Re: Sick

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It is annoying, but sometimes doctors do just prescribe the newest treatment even when it's not more effective than another, or it takes 3 days to cure an infection instead of 5 but it costs 3 times as much. Some health plans let you check online to see what's required. Sometimes they want proof that you've tried the cheaper stuff first, i.e. step therapy. Other times they want a reason why it's clinically indicated in your case. Free samples influence prescribing patterns a lot and tend to encourage the use of expensive branded drugs over generics.


Posted by: Bostoniangirl | Link to this comment | 09-18-08 6:01 PM
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Coincidentally, this post came up right next to this one in my RSS reader.


Posted by: Minivet | Link to this comment | 09-18-08 6:07 PM
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1: tend to encourage the use of expensive branded drugs over generics

True; that's why there's a formulary according to which some (generic, usually) medications are reimbursed at a higher rate than other (brand-name, usually) types. Level 1 medications, Level 2, and so on.

I've never encountered an insurance plan according to which a prescription doesn't count as prior authorization. This just seems nuts. Stanley, you have got to tell us, when the revelation has been made clear to you, in what further authorization consists.


Posted by: parsimon | Link to this comment | 09-18-08 6:16 PM
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The step therapy BG refers to seems weird ... but okay: how would a doctor make clear that she has decided that yes indeed, this patient is to have this medication now, and never mind those other steps.

I'm outraged on Stanley's behalf. Weird health plan you got there, my friend.


Posted by: parsimon | Link to this comment | 09-18-08 6:22 PM
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1: Thing is, I don't think there's a generic available yet. It's a relatively new medication (I think it was approved in 2005). And when there is a generic available, my pharmacy has always asked if I want the generic instead.

Stanley, you have got to tell us, when the revelation has been made clear to you, in what further authorization consists.

I presume, based on what the pharmacist said, they get my doctor on the phone with their in-house doctor to determine the specifics of my case. Which sounds an awful lot like second guessing to me. But that's just a guess.


Posted by: Stanley | Link to this comment | 09-18-08 6:23 PM
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"Authorization" must mean authorization by the MD with the health plan. The system is there to control costs by limiting MD's choices.


Posted by: John Emerson | Link to this comment | 09-18-08 6:27 PM
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Anthem - formerly Blue Cross CA - has a whole bunch of drugs "not on the formulary", which means one has to fight to get them. I recently discovered that they have a partnership with a company that makes a medication I had a bad reaction to - and they're still [after three weeks] dragging their heels on authorising an alternate medication. Can we say "conflict of interest"?

Meanwhile, the feds are prohibiting pharmaceutical companies from giving out free samples come January, which is ticking off my doctor because he gives them out to his patients who don't have prescription coverage. Way to go, Washington.

Now, I just wish my cat's antibiotic prescription hadn't been $40...


Posted by: DominEditrix | Link to this comment | 09-18-08 6:30 PM
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5, 6: Right, I was becoming heated. I've since remembered that I went through something like this when I broke my foot: x-ray, check. Shows nothing. MRI, MRI?

No. X-ray shows nothing, so an MRI will not be covered by the insurance company. Physical therapy! For a month (on a broken foot, yay). Well, that was an experience, anyway.

No improvement with physical therapy. Hm, okay: MRI! Oh -- broken foot! Surgery!

Anyway, more to the point, I tend to think of authorization as involving pieces of paper, not a phone call. I gather that's wrong (which is, again, strange; isn't the medical establishment all about paper trails?).


Posted by: parsimon | Link to this comment | 09-18-08 6:38 PM
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Yes, this prior authorization business is bullshit. And it's a good story to tell when you're trying to convince people that we need socialized medicine.


Posted by: Bave Dee | Link to this comment | 09-18-08 6:41 PM
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Don't be surprised if some of the more odious hurdle jumping is not incorporated into any UHC implementation in the US, for "cost savings".


Posted by: Tassled Loafered Leech | Link to this comment | 09-18-08 6:42 PM
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I will say this. In the other instance of a prior authorization confusion I've had, it became clear that the doctor's office does not want to have to be negotiating with your insurance provider on your behalf. That's not their job. I understand their deep resentment of it.


Posted by: parsimon | Link to this comment | 09-18-08 6:44 PM
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I tend to think of authorization as involving pieces of paper, not a phone call.

When I started working for the city a couple months ago and we switched insurance, we also had to do an "authorization" for my wife's prescription. It was a form that the doctor's office faxed over to the insurance company.


Posted by: gswift | Link to this comment | 09-18-08 6:45 PM
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Actually, from the MD's perspective, authorization is an arbitrary, almost whimsical requirement which is required for various drugs, procedures, office visits, etc. It often makes no sense at all, and each insurance company has its own standards. It is not unusual for an insurance company to require prior authorization for a drug when there is no alternative, and not require it for a treatment when there are many alternatives. In urgent cases, we sometimes use medications that cost thousands of dollars and have to get the "prior auth" (that's what we in the business call them) retrospectively. And sometimes, we don't get it.


Posted by: Dr. Oops | Link to this comment | 09-18-08 6:47 PM
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Actually, from the MD's perspective, authorization is an arbitrary, almost whimsical requirement which is required for various drugs, procedures, office visits, etc. It often makes no sense at all, and each insurance company has its own standards. It is not unusual for an insurance company to require prior authorization for a drug when there is no alternative, and not require it for a treatment when there are many alternatives. In urgent cases, we sometimes use medications that cost thousands of dollars and have to get the "prior auth" (that's what we in the business call them) retrospectively. And sometimes, we don't get it.


Posted by: Dr. Oops | Link to this comment | 09-18-08 6:47 PM
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Well, I guess everybody has to double post sometime. Popped my cherry.


Posted by: Dr. Oops | Link to this comment | 09-18-08 6:48 PM
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The prior authorization thing is often wrongly done, but there are cases when a doctor unknowingly prescribes, for example, a more expensive drug for a less expensive generic which is just as effective. Drug companies heavily appropriate their expensive drugs which are still under patent, sometimes quite wrongly.

This sounds sort of Republican, but the same things will come up under socialized medicine or any other form of public medical insurance.

"Ideal medicine" could only be practiced for self-financing patients worth tens of millions of dollars, and it wouldn't necessarily be superior to ordinary medicine.


Posted by: John Emerson | Link to this comment | 09-18-08 6:53 PM
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Not to forget, the stock market has been going down, which makes this the season for raising rates and/or making it more difficult to spend health insurance money.

max
['So if they can save money by making you sicker, they will.']


Posted by: max | Link to this comment | 09-18-08 6:54 PM
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Last week I went to get Caroline her Kindergarten booster shots. As soon as I got in the room they asked me to sign a piece of paper (luckily for once I asked before signing). It's for a second chicken pox shot. I, thinking she already got the first one, which I didn't even really want since chicken pox is not that bad, but since the shot is required for school we did it anyway, say "is this required for school?" "No, but we're recommending it because some kids are getting chicken pox after the first shot." I have to sign because the shot is not covered by our insurance. It costs $132. Last month Caroline's cousins got chicken pox after the first shot, and it was just a rash, not even an itchy rash. I say, "can I say no?" the nurse says "sure." (wow, it would have been helpful if she had initially presented this as a choice that I had, rather than a form I had to sign). So I said "No." We got the shots for the diseases we actually don't want to get (polio, diphtheria, etc.). Administered ice cream, stickers, lollipops, and, still sniffling, got the heck out.


Posted by: Molly helpy-chalk | Link to this comment | 09-18-08 6:59 PM
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Stanley is on the pharmacy watch list.


Posted by: will | Link to this comment | 09-18-08 7:04 PM
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Thank God we don't have national health care so no bureaucracy can get between me and the treatment I need.

I am very much, as you might expect, looking forward to next Thursday, when a dental student at NYU drills off the outside of one of my upper molars with minimal pain medication because I have no dental insurance and can only afford student care, which takes a few months of especially long visits involving double and triple examinations, listening to the various student dentists fight out loud about what treatments are needed. Thanks, America!


Posted by: A White Bear | Link to this comment | 09-18-08 7:08 PM
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Not that insurance companies don't suck, but Emerson's right, UHC won't fix this sort of thing. Any system of paying for health care will require rules for who gets what, which will be applied by people, who will fuck up in all sorts of clever ways.


Posted by: Not Prince Hamlet | Link to this comment | 09-18-08 7:09 PM
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It is possible that they won't be actively malicious, though.


Posted by: ben w-lfs-n | Link to this comment | 09-18-08 7:10 PM
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My son got chicken pox as an adult, and it's horrible then, with the possibility of serious permanent effects.


Posted by: John Emerson | Link to this comment | 09-18-08 7:14 PM
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21: Right. The question becomes whose responsibility it is to suss out the details of the insurance provider's requirements in conjunction with the health care plan provided by the doctor(s).

One obstacle to this happening as things stand now is the sheer variety of plans out there; health care providers need to be reasonably familiar the vagaries of scores of plans. A nationalized plan, with, presumably, different levels of coverage, would at least be easily looked up, preferably even by the patient him or herself.


Posted by: parsimon | Link to this comment | 09-18-08 7:17 PM
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22: Sure, but the role of active malice in the current system tends to be overstated. We went through a bit of pre-authorization hell a couple of months ago for a family member, and the Medicare rules were pretty similar to the private carrier's (the local Blue). OTOH, going from a whole bunch of different sets of weird arbitrary rules enforced by idiots to one set of weird arbitrary rules enforced by idiots would be a huge improvement.


Posted by: Not Prince Hamlet | Link to this comment | 09-18-08 7:19 PM
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I've just destroyed analytic philosophy again over at Crooked Timber. Someone give me a cookie for not doing it here.


Posted by: John Emerson | Link to this comment | 09-18-08 7:21 PM
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it's horrible then

I didn't catch it until I was 13, and I had a godawful case of it. Never been sicker in my life.


Posted by: apostropher | Link to this comment | 09-18-08 7:23 PM
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7: Dr. Carlat of the psychiatry blog who used to push Effexor as a paid educator has recently given up giving out samples because it turns out that most samples go to insured patients, and when they go to the uninsured, it just increases their prescription costs. See Are Free Samples Bad for Patients?


Posted by: Bostoniangirl | Link to this comment | 09-18-08 7:25 PM
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26: Jesus, John, don't tell me you carried on about that NEH grant program. Anyone ever tell you that you're a snot-nosed brat?


Posted by: parsimon | Link to this comment | 09-18-08 7:29 PM
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I had a problem where I got prescribed terazol, because it kills a wider range of fungus. It turned out that it wasn't approved and required step treatment. I used the OTC miconazole (which my subsidized insurance let me get with a generic co-pay w/ a prescription). That took forever, and since the co-pay is now $10 and not $5, it would have been better if the stupid pharmacist had told me to buy the generic stuff from CVS, but she worked for a hospital pharmacy, so...

It didn't work completely, so I got fluconazole which costs $8, less than my co-pay, though you can get it at Target for $4. The NP I saw didn't want me to use it causse she thought it would interact with my other drugs, but when I called back, the non NP nurse who talked to my doctor foudn out that the diflucan would be fine, and that I could just avoid taking or cut in half one of my PRN drugs.

Anyway, I agree with NPH that one set of stupid rules would be an improvement.

We also need to get mental health parity in Medicare. Medicare beneficiaries pay 50% co-insurance for mental health care, unlike the 20% they pay for everything else. Plus, there are life time limits and their reimbursement rates for psychiatrists are pitifully low--worse than for PCPs. There's a whole thing on the front page of the APA's website about the implications of opting out of Medicare completely.


Posted by: Bostoniangirl | Link to this comment | 09-18-08 7:38 PM
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You're welcome to respond there, Parsi.

As I explained at CT, philosophers like rigid given structure, work by consensus and hate argument. Those poor bastards.

In all seriousness, you my find me an annoying nuisance, but I'm right and the things I'm talking about have had a weighty influence on my own life and have also been socially generally harmful. I'm really not worried about the etiquette and decorum of the situation; actually, I think that the imposed etiquette and decorum are smothering. I'm happy that the internet had given me a small voice.


Posted by: John Emerson | Link to this comment | 09-18-08 7:43 PM
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CT is now monitoring my comments, so I'll post here:

See, this is my situation. My political world is defined by New Class anti-populist technocratic liberal specialists on the one hand, and a coalition of Armageddonists, upper-middle-class populist market worshippers, and neocon Risk players on the other. Marxists are not a factor. Pomos are an inland drainage that will never go anywhere, like the Dead Sea.
It's just me against the world. I drink much less than you'd expect. I'm 62 years old and I still have a functioning liver.

people can cease to thank me for not posting here.


Posted by: John Emerson | Link to this comment | 09-18-08 7:45 PM
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John, of course you should speak as you like, but insulting any and every professional philosopher -- even those who once participated in the profession -- into the bargain is not going to win you friends.


Posted by: parsimon | Link to this comment | 09-18-08 7:55 PM
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Nothing to gain by making friends.

Professionals get whiny when outsiders criticize them. Rationality is for within the profession. It's a biz or cartel.

I did not insult you, but you chose to be insulted.


Posted by: John Emerson | Link to this comment | 09-18-08 7:57 PM
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To go on, remember wa back when when Russell and friends said horrible things about the absolute idealists? Or back when analytic philosophers were saying horrible things about the people they were driving out? I'm saying horrible things about analytic philosophers.


Posted by: John Emerson | Link to this comment | 09-18-08 7:59 PM
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I'm not in the mood for this kind of threadjack.


Posted by: parsimon | Link to this comment | 09-18-08 8:01 PM
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Over to CT with you!


Posted by: John Emerson | Link to this comment | 09-18-08 8:09 PM
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Feel free to stop by my blog, Stanley, where we've got plenty of people who are ready and willing to tell you that you don't have the right to have your prescriptions filled.


Posted by: bitchphd | Link to this comment | 09-18-08 8:58 PM
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I work for a Blue Cross company. We don't do active malice. But we are big on gross incompetence, poorly functioning systems, and ridiculous overhead.


Posted by: Franklin Pierce | Link to this comment | 09-18-08 9:07 PM
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39 is possibly less Presidential than it was meant to be, if anyone Ben is around to fix it.


Posted by: Not Prince Hamlet | Link to this comment | 09-18-08 9:18 PM
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Oops...


Posted by: Franklin Pierce | Link to this comment | 09-18-08 9:21 PM
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Next time better go Presidential as GWB.


Posted by: Not Prince Hamlet | Link to this comment | 09-18-08 9:22 PM
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39-41: fixed. But next time we need your primary-care doctor to submit a form.


Posted by: Stanley | Link to this comment | 09-18-08 9:24 PM
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42: Oh goody, then we can argue over "we don't do active malice."


Posted by: parsimon | Link to this comment | 09-18-08 9:25 PM
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He IS W-lfs-n Lite!


Posted by: Not Prince Hamlet | Link to this comment | 09-18-08 9:25 PM
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By the way, my primary care physician is now requiring that any referral forms be requested and filled out at the time of your office visit. If you discover a need for a referral (say, after your tests results come in), you must come in for another office visit, with co-pay, to get it. It's because of the paperwork, it is said.

Thanks for letting me know.


Posted by: parsimon | Link to this comment | 09-18-08 9:29 PM
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Another good thing about UHC would be making doctors lives suck less so they don't quit when we pay them less money.


Posted by: Not Prince Hamlet | Link to this comment | 09-18-08 9:31 PM
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47: Agreed.


Posted by: parsimon | Link to this comment | 09-18-08 9:34 PM
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Thanks for fixing that.

One thing I think a lot of people don't realize about their insurance is that, much of the time, your insurer isn't actually your insurer. And by that I mean, your insurer isn't assuming the risk of your illness - rather, the insurance company is merely doing the administration, while the cost of paying for your health care is actually born by whomever is the sponsor of your risk pool. The larger an organization you work for, the more likely this is to be true.

Thus, while my Blue Cross company handles all the paperwork for employees of the State of ________, its actually the State of _______ that is picking up the tab when it's covered employees get sick. As such, Blue Cross doesn't really have a say as far as what is covered, or if you need authorization for prescriptions, or all that jazz.... those decisions are all made by the employer when deciding what kind of plan they want to pay for.


Posted by: Franklin Pierce | Link to this comment | 09-18-08 9:35 PM
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As such, Blue Cross doesn't really have a say as far as what is covered, or if you need authorization for prescriptions, or all that jazz.... those decisions are all made by the employer when deciding what kind of plan they want to pay for.

Wouldn't it be more accurate to say that those decisions are put together out of some combination of what the employer wants to pay for, what the insurer wants to offer, and what state insurance regs require (when they apply)?


Posted by: Not Prince Hamlet | Link to this comment | 09-18-08 9:41 PM
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50: Yeah, that would be more accurate. Basically the insurer give the employer a choice about how anal they should be. And less anal equals more expensive.

But my point is that, in many cases, Blue Cross doesn't have a vested interest in whether they pay for your broken arm or not. They are just going to pass the bill along to your employer anyway.


Posted by: Franklin Pierce | Link to this comment | 09-18-08 9:49 PM
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Just to jump in w/o reading the thread: AB had the exact same situation with some recent prescription, same wording and everything.

The trouble with the premise in BG's very reasonable 1 is that it presumes that the doctor is unaware that she is working within the modern American medical system. Unless this is the doctor's very first dealing with "insurance," then she is already well aware of the competing priorities, etc. Given that, in its infinite majesty, the American system requires that doctors know as much about insurance forms as they do about human physiology, I have trouble with the premise.

IOW: Fuckers.


Posted by: JRoth | Link to this comment | 09-18-08 9:53 PM
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Franklin, I'm afraid you're just going to have to accept the fact that you work for the devil. No one wants to see the insurer's side of any of this.


Posted by: bitchphd | Link to this comment | 09-18-08 9:57 PM
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No one wants to see the insurer's side of any of this.

Speak for yourself.


Posted by: teofilo | Link to this comment | 09-18-08 9:59 PM
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See, this is my situation. My political world is defined by New Class anti-populist technocratic liberal specialists on the one hand, and a coalition of Armageddonists, upper-middle-class populist market worshippers, and neocon Risk players on the other. Marxists are not a factor. Pomos are an inland drainage that will never go anywhere, like the Dead Sea.

Is this different from 1925?

max
['If he's were actually Franklin Pierce, he'd have to be back from hell.']


Posted by: max | Link to this comment | 09-18-08 10:04 PM
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You had a left in 1925, but not now. You even had pragmatists and progressives. All that remains is the New Class and the hard right.


Posted by: John Emerson | Link to this comment | 09-18-08 10:06 PM
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And populists.


Posted by: John Emerson | Link to this comment | 09-18-08 10:09 PM
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Dude, I don't even understand the distinction you draw between the New Class &c. on the one hand, and the coalition of &c. on the other. Which hands are these again? Or is that the point?

On review: ah, I see what you intend by that distinction. Not the way I would read it.


Posted by: parsimon | Link to this comment | 09-18-08 10:14 PM
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New class is Democrats, icluding most Democrats.


Posted by: John Emerson | Link to this comment | 09-18-08 10:17 PM
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"Including most liberals". And so to bed.


Posted by: John Emerson | Link to this comment | 09-18-08 10:18 PM
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The Devil? Nah.... more like the Borg. Only, waaaaaayyyy less efficient.

The alternative in my area would probably involve working for the defense industry. I chose the health care industrial complex instead of the military industrial complex. Puts food on the table. Also, five weeks of vacation.

I think that insurance companies are what you get by default. They exist because nobody ever spent the political capital to come up with a better system. And since they are such a vested interest at this point, everyone is fucked. Sorry about that.

If it was up to me, everyone would be covered by Medicare. Single payer, baby!



Posted by: Franklin Pierce | Link to this comment | 09-18-08 10:19 PM
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Oh, I don't know, Franklin, you could have worked in the book trade.


Posted by: parsimon | Link to this comment | 09-18-08 10:31 PM
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Yeah, I did try to get a job with Random House, but they wanted me to work with AS/400s. I decided I'd rather spend my life denying medicine to sick children than work on those infernal machines.


Posted by: Franklin Pierce | Link to this comment | 09-18-08 10:37 PM
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I wouldn't know what an AS/400 is, but I'll take your word for it.


Posted by: parsimon | Link to this comment | 09-18-08 10:43 PM
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You had a left in 1925, but not now. You even had pragmatists and progressives. All that remains is the New Class and the hard right. [...] And populists.

If factor out the populism of 1925 or so, I keep coming up with a tiny left. Your La Follette types may have been leftish, but they were also populist and didn't hold a lot of power. (One could say the say about many middle-class Democrats.) So I am not seeing this here, except to say that the failure of Marxist-Leninism killed that (always small) fraction of the Left (and left room for the anarchists to reemerge).

So this sounds a touch like some old conservative dude pining for the Golden Age of Yore that inevitably looms larger in the imagination than in actual fact.

max
['The Armageddonists are the new radicals.']


Posted by: max | Link to this comment | 09-18-08 10:43 PM
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An AS/400 an antiquated IBM computer that still contains some ridiculous portion of the worlds business data. By working in the insurance industry, I get to work with far more powerful and expensive antiquated IBM systems.

You know how health insurance companies leach off the productivity of society? Well, the number one leach off of our health insurance company is IBM. Given what they can get away with ripping off our industry, I can't imagine Big Blue supporting universal heath care anytime soon...


Posted by: Franklin Pierce | Link to this comment | 09-18-08 10:56 PM
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No doubt. I was just cravenly hoping that your conscience and needs were satisfied by your work.

But honestly, this is rude of me, and I apologize. The conversation has reminded me that despite the price I pay for the work I do (in the book trade), chiefly in income, it's a trade-off, and there are benefits I wouldn't like to do without.


Posted by: parsimon | Link to this comment | 09-18-08 11:04 PM
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in many cases, Blue Cross doesn't have a vested interest in whether they pay for your broken arm or not. They are just going to pass the bill along to your employer anyway

True in the short term, but my impression is that the ability to keep costs down is a significant part of what the insurers are marketing when renewal time comes around.


Posted by: Not Prince Hamlet | Link to this comment | 09-18-08 11:32 PM
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If automatically denying reasonable claims and forcing them to be appealed, time after time, isn't active malice, then what do you call it? Passive malice? As far as I can tell, the only thing that gets a health insurance company to do its job is reporting it to the state insurance commissioner.


Posted by: y | Link to this comment | 09-18-08 11:54 PM
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It's right that under a universal system there are still going to be restrictions on what a doctor can prescribe and where that prescription will be covered by the state.

In the UK there's a single body -- N.I.C.E -- which carries out evidence-based assessments of various drugs and procedures and decides what a doctor can prescribe or what a surgeon can do and what the state will pay for.

Occasionally you run into problems when people want some incredibly expensive drug on the NHS and N.I.C.E decides that the evidence for its effectiveness is insufficient to justify its cost [over some alternative]. This tends to produce lots of bad publicity for N.I.C.E. with people dying of cancer X going to the media claiming that the lack of drug D is a scandal and N.I.C.E. claiming that D costs 50,000 a year and there are only two badly constructed research studies that have shown a 2% increase in life expectancy [or whatever].

http://www.nice.org.uk/

Any universal system is going to have to have a similar process along with the attendant publicity when either the process gets it wrong -- and denies a treatment that is genuinely effective -- or gets it right -- but special interest groups make a huge fuss about it.


Posted by: nattarGcM ttaM | Link to this comment | 09-19-08 12:29 AM
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53: NHP, you know that large private employer plans are governed by ERISA and state insurance regulations don't apply. I don't know what the deal is with government plans. My primary care practice group is part of a teaching hospital. They have people who know how to handle insurance referrals, but the doctors themselves aren't always aware of the rules; there are simply too many of them to learn. They're too damn busy to require an extra visit to fill out the paperwork, and they are almost always referring you within the hospital. I think that the hospital doesn't make much money on primary care, but it makes up for it in the other services, and it has a good fundraising wing. The CEO is always going on about the need to pay cognitive specialists more. People who do things to you get paid a lot more than people who think about your problems and give you drugs. This encourages a lot of procedures. It's a much better deal to be an interventionist cardiologist than a non-interventionist one. This procedure-based fee for service model is a legacy of the Blues and Medicare. Private insurers often follow Medicare's lead, and some are starting to institute pay for performance which Medicare is gradually introducing. They are starting to avoid paying huge hospital bills for pay for performance and refusing to pay for never events, e.g., removing the wrong kidney or doing surgery on the wrong knee.


Posted by: Bostoniangirl | Link to this comment | 09-19-08 1:26 AM
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I just picked up a prescription yesterday, and as I am not old, young, very ill, or unemployed, I had to pay the prescription fee.

But it was 50p less than the last time I picked up a prescription, because the government just cut the fee. So I paid £5.

I've no idea what the medication I'm taking now would cost me if I were paying for it. But I don't have to care, because of that awful socialized medicine thing we have here. I pay my taxes, I get health care.

(They're small blue pills which are super-cool anti-histamines that work without the drowsiness effect. So if someone asks what I'm taking, I can say "Viagra". )


Posted by: Jesurgislac | Link to this comment | 09-19-08 2:26 AM
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re: 72

Also, if the medicine you are buying actually costs less than the prescription charge, most pharmacies will sell it to you rather than charge the prescription charge.


Posted by: nattarGcM ttaM | Link to this comment | 09-19-08 4:38 AM
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Max 65: In Minnesota a Socialist governor was elected in 1932, and his party (Farmer Labor Party) ran the state for more than six years. It didn't survive WWII, though. There were radical movements all over the place, and Roosevelt had to coopt them. Not toay.

I object to using "populist" as a smear word.


Posted by: John Emerson | Link to this comment | 09-19-08 5:47 AM
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63, 64: Dude, the AS/400! (Or as IBM now knows it, the i-Series.) Buck's been writing a newsletter about the AS/400 market, for various publishers, now including himself, for nineteen years.


Posted by: LizardBreath | Link to this comment | 09-19-08 6:12 AM
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Regarding NICE, another issue here is that you're not allowed to say "well, if NICE will only fund the price of Superzog and I want Quadrillidrop, I'll pay the difference". No, you'll have to pay the entire nut.

[enter long and futile debate on principle here]

Personally, I support this despite the illiberalism, because otherwise it would be far, far too easy for $futuregovernment to nobble NICE and defund more and more stuff, whilst saying that you can of course pay the difference out of your penny-off-the-income-tax.

As a rule, as Ttam points out, NICE disputes virtually by definition involve super-brand-new whizzydoo proprietary drugs that provide extremely marginal life extension for end-stage cancer patients, whereas any fule kno that the vast bulk of the benefits of medicine come in public health, early diagnosis, and surgery.


Posted by: Alex | Link to this comment | 09-19-08 6:46 AM
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Further, John, "populist" is a term of abuse in Europe because it usually means a permatanned, creepy guy in a fast car who intends to Stick It To Them In [capital city] by giving everyone a penny off the income tax, and eventually turns out to have rather disturbing opinions about the Second World War, and specifically Germany.


Posted by: Alex | Link to this comment | 09-19-08 6:49 AM
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Whoever named NICE was, one imagines, not a reader of C. S. Lewis' space trilogy.


Posted by: redfoxtailshrub | Link to this comment | 09-19-08 7:04 AM
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Populist is a term of abuse in the US for completely different reasons.


Posted by: Walt Someguy | Link to this comment | 09-19-08 7:16 AM
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well yes - referring to a great populist tradition makes no sense outside the US, except for maybe Hungary (where the description I gave above is much to the point) and Russia, so long as it's 19th-century terrorists you're thinking of.

NICE - National Institute of Clinical Excellence.


Posted by: Alex | Link to this comment | 09-19-08 7:21 AM
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re: 78

I had too look it up on wiki, but it wouldn't surprise me at all if someone, somewhere, did.


Posted by: nattarGcM ttaM | Link to this comment | 09-19-08 7:22 AM
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I recently read "The Populist Persuasion" and the author simply left out the populists (in Minnesota and Wisconsin) who actually were successful and accomplished something.


Posted by: John Emerson | Link to this comment | 09-19-08 7:23 AM
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Perhaps the only laudable initiative of Walmart: the $4 generic prescriptions. A family member is involved in seeing that poor people get maintenance prescriptions, and the program has made his job a lot easier. (I use the competing program of Target, and their drugs are manufactured by Indian companies, but at least they're company names I know.)


Posted by: Minivet | Link to this comment | 09-19-08 7:57 AM
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I could have gotten a generic drug for $4 at Target which was less than the cost of my co-pay, but it would have required a complicated trip to the burbish area where Target is. It's also the case that my doctor's office already had the fax number of the CVS from the Street from me in her computer attached to my EHR, and I'd have had to look up the Target address to get something different.


Posted by: Bostoniangirl | Link to this comment | 09-19-08 8:16 AM
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a complicated trip to the burbish area where Target is

Wellington T stop on the orange line?


Posted by: Brock Landers | Link to this comment | 09-19-08 8:19 AM
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I've always gone to the one in Watertown. I only just realized that there's one in Somerville. It was a one-off thinG for an infection, and there's oen drug that I could get there regularly, but I take other drugs and it could be a hassle.


Posted by: Bostoniangirl | Link to this comment | 09-19-08 8:27 AM
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78: That was my first thought, too--guess they finally got Bracton wood, eh? But at least this means that the Evil Anti-Christian Bureaucrats have finally scuppered Lewis's horrible Christian future. Roll on, NICE, that's what I say.


Posted by: Frowner | Link to this comment | 09-19-08 8:29 AM
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Prior authorization is used in some state Medicaid programs as well. In Louisiana it involves the doctor calling a hotline staffed by pharmacists and answering a series of questions (have other therapies been tried, is there some special reason why the patient couldn't have one of those alternative therapies, etc.). It just shifts some of the pressure by drug reps from doctors to the government agencies that establish the content of the formulary.


Posted by: Amber | Link to this comment | 09-19-08 8:47 AM
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69: Around here, its more likely to be gross incompetence - on both an individual and a systemic level - than active malice. But there are other companies where it may be active malice. I can't speak for the whole industry.


Posted by: Franklin Pierce | Link to this comment | 09-19-08 8:55 AM
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have other therapies been tried, is there some special reason why the patient couldn't have one of those alternative therapies, etc.

Right. Which my doctor already went over with me, the patient. Because she's a competent and trusted member of my insurance company's network. Until they second guess her and staff up with a bunch of doctors rather than just pay for the medicine their in-network doctor already prescribed.


Posted by: Stanley | Link to this comment | 09-19-08 8:56 AM
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One thing I would like to see is doctors getting away from writing prescriptions, and simply coming up with a diagnosis. Then you would take your diagnosis to the pharmacy, and the pharmacist would come up with the prescriptions.

In most cases, the pharmacist is actually far more knowledgeable about a wide range of medications, while a doctor just has a limited set that they know and stick with. But, under today's system, pharmacists are basically just highly trained clerks behind the desk at CVS.


Posted by: Franklin Pierce | Link to this comment | 09-19-08 9:01 AM
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My pharmacist does suggest generic substitutes and is very thorough about warning you about side affects and interference from food and other drugs. I believe that he is a rare individual exception, however. I agree that pharmacists are much more on top of the drug game than MDs, who are unduly influenced by drug reps and advertising.


Posted by: John Emerson | Link to this comment | 09-19-08 9:04 AM
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Your doctor sounds like a good egg, and apparently was not just prescribing the drug of whatever company gave him the coolest new pens. Such virtue is not universal.

The PA requirement had some interesting effects on the COX-2 prescription rates for Medicaid patients. Would you feel better if you knew that fewer people got Vioxx instead of Tylenol due to such requirements?


Posted by: Amber | Link to this comment | 09-19-08 9:06 AM
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Pharmacists spend four years studying pharmacology whereas M.D.s only take a course or two in it. But then their brains rot.


Posted by: Bostoniangirl | Link to this comment | 09-19-08 9:10 AM
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It's not even the second-guessing, it's the non-transparency. What's so maddening about dealing with health insurance is that there are all of these insane little procedural steps which the doctor has to know about and take. And I totally sympathize with the doctor in this scenario -- they shouldn't need to worry about all the insane little insurance company procedures -- but when they don't jump through all the hoops, the patient has to straighten it out, and doesn't have easy access to the doctor to know what they did or didn't do, or to make them do whatever the necessary step is.

I tend to run into this after the fact, when I get letters telling me something isn't covered; it's usually some failure to properly transmit information between the medical care provider and the insurance company. But figuring out what the doctor should have told the insurance company, and making them correct the error, is maddeningly difficult.

I've been getting bills for five years from my kids' pediatrician for a checkup that wasn't covered. My insurance only covers one checkup a year, and this one was uncovered as a second. The problem is that I only took Sally in for one checkup. I am pretty sure what happened is that the office erroneously coded an earlier visit for an illness as an annual checkup, and then when the real one came around it looked as if it were the second one that year. I spent a couple of months when I started initially getting letters about it making phone calls and trying to straighten it out, and couldn't get anyone in the doctor's office or the insurance company to either help me figure out what happened, or how the error could be corrected.

While I like the pediatrician, and it's a shame they didn't get paid, damned if I'm going to pay for an annual physical that was covered by my insurance because they can't communicate successfully with the insurance company.


Posted by: LizardBreath | Link to this comment | 09-19-08 9:13 AM
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That crossed with a bunch of other comments -- I don't mind cost consciousness, or taking some autonomy in prescriptions away from doctors (although the idea of turning prescriptions completely over to pharmacists seems weird to me -- surely there are subtleties in a diagnosis that you want a doctor to think about?).

What drives me insane is that the onus of coordinating the team of medical decisionmakers -- doctor, insurance company, pharmacist -- gets placed on the patient, as the one who gets financially and medically injured when they're not coordinating. Doctors try, but the system seems to be set up so that they largely don't know when they need to be coordinating with someone, or who, or how.


Posted by: LizardBreath | Link to this comment | 09-19-08 9:19 AM
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In most cases, the pharmacist is actually far more knowledgeable about a wide range of medications, while a doctor just has a limited set that they know and stick with. But, under today's system, pharmacists are basically just highly trained clerks behind the desk at CVS.

Geez, now I have to jump in and defend BR's honor.

Pharmacists are only highly trained clerks if you let them. They are often asked questions and called upon to educate people about medications.


Posted by: Will | Link to this comment | 09-19-08 9:22 AM
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National health insurance doesn't address the question of malice. In fact, it makes it worse. Insurance companies don't stand to benefit from malice - they may do things that seem malicious, but their real interest is in keeping costs down. Under a national health insurance scheme the policies are subject to political intervention. Sooner or later the Movement Conservatives will be back in power, and they will attempt to discredit the national health insurance scheme by enacting policies that make it unpleasant to use. This is something that needs to be considered in setting up the plan in the first place. I predict that during the inevitable coming attempt to get some sort of comprehensive national healthcare system set up there will be attempts, some of them successful, by movement conservatives to insert policies and requirements that directly hurt the people covered.


Posted by: togolosh | Link to this comment | 09-19-08 9:23 AM
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What drives me insane is that the onus of coordinating the team of medical decisionmakers -- doctor, insurance company, pharmacist -- gets placed on the patient, as the one who gets financially and medically injured when they're not coordinating. Doctors try, but the system seems to be set up so that they largely don't know when they need to be coordinating with someone, or who, or how.

Well, the doctors write the prescription, and then the pharmacist has a job to do.

Checks and balances. opportunity to educate.


Posted by: Will | Link to this comment | 09-19-08 9:24 AM
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You want to know what a big nasty problem is?

Insurance companies have very little reason to deny claims.

If they deny it, a certain percentage doesnt challenge it.
Those who challenge it only get back what the insurer should have paid to begin with.

Sure, there are "bad faith" denial lawsuits, but not many.


Posted by: Will | Link to this comment | 09-19-08 9:26 AM
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99: But doctors, like Stanley's, often don't know when they have to clear their prescriptions through a third-party decisionmaker at the insurance company, and the patient suffers. Whether the involvement of another decisionmaker is good or bad, I'm not 100% sure of -- it's probably not a terrible thing.

Where the process is screwed up enough that Stanley can't get his medicine covered at the time when he needs it because the doctor didn't know about or didn't comply with the process, that's unambigiously awful.


Posted by: LizardBreath | Link to this comment | 09-19-08 9:28 AM
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Pharmacists are only highly trained clerks if you let them. They are often asked questions and called upon to educate people about medications.

That's basically my point..... pharmacists are a great resource that often gets wasted. Just having them around for the purpose of "educating people about medications" isn't enough. They should be using their vast knowledge to make the actual drug choices, rather than leave it only to doctors who are less knowledgeable in that area of the medical field.


Posted by: Franklin Pierce | Link to this comment | 09-19-08 9:30 AM
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100: I assume there's a "not" missing in there, in which case I agree. I'm not a big user of medical services, but I'm running about 50/50 on fairly ordinary things being initially denied, and then covered as soon as I call up to say "hey, no really, your document says you cover this routine eye exam" or whatever.


Posted by: Nathan Williams | Link to this comment | 09-19-08 9:31 AM
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96: although the idea of turning prescriptions completely over to pharmacists seems weird to me -- surely there are subtleties in a diagnosis that you want a doctor to think about?

Indeed. The suggestion seems off in a number of ways. For example, I take a medication which is the second choice given my diagnosis, because I tried the first choice and proved to be allergic to it; this is part of my medical history, and the pharmacist presumably isn't privy to that. There are broader questions of medical history, as well as future planning, as well (planning to take birth control in the near future? Well, we won't prescribe you this now, then, but rather that).

If the goal is to diminish the influence of pharmaceuticals reps on doctors, surely we might regulate the reps rather than take decisions out of doctors' hands.


Posted by: parsimon | Link to this comment | 09-19-08 9:32 AM
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98: Insurance companies don't stand to benefit from malice - they may do things that seem malicious, but their real interest is in keeping costs down.

Okay -- making bad-faith decisions to control costs in ways that aren't compatible with providing the health-care coverage they've contracted to provide? Is effectively malicious. If an insurance company is denying claims randomly in the hopes that at least some people will just pay and not argue about it, or the doctors will eat the loss, I don't care if the insurance company is staffed by nice, kind people who are only motivated by the desire to control costs, rather than by a desire to injure. The effect is malicious.


Posted by: LizardBreath | Link to this comment | 09-19-08 9:34 AM
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They should be using their vast knowledge to make the actual drug choices, rather than leave it only to doctors who are less knowledgeable in that area of the medical field.

And hijinks ensue.


Posted by: potchkeh | Link to this comment | 09-19-08 9:37 AM
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||
I just had a talk with the vet about by cat's urinary problem. One possible long term solution if he relapses is to chop off his dick. The fun part was the contortions and awkwardness from the vet as she danced around the issue, trying to break it to me gently. Clearly she has had some really bad reactions. You know you have serious anxious masculinity issues when you're worked up about your neutered cat's penis.
|>


Posted by: togolosh | Link to this comment | 09-19-08 9:40 AM
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105: I think there's something to be said for distinguishing malicious effect from malicious intent. The one can be mitigated by restructuring of incentives, whereas the other can only be handled by going directly after the people responsible.


Posted by: togolosh | Link to this comment | 09-19-08 9:44 AM
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this is part of my medical history, and the pharmacist presumably isn't privy to that.

Well, ideally, the pharmacist would have access to your Electronic Medical Record, and thus would be privy to the relevant historical information. Unfortunatly, Electronic Medical Records only actually exist in the land of unicorns and rainbows.


Posted by: Franklin Pierce | Link to this comment | 09-19-08 9:45 AM
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109: Call me paranoid, but I'd rather keep the Electronic Medical Record in that land. Privacy, you know. In any case, unless it's one hell of a record, it's not going to include a whole slew of circumstances I discuss with my doctor. And, also, plus, my record's rather large. Asking a pharmacist to become familiar with it would be akin to asking him or her to become my doctor.


Posted by: parsimon | Link to this comment | 09-19-08 9:51 AM
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Also, I'd like to see Registered Nurses be empowered to work with pharmacists to provide prescriptions.

Basically, I think the medical establishment needs to be less doctor-centric.


Posted by: Franklin Pierce | Link to this comment | 09-19-08 9:52 AM
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requirements that directly hurt the people covered

No anesthetic until the second visit?


Posted by: Tassled Loafered Leech | Link to this comment | 09-19-08 9:52 AM
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The amount of extra paperwork involved with insurance claims and HMOs is unbelievable. Not only the HMOs and insurance companies themselves do mostly paperwork, but the doctors have to have a well-trained person to take care of their end. Socialize medicine would be worth it just to reduce paperwork and bureaucracy. (Ha! Is joke! -- but not at all, really).


Posted by: John Emerson | Link to this comment | 09-19-08 9:52 AM
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111: RNs, not NPs? That seems really weird to me -- I hadn't known that RN training was directed toward diagnosis and prescription at all. Giving NPs more autonomy sounds fine.


Posted by: LizardBreath | Link to this comment | 09-19-08 9:58 AM
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The thing about pharmacists is that they're more specialized than doctors and know more about their specialty. It's a big plus.


Posted by: John Emerson | Link to this comment | 09-19-08 9:59 AM
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Call me paranoid, but I'd rather keep the Electronic Medical Record in that land. Privacy, you know.

Privacy is a valid concern, but you are never going to reduce medical costs as long as everything continues to be on paper. Isn't the root of this thread basically a complaint about how inefficient the whole damn system is?


Posted by: Franklin Pierce | Link to this comment | 09-19-08 10:00 AM
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Really, and I think I got this from Dr. Oops in some sense, although she should correct me if she checks back into the thread, pulling doctors out of the GP role might not be a crazy idea. For routine medical care, prescribing antibiotics and such, NP's are perfectly sufficiently trained and cheaper, and for anything even a little out of the ordinary, you should probably be dealing with a specialist.


Posted by: LizardBreath | Link to this comment | 09-19-08 10:00 AM
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Unfortunatly, Electronic Medical Records only actually exist in the land of unicorns and rainbows.

And the VA, which from what I read is functionally equivalent.

Not only the HMOs and insurance companies themselves do mostly paperwork, but the doctors have to have a well-trained person to take care of their end. Socialize medicine would be worth it just to reduce paperwork and bureaucracy. (Ha! Is joke! -- but not at all, really).

Yeah - doctors ought to be mobilizing for this reason. Socialized medicine would cut their costs much more than, say, tort reform would cut their malpractice insurance, even if that were a non-evil and valid pursuit. (OTOH, I imagine they aren't keen on working under a DRG system all the time.)


Posted by: Minivet | Link to this comment | 09-19-08 10:07 AM
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114: Yeah, NPs before RNs I suppose. But give the RNs some specialized training, have them work together with pharmacists, and there are probably a range of maladies they could address. NPs could address a wider range of maladies, and physicians could focus their work on the more specialized cases.


Posted by: Franklin Pierce | Link to this comment | 09-19-08 10:08 AM
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Musing vaguely about pharmacists, wouldn't it be nice if they were conventionally understood to provide guidance through the OTC shelves: "Golly, Pharmacist Bob, I have these minor yet annoying symptoms that don't seem worth going to the doctor for. Any suggestions?" and then he'd say either "Why, this shelf includes many fine products that might help you, and here are specific plusses and minuses of each." or "Man, I think you should probably go talk to a real doctor about that one."


Posted by: LizardBreath | Link to this comment | 09-19-08 10:13 AM
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It is annoying, but sometimes doctors do just prescribe the newest treatment even when it's not more effective than another

There is a veritable army of very pretty young (mostly) women wandering around physicians offices as we speak --- helping this to happen.


Posted by: soup biscuit | Link to this comment | 09-19-08 10:16 AM
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120: Pharmacists in Spain work something like that, or at least they did as of 2000. I went in, described my symptoms, and got some sort of antibiotic for like $5. Doctor visits are reserved for severe problems.

Pharmacists in Spain also get like seven years of school, IIRC.


Posted by: Stanley | Link to this comment | 09-19-08 10:17 AM
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117: I'm not sure that dealing with a specialist for chronic conditions makes much sense. If you're diabetic, but the condition is well-controlled and has been for years, it doesn't particularly make sense for you to regularly see [whoever specializes in diabetes] in order to say, "Yep, yep, I've been fine, no problems, checked my blood sugar this morning and it looks good; let's draw some blood, as usual, and check it, and again it should be fine as it has been for years."

You do need to see someone regularly, but probably not a specialist unless something actually happens. Do you know what these specialists charge?!?!?!?


Posted by: parsimon | Link to this comment | 09-19-08 10:19 AM
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121: Wow, there'd be a fun sociological experiment -- take some still disproportionately male specialty, and try to figure out how much effect the blandishments of drug reps had by looking at differences between prescription patterns of male and female physicians. (It probably wouldn't work in a specialty with a lot of female doctors, because the reps would have adjusted to that.)


Posted by: LizardBreath | Link to this comment | 09-19-08 10:20 AM
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This is why i usually just buy my meds from overseas. Takes longer but doesn't require a doctors visit.


Posted by: yoyo | Link to this comment | 09-19-08 10:22 AM
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About pharmacists, I think Kaiser Permanente integrates the pharmacist into the practice. The pharmacist becomes another provider.

When I was in Australia, I needed some aspirin for a headache. It was not available off the shelf. I had to see the pharmacist, who asked me what other meds I was taking and why I needed the aspirin. I was annoyed and impressed by that approach.


Posted by: md 20/400 | Link to this comment | 09-19-08 10:22 AM
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123: I'm repeating stuff I've heard, rather than stuff I have data on, but my understanding is that outcomes for people getting their routine care for chronic diseases from appropriate specialists are head and shoulders better than people getting chronic care from GPs. Nothing against GPs, but they just can't know all the little quirks of all the little diseases the same way a specialist can.

While specialists are more expensive, it might make sense to do the saving at the low end; have an NP to weigh your kids, prescribe you antibiotics, and at the first sign of something weird say "Dude, over my pay grade. You go see Dr. Specialist about that."


Posted by: LizardBreath | Link to this comment | 09-19-08 10:25 AM
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LB, lady doctors are all lesbians. What you would have to look at is the particular styles of the individual drug reps. The best would be able to go either way, of course.


Posted by: John Emerson | Link to this comment | 09-19-08 10:25 AM
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I'll have to inform Dr. Oops. I don't think she knew there was a requirement.


Posted by: LizardBreath | Link to this comment | 09-19-08 10:26 AM
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I don't think the drug co reps even have so malicious influence. I think a lot of doctors aren't up to speed on the latest treatments, and the reps are the only way they really get new information.


Posted by: yoyo | Link to this comment | 09-19-08 10:27 AM
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internal medicine is the hardest field, i think. you have to know enough about everything to not miss a problem that is something serious. seems very stressful and not well paid (well, comparitivly.)


Posted by: yoyo | Link to this comment | 09-19-08 10:31 AM
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127.1: I don't doubt that studies show that this is true overall. I'm not sure it means that every individual with a chronic condition needs to see a specialist for routine checkups.

One last point about the advisability of GPs: they are to provide a more holistic form of health care, no? They say things like: You know what, it's now time for you to go for a baseline mammogram; here's a referral for that. or, I see you've been steadily gaining weight in the last year or two, and you're looking pretty tired; anything up? or, Well, your iron's on the low side; ah, you're a vegetarian? There's a website, here, where you can read up about iron-rich foods.

I'm not sure where that sort of thing comes from with the NPs for minor maladies, specialists for anything out of the ordinary model.


Posted by: parsimon | Link to this comment | 09-19-08 10:36 AM
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I think a lot of doctors aren't up to speed on the latest treatments, and the reps are the only way they really get new information.

Fortunately, these drugs reps only provide objective information.


Posted by: Will | Link to this comment | 09-19-08 10:38 AM
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Personally, I support this despite the illiberalism,

so do I, mainly on the grounds of equity as between patients; though the policy creep problem also concerns me.

The NICE/cancer drugs issue is exacerbated by the fact that some of the PCTs (and whatever the Welsh equivalent is) will fund the drugs anyway, on a different interpretation of the 'exceptional circumstances' rule.


Posted by: jayann | Link to this comment | 09-19-08 10:44 AM
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132: I don't doubt that studies show that this is true overall. I'm not sure it means that every individual with a chronic condition needs to see a specialist for routine checkups.

Within the limits of necessary cost constraints, unless you've got some criterion to distinguish people with chronic conditions who need specialists from those who don't, I think it largely does mean that, or at least that they'd be better off with specialists.

One last point about the advisability of GPs: they are to provide a more holistic form of health care, no?... I'm not sure where that sort of thing comes from with the NPs for minor maladies, specialists for anything out of the ordinary model.

I'm now babbling with no real basis for anything I'm saying. With that disclaimer, I think the idea is that that sort of thing would come from your NP. The NP, because the training is so much cheaper, could afford to spend more time with you, and build up more of a sense of your health baseline and so on, and a masters degree sounds like plenty to keep on top of 'Vegetarians need to watch their iron'. But all they'd be doing treatment-wise is (a) minor maladies; and (b) watching you like a hawk for indications that you were really sick, at which point they'd refer you.


Posted by: LizardBreath | Link to this comment | 09-19-08 10:46 AM
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135.1: unless you've got some criterion to distinguish people with chronic conditions who need specialists from those who don't

The criterion in my own case was met by the specialist I was seeing saying, "I really don't need to see you regularly any more, as you're maintaining nicely, so let's just transfer your routine checkups to your GP." I guess that would suffice.

As for 135.2, as long as someone is providing that sort of oversight and information -- essentially taking over the GP's role (not because there's no role to be played, because it would be cheaper?) -- I'd have no beef. It becomes a technical question about whether the training received by NPs is adequate to the task; only the medical establishment is qualified to answer that question, I'd think.


Posted by: parsimon | Link to this comment | 09-19-08 10:55 AM
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They say things like: You know what, it's now time for you to go for a baseline mammogram; here's a referral for that. or, I see you've been steadily gaining weight in the last year or two, and you're looking pretty tired; anything up?

For most people I don't think your doctor is really remembering this. They are reading a chart. I usually see my primary care physician once every 1 to 1.5 years. I doubt he remembers my name without it being on my chart. An NP or RN can do that just as well.


Posted by: CJB | Link to this comment | 09-19-08 10:55 AM
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Update: I called the doctor's office to check on things. The receptionist explained that I had to have the pharmacy fax the doctor's office; then, she (the receptionist) would call the insurance company; then, the insurance company would send coverage confirmation to the pharmacy.

"All of this is just a little insane, right?" I said to the receptionist.

She chuckled and said, "Well, yeah."


Posted by: Stanley | Link to this comment | 09-19-08 10:55 AM
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My experiences with specialists have generally been negative. They tend to focus on their area of specialization and not consider the impact of their prescriptions on other areas. I'm in the middle of a bout of back problems that are aggravated by, and in turn aggravate, my recurring depression. The specialists I'm seeing for my back have been singularly useless in handling the interaction, to the point where I have simply refused to take some of the medication prescribed because it has a side effect profile that would indirectly make my depression worse.

I find GPs to be far less prone to the Meat Machine model of medicine and much more likely to consider non-drastic approaches to problems. I've never had a specialist suggest that perhaps doing nothing and just keeping an eye on the problem is the best approach. In practice, that's often quite a good way to handle certain types of problems - the body is remarkably good at healing itself, and nearly all medical interventions have some sort of side effects.


Posted by: dwayne elizondo mountain dew herbert camacho | Link to this comment | 09-19-08 10:58 AM
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I find GPs to be far less prone to the Meat Machine model of medicine

My experience as well. The proposed revision (NPs + specialists) seems to be coming from a wish to produce formulae for treatment, such that if certain boxes are checked off in a medical history, an automaton will know what course of action to take.

Don't we know by now that that's exactly wrong?

It also strikes me that the proposed model assumes (younger) people with few health problems to speak of, and who rarely need to see a doctor; as we age, this becomes less and less true, and less and less advisable.


Posted by: parsimon | Link to this comment | 09-19-08 11:08 AM
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Hey, would this be a good thread for requesting medical advice? I think it would be!

I've always gotten migraines, but never severe ones, and in decreasing prevalence since HS. I'd say that I'm down to 2-3 per year. Therefore, I've never looked into modern treatments, etc.

Now, I've gotten 3 in 3 weeks, including 2 in 3 days (one very mild - basically just aura - the other pretty severe by my standards). With them so close together, I can pretty well say that there was very little difference between the days that I got them and didn't get them (indeed, at least as much difference between days with as days without).

In particular, my caffeine consumption has become very regular: one can of Mt. Dew between noon and ~3 pm, more or less every day. Perhaps once a week I'll have a second serving of soda. I've always used caffeine, but this is pretty much the least I've used in my whole life, and it's been consistent for a year or two now. All 3 of these headaches have happened between 4 and 8 pm, but historically I've gotten them whenever.

Now, I plan to see my doctor about this - it's starting to impinge on my workday - but just now, as I started my lunch and soda, I started to maybe experience some aura. I still can't tell - it may be a false alarm, and I may be getting paranoid. BUt I figured I'd look for some input from you all, in the expectation that you're faster than my doctor.


Posted by: JRoth | Link to this comment | 09-19-08 11:11 AM
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when you have a headache - pull your hair, it's a confirmed and working wonders on me advice
sorry, bald people, you can try some menthol towels wrapped around your head perhaps


Posted by: read | Link to this comment | 09-19-08 11:16 AM
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Don't we know by now that that's exactly wrong?

To the extent that you call it "evidence-based medicine", I think research shows that it works pretty darn well.


Posted by: LizardBreath | Link to this comment | 09-19-08 11:17 AM
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143: Heck no, it's clear that medicine based on no evidence is better.


Posted by: parsimon | Link to this comment | 09-19-08 11:22 AM
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No, seriously, "evidence-based medicine" is a term of art, I'm not being snarky. If you take 100 patients, and treat fifty of them on the basis of "Looking at the most recent research, patients with those objectively measurable characteristics have the best outcomes when you treat them with protocol X", and you hand the other fifty over to wise old Doctor Bob, who's been working in the field forever and keeps up with the latest research but relies on his clinical judgment on a case-by-case basis, the 'evidence-based' mindless automaton consistently leaves (again, I don't have stats) wise old Dr. Bob's clinical judgment in the dust.


Posted by: LizardBreath | Link to this comment | 09-19-08 11:30 AM
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LB is disrupting my chi with her negative vibes. I think I might need to go see my doctor.


Posted by: pdf23ds | Link to this comment | 09-19-08 11:34 AM
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Hey! My head's getting ready to explode here! I'll take advice from Dr. Bob OR an automaton.

Actually, the aura seem(s) to have dissipated, so maybe a false alarm.

What I don't get is that, from my understanding of the likely links between caffeine and migraines, what I'm doing is the very least likely thing to cause migraines. Other environmental factors don't play: lovely, consistent weather for all 3 incidents, stress levels ranging from 6 to 0 to 3 (out of 10), etc. Exercise both absent and present. Obama both leading and trailing.


Posted by: JRoth | Link to this comment | 09-19-08 11:36 AM
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Now that's snarky.


Posted by: LizardBreath | Link to this comment | 09-19-08 11:36 AM
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JRoth, I haven't had significant migraine problems for several years (knock on wood), but I didn't think caffeine contributed particularly to migraines either. The only additional issue with the Mt. Dew that occurs to me is sugar. ? Um, if the migraines occur a couple of hours after the soda, you're having a sugar low after having had the soda?

I suppose you could try eliminating the soda altogether, or having caffeinated tea, maybe iced tea, no sugar, instead.


Posted by: parsimon | Link to this comment | 09-19-08 11:48 AM
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The alternative in my area would probably involve working for the defense industry.

Well, my current financial needs are met indirectly by the defense industry, so. OTOH, Mr. B. genuinely believes in the principles (as he sees them) of his job.

I leave it as a puzzle for the reader whether that is better or worse, morally speaking.


Posted by: bitchphd | Link to this comment | 09-19-08 11:51 AM
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the 'evidence-based' mindless automaton consistently leaves (again, I don't have stats) wise old Dr. Bob's clinical judgment in the dust.

I have to think this depends alot on how good Dr. Bob is. Anyway, where are you getting the "objectively measurable characteristics" other than Dr. Bob using his clinical judgment to ask the right questions/take the correct measurements?

(That said, a 9 year old plus a computer diagnosed my shingles and the M.D. who then treated me couldn't keep the difference between antiviral and antibiotic drugs straight, so point to automatons and children.)


Posted by: Di Kotimy | Link to this comment | 09-19-08 11:52 AM
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Magnesium supplements were the only non-drug thing that had a significant impact on my migraines.


Posted by: Amber | Link to this comment | 09-19-08 11:58 AM
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It strikes me that what Dr. Bob may be good at, and which studies of the efficacy of evidence-based medicine leave out, is preventative care. The studies assume an already-existing problem: this person has diabetes (say). Dr. Bob might be able to head that oncoming diabetes off at the pass; his efficacy at this will not be measurable.


Posted by: parsimon | Link to this comment | 09-19-08 11:58 AM
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I didn't think caffeine contributed particularly to migraines either

Caffeine helps migraines (Excedrin Migraine, frex, is just Excedrin with 500mg or so of caffeine). My understanding is that you want to keep a relatively low intake of it, though, so that you don't build a superhuman tolerance to it and it remains effective. My body is so used to daily caffeine megadoses that it's mostly useless when migraines strike.


Posted by: apostropher | Link to this comment | 09-19-08 11:59 AM
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151: I'm referring to, rather than citing, studies, and this is stuff I've been told about rather than read, so I may be way off base. But my understanding of the research is that you simply can't find any Dr. Bobs, even the best, who can consistently get better results than someone making solely 'evidence-based' treatment decisions.

Now, this is limited -- as you say, judgment is absolutely necessary at the symptom-identification data gathering stage, and it's also necessary because there isn't good research for every specific situation.


Posted by: LizardBreath | Link to this comment | 09-19-08 11:59 AM
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I have to think this depends alot on how good Dr. Bob is.

I'm betting that it also depends on the nature of the problem being addressed. My recollection is that inquiry into the relative merits of doctors vs. hard rules is relatively recent.


Posted by: SomeCallMeTim | Link to this comment | 09-19-08 11:59 AM
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JRoth is bald or balding
otherwise he would try and confirm or deny my method


Posted by: read | Link to this comment | 09-19-08 12:01 PM
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Um, if the migraines occur a couple of hours after the soda, you're having a sugar low after having had the soda?

I would guess not - I eat fairly continuously over the day, so blood sugar should be consistently high, and as far as any actual sugar rush, I've had peach pie for breakfast 3 mornings in a row, with a migraine only once, so I doubt that's it.

Annoying.


Posted by: JRoth | Link to this comment | 09-19-08 12:01 PM
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153: Why would preventative care be any harder to measure? I'm vaguely throwing around research I've been told about, so I don't know what's been done, but if Dr. Bob is doing preventive care, he's doing it on the basis of something about the patient. So you take X patients who present as needing preventive care, and give half of them to Dr. Bob and treat the other half in an 'evidence-based' fashion, and the results should tell you who's doing a better job.


Posted by: LizardBreath | Link to this comment | 09-19-08 12:03 PM
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157: read is too fucking awesome.

Also, correct. But as I said, no actual headache today, so I can't test it.


Posted by: JRoth | Link to this comment | 09-19-08 12:03 PM
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500mg or so of caffeine

Erm 65 mg of caffeine. 250 each of acetaminophen and aspirin.


Posted by: apostropher | Link to this comment | 09-19-08 12:03 PM
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If you just get a the migraines a few times a year, get one of those expensive serotonin agonist treatments to carry around in your satchel.

when you meantioned dr. bob, i thought you meant dr-bob.org/babble


Posted by: yoyo | Link to this comment | 09-19-08 12:04 PM
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What's 65 mg of caffeine in cups of coffee? Wouldn't it be more fun to take an asprin and have a cup of coffee, if the dosage is close?


Posted by: LizardBreath | Link to this comment | 09-19-08 12:05 PM
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That said, a 9 year old plus a computer diagnosed my shingles

Please tell me that you didn't let Rory google "skin rash" or "what is that nasty stuff on mom's skin?"?!?!?


Posted by: Will | Link to this comment | 09-19-08 12:07 PM
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158: Yeah, I didn't think it really could be the sugar. It's my experience too that, as Apo says, caffeine usually helps with migraines.

You probably know that migraines are considered pretty mysterious and are usually a question of life management (drat; no automatons for you). So, no idea. Maybe the doc will help.

My sympathies.


Posted by: parsimon | Link to this comment | 09-19-08 12:09 PM
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Di, I've been having some lower back pain. Couldnyou connect me with Dr. Rory?


Posted by: John Emerson | Link to this comment | 09-19-08 12:10 PM
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What's 65 mg of caffeine in cups of coffee?

Roughly one. Though not if you brew it at the stregth I do. My problem is that when I get a migraine, nothing will stay in my stomach for any length of time, including coffee, pills, or water. Pot helps some, though the actual process of smoking is pretty unpleasant as well. My usual tx is to lie in a completely dark room and just suffer through it.

And I don't want to alarm you unnecessarily, but if you have a sudden spike in headache frequency, you should definitely go see a doctor about it.


Posted by: apostropher | Link to this comment | 09-19-08 12:14 PM
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164: No, no, no. I plugged symptoms into a medical automaton website, which generated a list of possible diagnoses. Then I made Rory compare my back to the relevant (and exclusively wholesome, thankyouverymuch) pictures:

"How about contact dermatitis?"
"It's shingles, Mom."
"Did you look at eczema?"
"Shingles."
"Well what about -- "
"You just don't want to accept this, do you...?"


Posted by: Di Kotimy | Link to this comment | 09-19-08 12:16 PM
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166: I would, but she's starting to get a little cocky. (Based on historical evidence, though, she'd recommend you go for a massage.)


Posted by: Di Kotimy | Link to this comment | 09-19-08 12:19 PM
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So you take X patients who present as needing preventive care

Dr. Bob's the one who determines who presents as needing preventive care. We need him. Maybe an NP can take his place; we really don't know.

In any event, relative comity. It's the need for judgment at what you call in 155 "the symptom-identification data gathering stage" that I had in mind in calling the automaton model "exactly wrong." Realize that 'symptoms' here may be something as simple as someone consistently looking rather tired, gradually gaining weight, and slowly becoming more pasty-looking. I dislike the mechanistic way in which evidence-based medicine apparently wishes to view these things, and I don't think this is merely aesthetic preference on my part.


Posted by: parsimon | Link to this comment | 09-19-08 12:21 PM
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Trust Dr. Bob?! I've watched Veterinarian's Hospital. He's a quack who has gone to the dogs.


Posted by: md 20/400 | Link to this comment | 09-19-08 12:24 PM
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parsimon, do you think the kind of models used in medical expert systems have something fundamentally wrong with them, or do you just think that doctors can do that sort of thing better using more accurate, though less explicit, models in their heads?


Posted by: pdf23ds | Link to this comment | 09-19-08 12:26 PM
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I've never had a specialist suggest that perhaps doing nothing and just keeping an eye on the problem is the best approach.

This may say more about the specialists you've seen than about specialists in general. I've been seeing specialists for a couple of chronic conditions for years now, and both of the ones I go to regularly at this point have made precisely this suggestion. They'll both tell me about *other* options as well, but only in the context of "these are the various choices you can make, and doing nothing and keeping an eye on things is just as valid as any of them".


Posted by: Josh | Link to this comment | 09-19-08 12:28 PM
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The criterion in my own case was met by the specialist I was seeing saying, "I really don't need to see you regularly any more, as you're maintaining nicely, so let's just transfer your routine checkups to your GP."

Purest anecdata, but my mom has severe kidney damage because the GP who was handling her routine monitoring after her specialist retired fucked it up. Sometimes it helps to be dealing with someone who's acutely focused on WHY they're monitoring whatever it is they're monitoring.


Posted by: Not Prince Hamlet | Link to this comment | 09-19-08 12:29 PM
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167: when I get a migraine, nothing will stay in my stomach for any length of time, including coffee, pills, or water.

Apo, a long time ago a friend's dad (whom I now think of as guru of the blessed clouds) recommended, and brought to my bedside, a large, wide bowl of very strong, hot, steaming coffee -- undrinkably strong. The idea was that I'd breathe in the fumes, since smell is one of the only senses that still functions without excruciating pain during a migraine. It worked after a while! Calming, too.


Posted by: parsimon | Link to this comment | 09-19-08 12:29 PM
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Rory's bedside manner is firm.

Shingles is a late effect of chickenpox, whih we were discussing the other day re vaccinations.


Posted by: John Emerson | Link to this comment | 09-19-08 12:29 PM
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I've been seeing specialists for a couple of chronic conditions for years now

Masseuses promising happy endings are not the sort of specialists being discussed.

As I understand it, the problem being referred to is just the "every problem looks like a nail if you have a hammer" problem that happens everywhere. I'm not sure that there's a silver bullet available.


Posted by: SomeCallMeTim | Link to this comment | 09-19-08 12:32 PM
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Making Light has a sidelight linking to a humourous medical study on Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. Evidence? not so much.


Posted by: md 20/400 | Link to this comment | 09-19-08 12:34 PM
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There's one right here. And here. Oh, and here. In fact, there seems to be no shortage of them.


Posted by: pdf23ds | Link to this comment | 09-19-08 12:34 PM
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When you can't find a silver bullet, every problem looks like a werewolf.


Posted by: Bave Dee | Link to this comment | 09-19-08 12:36 PM
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I missed the vaccination discussion. FYI parents -- they recently changed the recommendations for the chicken pox vaccine from one shot (at age 1?) to a shot plus booster sequence. We were a little worried that having only gotten the one shot wasn't going to be enough to protect Rory from contracting chicken pox from my shingles. Thankfully, she was okay.


Posted by: Di Kotimy | Link to this comment | 09-19-08 12:38 PM
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180: This is particularly problematic--as we've learned from the Buffy texts--when the problem is in fact a good-looking vampire.


Posted by: SomeCallMeTim | Link to this comment | 09-19-08 12:39 PM
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172: do you think the kind of models used in medical expert systems have something fundamentally wrong with them, or do you just think that doctors can do that sort of thing better using more accurate, though less explicit, models in their heads?

I need to get some work done, but briefly, I think the mechanistic model works fine once a problem has actually arisen and/or been identified, and if -- a large if -- every factor impacting the potential success of the treatment course has been, er, logged in.

I really need to work now.


Posted by: parsimon | Link to this comment | 09-19-08 12:41 PM
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The relevance to parachute use is that individuals jumping from aircraft without the help of a parachute are likely to have a high prevalence of pre-existing psychiatric morbidity. Individuals who use parachutes are likely to have less psychiatric morbidity and may also differ in key demographic factors, such as income and cigarette use. It follows, therefore, that the apparent protective effect of parachutes may be merely an example of the "healthy cohort" effect.

Posted by: John Emerson | Link to this comment | 09-19-08 12:44 PM
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Dr. Bob's the one who determines who presents as needing preventive care. We need him. Maybe an NP can take his place; we really don't know.

Here, I'm really way out without support, vaguely regurgitating stuff I talked about with some NP's I used to work with before law school. But that's exactly what I'm arguing, that an NP can take his place.

Dr. Bob has a shitload of incredibly expensive basic science training and residency and so forth. What his value added is here, though, is to spend time really looking at and interacting with patients to be able to identify all of the relevant information when they have health problems, so everything relevant can be considered.

I think there's a fair argument that given a choice between someone who, because of the cost of their training, can devote ten minutes to looking at you and then making a quick treatment decision about a condition he sees twice a year (the GP), or someone who can spend half an hour really interacting with and listening to you, can treat minor things, and for anything major can identify that 'this, this, and this just aren't right. While I think it probably means X, I know that an endocrinologist will really know what's going on here.'


Posted by: LizardBreath | Link to this comment | 09-19-08 12:44 PM
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JRoth:

I've only ever had one full-blown migraine, but I have lots of experience with weird visual symptoms. Until very recently, I only experienced them after prolonged and strenuous exercise, like a few hours of pickup basketball, and even then, only very sporadically. Recently, however, I've experienced similar symptoms after ingesting an extraordinarily big dose of caffeine (for me, at least), like a large Starbucks drink.

Frustrated, I did some poking around on the web, and found that people with caffeine allergies seem to experience the same symptoms. I'd never had problems with caffeine before, but the descriptions I read of the symptoms of even mild caffeine allergies were persuasive.

Bottom line (keeping in mind that I sure as hell ANADoctor): caffeine can cause weird visual symptoms, whether they're directly connected to migraines or not. Based on my own experience, I'd recommend experimenting with moderating your caffeine intake, regardless of what people above have been saying about caffeine as a migraine inhibitor.


Posted by: NickFranklin | Link to this comment | 09-19-08 12:48 PM
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Whoops, I trailed off in the middle of a sentence there. Finishing the last sentence with "that the latter is preferable" would probably work.


Posted by: LizardBreath | Link to this comment | 09-19-08 12:50 PM
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Just want to pipe in and say that internal medcine and primary care are not identical. Internists can be primary care providers as can people with specialties in family medicine, but there's also a growing specialty known as the hospitalist, someone who coordinates the care of patients with more than one disease while in the hospital.

I haven't had great luck with NPs. They prescribed systemic antibiotics for acne without discussing the risk, and one could just about handle a yeast infection. I do like my PCP. She had me in to do an EKG, because the sleep center used some stupid machine that wouldn't do a print out.

(It turns out that off the beta blocker my heart rhythm was totally fine and on it, it was only slightly lower than normal. Satisfied that I don't have a thyroid problem or messed up electrolytes, I can go back on it at a low dose. Yay!) She didn't think that I needed to see a cardiologist or get sent for an echo, but every EKG done at the hospital is reviewed by a cardiologist, so I'll be contacted if the cardiologist thinks that there's a problem, but I don't need to get referred to one..


Posted by: Bostoniangirl | Link to this comment | 09-19-08 12:51 PM
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185: Comity! My friend the PA has been consistently more reliable than my GP on basic medical issues. Better than the GP on some of the specialized stuff, too -- mostly because (I think) she's better at admitting the limits of her knowledge and looking things up when she needs to. (I.e. GPs who refused to admit that they aren't endocrinologists and fucked up some thyroid issues because they were about 5 years behind the curve on the standards.)


Posted by: Di Kotimy | Link to this comment | 09-19-08 12:51 PM
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LB: You'd need aspirin and acetominophen plus coffee. A cup of Starbucks will give you about 250 mg of caffeine--which is so much more than the 65 mg found in regular drip coffee.


Posted by: Bostoniangirl | Link to this comment | 09-19-08 12:53 PM
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190: That would explain the difficulty in switching back to home-brewed coffee...


Posted by: Di Kotimy | Link to this comment | 09-19-08 1:02 PM
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A handy site for answering all your caffeine-content questions.


Posted by: Otto von Bisquick | Link to this comment | 09-19-08 1:05 PM
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If you currently tolerate caffeine too well for it to help in regular doses, I suppose you could always try larger doses with caffeine pills, which are available OTC just about anywhere, and let you take as much caffeine as you dare without gorging on sugar or coffee.


Posted by: pdf23ds | Link to this comment | 09-19-08 2:06 PM
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192: Almost all of my caffeine-content questions. They don't list the three energy drinks I go to when Full Throttle isn't on sale: Deton8, Blue Streak, and Caballo Negro (with Cat's Claw extract!).


Posted by: apostropher | Link to this comment | 09-19-08 2:11 PM
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for,
a paper


Posted by: read. | Link to this comment | 09-19-08 2:18 PM
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From read's link:

These recommendations have not been demonstrated to improve outcomes in longitudinal studies.

Bummer.


Posted by: LizardBreath | Link to this comment | 09-19-08 2:21 PM
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My sister-in-law gets bad migraines fairly frequently, and she also has the "can't keep pills or anything else down" problem. Her doctor prescribed a suppository form of, I think, Emetrix. Apparently it works like a charm and she's been able to live migraine-free for a couple of years or so. So, apo, I recommend you take my advice and shove it up your ass.


Posted by: M/tch M/lls | Link to this comment | 09-19-08 2:30 PM
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195: I notice they didn't include hair pulling.


Posted by: togolosh | Link to this comment | 09-19-08 2:50 PM
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hair pulling is a completely novel pain relieving method, i'd have liked to name it after me, but some other people's friend's moms were using it already, they confirmed the effect
about the abstract's ending it's so yingyang, duality and as expected and means maybe cope with pain as you like


Posted by: read | Link to this comment | 09-19-08 3:17 PM
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200!


Posted by: read | Link to this comment | 09-19-08 3:31 PM
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they confirmed the effect
about the abstract's ending it's so yingyang, duality and as expected

chakras?


Posted by: pdf23ds | Link to this comment | 09-19-08 3:34 PM
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Emetrix sounds like a cool mythological creature. "I was doing fine until I met the Emetrix. Then it was a quick trip to the vomitorium for me."


Posted by: F | Link to this comment | 09-19-08 9:00 PM
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Readism works for a lot of short-term pain relief, but what about the people with most pain of all, the agonized skinheads?!


Posted by: CN | Link to this comment | 09-19-08 10:09 PM
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apo, I recommend you take my advice and shove it up your ass

The last time I took your advice, I walked funny for a week.


Posted by: apostropher | Link to this comment | 09-20-08 3:02 AM
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204: I still feel guilty about that "all the cool people are wearing only one platform boot this season" advice, but I really thought you'd cop sooner to the fact that I was joking.


Posted by: M/tch M/lls | Link to this comment | 09-20-08 8:21 PM
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Back on topic, you know what I hate? When you go off a prescription drug but you still have some left over. It seems so sensible to pass it on to someone else, especially someone who has crappy or no drug coverage, you know?

I, for instance, no longer take L-x-p-o, but have a full bottle. Gosh darn it, though, it's illegal to give it to someone who's got a prescription for it. I really hate that.


Posted by: Sir Kraab | Link to this comment | 09-21-08 11:06 AM
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Is there some implied *nudge nudge wink wink* to current Unfoggedian takers of L/x/pro going on in 206?


Posted by: M/tch M/lls | Link to this comment | 09-21-08 2:41 PM
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Paging Dr. Standpipe.


Posted by: Sir Kraab | Link to this comment | 09-21-08 9:42 PM
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