Hacker News Reader

Comment by Communitivity | Hacker News Reader

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.

View on HN

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.

Point taken, thanks.

Litigation does have a preventative effect, but I only see its effects at a more macro, large-scale level, like removal of Vioxx from the market. We are lacking more effective micro, local-scale incentive mechanisms to effect change more incrementally instead of waiting for a generation of doctors to pass through, or for the nuclear blast from litigation to blunt-force change the medical landscape. Just as basic hygiene was the game changer for public health and increasing median lifespans in the past several centuries, I anticipate a smaller, basic change like checklists will in hindsight materially, beneficially alter medical cost and delivery outcomes.

Own technical fields faces similar challenges, so this is I suspect a very human gap.

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.

Reply on news.ycombinator.com