4 ms·

This whole incident hasn't done much to shake my impression that US doctors are interested first and foremost in making sure they get their "cut" on every presc

by paulmd 7y ago

This whole incident hasn't done much to shake my impression that US doctors are interested first and foremost in making sure they get their "cut" on every prescription, even when the drug is relatively innocuous. Like fine, we can have this discussion about chloroquine. It's behind-the-counter in the UK, so on par with sudafed in terms of access control, and OTC in a lot of countries that actually have to deal with malaria directly. But the same argument gets applied to stuff like oral contraceptives, which are straight-up OTC in a lot of countries too, and can simply be discontinued if you notice symptoms. At the same time, we allow drugs with insanely narrow theraputic ranges like tylenol/acetaminophen/paracetamol (seriously, almost as bad as the chloroquine people are freaking out about, a normal dose is 1-4g and a lethal dose can be as low as 5g) to be sold OTC here with no questions whatsoever. We allow combination products despite obvious risks for multiple dosing, we allow combination products to "dissuade addicts" from abusing opiods (like any addict has ever been dissuaded by a risk bodily harm). And doctors don't make a peep about that, because they're not accustomed to getting their cut on that one. That's also why the AMA resists nurse practitioners so hard. The truth is, a lot of those drugs really should be "behind the counter", a pharmacist should simply have to give you a quick rundown of possible symptoms and what to do if you notice them (discontinue and see a doctor or go to a hospital depending on urgency, same as you would do with a doctor-prescribed drug), but doctors won't allow that because they wouldn't get their cut, so we just call them "nurse practitioners" instead. US doctors really like playing gatekeeper, to a much greater extent than other countries (where coincidentally, money doesn't come into the picture as much).

pkaye 7y ago
Do doctors "get a cut" when their patients buy from a neighborhood pharmacy?
- paulmd 7y ago
  They get a couple hundred bucks for a 5 minute office visit to write the prescription, yeah. I'm fine if there's a serious reason for a physical examination, but a lot of stuff the doctor is effectively filling the role of a pharmacist: telling you side effects and if you have this set of serious side effects then to stop it and/or go to a hospital, here's your script, pay at the front desk. A lot of stuff is unnecessarily shoehorned into Rx-only, and despite a lot of talk about "reducing costs" there is no real drive to actually do so. A great example is oral contraceptives. You may have to try a couple different blends before you find the right mix for your body. Some of them will be uncomfortable. Some may cause dangerous bleeding and you need to go to a hospital. There is not zero risk here, or with any drug. But the doctor has no way of telling which might be which for your particular body, they are there to tell you the risks, sign the paper and let you try it out. And that's why oral contraceptives specifically are being looked at as something that could be moved out of Rx only and to either OTC or pharmacist-prescribable - but the problem is there are really a lot of drugs that don't belong there. A pharmacist can read the risks to you just as easily and not charge you $250 for a 15 minute office visit and another $250 for a one-month followup 15 minute office visit. I have lots of 6-month maintenance visits that are literally 5 minutes. Everything going well? "Yup!" "OK, we'll call in your prescription, pay up front". They're just using their gatekeeping power to extract a check.
  - jac241 7y ago
    They don't make a couple hundred bucks. A 99213 established outpatient visit is worth 0.96 work RVUs * $36.0391 Medicare conversion factor = $34.59 for a standard outpatient visit. Even if you add the facility RVU = 0.48 + malpractice RVU 0.08 that is $54.78 for an outpatient visit. To make a couple hundred bucks, you need to do something like placing a stent for someone who is having a heart attack: CPT code 92941 - 12.31 work RVUs = $443.64. All this information is available online. You can look up the physician fee schedule straight from the CMS. https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=2&HT=0&H1=92941&M=5 https://www.cms.gov/apps/physician-fee-schedule/search/searc... . Here are the cardiology codes - https://myheart.net/cardiology-coding-center/coronary-intervention-cpt-codes-and-rvu/ https://myheart.net/cardiology-coding-center/coronary-interv... To add an additional data point, doing a heart transplant is 89.50 wRVU * 36.0391 = $3225. I don't think doctors are living as well as you think. CPT code 33945.
    - paulmd 7y ago
      Providers don't bill Medicare rates to normal patients, so none of that is valid. Providers in fact make a point that they lose a significant amount of money at Medicare rates and have to limit the number of Medicare/Medicaid patients they see as a result. I can confirm that a "45 minute" (5 minutes with nurse taking vitals, 25 minutes waiting in office exam room, 15 minutes with doctor) specialist "new" office visit was just billed to me for $246. They didn't charge me half the rate they charge a heart attack, they charge the heart attack patient 100x as much. I don't think you understand how US billing works. Probably not from the US, or probably not subject to the system due to age (child or senior) or privilege (an engineer on a cadillac PPO plan perhaps). Anyone who has ever experienced the US system knows that's absolutely normal.
      - jac241 7y ago
        You said physicians get paid a couple hundred bucks for each visit. I provided the source that says how much a physician gets paid by medicare for an established outpatient visit. An outpatient visit for a new patient (99203) is 1.42 wRVU + 1.48 facility RVU + 0.13 malpractice RVU = 2.14 RVUs = $109 for Medicare. A complex new visit (99205) is 3.17 wRVU + 2.40 facility RVU + 0.28 malpractice RVU = 5.85*36.06 = 210 dollars. The facility RVU is the amount given to pay for staff, rent, and other overhead. In general, if a physician is employed, they are getting just the wRVU for the visit. For outpatient visits, this source says medicare pays 92% of what private insurance pays for established outpatient visits, and 80% overall https://money.cnn.com/2014/04/21/news/economy/medicare-doctors/ https://money.cnn.com/2014/04/21/news/economy/medicare-docto... . I am a US citizen who used to be a software engineer who now attends a US MD Medical school and I have student health insurance. For the heart attack patient, it isn't the physician who is charging the huge amount. It's the hospital. The physician is only going to get a certain factor (somewhere between 1x - maybe 3x on the extreme end) of that $440 for the wRVUs.
- jac241 7y ago
  No, the Stark Law prevents that (self referral, referring to another business the physician has a stake in) https://en.wikipedia.org/wiki/Stark_Law https://en.wikipedia.org/wiki/Stark_Law . Physicians are paid according to a fee schedule that decides how much each thing they do is worth. Each procedure or office visit is assigned a work Relative Value Unit, which is multiplied by a conversion factor ($36.0391 for Medicare) to determine how much a physician gets paid. Private insurance generally follows the Medicare RVU scale, and has an adjustment ~120-150% for the conversion factor (just a guess, only a student). This conversion factor was $36.6873 in 1998, so, adjusting for inflation, Medicare values each thing a physician does at 62% of what it did in 1998. I hate that most of my posts on this site are about this topic, but so many people on this site get it so wrong when it comes to how physicians are paid.
headmelted 7y ago
I would love to know where in the UK chloroquine is behind-the-counter and not prescription only.
- paulmd 7y ago
  Chloroquine is class P (pharmacy medicines), which is effectively "behind-the-counter but the pharmacist tells you how to use it". The idea being that if you want to take a trip to somewhere tropical, you don't have to tie up a GP with a standard, low-risk medication, but it's not quite so low-risk that you just put it on the shelf. Behind-the-counter, if you will. https://en.wikipedia.org/wiki/Over-the-counter_drug#United_Kingdom https://en.wikipedia.org/wiki/Over-the-counter_drug#United_K... > Pharmacy Medicines (P) are medicines which are legally neither a POM or GSL medication. These can be sold from a registered pharmacy but should not be available for self-selection (although directions to discuss a 'P' product may be allocated shelf space with associated GSL items). 'P' medications are reserved from the GSL list as they are either associated with a need for advice on use, or used in conditions which may require referral to a medical prescriber. Suitable trained counter assistants may sell a 'P' medication under the supervision of a pharmacist and will ask questions to determine if the customer needs to be referred for a discussion with a pharmacist.
  - headmelted 7y ago
    I’ve been trying to buy some since early January and haven’t found a single pharmacist who will sell it to me. If you know of one, please let me know.
    - DanBC 7y ago
      No-one carries it because they'd have hydroxychloroquine instead. Hydroxychloroquine is prescription only. You're not going to be able to get a registered professional to give you anything for off-label experimentation, especially not something with potentially serious side effects like chloroquine.
      - 7y ago

by paulmd 7y ago

pkaye 7y ago

Do doctors "get a cut" when their patients buy from a neighborhood pharmacy?

paulmd 7y ago
They get a couple hundred bucks for a 5 minute office visit to write the prescription, yeah. I'm fine if there's a serious reason for a physical examination, but a lot of stuff the doctor is effectively filling the role of a pharmacist: telling you side effects and if you have this set of serious side effects then to stop it and/or go to a hospital, here's your script, pay at the front desk. A lot of stuff is unnecessarily shoehorned into Rx-only, and despite a lot of talk about "reducing costs" there is no real drive to actually do so. A great example is oral contraceptives. You may have to try a couple different blends before you find the right mix for your body. Some of them will be uncomfortable. Some may cause dangerous bleeding and you need to go to a hospital. There is not zero risk here, or with any drug. But the doctor has no way of telling which might be which for your particular body, they are there to tell you the risks, sign the paper and let you try it out. And that's why oral contraceptives specifically are being looked at as something that could be moved out of Rx only and to either OTC or pharmacist-prescribable - but the problem is there are really a lot of drugs that don't belong there. A pharmacist can read the risks to you just as easily and not charge you $250 for a 15 minute office visit and another $250 for a one-month followup 15 minute office visit. I have lots of 6-month maintenance visits that are literally 5 minutes. Everything going well? "Yup!" "OK, we'll call in your prescription, pay up front". They're just using their gatekeeping power to extract a check.
- jac241 7y ago
  They don't make a couple hundred bucks. A 99213 established outpatient visit is worth 0.96 work RVUs * $36.0391 Medicare conversion factor = $34.59 for a standard outpatient visit. Even if you add the facility RVU = 0.48 + malpractice RVU 0.08 that is $54.78 for an outpatient visit. To make a couple hundred bucks, you need to do something like placing a stent for someone who is having a heart attack: CPT code 92941 - 12.31 work RVUs = $443.64. All this information is available online. You can look up the physician fee schedule straight from the CMS. https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=2&HT=0&H1=92941&M=5 https://www.cms.gov/apps/physician-fee-schedule/search/searc... . Here are the cardiology codes - https://myheart.net/cardiology-coding-center/coronary-intervention-cpt-codes-and-rvu/ https://myheart.net/cardiology-coding-center/coronary-interv... To add an additional data point, doing a heart transplant is 89.50 wRVU * 36.0391 = $3225. I don't think doctors are living as well as you think. CPT code 33945.
  - paulmd 7y ago
    Providers don't bill Medicare rates to normal patients, so none of that is valid. Providers in fact make a point that they lose a significant amount of money at Medicare rates and have to limit the number of Medicare/Medicaid patients they see as a result. I can confirm that a "45 minute" (5 minutes with nurse taking vitals, 25 minutes waiting in office exam room, 15 minutes with doctor) specialist "new" office visit was just billed to me for $246. They didn't charge me half the rate they charge a heart attack, they charge the heart attack patient 100x as much. I don't think you understand how US billing works. Probably not from the US, or probably not subject to the system due to age (child or senior) or privilege (an engineer on a cadillac PPO plan perhaps). Anyone who has ever experienced the US system knows that's absolutely normal.
    - jac241 7y ago
      You said physicians get paid a couple hundred bucks for each visit. I provided the source that says how much a physician gets paid by medicare for an established outpatient visit. An outpatient visit for a new patient (99203) is 1.42 wRVU + 1.48 facility RVU + 0.13 malpractice RVU = 2.14 RVUs = $109 for Medicare. A complex new visit (99205) is 3.17 wRVU + 2.40 facility RVU + 0.28 malpractice RVU = 5.85*36.06 = 210 dollars. The facility RVU is the amount given to pay for staff, rent, and other overhead. In general, if a physician is employed, they are getting just the wRVU for the visit. For outpatient visits, this source says medicare pays 92% of what private insurance pays for established outpatient visits, and 80% overall https://money.cnn.com/2014/04/21/news/economy/medicare-doctors/ https://money.cnn.com/2014/04/21/news/economy/medicare-docto... . I am a US citizen who used to be a software engineer who now attends a US MD Medical school and I have student health insurance. For the heart attack patient, it isn't the physician who is charging the huge amount. It's the hospital. The physician is only going to get a certain factor (somewhere between 1x - maybe 3x on the extreme end) of that $440 for the wRVUs.
jac241 7y ago
No, the Stark Law prevents that (self referral, referring to another business the physician has a stake in) https://en.wikipedia.org/wiki/Stark_Law https://en.wikipedia.org/wiki/Stark_Law . Physicians are paid according to a fee schedule that decides how much each thing they do is worth. Each procedure or office visit is assigned a work Relative Value Unit, which is multiplied by a conversion factor ($36.0391 for Medicare) to determine how much a physician gets paid. Private insurance generally follows the Medicare RVU scale, and has an adjustment ~120-150% for the conversion factor (just a guess, only a student). This conversion factor was $36.6873 in 1998, so, adjusting for inflation, Medicare values each thing a physician does at 62% of what it did in 1998. I hate that most of my posts on this site are about this topic, but so many people on this site get it so wrong when it comes to how physicians are paid.

headmelted 7y ago

I would love to know where in the UK chloroquine is behind-the-counter and not prescription only.

paulmd 7y ago
Chloroquine is class P (pharmacy medicines), which is effectively "behind-the-counter but the pharmacist tells you how to use it". The idea being that if you want to take a trip to somewhere tropical, you don't have to tie up a GP with a standard, low-risk medication, but it's not quite so low-risk that you just put it on the shelf. Behind-the-counter, if you will. https://en.wikipedia.org/wiki/Over-the-counter_drug#United_Kingdom https://en.wikipedia.org/wiki/Over-the-counter_drug#United_K... > Pharmacy Medicines (P) are medicines which are legally neither a POM or GSL medication. These can be sold from a registered pharmacy but should not be available for self-selection (although directions to discuss a 'P' product may be allocated shelf space with associated GSL items). 'P' medications are reserved from the GSL list as they are either associated with a need for advice on use, or used in conditions which may require referral to a medical prescriber. Suitable trained counter assistants may sell a 'P' medication under the supervision of a pharmacist and will ask questions to determine if the customer needs to be referred for a discussion with a pharmacist.
- headmelted 7y ago
  I’ve been trying to buy some since early January and haven’t found a single pharmacist who will sell it to me. If you know of one, please let me know.
  - DanBC 7y ago
    No-one carries it because they'd have hydroxychloroquine instead. Hydroxychloroquine is prescription only. You're not going to be able to get a registered professional to give you anything for off-label experimentation, especially not something with potentially serious side effects like chloroquine.
    - 7y ago