug for 3.3 years to prevent one cardiac event.)

Number needed to harm is another important factor. All patients were harmed by DES [1], before it was withdrawn...

[1] https://en.m.wikipedia.org/wiki/Diethylstilbestrol

FTA,

>>> Americans may soon be able to get cholesterol-lowering medications

Going to the doctor to get such a medication is one more occasion to be reminded to check your diet before jumpin' on pills...

For the newly available medication, I'd suggest to raise their price by half the price of going to thte doctor to get the script. That money would then be given back to social health care system :-) So the patient pays less, have more flexible access to the medication and healthcare system benefits too :-)

> The basic argument is that when you make seeing a doctor to get access to a drug optional, you also make it a luxury; it changes patient expectations and thus behavior.

It seems in the us, seeing a doctor already is a luxury.

Read the article, it will have a questionnaire to determine if people should be given the drug

I think allowing diabetics access to life saving medication is preferable, even if there's some moron that's going to kill himself by injecting something he has no idea about (and they do that already)

The proposal wouldn't allow the sale of controlled medication like antidepressants

The rest just sounds like undue gatekeeping

I did read the article. In future, please refrain from insinuating someone has not read the article, it is against the guidelines for comments:

>Please don't insinuate that someone hasn't read an article. "Did you even read the article? It mentions that" can be shortened to "The article mentions that."

In particular, I was replying to Lanthanide’s comment on the system in Saudi Arabia.

I agree with IanCal, giving insulin to someone not already prescribed it is hard to justify. The risk of harm is much greater than the possible benefit, especially when they could just go see a doctor (routinely or as an emergency). I am from the UK so perhaps I live in what you would consider a nanny state, as guns are not freely available. As a point of information, in the UK antidepressants are not controlled more than any other prescription drug, I don’t know how that differs in the USA

> I think allowing diabetics access to life saving medication is preferable,

I don't think anyone is arguing for diabetics to not have access.

My problem here is how someone knows they are diabetic.

But I saw little in the article actually describe what the process would be for deciding what can be sold like this, I know diabetes is not mentioned.

> My problem here is how someone knows they are diabetic.

Again, I don't really see why this would be the problem of the person selling it, unless you prefer living in a nanny state.

There are a multitude of OTC and other readily sellable stuff that if misused can cause death. Complaining about selling insulin freely and the dangers of it in a place where guns are sold like candy is a farce.

Make them sign a waiver and be done with it.

> The first reason is that many medications carry significant risks.

People regularly poison their livers with hypervitaminosis A, yet vitamin A supplements, liver meat, and other extremely dense sources of vitamin A are not labelled in any way which would indicate this danger. Beyond products, the sheer number of ways you could kill yourself in this world is staggering, why is it more wrong to be exposed to risk from pharmaceuticals than from something like traffic or supplements?

[on the risks of self-medication]

I currently live in the Maghreb and the situation is here as it was described for Saudi Arabia. An important difference to Western countries is that pharmacists seem to play a much more important role here: I have to justify every purchase (even for very common broad spectrum antibiotics) and locals tell me they regularly seek advice at the local pharmacy first. Think "doctor's appointment pre-screening". And my highly subjective impression is that the quality of this pre-screening surpasses service in western pharmacies by far.

Though, the problems you point out are very real, just mitigated by the different situation.

Another thing that makes the situation incomparable to western countries is the low density of qualified doctors: If you need psychotropics here in my village you would have to move several hours away into the next big city to do a therapy. So it is: diagnosis, prescription and off you go. One can go on with a single prescription for years and I dare to say that the debate on whether this is good or bad here is still open.

There are tradeoffs. My guess is that very few people will bother to abuse the drugs that can't get you high, relative to the benefits of increased accessibility.

Presumably the slippery slope would be the profit incentive for manufacturers.

Being able to go from "Ask your doctor about..." to "Try..." is a major shift.

You are already on the slippery slope if you allow public "ask your doctor about" advertisements for anything more substantial than mild painkillers or flu symptom remedies.

This type of aggressive drug ads is pretty much unique to the US. It's your MD's job to stay up to date with drug developments and prescribe what would work for you.

So? We don't require a prescription for fruits and sandwiches.

Fruits and sandwiches don't have a long list of possible side effects (read quickly in a low tone of voice)

Really? You don't see any difference between a banana and an anti-depressant for example?

The cap for repeat prescription is at 3, at least were do I live which is in Puerto Rico. So the patients that needs those concurrent medications like levodopa or Humalog goes to see the Doctor and they ask for a prescription refill without date.

Big name pharmacies like Walgreens or CVS won’t dispatch u a medication without a prescription, the town pharmacies (Mom and Dad) would do it.

A week ago I avoid the hassle and loss of time (travel, waiting time, and $) just going through the town pharmacy and asking for a antibiotic, having a prescription won’t make any difference as the insurance plan won’t cover it.

This is an entirely theoretical argument.

As OP says, this system exists in the real world and how it actually works can be studied.

A desperate person without money to pay for Drs to get prescriptions will order from mexico or use veterinarian medication (true story). If those two options are not available the person will suffer in agony.

Preventing people from getting the medication they need is a terrible idea.

I am based in the UK, and as such my opinions are based towards a national health service free at the point of use. I am against a system lacking free health care for reasons such as this.

I actually agree with most of your points. I don't think this is ideal at all, I just think it's a less-harmful solution (and hopefully a temporary one) in the face of systemic dysfunction in healthcare. The alternative seems to skew less towards "oh I guess now I should see a doctor about that condition now" when facing pharmaceutical hurdles and more towards the "I guess I will tough it out; I can't handle the wait times for public hospitals or the costs of private ones". The lack development in centralized patient records entrenches this problem.

The self-medication thing is a seriously double-edged sword. You elucidated why very clearly. I have two reasons though to believe that it's a SLIGHTLY less risky practice over here;

1, pharmacists are very engaged with patients in recommending medications and constantly steer them to doctors- and they are more confidant with in-class substitutions rather than dispensing to a patient outright without vitals or history (beyond what is disclosed orally by the patient). However, they'll still recommend medications freely when they judge them as being unlikely to go to a doctor otherwise, hence risking more damage. Lesser evil and all that.

2, a long history of OTC availability of medications, where controlled prescriptions are the exception rather than the norm, seems to have lead to a culture of caution and careful reading of medication leaflets, asking the pharmacists, etc. I don't mean this as necessarily a good thing, I think this is more of a "you're on your own" mentality with regards to being careful with medications. This mentality grew, I think, partially from issues with access to doctors (governmental neighborhood health centers, kind of like small GP practices in the US/UK, are a somewhat new thing here. It was all centered around huge hospitals in the past). The bigger problem, in my opinion, is that this mode of thinking is about to be reinforced further by rising healthcare costs in the face of the rapid privatization of the healthcare sector, and it will clash with increasing OTC regulations.

One aside I will say about antidepressives which you mention; I think this merits a special examination separate from the rest of the healthcare issues. I've slowly come to realize that a massive portion of the population here are actually on antidepressants (mostly SSRI and SNRI meds). Why is this notable? Because it's not anywhere near commensurate with the number of people using psychotherapy or visiting psychiatrists. The reason, I believe, is because there is such a stigma around mental illness here that I think it would be very difficult to get many of these patients into more suitable therapy, and OTC Prozac or what have you helps hide the ""shame"". We're finally, FINALLY slowly moving past this stigma, probably catching up with the public attitude of the US/EU towards mental health in the 1980s or so. I really hope this will eventually lead to mental health patients not feeling that they need to self-medicate.

Edit: I forgot to mention that you're also completely correct in the assumption about quack medicine. It is, unfortunately, endemic here. It's a constant struggle to convince loved ones that, no, Supplement X is neither a peer-reviewed medication nor is it an alternative for treatment. At the very least the regulatory environment is increasingly more strict about misleading medical claims on herbal products, etc

I have always thought that it was completely asinine and unnecessary that my female friends were having to visit a doctor to renew a prescription that rarely changed for years at a time.

Things like... hypertension medications, ...are all OTC.

This would be so nice. Every time I switch providers, I have to hear the same tired "Lisinopril is the modern blood pressure medication and it's certainly all that you need!" "No asshole, it doesn't work for me and it makes me cough 17 times a minute, 1440 minutes a day. Just give a water pill, which does work and has worked for years."

This is actually what irritates me and keeps me away from doctors. Its seems to be 99% seat of the pants guess work, and in my case the doctors seem to have a pretty poor batting average. I get that antibiotics are over-prescribed, but do I really need to have the same test run again for the 3rd time to see if I'm lying about the antibiotic not doing a darn thing?

I get that treatment is frequently trial and error when it comes to medications, but the doctor/patient/pharmacist loop is BS, particularly for minor/frequent issues.

Take for example that I seem to run myself into poison ivy a couple times a year while mountain biking. Do I really need to fight to see a doctor/nurse/whatever just to have the same prescription I've gotten the last couple years straight? Or for that matter, maybe I should experiment more with stronger allergy medications to avoid the nasty withdraw I seem to get from prednisone.

Worse, what irritates me, is like the GP, it seems a lot of the common "safe" prescriptions in the US are over the counter in the rest of the world.. I know this, but got myself quite a surprise last time I was in mexico, because the hotel gift shop had viagra next to the advil!

I find it doubtful that Atorvastatin was not available for health/risk reasons. I can buy it cash in 5 minutes, no questions asked.

What tends to happen in some EU countries is that the retail drugs are heavily subsidized by the government, and then all kinds of kludges are put in place to prevent people buying bulk quantities and reselling them in some other EU country where the price is much higher - the export itself being 100% legal on the single market.

The subsidy/export explanation does make a lot more sense, since it's not exactly in a high-risk drug class. I suppose those regulations could have been misinterpreted by him to mean he needed a prescription.

(unless Austria, where this happened, really does have very strict OTC drug laws on medical grounds)

Off topic but: birth control is OTC in Saudi Arabia? That busts a stereotype.

Aisle 5, right next to the condoms and lube bottles =) and Victoria Secret makes money hand over fist here.

This would be off-topic here, but I think most people outside of the region would be stunned about the state of sex-change operations over here. They happen VERY frequently, albeit with a heavy veil of privacy.

Male -> female or female -> male? I have no desire to have a sex-change, but if I had to choose between living as a woman in Saudi Arabia and having invasive surgery and hormone therapy, I might choose the latter.

Both. Anecdotally I’d actually say that the ratio of MTF surgeries to FTM ones is higher than usual over here.

Assuming that Christian laws apply to an Islamic country is a strange stereotype.

“ And I think they should remain so, because from what I've seen the damage from misusing those drugs against pharmacists' advice is far less than the damage from going without them due to the difficulties encountered in seeing a doctor.”

When people start self prescribing antibiotics even for minor stuff, it’s not a problem because of the minor risks to them, but because of the major risk to the entire society. We are seeing more and more antibiotic resistance germs and if we don’t collectively work to reduce antibiotic usage we end up exasperating the issue.

Do you guys also allow drug advertisements? The only problem I see is our drug producers here using advertising to push people into buying and using drugs that they really shouldn't be using and inadvertently causing themselves a myriad of additional health problems. Im 100% for people being able to use whatever drug they wish, provided that they actually know what they are taking and what it does. Any half decent advertiser though would leave that as an open-ended as legally possibly interpretation in order to drive sales though.

Not in the US style of drug ads, but not completely banned either; things like Tylenol and the various cold and flu drugs can be advertised. I’ve never seen ads for something that would be prescription-only in other countries except for Viagra and a coupe of other ED drugs, and that’s an edge case.

As far as I can see all drug advertisements (including things such as social media promotions) have to be approved by the Saudi FDA, and they don’t seem lenient at all in allowing ads for anything beyond the aforementioned meds.

There are better ways to go about this. As others have noted, there must be a mechanism for a continual prescription to be easily filled, e.g. insulin, metformin, etc. I could see a long term prescription that has to be renewed each year and is good at any pharmacy.

For the short term prescriptions though, cutting the doctor out of it makes people much more susceptible to marketing (instead of 'ask your doctor if you need X' we'll get 'You need X if you have any of a, b, and c...get it now before it's too late'.

Also, the doctor is aware of your health history and can spot reasons you specifically shouldn't take a drug, or better alternatives. Maybe you are overweight and one diabetes drug would work for you, but this other one will also help you lose weight. Maybe you have a loss of kidney function, and shouldn't be taking metformin. Your pharmacist should catch drug interactions, but they can't catch problems that would result from your past medical history.

For me this is big pharma getting their way, at our cost, in more ways than one.

It's a trade off since Doctors have a habit of using their prescription power to force you to schedule unnecessary visits to boost profits and they are not immune from marketing pressure.

> It's a trade off since Doctors have a habit of using their prescription power to force you to schedule unnecessary visits to boost profits and they are not immune from marketing pressure.

Citation needed. I'm sure are a few doctors out there who do that, but I have a hard time believing that's so widespread that it's a "habit" of "doctors." For instance, my doctor will reissue my long-term prescription if I call him, the next I hear of it is when the pharmacy sends me a notification saying it's ready.

That said, I'm sure there are prescriptions that actually do require regular long term medical monitoring by a professional, even if a lot of people are annoyed by that and therefore think it's unnecessary.

For just one example: 33% of doctors always require a pap smear and pelvic exam to renew a birth control pill prescription. This is despite the fact that the WHO and ACOG both advise that the pills can be safely prescribed without the exams.

33% certainly counts as more than a "few" in my book.

Citation:

https://www.reuters.com/article/us-birth-control/women-seeki...

There's a generalized problem in medicine that it takes a long time for new standards to trickle into common practice. It often doesn't fully turn over until an older generation of doctors retires.

It seems to me that, of many imperfect systems, one where doctors have control is more preferable. They are legally and duty bound to serve their patients. The same can't be said of pharma company marketers, not by a long shot.

Let's solve the right problem (updating doctors with new training), not the wrong one (let people but prescription drugs they may not understand). Not all drugs are as cut and dry as birth control pills may seem to be.

Please see this report by the American College of Obstetricians and Gynecologists : https://www.acog.org/Clinical-Guidance-and-Publications/Comm...

It discusses a series of studies on the "ability of patients to self-screen for birth control pill eligibility", and determines that patients are good enough at self-screening that the medication may as well be over-the-counter.

It sounds like, from the initial article, that the FDA is taking a similar approach: "Drug companies would have to submit data to the FDA that shows consumers are capable of accurately assessing their need for a medication and their ability to use it correctly."

Obviously we'd need to wait to see what the FDA actually approves/disapproves for these purposes, but it actually seems quite likely the approved drugs will, in fact, be restricted to cut and dry ones, such as birth control pills.

Thanks for the link. I'd like to see intelligent changes to the system in these cut and dry cases where we are unlikely to do harm through action. The problem is, I don't think statins, the first drug in the article, fall under that category.

BTW, the 33% number you cite in parent comment doesn't include responses to the pap smear question, only the pelvic exam, and is specific to family doctors.

> There's a generalized problem in medicine that it takes a long time for new standards to trickle into common practice.

In the US, where we have no standards of care, this is true. In centralized systems like France, doctors receive updates to expected standards of care annually based on analysis of the latest evidence.

This has interesting effects. My father did the statistical work for a set of expert consensus guidelines in psychiatry. He found an interesting pattern: the European practitioners produced basically the same decision tree, from Sweden to Spain (that is, physicians practicing in completely independent healthcare systems). American practitioners were so scattered that sometimes you couldn't extract guidelines.

This is also why you can have an operation done safely in a rural hospital in Italy, whereas in a rural hospital in the US, the only thing you should let them do is put a bandage on you and transfer you to a real medical center in a major urban area.

Italy is 5x as dense as the USA. There is no equivalent to rural USA in Italy.

I'm not talking about Montana. I'm talking about Virginia outside of Charlottesville, Richmond, and Washington, DC.

> They are legally...bound to serve their patients.

In the US, with the cost of attorney-mediated access to the judicial system, this is not really a protective constraint for the bottom 90-95% of the population against exploitation by unethical medical providers.

I'm interested in discussions about data transparency: anonymized, aggregated data about the patient population seen, the outcomes, and the amount spent, per doctor or set of doctors (if multiple specialists are seen). The former data set so doctors don't start cherry-picking for best outcome patients. The latter data set so doctors can start observing the average and median standard of care, and there is more uniformity of care across the field.

At the moment, only the health insurance companies have access to this kind of data.

I don't agree. It is a protective constraint because of the legions of trial lawyers who are happy to bring a malpractice suit, albeit mostly for their own benefit and not the patient's, due in part to the general lack of financial awareness in the poor.

It doesn't come close to making anybody whole when things go wrong, but the threat of litigation certainly modifies the way medicine is practiced.

> ...albeit mostly for their own benefit and not the patient's, due in part to the general lack of financial awareness in the poor.

> It doesn't come close to making anybody whole when things go wrong...

You are advocating that the system works for a value of "works" that rises above the hurdles of incentives where the minuscule fraction that trickles down to the patient and where "the way medicine is practiced" is a lucrative enough target for the expensive litigation. If you build software systems like you advocate for course corrections in medical practice, then you'd bin every trouble ticket until it came from a "big enough" customer with a "severe enough" problem. To each their own, but I'm personally in favor of granular, incremental changes that are more manageable and responsive to the market.

Waiting for litigation to change medical practices is no different than ignoring a defect in the design, implementation, and testing phases of software, and letting users find it beat down your door before fixing it. US doctors largely won't even adopt checklists yet, despite proven efficacy. It is unacceptable to have to wait for future litigation to see it adopted in mainstream medical practice.

I'm not saying it works. I said it operates as a protective constraint. The current system undeniably prevents some cases of medical malpractice. You're talking about repairing harm done, and I'm talking about preventing harm.

For the record, I agree that there are many things that could be improved in the current medical system.

Well, birth control pills aren't really safe. I guess they're safe compared to a pregnancy, but they do have potentially serious side effects. It seems reasonable to have periodic checks for those, if you're taking them.

As the GP pointed out, pap smears and pelvic exams are not medically necessary prerequisite to a birth control prescription and adding those procedures don't make prescribing birth control pills safer. They are an artificial barrier to access birth control.

Pap smears (when done at the recommend intervals - most doctors overtest) are extremely beneficial screening tool and they save lives, but they have nothing to do with birth control - the purpose of a pap smear is to screen for cervical cancer.

In fact, the current recommendation is to wait until a women turns 21 before starting pap smears, yet many (most?) women will require contraceptives before 21.

It's also false that "birth control pills aren't really safe." - "potential to have serious side effects" is not even remotely the same thing as "not really safe." Oral contraceptives are not more dangerous than NSAIDs like ibuprofen. Both The American College of Obstetricians and Gynecologists [1] and The American Academy of Family Physicians [2] recommend over the counter access to oral contraceptives based on the availabile evidence

[1] https://acog.org/Clinical-Guidance-and-Publications/Committe...

[2] https://www.aafp.org/about/policies/all/otc-oral-contracepti...

They're safe compared to Tylenol too.

It's a huge step to go from "they're not completely safe" to "...and therefore a doctor needs to be constantly checking up on you". Lost of things have potentially serious side effects, including most OTC medicine. And?

I mean, peanuts are pretty dangerous too; they kill people every year, and the side effects are potentially extremely severe. Does that mean a doctor needs to be involved in the process of me buying peanuts?

> It seems reasonable to have periodic checks for those, if you're taking them.

Reasonable is a low bar. Your suggestion does seem reasonable, inasmuch as I can see a reason why you'd want to do it. I can see reasons why you wouldn't too. We need more than that.

> I guess they're safe compared to a pregnancy, but they do have potentially serious side effects. It seems reasonable to have periodic checks for those, if you're taking them.

Pap smears and pelvic exams, however, are not checks for the potential serious side effects of birth control pills.

It's about like being forced to have a colonoscopy before being allowed to get NSAIDs, because NSAIDs have potentially serious side effects.

Lots of things that are generally considered safe can have potentially serious side effects. Some of these are available over the counter. This doesn't mean they aren't really safe, it means that some folks have bad experiences.

It isn't just that it is safer than being pregnant. It is seriously better for some folks to take birth control because of the severity of their monthly cycle.

Some folks can't take tylenol. Ibuprofen can cause ulcers. Folks take heartburn pills (such as Prilosec) without being diagnosed. A body can form a dependence on certain laxatives. This doesn't mean they aren't generally safe for folks when used properly. Having some of these only available after talking to a pharmacist shouldn't shouldn't be a big deal, especially if you have to get the first dose with a prescription from the doctor.

What isn't reasonable is folks having to have an actual visit to the doctor every time a prescription runs out. It isn't reasonable to force people to have unnecessary pap screens to get birth control either - so long as your tests are normal and you aren't having other issues, there is no reason to have one every year even. Every 3 years tends to work out just fine.

Personal experience:

I was getting an annual physical from the doctor who had written a prescription that was expiring. We discussed the condition and agreed I needed a renewal. I was told I had to come back for a separate visit "because Obamacare required it" My translation: because he couldn't bill for writing out the prescription during well-check, and because he wanted/needed to charge for it. Oh, and blaming Obamacare because I live in a predominantly Republican area.

Doctors have to wrestle with insurance companies as much as you do.

I'm sure he didn't think of it this way, but I'm on a high-deductible health insurance plan and will not meet my deductible, so he was directly asking for the money from my pocket to his office revenue, with all the overhead of the insurance company and an additional office visit thrown in (1.5-2 hours of my time), instead of a 1-minute "write the prescription while we are here."

It was directly the grandparent's case, of doctors requiring unnecessary visits to maximize their profit.

Even if I had no deductible or co-pay, where do you think the insurance company gets the money to pay for this extra visit? It's from the insurance premiums we all complain about (that is, from my pocket).

Again, I don't think the doctor thinks of it that way. He just thinks, "We have to separate well-patient visits from any other services", not, "If I make this patient pay $300 and spend 2 hours, I can pocket another $100 for 1 minute's work."

Citation needed? Have you never been to the doctor in the US?

This "citation needed" thing for every little fact and factoid is getting weary. Yes, often facts are cited that require more evidence than merely recitation. But if you overuse "citation needed" then it loses its power as you come across as attempting to pettily shut down people you disagree with. Use it with care.

My experience is that I don't even need to call to get my prescriptions refilled. I login to my doctor's EMR portal, select medication from the menu on the left, select the check boxes next to the medications I need refills of and click the refill button. A few hours or the next day at the latest my Walgreens app alerts me that my prescriptions are ready.

The prescription is probably good for some limited number of refills.

No, if it’s good for refills then that process isn’t even necessary until those refills run out; the pharmacy keeps track of them automatically. What GP is describing is a refill authorization request, which happens when no refills are left. It does require the doctor’s approval, but usually does not require a visit as a matter of course, unless there’s a concern the dosage may need adjusting based on, say, new lab tests.

The above mentioned case of doctors who require a pap smear for birth control is unrelated; it’s a barrier to access to contraceptives, which is motivated not by medical concerns or even greed, but by politics.

>but usually does not require a visit

Things are probably different if this is a long term doctor you've established a relationship with; but in my experience no lab tests were done, just a lot of unnecessary paperwork and pay the lady at desk.

It would not happen if you could not sue a doctor for renewing a prescription after a 1 year period and the patient died because he shouldnt have taken that drug anymore.

Doctors have insane liability standards, particularly in the US.

For what it's worth, the UK has had a three-tier system of medicine licensing (prescription-only, pharmacy-only and general sale) since 1968. In 2006, pharmacists with additional training gained the right to independently prescribe any prescription-only medicine within their clinical competence. Repeat prescriptions can be requested online and sent electronically to a pharmacist of the patient's choice. Obviously YMMV.

https://www.nhs.uk/common-health-questions/medicines/what-is...

https://www.pharmacyregulation.org/education/pharmacist-inde...

https://www.nhs.uk/NHSEngland/AboutNHSservices/pharmacists/P...

NZ has done something similar. Seems to work quite well; I recently went to a pharmacy looking for an OTC solution for a mild infection (it didn't seem worth seeing a doctor over, and I didn't have time anyhow) and ended up with a prescription from antibiotics written by the pharmacist, which was super useful and convenient.

Also in the case of oral contraceptives, a change recently went through here (last year I believe) making oral contraceptives OTC as long as the purchaser had been prescribed them within the last 3 years. Bit of an odd compromise, but a nice stepping stone towards greater liberalisation if it doesn't end up causing issues.

> Your pharmacist should catch drug interactions, but they can't catch problems that would result from your past medical history.

They can and do. See, e.g., https://www.sciencedirect.com/science/article/pii/S131901641...

Pharmacists in the U.S. are highly trained medical professionals. A Pharm.D is a professional doctorate. Their expertise extends beyond chemistry, and more importantly are trained well enough to know when to seek the advice of, or refer a patient to, an M.D.

It's not that pharmacists aren't trained well enough to do these things. The real issue is that most electronic medical records are locked behind proprietary walled gardens. Outside HMOs and similar vertically integrated medical systems, pharmacists don't have reliable access to medical histories. This is a solvable problem, though.

This situation perfectly illustrates how underutilized pharmacists are in the health care system. A few states are passing laws that will allow pharmacists to prescribe certain medications but it’s happening slowly due to the typical pressures of lobbies and insurance companies.

Also, the doctor is aware of your health history

Your doctor skims your notes in the 20 seconds between the receptionist calling your name and you entering her office, in handwriting she can barely read herself, and has forgotten you before you’re even back in the waiting room after spending 5 minutes talking to you while she’s really thinking about the new Audi. That’s as far as the awareness goes.

Thanks for speaking for the entire medical profession. That is in fact what a terrible physician does, and not what myself or other newly trained physicians aspire to do.

You may not aspire to it, but you likely will have to do it if you want to remain employed in many areas.

I have multiple friends who made it all the way through residency and have since stopped practicing within years of "graduating. The OP describes the profession much better than you do, as a whole.

Double booking patients, requiring certain revenue targets, massive amounts of useless paperwork, etc. Considering the varying ranges of where they took up residency I'd say this is endemic industry-wide. Also jives with my personal experiences with the medical field.

They should start their own practice and set their own rules. Good practices/doctors in my area are so in demand most aren't accepting new patients.

Is it even possible to set up an individual practice these days? Most individual practices were established decades ago. Most new physicians will work with an established group practice on contract.

It would be for those physicians without crippling debt loads. So, no, for those whose medical degrees were issued in the last couple of decades, it isn't possible.

Its not because billing is so complicated that it takes up to 50% of the doctors tie to manage his own practice.

Big companies have more people doing billing alone than doctors themselves. Pretty clear cut case that regulation is the enemy of efficient markets.

Wouldn't this be a perfect opportunity for a startup to handle billing for small doctor's offices?

There are several but its not as easy as it sounds. Its a very labor-intensive task. Its kind of like saying that a startup should be going to peoples homes and cook for them according to their liking.

The issue is that doctors work for insurance companies and that means you need to do things a certain way they like while matching the way they practice and document their medical decisions.

I could explain more since I am part of one of these startups :)

If you live in a location that has poor selection of GPs then it should be your choice to opt out without denying yourself access necessary medication.

If you don't go to a doctor, how do you know it's necessary?

If you’ve been taking the same medication for 10 years, then on day 1 of year 11 you need a refill, pretty good chance you know it is necessary. I wouldn’t claim you never need to see a doctor, but it is equally absurd to suggest you always need to see a doctor. My experience has been that I ask for refills, and my doctor unquestioningly gives them. It would save the whole system money and time if I could just refill them myself.

That is not at all the experience I have with my doctor, where the intake NP does a whole litany of the past several years worth of doctor visits before I’m seen.

I’m ok and I think glad that pharmacists don’t even have access to that information.

On your first visit or every visit thereafter? I think the issue is the overhead of unecessary repeat visits.

Every visit thereafter.

Not sure how your anecdata is any more or less valid than mine...

I never said it was! My point was just that a pharmacist probably couldn't replicate the routine experience that the large health provider chain my doctor works in provides for patients.

I sit with my primary care doctor at least a half hour each visit, but then I'm lucky. I live very close to a first class VA medical center. I don't believe the west palm beach center can be beat.

I'd also be concerned it might exacerbate the opioid epidemic.

Opioids would not be part of this change. This is for stuff like high blood pressure, cholesterol, migraines and asthma (according to the article).

... because physician prescribing did so much to prevent that epidemic?

Not trying to be snarky--I understand the argument--just pointing out how absurd that seems to be to some.

When you already know what drug you need and just need somebody to sign a prescription, it's a very silly and awkward process to find a doctor, make the appointment, wait for the appointment, show up to the appointment, fill out the history forms and so on, meet with the doc, tell them you've got [disease] and the drug for it is [drug], let them examine you until they agree with your "diagnosis" of [disease], and let them recommend and prescribe [drug]. It makes you feel sorry for the doctor almost.

I can certainly relate to this, as I have to see a neurologist every two years or so for cluster headaches. When a cycle starts, I need a prescription for medicine and oxygen immediately, because I'm getting very painful headaches every day for two months or so.

The problem is, my neuros keep retiring, so I have to start over, begging for an appointment from a new one who doesn't have anything sooner than three months out. When I finally get in, I tell them my previous dosage, and they write me a script.

I was advised in a situation like this to ask the receptionist to connect you with the doctor's nurse. Nurse is more available than doctor, and is more competent than the receptionist. YMMV.

I agree with this. Many of the supplements I get online are just as risky as anything a doctor can prescribe to me. I already know more about these chemicals and drugs than any doctor I have met. What's more, I have yet to meet a doctor that even cares about the supplements I take.

> What's more, I have yet to meet a doctor that even cares about the supplements I take.

Reminds me, some time ago I researched a supplement extensively before taking it. Then when it turned out to be helping me, I asked my doc if it was safe to continue taking it. He just Googled it, clicked on the first search result, and determined it was safe.

Yes well I am sure that's what the guy next to me when I was in hospital last year thought until he took supplements plus his prescribed meds and had 100% kidney failure.

Do you remember what supplements and meds he took?

Large doses of Zinc some reaction with his other meds and the hadn't told his GP about the zinc pills.

What were the results of the autopsy?

luckily they caught it in time though I suspect his daughter had some strong words for him.

what supplements, if you dont mind me asking? what what use? (if they are a medical condition and not health or "nootropic" feel free not to say)

It is a rather large list. I am reversing the cumulative damage to my body.

To add to the discussion however, I would include sub-components of supplements such as BioPerine which is just a commercial version of piperine. Several supplements I take have this and it changes how drugs are processed in the liver. Drugs that would normally have a small chance of minor side effects can suddenly have dramatic and unpredictable side effects.

> it's a very silly and awkward process to find a doctor, make the appointment, wait for the appointment, show up to the appointment, fill out the history forms and so on, meet with the doc, tell them you've got [disease] and the drug for it is [drug], let them examine you until they agree with your "diagnosis" of [disease], and let them recommend and prescribe [drug].

I'm with you up until all the people who "know" they need antibiotics for things that antibiotics don't work for. There's strong public health justification for putting a doctor in the loop on occasion.

+1. Obviously not every drug can be self-prescribed, and not every condition can be self-diagnosed.

Remember when you needed to go to a doctor to get a prescription for Fexofenadine or one of the many other antihistamines? Seems ridiculous in retrospect. We should limit ourselves to a year, maybe two at most, of prescription-required status for new drugs that should be over-the-counter, and only to get some experience (data). Some drugs should require a new N-year prescription every N years as patient conditions might change requiring examination.

>it's a very silly and awkward process to find a tech person, make the meeting, wait for the meeting, show up to the meeting, tell them your issue and the solution for it is [solution], let them examine your problem until they agree with your "diagnosis" of [problem], and let them recommend and prescribe [solution]. It makes you feel sorry for the tech person almost.

There is a reason why we have specialists. Yes, you could be your own lawyer, doctor and engineer but there are very good reasons they exist: to make sure you aren't doing dumb things they know better.

One can represent themselves. It might be dumb, but people should have the right to be dumb when they're the only ones getting hurt. That's why I have no problem with engineering requirements: when a bridge, airplane, whatever falls down and goes boom, it's not only the owner who's affected.

I'm an adult. It's legal for me to buy and drink bleach. It would be very stupid of me to do that, but I can. I should be able to do the same with prescription drugs, if I want to. Yes, including eating a whole bottle of warfarin and dying messily. It's my body and my life, not yours.

> One can represent themselves. It might be dumb, but people should have the right to be dumb when they're the only ones getting hurt...

The difference is there isn't a massive industry that will try to persuade consumers to do something as dumb as choosing to represent themselves pro se. There's no way for others to profit off that kind of stupidity.

On the other hand, the drug industry already advertises to consumers heavily to convince them to take prescription medication that they may very well not need. That kind of consumer stupidity can be very profitable, so the vultures will descend from the heavens to persuade people that the dumb choice is really the best one for them.

> The difference is there isn't a massive industry that will try to persuade consumers to do something as dumb as choosing to represent themselves pro se. There's no way for others to profit off that kind of stupidity.

Wouldn't you like to attend my seminar on the importance of representing yourself? Also, check out my book. And follow me on Twitter.

> Wouldn't you like to attend my seminar on the importance of representing yourself? Also, check out my book. And follow me on Twitter.

That doesn't happen, or at least it doesn't happen at anything close to the scale of prescription drug advertising.

Also, representing yourself pro se is a daunting, complicated endeavor. Buying a pill is not if you have the money, as you can clearly see with the supplement industry.

The average adult can be quickly and reliably trained to use bleach appropriately: "Should I drink bleach? No. Always no."

On the other hand, the average adult requires six or more years of education and training to manage warfarin appropriately.

I'm being somewhat glib for effect, but do you not see a critical distinction there?

In the interest of public health, we make all kinds of laws to protect people from things they cannot be expected to do safely. Why is it unreasonable to protect people from dangerous medications?

I'm willing to bet that very few people accidentally consume bleach or warfarin under the belief that it is beneficial.

However, it's far more likely that a layman gains cursory information about a drug and its effects, while lacking the specialized knowledge required to safely prescribe it.

In short, it's far easier to accidentally poison yourself with prescription medication that it is with bleach, and we have measures in place to prevent such accidents for a reason.

> I'm willing to bet that very few people accidentally consume bleach or warfarin under the belief that it is beneficial.

I believe that a number of children and adolescents tried to consume Tide detergent pods. [1]

[1] https://www.usatoday.com/story/news/nation-now/2018/01/11/ti...

What exactly do you think constitutes an "accident"? Have you ever accidentally purchased a drug that required an over-the-counter interaction and consumed it?

Isn't that what the directions that are on every bottle are for?

Yes, and when you're left alive and disabled you should have the right to become a ward of the state.

> It's my body and my life, not yours.

I suspect @shub would disagree.

Far from being just for those trying to self-medicate, this process also applies to anyone who's been diagnosed by another doctor, but happened to move, or can't get their records for whatever reason, or whose new doctor insists on a full work-up regardless because they're not comfortable skipping it.

But medicine is dealing with your own body and I would argue that you’re the world expert on your own body.

This is the kind of logic that has brought us the plague of “As a mom, I know what’s best for my kids’ health and that’s why I’m not getting them vaccinated.” Despite what a charming mantra it sounds like, people are not automatically experts on themselves any more than on any other subject.

I have mixed feelings about this, especially considering the US is the only first world country where direct-to-consumer marketing is allowed for medications.

Bypassing the prescription requirement is of course of significant value to drug companies, who expend quite a bit of resources to sway doctors with free lunches, conferences and soft persuasion tactics.

Usually I welcome the freedom to chose but this doesn't increase availability: the bottleneck is not with the doctors, it's with pricing. Drug prices aren't going to go down with this measure, and will remain 3-5x the price of the exact same meds sold in Europe.

One of my friends has type I diabetes, in more than one times, she needed urgent visit/call to her doctors just to get the medicine she has being taken for years.

I have type 1 diabetes, and this is a constant fear of mine. It’s absurd that I should have to go through my insurance company to be able to get more medicine if I need to.

I had this realization after a family emergency had me flying cross country on, 2 hours warning.

Walmart sells Novolin R/N for 25$ a vial without prescription. In all but three states I think, it is legal to purchase veterinary needles.

Novolin isn't probably as good as what you've been prescribed. But it will keep you alive.

This is the most atrocious thing to do by not to letting people with Type 1 buy their Insulin medication. I just don't see a reason why this is so much regulated. Like some meds which are partially regulated, where you can request a Pharmacist and they can give you would be reasonable in this case.

Insulin is regulated because you can very easily die from using it improperly.

Older versions are available OTC in at least parts of the US.

I don't know if this is helpful to you, but Walmart pharmacies have inexpensive insulin if you ask for it.

This is regular insulin, its quite unstable (by unstable I mean that its release mechanism is quite slow and requires a lot of planning compared to more modern 'fast acting' insulins.

with that said, as a type 1 - if I was in a predicament you bet i would go, if i recall they sell it for 25 a vial, whereas a vial of normal, fast acting insuling is ~250.

*usd

What you’re talking about goes far beyond what the FDA is proposing.

The drugs the FDA wants OTC are drugs that have already gone generic like statins. There is very little financial incentive to push consumers to buy drugs they don’t need.

> There is very little financial incentive to push consumers to buy drugs they don’t need.

I have to disagree: Homeopathics and Viagra.

In general I am in favor of this change, but homeopathy and vitamins are 'generic' and companies see a huge incentive to sell them, even if we do not need them. Supplemental vitamins are mostly wasted when you urinate.

Viagra is another drug I can (and do) see a lot of money spent to encourage people to take even if they do not need it.

The margins on homeopathic are way higher than generic drugs and there is a ton of competition among manufacturers.

Most generic companies make their profit off the first 6 months of exclusivity. The rest of the time they are barely breaking even (hence the drug shortages).

> Most generic companies make their profit off the first 6 months of exclusivity. The rest of the time they are barely breaking even (hence the drug shortages).

I read that it was due to factory outages and the government keeping tight control over production of controlled substances. The FDA actually forced Pfizer to give up their quota this year to other manufacturers because they didn't produce enough of it due to their factory outages. It seems more like a large business playing hardball with the government and insurers than a lack of profit.

Also, you need to provide proof of your assertion of generics barely breaking even. I just glanced at Mylan who sells generics. They bring in 2B a year in operating cash flow on 12B in revenue.

> the US is the only first world country where direct-to-consumer marketing is allowed for medications.

Not quite. It's allowed in New Zealand too. There have been many calls to change that, but so far it's still allowed.

It's not quite as bad in New Zealand as the states though, since most of the time if you go to the doctor they'll prescribe you generic, state subsidised medicine.

I've never really noticed much direct-to-consumer marketing, except for Viagra and Cialis.

I haven't watched broadcast TV in years, but I certainly remember quite a bit growing up - maybe rules have tightened? I have no experience with US advertising, but yeah, privatised medicine must lead to issues we don't get.

> especially considering the US is the only first world country where direct-to-consumer marketing is allowed for medications.

Relevant book on this topic, and highly recommended read: https://www.amazon.com/Overdosed-America-Promise-American-Me...

So ease access to the drugs and tighten the regulations around advertising. The fact we have consumer-driven ads for prescription drugs at all is like something you'd expect in a satire novel :P

The cynical view is that other countries have restrictions around drug advertising because if an expensive drug is demanded they have to pay for it through their single payer system. I can imagine not wanting the population to find out that there is cure for Hepatitis C but it costs the country 20k per person. Not all countries are as forward thinking as Australia:

http://theconversation.com/australia-leads-the-world-in-hepa...

While I applaud cynical views in general, since most of the rest of the world has restrictions on the prices of prescription drugs this idea doesn't work in most cases.

There is a more cynical view, and you should definitely take it. Less doctor involvement means more people taking prescription drugs (the pharma companies hope).

As an aside, I cannot tell you how angry our direct-to-consumer drug advertisements make me. Especially the ones that are marketed to people with terminal diseases offering them hope (but in the small print offering perhaps 3 months longer life, not guaranteed).

Everyone involved in the process should be ashamed of themselves.

> As an aside, I cannot tell you how angry our direct-to-consumer drug advertisements make me. Especially the ones that are marketed to people with terminal diseases offering them hope (but in the small print offering perhaps 3 months longer life, not guaranteed).

After reading an related article (http://slatestarcodex.com/2013/07/17/who-by-very-slow-decay/) a few weeks ago, it's no surprise that the market has answered the calls of those who really do want doctors to do everything and anything to prolong their loved ones lives. The selling point for these medications are hope, and I agree that it'd be sensible to regulate advertisements so consumers can truly weigh the benefits versus the costs before they in an emotional state.

thanks for the link, it was a good read.

Only New Zealand and the US allow prescription drug marketing directly to consumers. And yet, all other developed nations seem to be doing well managing pharma access for their citizens.

A cynic might think this policy is intended to juice US pharma profits.

idk, the past few times I was in Russia I saw a plethora of adverts on TV for drugs.

Not prescription drugs.

Making it easier to get drugs exacerbates this problem: people start widely prescribing themselves drugs that do them harm, in combinations they don’t understand, all believing what the pervasive advertising mind-control system tells them to believe.

Our current situation is terrible; this just makes it worse.

Similar to this idea, the province of Alberta in Canada allows pharmacists to write prescriptions for patients with only the only limit that they can't prescribe controlled substances.

100% agree. I'd love to see this in the US. most pharmacists have way more knowledge about drugs, their interactions and other issues that can crop up with prescription drugs. Given a diagnosis they are typically better at prescribing the correct medication than a general practitioner. It's also a lot cheaper than a doctors visit for insurance.

You handwave over “given a diagnosis” like it’s an irrelevant detail.

You appreciate this is the largest part of the problem, surely?

I would be interested to know what percentage of prescriptions are for things which can't be diagnosed by a pharmacist (or are just requests for a refill of an existing medication).

I think this is the point of the nurse practitioners that CVS (or was it walgreens/etc?) had in some of their stores a few years ago. When my kids were in day care and got frequent ear infections, I could tell by their behavior it was time to check their ears and.. well i'm not a doctor but I can probably tell if you have an ear infection with my cheazy/plastic over the counter otoscope I impulse purchased from said drug store. Going to the doctor to get the same prescription I had filled two months previously is just silly.

Same thing with my poison ivy...

I don't think it's the place of a pharmacist to diagnose people. But I do have a friend who's a pharmacist and they see doctors consistently poorly picking medicine for things they've diagnosed.

I get that the initial diagnosis is the biggest part. But there is a ton of domain knowledge in drug interactions, expiration, etc that doctors just don't deal with on a daily basis. It makes sense to separate the jobs so each individual can get the best at their role. I don't mean to undermine diagnosis that's a huge deal, but I'd love to see doctors focus on what they do best.

In certain states, you can get a prescription for some medications online. I've taken birth control for years and this is the most efficient option for me without the $150 co-pay my gyno charges.

This seems quite different; pharmacists are trained professionals, and not a mobile phone app.

I like this, with the exception of anti-biotics because misuse would spread immunity.

You can already buy most standard antibiotics without a prescription if you don’t mind taking fish medication ;) amoxicillin, ciprofloxacin, penicillin, etc are all readily available through amazon and are identical to the human version.

I think it would be possible to create a system of law which would encourage people to take their full course of antibiotics.

Presumably only for trivial conditions id hope.

Edit it will also lead to over prescribing of antibiotics and cause drug resistance to rise

I'd actually hope not. Many people have chronic conditions which require periodic visits to a doctor mainly for the same prescription to be renewed. A doctor should absolutely be involved in follow-up management, but don't make patients go every two or three months just to get the same prescription as last time and to get insurance to cover the meds.

Once a chronic but potentially well-managed condition is diagnosed, let people record their blood pressure, blood sugar, weight, and whatever and submit it for records. Let them renew their prescription with the pharmacy without spending hours finding an appointment that then takes hours to actually be seen. If their condition hasn't changed, once or twice a year with the doctor should be plenty.

As some one who has lived with a serious chronic condition id say the opposite - I don't have anyting against my local pharmacy (and they have been good and even hand delivered meds )

But I suspect that they probably have two at most patients like me as opposed to the nephrology specialists who see dozens of people like me each week.

Are there easy at-home tests that would be useful data for your doctor? Is once a month necessary for this specific condition? Is three months? What about keeping records and sending them to the doctor every couple of weeks so an extra appointment can be scheduled, but only once every four or six months normally?

I have hypertension. I've had it for years. It doesn't just go away, but it doesn't (at least in my history) rapidly get worse. I can take my blood pressure at home and chart it. The same medication I have always taken works and at the same dosage. Yet most doctors want to see me every two months to renew the prescription, prescribing a one-month supply with one refill. The stuff's shelf stable for a few years. Why can't I get a six month prescription?

> Presumably only for trivial conditions id [sic] hope

I'd hope not. I used to be asthmatic. At one point in my life, getting--and paying co-pay for--a doctor's appointment was not easy. There were nights when I weighed suffering a little longer against the risk of triggering an ER visit. Being able to go to a pharmacy to get albuterol would have made a tough time easier with minimal risk to anyone else.

Why are you no longer asthmatic? Did you move to a less polluted/better climate area? Change your diet? Something else?

> Why are you no longer asthmatic?

I managed the allergic reactions that were causing it. Far too late in life, I discovered I'm allergic to grass. So I avoided hiking in grass and started popping a Zyrtec when my dog came back from running around in it. (I'm still allergic to my cat, but unless he sleeps on my chest it's manageable.) Solved the problem sufficiently that I no longer have an inhaler.

I would be interested in this as well. I feel like my asthma got worse since I moved to an apartment next to a busier road.

I can't speak for JumpCrissCross, but there are 3 things that improved my asthma:

1) Eating better. Low level inflammation is terrible for people with auto-immune disorders, to which the trio of asthma, eczema, and allergies belong.

2) Moved closer to the ocean - salt air is great for the lungs, and really has a way of helping deal with any allergies you might have to local pollen

3) RUN! seriously, aerobic exercise for 45 minutes to an hour (anything less doesn't count) is a literal life-changer. Yeah, it really does suck for the first two weeks (if you're doing it every other day), but after that you'll start to feel amazing. You'll lose weight, which also helps with the breathing. And you'll have way more energy and higher happiness levels, which will help you want to move around more and be outside, which again will help with your asthma. Seriously, if I could do only one, this one is it. Run. Or swim if you can't (I only run on sand or dirt because my knees are shot).

Best of luck!

Not everyone's asthma is like yours. For example, trying to run for 45 minutes would kill me these days. My asthma is triggered by exercise and even when I used to exercise quite a lot and was on more medication it was a struggle. So don't assume everyone's condition is the same as yours.

Ilaksh, I seem to have touched a bit of a nerve here. I know, I used to respond the same way to similar advice. I wasn't assuming anything about anyone's condition - I was giving personal advice based on my experience. I say this as a person who grew up with extremely exercise-induced asthma - I used to run a slower mile than I walked (due to collapsing multiple times), went to the hospital multiple (6+) times a year (from ages 8-20), etc. Also, running in dry and not-salty humid climates is still a bad idea for me, or around certain kinds of trees. Running for 45 minutes was something I worked up to around the age of 25 - started with 5 or ten minute periods, interspersed with walking, until I was able to do another brief run, etc. When I stopped running for a few years, my issues came back, with multiple hospitalizations from 28-30, until I started up again around 30.

Part of the issue with exercise-induced asthma, for me personally, was also general nutrition and health - I found that as I earned more income, and switched to a diet higher in fats and vegetables and lower in carbohydrates, my condition significantly improved, providing a positive feedback loop with the exercise that eventually has brought me to being nearly symptom-free today (34). Your mileage may of course vary.

The main reason I focused so much on the running is because for most of my life I thought it would kill me, and always told myself that the reason that I didn't run is that it was bad for me. In the end it was exercising more and eating better (in a better environment) that saved me. Hopefully you'll find the trick for you - living with asthma is really unpleasant, to understate it.

But there is still the implication that my disease is the same as yours and that I just need to run out of it. I was extremely active throughout my youth including intensive training for wrestling and less intensive training for two other sports and in no way did exercise diminish my asthma throughout many years. So although I do look forward to becoming more active again, I will need to increase my medication dosage and use a rescue inhaler every day and I will never be symptom free. I am not like you.

Can't you just logon and order a repeat prescription which is then delivered to your local pharmacy.

> Can't you just logon and order a repeat prescription which is then delivered to your local pharmacy

No, I had to physically go to the doctor to get the prescription renewed every so often.

Beyond time. I find it pathetic that living in the "land of the free, home of the brave" I need to travel out of the country to be able to pick up basic medications without a permission slip from the authorities. I utterly refuse to pay $100+ so I can get a signed hall slip from a doctor to get what I knew I already needed.

This perhaps will save me some travel costs every few years when I go to restock the personal pharmacy.

My pharmacist friends have long bemoaned the 'go to the doctor for everything' scheme. Some conditions are easily diagnosable and the side effects of the drugs are minimal. They'd much rather see the doctor as an escalation if treatment isn't responding or the patient has additional symptoms that could indicate something more serious. The behind-the-counter system is a great idea.

Yes, it's incredibly inefficient to have highly trained, expensive doctors acting as tier-1 tech support. But they have a powerful union, so they can keep being paid top dollar for their grunt work.

The kinds of doctors that work as "tier-1 tech support" -- that is, primary care -- are not being paid top dollar, believe me. After you account for the cost of education, delay of entry to the workforce, hours worked per week, and the fact that insurance compensation models are biased towards specialty care and procedures, and it starts to look like bad financial planning.

"Some conditions are easily diagnosable and the side effects of the drugs are minimal."

Sounds like a good time to see an NP/PA. Things should be triaged more effectively. Pharmacists <-> PA/NP <-> MD/DO.

That chain you're outlining is part of the problem with health care in the US.

It's not just pharmacists or PAs, it's psychologists, optometrists, dentists... The problem is we have this over regulated system that doesn't recognize the actual capabilities of many in the system that could be doing a lot more than they are, we're it not for professional lobbying around turf.

There are huge unrecognized bottlenecks to care that have everything to do with inaccurate regulatory assumptions about who can do what, starting with the consumer themselves.

I get a little upset about the idea of triaging down a chain, because the triage chain itself is a flawed idea. I dream of a much more competitive system where people get drug advice from professionals based on those professionals' training and expertise, regardless of specific training pathway or background.

Bravo. The AMA/FDA/insurance cartel cannot die soon enough.

I don’t care if you want a free market, or you want socialized medicine, both are preferable to government-enforced racketeering.

You mean the AMA and FDA should stop preventing patients from taking contraindicated combinations or failing to understand the risks they’re taking on by self-medicating? Pharmacology is complicated and dangerous. Letting corporations go hog-wild will harm many people.

You realize that's why the FDA introduced the "behind the counter" classification, that requires pharmacist interaction - and frankly, I trust my pharmacist on drug combinations more than my physician.

Correct. Which is why only so many drugs are behind-the-counter. More dangerous drugs or ones which need more guidance to avoid harm have tended to be prescription only.

IE, there’s a reason not every uncontrolled substance is OTC.

...that and we'd better start inventing some new antibiotics now. As it is now, physicans can barely prescribe them responsibly. If they are available as cold medicine antibiotic resistance will surge even harder than it is now. antibiotic resistance is a dramatically underappreciated problem.

This is why I feel only antibiotics should require a prescription - because of the tragedy of the commons.

And yes, I mean only antibiotics. You popping Vicodin for fun doesn't directly affect me, so it's none of my damn business.

Isn't human misuse of antibiotics a drop in the ocean compared to the livestock feed? Pretty sure we could completely stop all human misuse and we'd accomplish nearly nothing toward the goal of stopping antibiotic resistance.

I very much agree that live stock antibiotic use is a major issue, even with the recent regulatory advances, but I cannot agree that minimizing human misuse is trivial. Ignoring either issue leaves a flank wide open for attack.

That’s a good, simple example demonstrating a problem.

I also think pharmacokinetic effects are likely underappreciated by the general public.

Great, you've discovered the problems they solve for. Now solve the problems they create.

Then, weigh the two against one another.

Let us know what you conclude. Then we start the lobbying process...

So Americans can be even more heavily medicated? If you need a statin or high blood pressure medication, there should be a doctor in the loop to help motivate you with a healthy lifestyle.

You know the FDA stopped thalidomide being prescribed? there was an epidemic of kids born in the 60's with massive deformities in the Uk and Europe.

I'm always struck by the intensity with which some HN folks hate their doc - reminded of this by the number of comments invoking conspiracy theories about docs scheduling extra appointments to bill more or push more generic drugs.

Perhaps obvious but perhaps not: in the US and most EU countries I'm aware of, you can choose a new doc. You can shop around. Despite the flaws in online reviews, just as with Amazon, you can read between the lines. Choosing instead to avoid healthcare completely seems self-defeating.

I'm sorry to read so many horror stories - going to the doctor even for docs (especially for docs?) can be a frustrating experience. But while you're burning down the FDA, at least shop around and find yourself a good primary care doc.

For me the issue is not exactly “burning down” the FDA, but rather changing its purpose from regulatory to only advisory (and hopefully changing associated statutes). The FDA provides a very valuable service by identifying the risks associated with various food and drug. It is one thing to educate the public and say “XYZ presents risk of ABC for this specific group of consumers.” It is a very different thing to also add “therefore, consumers cannot make the decision to take on the risks associated with XYZ because the FDA (and associated governing bodies) have decided the general population should not take these risks (regardless of the overall risk level and their individual risk factors).”

This is more or less how I've felt. There are so many high-risk behaviors which are perfectly legal, and when our right to take risks in those ways is challenged, there is generally backlash; but in the case of drugs we are legally prohibited from taking risks.

I think the FDA's prohibitive authority does more to protect the interests of established pharmaceutical manufacturers, than the interests of consumers.

A rural hospital kept my grandma alive 10 extra days to milk Medicare for the maximum allotment. There is nothing American healthcare won’t do to make a buck

But your parents have control over hospice arrangements. The only thing a hospital can legally in most states do once you decide to let her die is to sedate if necessary and cut off food and let the body shut down.

What gives you the idea it was a conspiracy?

Wow, if you knew anything about how shitty our system is to dying people and their families I suspect you wouldn't be sealioning someone in GP's position.

I suffered for almost 15 years with something that was supposed to be easy to fix. The medical industry incompetence and exploitation is not limited to a country. The problem is world wide.

The problem is not that one given doctor can't fix an issue (which can happen). The problem is the monopoly they have on our health, preventing us to seek different solutions, get extensive tests done, etc. In the US it is easier to get liposuction than to get some basic testing done if your doc thinks it is unnecessary.

For example, depression is usually "solved" by prescribing SSRIs, but if you do some research, you find that there are perhaps hundreds of possible causes for it, none of which are usually tested for.

Yikes, my girlfriend is applying to med school as we speak. The medical industry is certainly a highly regulated, potentially overpriced service for decades now.

When I see a headline like this, I have to seriously ask myself: "Is this when the bubble finally pops, or will it be status quo for another generation?"

The medical changes in the US take forever for change to occur. Even if greater access to some of these common medications is to happen, it will take close to a decade or more to see it meaningfully impact the industry. There will likely be a few drugs that become available before that, but likely not many and not enough to change the cost basis much.

The US medical and pharmaceutical community is a very powerful political lobbying group as a whole and while some of this might be good for them they are not great at change, so it will be fought for years to come.

Medicine in the US may become more affordable, but will not lose its prestige or the solid return on investment for physicians overall, IMO.

I'd be pretty shocked if the pharmaceutical industry is against this. I would bet they _lobbied_ for it. They can already advertise direct to consumers, now those consumers will be able to go directly to purchasing medication with no intermediary (no "ask your doctor if X is right for you"). This seems like it's GREAT for them. I would expect marketing budgets to go up dramatically in pursuit of these disintermediated consumers, and those marketing dollars to have a great return on investment.

Do you have any reason to think otherwise?

Hmm, pharmaceutical industry lobbying seems to have had a significant bump in 2017, from $250 million to $280 million based on lobbying paperwork filed... https://www.opensecrets.org/lobby/indusclient.php?id=H04&yea...

It's not as great as you think for the pharmaceutical industry. They can't charge as much for OTC drugs because people won't pay for it.

If the drug (or a similar in class competitor) is available OTC then they also can't charge as much via prescription.

So both ways, prices go down.

Many times they still charge more for the prescription med still. Great example I just saw. We all know ibuprofen has been available as an OTC for a long time. Cheap to buy too, < $10 gets you a 100 cnt of 200mg pills at most pharmacies OTC in the US. But a physician can and will still prescribe 800mg Ibuprofen tablets to a patient. That prescription for say 40 tablets may cost the consumer $5-10 co-pay, but insurance has paid $35 or more. So the price per pill is drastically different, you can take 4 of the OTC pills and get the same affect.

The one difference in this example, the one 800mg pill is less harsh on the stomach than taking 4 of the 200mg pills. Which is the reasoning usually for this type of prescription, that and convenience for the patient.

> but insurance has paid $35 or more

Insurance does not actually pay that much. Because of drug rebates (paid by the drug manufacturer), clawbacks, and Co-Pays, in total the drug manufacturer gets about the same as they would for the OTC drug.

See here: https://money.cnn.com/2018/05/07/news/economy/drug-prices-re... (and that article barely scratches the surface).

Destroying that entire money-network would be probably the #1 thing that could help US medical spending. And as much as people hate Trump, he's probably the only one with the actual ability, and desire to do something about it.

Other presidents have cared, but they were too risk adverse, Trump would be like "hmm, looks good - do it and let's see what happens". That kind of risk taking gets him in a lot of trouble, but it's why he was elected, and why he still has support despite the INCREDIBLY stupid things he says.

Rebates and incentives are very common when a drug is on patent, but not once it is available as a generic. Insurers have to pay the generics generally and have no rebate for those, though I am sure there are exceptions. Even the article you linked points that out, and a drug like ibuprofen that is generic at this point, has no rebates or incentives, only a negotiated fee on the class of medication generally.

When I worked on doing data analytics for one of the large speciality pharmacies a while back, some of their medications had rebates in the low 5 figure range, the medications were typically a low 6 figure prescription. But for the generic meds they carried, there was no rebate and insurance paid the full fair at whatever was negotiated for the class of medications. That was a fun/educational project but also a bit depressing seeing how the system works. The pharmacies are also in this weird middle position where they have to process a lot of the data (and business rules), but can easily get squeezed out of the profit if they aren't savvy.

I am with you, destroying the supply chain money antics would be a huge benefit in the US to cutting down the waste and useless spending.

> he's probably the only one with the actual ability, and desire to do something about it.

I'll believe he has either the ability or the desire when I see it.

I dunno, the name brand for a generic I took costs ~$200 a month.

The generic is $7.

That a different thing, name brand vs generic.

This is OTC vs. Prescription.

Although I bet your insurance company doesn't actually pay $200 if they cover it - they probably get rebates that cover the difference, and then make you pay a higher co-pay.

It's not completely different, the branded drug faces pretty stiff competition and hasn't cut prices.

I can't say you are wrong. But also remember the industry is lobbing against many things right now which have come around in the past few years, including the perception of opiate prescriptions where they are trying to moderate the discussion. Hence spending has gone up considerably.

My personal logic is they typically have lobbied to keep most drugs regulated (or split) so to keep their reimbursements as high as possible. Most drugs once they go into the OTC market drop in margin, and volume does pick up but only to a point plus it comes with increased competition now.

The last few allergy medications like Zertec, Allegra, Claritin etc that were once prescription only went OTC and margins dropped for the OTC versions. However, you will find at least in the case of a couple of them the companies were pushing for them to be OTC from the beginning because they had developed the drug with the intent to be OTC. However, even if you look at OTC allergy meds, most can still be prescribed and hence paid for by medical insurance and the per pill price is drastically higher, but the out of pocket expense for the consumer is lower (which is just screwed up IMO). Last point on this, once it goes OTC the competition on manufacturing skyrockets, again driving down margins for everyone, similar to when a prescription med comes off patent initially.

I could see an argument though where the AMA and other physician lobbying groups here may diverge from the pharmaceutical lobbying but in general from my knowledge they work pretty close together.

It reads to me like these medications are _not_ going to be classified as "over the counter." Even though they will not require a prescription, that's the whole point.

I wonder if the regulations are written in some way to allow them to keep charging prescription prices without a prescription. The article definitely suggests it's a new "status", not merely making more things OTC.

From the OP:

> Finding a way to expand access to widely used prescription drugs has been a goal of regulators in recent years.

> The FDA explored the idea of a “behind-the-counter” designation in 2007 that would have required interaction with a pharmacist. The Government Accountability Office in a 2009 report on the proposal asked whether consumers would end up paying more for their drugs since nonprescription medications typically aren’t covered by insurance."

Note, since they aren't typically _covered by insurance_. A new designation that would be covered by insurance, fit into insurance schedules under "prescription", but not actually require a prescription -- hey, "everyone" wins!

From: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/u...

"Currently, nonprescription drugs can be marketed under either of two regulatory pathways: the Over-the-Counter (OTC) Drug Review (OTC Monograph Process) or the New Drug Application (NDA) process, and there are different requirements under each system. Today’s new FDA draft guidance, Innovative Approaches for Nonprescription Drug Products, applies to drugs under the NDA process and is intended to extend that NDA pathway to include therapeutic indications that have not, historically, been available for use without a prescription."

The (very brief) draft guidance itself: https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegula...

It’s literally not sustainable. The size of the population that has been priced out of access to medical services is approaching a majority if not already.

90% of Americans avoid doctors like the plague. 10% blow out their insurance like they just won the lottery.

I’m one of those 90%. I simply don’t trust that doctors’ incentives align with mine. Too often it seems they do nothing but shrug and bill you for the visit, send you for expensive blood tests, or send you to their specialist med school buddies so they can bill you for 5 minutes too.

Then there’s the billing: you don’t know what you’re going to pay until months later, after you sign a form saying you’ll pay anything they want! They will never quote upfront and will never itemize what they did.

My favorite doctors in 2018 all take cash and are all substantially more up-to-date than most insurance-system GPs.

The A-players have left the insurance system or are in academia, make no mistake.

For some cost-prohibitive things such as surgery, you really don't have much choice, though.

For some cost-prohibitive things such as surgery, you really don't have much choice, though.

Go overseas. To one of the medical tourism destinations. The care is far superior and the cost a fraction. Cheaper than the insurance premiums alone.

Highly regulated except for one critical aspect, and that is price. Other nations control the prices that are allowed to be paid for drugs.

Does your GF really want to rubber stamp things epipen Rxs? Once you have the allergy diagnosis, it generally doesn't go away.

It's kind of like low tech automation.

I think these days, whether or not a doctor or physician assistant "wants" to do something isn't really considered in the equation.

Basically, the schools jack up the medical practitioners with hundreds of thousands in debt, and the practitioners will do absolutely whatever is required to pay it off and eek out a living :(

I wouldn't do absolutely whatever is required to pay off my debt nor would my peers. But we can relate to the concerns of hundreds of thousands in debt as far as we can't "want" anything. We're just as trapped in the system as the patients we treat. No wonder why there is a spike in suicides after medical school.

It's just shifting to pharmacists who are also medical professionals, it was inevitable given the success of pharmacy based immunization programs.

I think this is good. For many people a lot of the costs are the doctor visits. Look at the Walmart 100 common generics for $4. I wouldn't be surprised if 50% of the hospital visits can be solved by one of these generics but then we add an expensive doctor visit to get a $4 medicine. There needs to be a more affordable solution.

> I wouldn't be surprised if 50% of the hospital visits can be solved by one of these generics but then we add an expensive doctor visit to get a $4 medicine.

Its really not surprising that the expensive part isn't the drug but the expertise to select the correct drug; it's true in lots of fields that the equipment or consumables aren't nearly as expensive as the brain to choose which of those to use and how.

Bits are a lot less expensive than the software engineers that arrange them.

The true root of the problem is largely systemic: healthcare is a for-profit system in this country and was poorly designed in the first place.

For example, employment based health insurance is largely a relic from WW2 because companies couldn't increase wages and offered it to entice workers. This was logical at the time, but in the 21st century makes very little sense.

Until we can turn it into a true public service, little will change. We can band aid the solution as much as we want but we will never be able to resolve the true core problems.

Let me know when I can get Adderall without having to jump through endless hoops...I can probably get cocaine delivered to my door with less effort.

> Patients could answer questions on a mobile-phone app to help determine whether they should be able to access a medication without a prescription.

The primary issue I am concerned with is self ownership of my body, and the freedom to choose for myself which drugs I will consume. Transferring the permission process from a human medical professional to an algorithmic goverment agent does not give me anymore of what I want.

It's a step in the right direction. Doctors' stranglehold on pharmaceuticals won't disappear overnight.

I think it's a step in the wrong direction. The authority of approving drug use is moving from private citizens (doctors) to the government. A step in the right direction would be making more drugs otc.

A permission process seems inextricable from a system in which there are regulations. But algorithmic agent would theoretically make approved drugs more accessible. The expense and time of a doctor visit is enough friction to stop people from getting drugs they may find beneficial.

Recreational Cannabis has lots of regulations, and the only permission needed is a legal id and being an adult in several states.

My goal isn't to reduce friction for accessing medicine. A person would be a fool to not jump through the hoops required to gain access to life improving medications. The low cost of a quarterly doctor's visit for a continuous prescription is well worth the benefits a modern pharmaceutical can provide.

My goal is to have ownership of my body. It's a personal insult that I even have to ask permission.

There are many systems in which production requires the following of regulations but the purchasing and consumption does not, i.e. food.

There is definitely more leeway with food. But the FDA, for instance, bans raw milk from interstate sales: https://www.npr.org/sections/thesalt/2015/02/20/387558373/wh...

Local governments can also regulate what food is purchaseable, more specifically, who is legally allowed to sell food; restaurants have to agree to pass health inspections, for instance. As another example: Peking Duck was effectively illegal because of health regulations until legislators (of Asian descent) were able to pass laws saying otherwise: https://www.nytimes.com/1982/03/31/us/around-the-nation-cali...

This can't come soon enough. I hate going to the doctor in general, but especially for basic shit I've been using for years.

Nurse practitioners are already great for when you just have an infection and need some anti-biotics. They have little clinics with them in many drugstores these days.

NPs can already prescribe drugs (just not narcotics, iirc).

Nurse Practitioners can prescribe Class II narcotics in most states, if their supervisor physician allows it.

Thanks for clarifying that.

Interesting that they mention Naloxone.

In Australia (VIC at least), Naloxone is available for free over the counter at the pharmacy. Needles are also readily available (and I'm fairly sure they're free).

It doesn't really make sense for Naloxone to be prescription. Smack users aren't going to go to the doctor for a prescription. You can't get high off the stuff, all it can do is take you off a high and keep you breathing until an ambulance arrives.

On the other hand, if I want painkillers with opioids like panadeine (codeine + acetaminophen), I need to get a prescription. Same if I want cold medicine containing psuedaephidrine, because I might make methamphetamine with it.

If you are in Australia you can get pseudoephedrine without a prescription - you just give the pharmacist your drivers license and ask for the stuff that works. How pharmaceutical companies can be allowed under our fair trading laws to sell phenylephrine I don’t know.

Given the degree to which people waste time and money taking supplements that do absolutely nothing, this doesn’t seem like a great idea. Sure, if you are on HN and stay up late reading meta-analyses it would be fine, but then governing the “Democratic Republic of HN” would be very easy in many ways.

If there was actually a proper system to enable evidence based and cost-effective usage of pharmaceuticals without doctors it might improve things for patients, but I don’t see that there is.

This sounds like a bad idea until I remember that most countries have this arrangement and I've made liberal use of it to great benefit... but mostly that has to do with the lower cost of drugs everywhere but the United States. I stock up every time I go to Europe, and I just made a run to Tijuana for medication my insurance company doesn't cover.

The downside is that insurance wouldn't cover these often expensive medications if they are OTC.

looks like this is a draft guidance document, so it may not actually come into effect for a while. something like this seems like it would be massively controversial, and thered probably be a lot of debate on both sides. overall though the idea is very interesting.

something like 20% of US health spend is on outpatient care. i dont know how much of that relates to medication management, but id imagine a lot does. PCPs get paid more when they manage a patients medication, and many psychiatrists make nearly all their income from adjusting prescriptions. im sure other specialties are similar. so this theoretically enables some of that work to be done without the physician. this could significantly reduce cost of outpt services, although it will depend very much on how hard it is for pharma companies to demonstrate non rx use of their products is safe and effective. it may be the case that only a few meds actually are eligible, or that many are, once the guidance is finalized

i havent read the guidance doc yet so dont really know how this would play out in terms of who decides what to rx if not a doc.

i personally am sort of disappointed to see doctors becoming even more sidelined. doctors really do an important job of filtering info for patients, advocating / negotiating with insurance companies, and looking out for them. this could potentially be one less protection for patients as large companies get more power to control info. id like to see cost taken out of the system by reducing pricing power by breaking up large providers rather than disintermediating doctors, but that isnt within fda's mandate, so i understand why fda would go for something like this

this could be good for patients if it is implemented in a way that doesnt give pharma too much power over patients. cost would decrease and access to meds could increase. however there may be more patients taking medicines for reasons other than the health benefits (ie marketing power / influence)

> i personally am sort of disappointed to see doctors becoming even more sidelined. doctors really do an important job of filtering info for patients, advocating / negotiating with insurance companies, and looking out for them

Tell that to my doctor, who on a routine checkup sent me to the lab for lab work without clearing it with my insurance company. I got a nice $600 bill for the lab work that the insurance company didn't agree was 'preventative.' After calling the insurance company they ended up waiving it, but told me that in the future I should clear every single thing the doctor orders with them, because the doctors won't do it.

The supply of doctors in the US is artificially constrained, and physician care costs more here than anywhere else in the world. Anything that removes them from the equation, especially for basic things like prescriptions, is a plus in my book.

Exciting news. My only hope is they they would simultaneously dial back medication advertisements.

In China, you can't even buy loperamide. I think, they think that you can get high on it if you eat a bucket load of it

Sounds like a way to mimic the success of over the counter medications like ibuprofen, whose prices have been slowly creeping up for years.

Many of the major profitable blood pressure and statins are off patent, so the drug companies need to make more money.

I’m sure this status will limit or eliminate insurance contributions, so now you’ll pay more for generic because 50 million individuals lack the buying power of CVS and the other PBMs.

Incorrect. 200 mg Ibuprofen is 2 cents a pill at Walmart.

https://www.walmart.com/search/?query=ibuprofen%20200mg%2050...

Walmart physical stores “brick and mortar”, charges different price for the same product, taking into account different “factors” like local competition.

Pointing at a single data point is not enough evidence to show that an upwards trend does not exist.

The single data point is the exact same single data point mentioned in the comment as the only evidence that an upwards trend existed in the first place.

...And the generic gelcap that is heavily marketed and merchandises better costs 7x more.

Finally we come to common sense.

This will be great for pharmaceutical profits, not so great for insurance premiums.

Why wouldn't it have the opposite effect?

Patients aren't price sensitive when their insurance provider is paying. It creates a suboptimal three (or four) party pricing problem.

It seems like it would be preferable if patients chose whether to follow a physician's instructions based on whether they got sufficient utility or quality of life improvements from the pharmaceutical to justify the cost. Likewise, if patients incur lower costs on the insurance provider their business is more valuable, and competing insurance providers will try to undercut them resulting in lower prices.

The only "loser" in this scenario seems to be the pharmaceutical companies, which will come in the form of a combination of short term reduced shareholder profits, and long term slower pharmaceutical research. However, it is not difficult to argue that if drug expenditures are too high, it ultimately comes down to paying the bills for over investment in research rather than the cost of production.

I think if anything this would slightly lower insurance premiums, since insurance generally doesn't cover nonprescription medications.

As for the effect on pharmaceutical companies, it could go either way. On one hand, it makes it much easier for customers to buy them. On the other, the customer is paying for it out of pocket, and the price is right there on the box. If there are multiple drugs that treat the same condition, customers will take into account price when choosing which one to buy, and so you'll start to see the effects of a free market encouraging competition and driving down prices. Of course, if there isn't any competition for that drug category they can make the price whatever they want and the poor will wind up screwed.

You have that 100% backwards.

Insurance premiums will go down since OTC drugs are not covered by insurance. Pharmaceutical profits will also go down because people are much more price sensitive for OTC drugs, so they can't charge as much.

I could be wrong, but I was under the impression that some plans will cover OTC medication if a doctor "prescribes" them for you.

According to the article, these drugs won't be considered OTC, they still need a pharmacists approval. I don't know how that will affect coverage, if at all.

> I could be wrong, but I was under the impression that some plans will cover OTC medication if a doctor "prescribes" them for you.

Yes, that is correct. But the idea here is to have a person decide to take it without having a Dr prescribe it, so insurance will not cover it.

Probably not very good for patients either.

How do they propose to deal with the potential dangers of drug interactions?

Today you can research drug interactions online just like many doctors do. I have to do this for the combination of supplements and the one prescription, since most doctors are not trained in this area.

In the majority of cases, online interaction checkers might be OK. But please be aware that there's more to drug interactions than using online checkers.

You can have a drug interaction that is red-flagged but can be deemed harmless depending the patient's medical background (QT prolongation). In other cases the interaction can be undocumented, and relies on the instinct and knowledge of the medical professional to piece together the pharmacology and make a judgement of the risk to the patient (co-sedating drugs, drugs that are processed by CYP2C19 vs CYP3A4 enzymes -- there's a big difference).

Also need to take into consideration the timeline of administration. Some drugs clear very slowly from the body, and simply taking one drug after the other is discontinued can be a dangerous assumption to make (antipsychotics).

There are a lot of other interactions that are flagged, but after careful appraisal of the evidence, they're not that much of a concern to the patient.

Also consider route of administration. Does taking a transdermal patch interact with an oral medication? What about eyedrops and inhalers? What are the absorption/distribution/metabolic/excretion characteristics of the drug? Peak drug concentration levels?

Some of these details are picked up online. But you need to be aware of fundamental gaps in your understanding of medicine. It's like being a self-taught developer. Sure you can learn enough on your own to be useful, but without the years of theory and fundamentals, you will hit a roadblock which can be costly.

You're fortunate to have both the intelligence and the time to do that effectively. Not everyone has the capability to assemble, decipher, and fully understand that information.

In my opinion, everyone should take the time to study the drugs that they are prescribed, as well as the interactions to foods and supplements. I believe this is more important that anything related to one's career or investments. You only get one body.

The guy sitting in the local fatburger downing the 128 oz of full sugar soda hasn't even bothered to understand their basic nutritional requirements - drug interactions are going to be waaayyy beyond them.

It sounds to me as if you're failing to grasp just how difficult that is to do for at least 80% of the population.

I completely understand that a majority have a big learning curve ahead of them. I am just not a fan of corporations and laws targeting the lowest common denominator. I should have the ability to consent to making these decisions myself, assuming I am willing to take the risks. I would even be fine with getting a government issued certification that verifies I am educated enough to make an informed decision.

If not the Hacker News crowd, who remains to think of the 20% for whom systematic paternalism is an enormous net drag?

> How do they propose to deal with the potential dangers of drug interactions?

My guess is greater reliance on pharmacy systems.

Drug interaction problems happen now; the current scheme fails to prevent this. Can you provide evidence that the proposed change will be significantly worse?

As some point the parade of horribles we're confronted with whenever any change is offered becomes preferable to the reality we're actually living.

Could be as simple as having the user input any other drugs, foods, substances, etc. they are currently consuming and then checking for interactions on the back end. There are already many sites that do this.

"The little blue ones and the big yellow ones."

"Results not found. Please read label and try again."

> Patients could answer questions on a mobile-phone app to help determine whether they should be able to access a medication without a prescription.

Day 2: Websites showing the correct answers to get anything you want show up.

This is an absolutely bonkers idea.

As opposed to the alternative where people buy said meds from a dude in an alleyway?

By that logic, I should already be able to buy medication from back-alley dudes.

While I could quite easily get ahold of Marijuana and other illegal drugs on the street or the dark side of the net, I have never seen an offer for non-narcotic prescription drugs.

No, the real "bad scenario" is "people go without drug that could help them because doctors & insurance are seen as too troublesome and expensive"

This is a good thing. Doctors, while good for some tasks, can have an adverse effect on the flow of medical issue processing and patient care commodity distribution. This initiative will lift the barriers to competition that forces us to depend on the stodgy old-fashioned personal visits. Medical issue processing should require no more than a few snapchats per conflict.

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