I appreciate an expert opinion here. What do you think is the actual rate of adverse events from Chloloroquine, and of what severity?
I prescribe Plaquenil extensively in patients with autoimmune conditions.The safety profile of this drug is excellent. It is also still used for malaria prophylaxis in healthy individuals .it is not a new drug. I don’t see the reason of labeling it as dangerous. The question is : does it work for Covid19 prevention and treatment? The answer is “the current limited evidence suggests that it does”. What i can tell you that I am aware of a number of doctors in the US who are currently infected or waiting for results who are taking the drug. And I cannot blame them.
Like fine, we can have this discussion about chloroquine. It's behind-the-counter in the UK, so on par with sudafed in terms of access control, and OTC in a lot of countries that actually have to deal with malaria directly. But the same argument gets applied to stuff like oral contraceptives, which are straight-up OTC in a lot of countries too, and can simply be discontinued if you notice symptoms.
At the same time, we allow drugs with insanely narrow theraputic ranges like tylenol/acetaminophen/paracetamol (seriously, almost as bad as the chloroquine people are freaking out about, a normal dose is 1-4g and a lethal dose can be as low as 5g) to be sold OTC here with no questions whatsoever. We allow combination products despite obvious risks for multiple dosing, we allow combination products to "dissuade addicts" from abusing opiods (like any addict has ever been dissuaded by a risk bodily harm). And doctors don't make a peep about that, because they're not accustomed to getting their cut on that one.
That's also why the AMA resists nurse practitioners so hard. The truth is, a lot of those drugs really should be "behind the counter", a pharmacist should simply have to give you a quick rundown of possible symptoms and what to do if you notice them (discontinue and see a doctor or go to a hospital depending on urgency, same as you would do with a doctor-prescribed drug), but doctors won't allow that because they wouldn't get their cut, so we just call them "nurse practitioners" instead.
US doctors really like playing gatekeeper, to a much greater extent than other countries (where coincidentally, money doesn't come into the picture as much).
I'm fine if there's a serious reason for a physical examination, but a lot of stuff the doctor is effectively filling the role of a pharmacist: telling you side effects and if you have this set of serious side effects then to stop it and/or go to a hospital, here's your script, pay at the front desk. A lot of stuff is unnecessarily shoehorned into Rx-only, and despite a lot of talk about "reducing costs" there is no real drive to actually do so.
A great example is oral contraceptives. You may have to try a couple different blends before you find the right mix for your body. Some of them will be uncomfortable. Some may cause dangerous bleeding and you need to go to a hospital. There is not zero risk here, or with any drug. But the doctor has no way of telling which might be which for your particular body, they are there to tell you the risks, sign the paper and let you try it out. And that's why oral contraceptives specifically are being looked at as something that could be moved out of Rx only and to either OTC or pharmacist-prescribable - but the problem is there are really a lot of drugs that don't belong there.
A pharmacist can read the risks to you just as easily and not charge you $250 for a 15 minute office visit and another $250 for a one-month followup 15 minute office visit.
I have lots of 6-month maintenance visits that are literally 5 minutes. Everything going well? "Yup!" "OK, we'll call in your prescription, pay up front". They're just using their gatekeeping power to extract a check.
All this information is available online. You can look up the physician fee schedule straight from the CMS. https://www.cms.gov/apps/physician-fee-schedule/search/searc... . Here are the cardiology codes - https://myheart.net/cardiology-coding-center/coronary-interv...
To add an additional data point, doing a heart transplant is 89.50 wRVU * 36.0391 = $3225. I don't think doctors are living as well as you think. CPT code 33945.
Providers in fact make a point that they lose a significant amount of money at Medicare rates and have to limit the number of Medicare/Medicaid patients they see as a result.
I can confirm that a "45 minute" (5 minutes with nurse taking vitals, 25 minutes waiting in office exam room, 15 minutes with doctor) specialist "new" office visit was just billed to me for $246. They didn't charge me half the rate they charge a heart attack, they charge the heart attack patient 100x as much.
I don't think you understand how US billing works. Probably not from the US, or probably not subject to the system due to age (child or senior) or privilege (an engineer on a cadillac PPO plan perhaps).
Anyone who has ever experienced the US system knows that's absolutely normal.
For outpatient visits, this source says medicare pays 92% of what private insurance pays for established outpatient visits, and 80% overall https://money.cnn.com/2014/04/21/news/economy/medicare-docto... .
I am a US citizen who used to be a software engineer who now attends a US MD Medical school and I have student health insurance.
For the heart attack patient, it isn't the physician who is charging the huge amount. It's the hospital. The physician is only going to get a certain factor (somewhere between 1x - maybe 3x on the extreme end) of that $440 for the wRVUs.
> The researchers found the gap between the prices Medicare and private insurers pay hospitals increased from 2015 to 2017. Specifically, the researchers found private insurers in 2015 on average paid 236% of Medicare rates, and by 2017 that grew to 241% of Medicare rates.
https://www.advisory.com/daily-briefing/2019/05/13/hospital-...
Again, I just provided you an example of me getting billed $250 for 15 minutes of physician time during an office literally this month. Right now. Just paid it today. Will seeing the bill solve this discussion for you?
> For the heart attack patient, it isn't the physician who is charging the huge amount. It's the hospital. The physician is only going to get a certain factor (somewhere between 1x - maybe 3x on the extreme end) of that $440 for the wRVUs.
That's not what we were discussing, you're changing the topic from an office visit to a heart attack. A doctor's office visit is mostly doctor time, there's no surgical ampitheatre necessary for an office visit. No recovery time in a hospital bed. Completely different situation.
$1000 an hour net billing rate for a specialist office visit sounds about right. That's what I just got billed.
And yes, student insurance is unusually generous and usually subsidized by the university in terms of provider reimbursement as well as direct rates. You are not paying the full freight there.
Furthermore, you are far, far off the reservation suggesting the normal billing for a heart attack is $3200. You are underneath the Dunning-Kruger curve here, you don't even know what you don't know and you think you are informed for it.
> Heart attack hospitalizations cost a median $53,384 and strokes cost $31,218, according to the study. The resulting catastrophic costs make it difficult for uninsured patients to keep up with basic living expenses such as transportation and housing, according to researchers.
https://newsarchive.heart.org/uninsured-patients-faced-devas...
Feel free to tell the American Heart Association that they're wrong by a factor of 15. Let me know when they update the article. You're wrong, it's no longer worth continuing the debate with you.
Again, like I said, I mean this in the gentlest possible way: if you think an average heart attack billing (not just for the doctor, the whole thing) is $3200, you're too privileged to have been exposed to the realities of the American system. You are more incorrect than you have the worldview to even grasp. Even the doctors' association themselves think you are wrong.
I'm not trying to change the topic from office visit to heart attack. I provided the RVU calculation for the outpatient visits. That is how much the physicians are getting paid. You said that physicians are making a couple hundred bucks of each outpatient visit, which I don't believe is accurate, and I provided the calculation of why I don't think that is accurate. The total cost of the visit can be $250, but the physician is not getting anywhere near that.
I don't think it's accurate to say that they will be able clear $1000/hr. There is additional time needed to document each patient (often equal to the amount of time seeing the patient). I think seeing 3 visits in that time is plausible, but the physician is not getting that whole $250 (which is the point I'm trying to make). The clinic revenue may be $750 for that hour, but that needs to cover all of the overhead, and the physician will get whatever is left.
Make sure you are looking for sources that compare how much the private insurance pays physicians compared to medicare in particular vs how much they pay hospitals compared to medicare. The numbers will be different.
The $53,384 is what the hospital charges for the heart attack. The physician only gets the wRVUs for the services they provide in the hospital (if they're employed), so the 12.56 wRVU for the cardiac revascularization + the admission history and physical (2.61 wRVU CPT 99222) however many days of progress notes (2.00 wRV 1x each day - CPT 99233) in the hospital and the discharge summary (1.28 wRVU - CPT 99238) they write for the patient. So if a patient got revascularized and were in the hospital for 4 days before being discharged that's 12.56 + 2.61 (admission day) + 2 * 2.00 (2 inpatient days) + 1.28 (discharge day) = 20.45 wRVUs for the admission = $737 for the physician for that hospitalization.
I'm trying to make the distinction here between how much the hospital gets paid vs. the physician who provided the care. It's not accurate to say the physician is making $53,384 for the heart attack hospitalization, that is what the hospital is charging. The physician may make ~$1000 for an admission like that. If the physician is self-employed or in a group, they will charge for the facility RVUs and malpractice RVUs as well, because they need to cover the overhead of having a clinic to see the patient after the hospitalization.
If your bill breaks down the overhead for the clinic separate from the physician charge, then I'll agree that the physician made the $250 straight cash, but I don't think that is in any way the average amount any kind of doctor will make off an outpatient visit. Look at what you're suggesting, that a physician makes $1000/hr * 2080 workable hours in a year (not likely a physician only works 40hrs a week..) = $2+ million a year.
The idea being that if you want to take a trip to somewhere tropical, you don't have to tie up a GP with a standard, low-risk medication, but it's not quite so low-risk that you just put it on the shelf. Behind-the-counter, if you will.
https://en.wikipedia.org/wiki/Over-the-counter_drug#United_K...
> Pharmacy Medicines (P) are medicines which are legally neither a POM or GSL medication. These can be sold from a registered pharmacy but should not be available for self-selection (although directions to discuss a 'P' product may be allocated shelf space with associated GSL items). 'P' medications are reserved from the GSL list as they are either associated with a need for advice on use, or used in conditions which may require referral to a medical prescriber. Suitable trained counter assistants may sell a 'P' medication under the supervision of a pharmacist and will ask questions to determine if the customer needs to be referred for a discussion with a pharmacist.
You're not going to be able to get a registered professional to give you anything for off-label experimentation, especially not something with potentially serious side effects like chloroquine.
There’s a non-zero chance this virus gets into my home and a high-90’s chance the health care system will just turn us away if we got in trouble.
The French study of HCQ had several limitations. Including that it was very small and some patients who got HCQ and progressed to go to the ICU were excluded from the study. Thus making the drug look better than it is
HCQ is not likely to be a miracle cure. It may be useful in combo with other drugs
It's easy to make not great data look like great data to untrained eyes. And it's tempting to cut scientific corners to bring forward a drug for covid-19. But if the drug doesn't work, we should be honest about that and look for better drugs
Should at risk people take HCQ as a precaution until something better comes along? Definitely. but we need to be careful in talking about its potential
Weren't the first studies done in combination with azithromycin (which is bizzare, as that's an antibiotic)?
The mechanism is also quite simple: administer them both together and the antimalarials kill the virus, the antibiotics kill the pneumonia.
I assume they chose that as a broad spectrum prophylaxis for and opportunistic concurrent infection but perhaps they chose it specifically for this reason.
Amazing drug otherwise. My autoimmune symptoms have greatly reduced on it. Wish I could take the full dose.