NICE + NHS = ICER...

[Stim4me]

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Socialized healthcare and access to care (i.e. Cancer meds) seems so medieval ... is this what we want; QLY analysis with no long-term societal analysis and consequences (i.e. Hep c meds for inmates)???

http://www.realclearhealth.com/arti...es_nice_and_icers_model_in_the_us_110350.html

 

[VA Hopeful Dr]

The government doesn't have infinite money, if they're going to pay for everything then a system like this is bound to result. I see this as a point to use in the argument against socialized medicine.

 

[SSdoc33]

Socialized healthcare and access to care (i.e. Cancer meds) seems so medieval ... is this what we want; QLY analysis with no long-term societal analysis and consequences (i.e. Hep c meds for inmates)???

http://www.realclearhealth.com/arti...es_nice_and_icers_model_in_the_us_110350.html

withhold treatment for hep C would and should be considered "cruel and unusual punishment". big pharma is charging 30k/year for the meds: that is your enemy

 

[Stim4me]

withhold treatment for hep C would and should be considered "cruel and unusual punishment". big pharma is charging 30k/year for the meds: that is your enemy

But this is happening in England where pharma is already massively regulated... France is a little more humane apparently. Our enemy is socialized Hc. Let's try more capitalism with universal "access" NOT universal coverage.

 

[SSdoc33]

But this is happening in England where pharma is already massively regulated... France is a little more humane apparently. Our enemy is socialized Hc. Let's try more capitalism with universal "access" NOT universal coverage.

universal access? are you going to take medicaid in PP? how is that universal access?

 

[Ducttape]

why so concerned? we already have a situation where many of those with Medicaid or other managed insurance policies do not get access to much of cutting edge healthcare.

this can be compounded because many private practice physicians feel that these patients do not need or deserve access to the specific talents of these physicians.

 

[Stim4me]

Where do I begin...

 

[Blitz2006]

universal access? are you going to take medicaid in PP? how is that universal access?

Exactly.

I grew up in Canada, went to medical school in the UK/residency for a bit and now a resident in the U.S.

UK is a 2 tier system. So NHS for everyone, if you don't like it, then go private (BUPA Insurance). This is superior to Canada, which is 100% Public (Private health care is ILLEGAL in Canada).

But yes, doctors in England get paid much worse (Pain Docs probably average around 200k). Whereas in Canada Pain Docs can hit 500k. Not bad for universal healthcare. And In Canada docs only bill 1 insurance company, the gov't. So you're not wasting time waiting for pre-authorizations, etc. If patient wants epidural tomorrow, SCS, they get it.

The best healthcare system in the world in my opinion is Australia. My friend is a cardiology fellow in Melbourne, and he told me that docs are required to work 50% public, and then can do 50% private. And unlike the NHS which is on its brink, socialized healthcare in Oz is pretty good service. And Cardiologists average 350-400k in Oz. Again, not bad.

I find it medieval here in U.S that you have to turn away patients/unable to prescribe medications because of insurance. But thats just me.

 

[Aether2000]

Perhaps private healthcare is illegal in Canada, but private pay is not in some provinces. I had a patient that was told self pay was illegal for a MRI in Ontario, so went to Montreal, paid $400 cash and went to the front of the line. But socialized healthcare does have a financial cost. Here is a link to the percentage of GDP taxation burden by Western country: https://upload.wikimedia.org/wikipedia/commons/7/7f/Tax_revenue_as_a_percentage_of_GDP_(1985-2014).png Canada appears to pay a whopping 42% total tax compared to the US 26% (http://news.nationalpost.com/news/c...-they-spend-on-food-shelter-clothing-combined)

 

[drusso]

Perhaps private healthcare is illegal in Canada, but private pay is not in some provinces. I had a patient that was told self pay was illegal for a MRI in Ontario, so went to Montreal, paid $400 cash and went to the front of the line. But socialized healthcare does have a financial cost. Here is a link to the percentage of GDP taxation burden by Western country: https://upload.wikimedia.org/wikipedia/commons/7/7f/Tax_revenue_as_a_percentage_of_GDP_(1985-2014).png Canada appears to pay a whopping 42% total tax compared to the US 26% (http://news.nationalpost.com/news/c...-they-spend-on-food-shelter-clothing-combined)

TNSTAFL.

 

[Blitz2006]

Perhaps private healthcare is illegal in Canada, but private pay is not in some provinces. I had a patient that was told self pay was illegal for a MRI in Ontario, so went to Montreal, paid $400 cash and went to the front of the line. But socialized healthcare does have a financial cost. Here is a link to the percentage of GDP taxation burden by Western country: https://upload.wikimedia.org/wikipedia/commons/7/7f/Tax_revenue_as_a_percentage_of_GDP_(1985-2014).png Canada appears to pay a whopping 42% total tax compared to the US 26% (http://news.nationalpost.com/news/c...-they-spend-on-food-shelter-clothing-combined)

No, its still illegal: http://www.nytimes.com/2006/02/28/w...e-clinics-surge-as-public-system-falters.html

Canada Health Act of 1984 states that healthcare must be provided for free. Docs are just finding loopholes in the system, illegally.

http://www.canadian-healthcare.org/page6.html

"Under federal law, private clinics are not legally allowed to provide services covered by the Canada Health Act. Regardless of this legal issue, many do offer such services."


Its only 25% once Trump comes in. Past 8 years it has been 35/39.6% + state tax, so basically on par with Canada.

 

[Aether2000]

True! In Denmark, the overall taxation rate is over 50% of GDP. They have socialized everything.... The happiest people on the planet- since they were ok with being beaten into submission by threescore years of not personally owning much of anything, living in a tiny apartment, driving a leased vehicle forever because they cannot afford anything else (cost of a VW Golf is $45,000) or using a bicycle because the cost of gasoline is $5.70 per gallon. It is a very different lifestyle than we are accustomed to in America- a lifestyle most Americans would not tolerate. But perhaps it is coming anyway. The financial plight of the millennials exactly parallels the lifestyle and financial situation in the Nordic countries, so they are demanding the same benefits as in these countries, blaming Gen-X and the BB for their plight. Perhaps they are not entirely wrong.

The marginal tax rates in the US have been 39% plus state taxes, but the overall tax rates compared to GDP are among the lowest in the Western world at 25-26% for the US. There are many third world countries with far lower overall taxation/GDP ratios, however have relatively much lower standards of healthcare

Regarding Canadian healthcare- here is a wikipedia citation re: the Canadian health system:
"Private health expenditure accounts for 30% of health care financing.[5] The Canada Health Act does not cover prescription drugs, home care or long-term care, prescription glasses or dental care, which means most Canadians pay out-of-pocket for these services or rely on private insurance.[4] Provinces provide partial coverage for some of these items for vulnerable populations (children, those living in poverty and seniors).[4] Limited coverage is provided for mental health care. Competitive practices such as advertising are kept to a minimum, thus maximizing the percentage of revenues that go directly towards care. In general, costs are paid through funding from income taxes. In British Columbia, taxation-based funding is supplemented by a fixed monthly premium which is waived or reduced for those on low incomes.[6] There are no deductibles on basic health care and co-pays are extremely low or non-existent (supplemental insurance such as Fair Pharmacare may have deductibles, depending on income). In general, user fees are not permitted by the Canada Health Act, though some physicians get around this by charging annual fees for services which include non-essential health options, or items which are not covered by the public plan, such as doctors notes, prescription refills over the phone.[4]"

 

[Blitz2006]

True! In Denmark, the overall taxation rate is over 50% of GDP. They have socialized everything.... The happiest people on the planet- but as long as you are beaten into submission by threescore years of not personally owning much of anything, living in a tiny apartment, driving a leased vehicle forever because they cannot afford anything else (cost of a VW Golf is $45,000) or using a bicycle because the cost of gasoline is $5.70 per gallon. It is a very different lifestyle than we are accustomed to in America- a lifestyle most Americans would not tolerate. But perhaps it is coming anyway. The financial plight of the millennials exactly parallels the lifestyle and financial situation in the Nordic countries, so they are demanding the same benefits as in these countries, blaming Gen-X and the BB for their plight. Perhaps they are not entirely wrong.

Agreed.

Its a difference in core belief about health. Health in the rest of the world is a right. In the U.S its a privilege. Its that simple. Outside of education/healthcare, Canada and UK are very capitalist, on par with the U.S. I believe I read in an article that London recently overtook NYC in the financial world with regards to monetary trades/assets.


I'm confused about your statement. The article you posted is reporting a raw tax rate of 42%.

Tax Percentage to GDP ratio in Canada is: 32%

https://www.oecd.org/tax/revenue-statistics-canada.pdf

Tax Percentage to GDP ratio in USA is 26%:

https://www.oecd.org/tax/revenue-statistics-united-states.pdf


So Canada is only 6% higher, but you get free healthcare and graduate education is much cheaper (Most expensive med school in Canada is Univ. of Toronto, $20K/year, which is equal in quality to Columbia Meds, which is 60K/year).

 

[Blitz2006]

withhold treatment for hep C would and should be considered "cruel and unusual punishment". big pharma is charging 30k/year for the meds: that is your enemy

In the UK/NHS, all prescriptions cost $12 flat rate. Whether its cymbalta or tylenol or melatonin or lyrica or prozac or...., $12.

http://www.focusondisability.org.uk/prescriptions.html

And if u're above 60 or below 16, the $12 is waived.

I prescribed melatonin today for a patient and he called back saying insurance won't cover it and its $280 for 1 month supply. Might as well buy a new mattress, probably would help him sleep better!

 

[Blitz2006]

why so concerned? we already have a situation where many of those with Medicaid or other managed insurance policies do not get access to much of cutting edge healthcare.

this can be compounded because many private practice physicians feel that these patients do not need or deserve access to the specific talents of these physicians.

Exactly. I believe in the NYC area over 75% of psychiatrists don't take insurance, cash-only. So pumping more psychiatrists (aka opening up more residency spots) isn't going to help universal access.

"Since 2005, the number of psychiatrists taking private insurance or Medicare has dropped almost 20 percent, to 55 percent, as of 2010, according to a study in the Journal of the American Medical Association. That compares with other specialties where 93 percent take private insurance and 86 percent take Medicare."

https://www.bloomberg.com/news/arti...s-are-failing-the-patients-who-need-them-most

 

[Aether2000]

The Frasier Institute (private) calculated the average overall taxation rate in Canada relative to income (this is more akin to what an individual feels when paying the tax than compared with GDP) however you are correct in the actual taxes/GDP are lower than this figure. This may suggest the average taxpayer in all countries feel a larger personal income tax bite than is reflected in the multi-country data....

Also healthcare in Canada does not equal healthcare in the US. There are compromises such as significant wait times and complete lack of insurance coverage of medications with healthcare expenditures for medications and ancillaries, raising the price of healthcare by 30%. There is less availability of services and limits on high tech.

 

[Aether2000]

How can melatonin cost $280 when it is available OTC at 5 cents a tablet?

 

[Blitz2006]

How can melatonin cost $280 when it is available OTC at 5 cents a tablet?

8 mg Ramelteon (rozarem).

https://www.drugs.com/price-guide/rozerem

I remember in england I used to prescribe this left, right and centre for insomnia. Even ambien requires pre-authorization here for certain patients.

 

[Aether2000]

Rozarem is not melatonin, but I catch your drift. We are getting crazy requests for preauthorizations for drugs that are OTC costing $4 cash, but may cost $10 via prescription that also entails preauthorization to obtain it. We tell patients to forget it- we will not preauthorize something that costs $4 over the counter....

 

[Blitz2006]

Rozarem is not melatonin, but I catch your drift. We are getting crazy requests for preauthorizations for drugs that are OTC costing $4 cash, but may cost $10 via prescription that also entails preauthorization to obtain it. We tell patients to forget it- we will not preauthorize something that costs $4 over the counter....

You know what I mean, Melatonin agonist! 🙂 But yeah, luckily Ramelteon isn't a "life-saving" treatment, so no biggie. But other stuff...

 

[Blitz2006]

The Frasier Institute (private) calculated the average overall taxation rate in Canada relative to income (this is more akin to what an individual feels when paying the tax than compared with GDP) however you are correct in the actual taxes/GDP are lower than this figure. This may suggest the average taxpayer in all countries feel a larger personal income tax bite than is reflected in the multi-country data....

Also healthcare in Canada does not equal healthcare in the US. There are compromises such as significant wait times and complete lack of insurance coverage of medications with healthcare expenditures for medications and ancillaries, raising the price of healthcare by 30%. There is less availability of services and limits on high tech.

There are lots of studies that show Canada is on par with USA in healthcare outcomes.

http://content.healthaffairs.org/content/25/4/1133.full

"At the other end of the income spectrum, there are no systematic health differences among adults in the most affluent households on either side of the border. In other words, affluent Canadians and Americans share very similar health characteristics, even while receiving health care under very different funding models."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3633404/

"Compared to the US system, the Canadian system has lower costs, more services, universal access to health care without financial barriers, and superior health status. Canadians and Germans have longer life expectancies and lower infant mortality rates than do US residents.
Finally, most Canadians and Germans think that their health care systems need minor to moderate changes, while in the United States a substantial portion of the population thinks that large and fundamental changes are needed."


http://www.epi.org/publication/webfeatures_snapshots_20071205/

"It is also noteworthy that despite Canada’s much lower expenditures on health care, Canadians consult with physicians far more often than do Americans. The average number of physician consultations per capita was 6.0 in Canada, versus 3.8 in the United States."


https://www.scientificamerican.com/...good-or-better-healthcare-than-united-states/


"Overall, the results favored Canadians, who were 5 percent less likely than Americans to die in the course of treatment. Some disorders, such as kidney failure, favored Canadians more strongly than Americans, whereas others, such as hip fracture, had slightly better outcomes in the U.S. than in Canada. Of the 38 studies the authors surveyed, which were winnowed down from a pool of thousands, 14 favored Canada, five the U.S., and 19 yielded mixed results."

In my humble opinion, I don't think Canada is >> USA overall, but I certainly don't think USA is >> Canada. Both are probably around the same.

 

[hyperalgesia]

I don't think the federal govt should have any role in health care delivery in the US, other than perhaps some research, grants, etc.

There's nothing wrong with "public" healthcare. But the US is unique in that each state has its very own tricameral government that is perfectly capable of levying taxes and providing free healthcare to every single one of its residents.

 

[Blitz2006]

I don't think the federal govt should have any role in health care delivery in the US, other than perhaps some research, grants, etc.

There's nothing wrong with "public" healthcare. But the US is unique in that each state has its very own tricameral government that is perfectly capable of levying taxes and providing free healthcare to every single one of its residents.

Exactly. Two-Tier System

 

[hyperalgesia]

It's going to be incredibly entertaining when Trump unveils his healthcare plan. Liberals will go ape-**** and act like it's Armageddon. Then Trump will start inventing new nicknames. Stock up on popcorn now.

 

[Aether2000]

Canada has a fine system- for Canadians- that will put up with mediocrity in access, lack of high tech, advances that usually lag, wait times, and a litigation system that pays very small amounts if any due to the disincentives to sue. While health outcomes are not significantly different between the US and Canada, part of that is due to lower expectations, since Canadians don't know any better. The WHO measures of outcomes are very good for Canada, in part due to the maternal care and child health care that is universally available. Longevity and overall health are not necessarily functions of the healthcare system but are due to other factors such as genetics, obesity (20.2% for Canada, 35% for US), smoking (14.6% Canada, 17% US), homicide rate 3 times higher in the US per capita, 6.5 times higher auto fatality rate in the US, physical activity rate weekly (52% Canada, 33% US), etc.

 

[SSdoc33]

we can argue about the merits of one system vs. another, but the REASON health care costs so much in the US is big pharma and the the insurance industry. how, exactly, does giving the CEO of cigna 100 million bucks a year improve the overall health of the US? how does selling a drug to canada at 1/10 the price that americans pay improve the health in the US?

states cant handle this. they dont have the muscle to push around Blue Cross or Pfizer. you end up with train wrecks like arkansas, west virginia, alabama, etc.

 

[Stim4me]

In America all our governmental welfare plans are failing or will soon fail due to miss management and lack of will to adjust benefits based on actuarial science and population changes. I'm glad that Canada has a stable health scheme, most of Europe doesn't. My guess is that a physician employee or hospitalist would do just fine in Canada or Australia, maybe even better with the cleaner air and gun control. Small business owners and pp are in a different ball game in this country, and not comparable to those countries for many reasons ....

If you're a cancer patient seeking access to onc meds, you are severely restricted in most socialized countries, as based on draconian QLY analysis as mentioned in the article. Most of us like to pontificate on forums and at dinner parties about other countries. But my guess is that most of us don't have family or friends with active cancer hoping to get cutting edge branded meds in Canada or England. At least in good old USA you get what you pay for. And if your luck, like in my state, all branded meds are covered by medicaid... go figure. Leave it up to states they know best, all
Governments are incompetent

 

[VA Hopeful Dr]

we can argue about the merits of one system vs. another, but the REASON health care costs so much in the US is big pharma and the the insurance industry. how, exactly, does giving the CEO of cigna 100 million bucks a year improve the overall health of the US? how does selling a drug to canada at 1/10 the price that americans pay improve the health in the US?

states cant handle this. they dont have the muscle to push around Blue Cross or Pfizer. you end up with train wrecks like arkansas, west virginia, alabama, etc.

We are sadly complicit in this to a degree though. Think about all the patients you see on new brand-name drugs that don't have any evidence that they work better than older, cheaper drugs.

Its one thing to use something like xarelto which has definite benefits over coumadin. Its another to have a patient on Vimovo (naproxen + omeprazole, $2000) when splitting that apart into naproxen and prilosec separately is $15.

 

[Stim4me]

We are sadly complicit in this to a degree though. Think about all the patients you see on new brand-name drugs that don't have any evidence that they work better than older, cheaper drugs.

Its one thing to use something like xarelto which has definite benefits over coumadin. Its another to have a patient on Vimovo (naproxen + omeprazole, $2000) when splitting that apart into naproxen and prilosec separately is $15.

To go back to another topic; voltaren gel, OCPs and codiene/tramadol are pretty much over the counter in most of the world... dems would throw a tantrum if OCPs weren't a female debate issue anymore ... see how politics ruins us.

 

[SSdoc33]

To go back to another topic; voltaren gel, OCPs and codiene/tramadol are pretty much over the counter in most of the world... dems would throw a tantrum if OCPs weren't a female debate issue anymore ... see how politics ruins us.

complete non sequitur.

 

[Blitz2006]

In America all our governmental welfare plans are failing or will soon fail due to miss management and lack of will to adjust benefits based on actuarial science and population changes. I'm glad that Canada has a stable health scheme, most of Europe doesn't. My guess is that a physician employee or hospitalist would do just fine in Canada or Australia, maybe even better with the cleaner air and gun control. Small business owners and pp are in a different ball game in this country, and not comparable to those countries for many reasons ....

If you're a cancer patient seeking access to onc meds, you are severely restricted in most socialized countries, as based on draconian QLY analysis as mentioned in the article. Most of us like to pontificate on forums and at dinner parties about other countries. But my guess is that most of us don't have family or friends with active cancer hoping to get cutting edge branded meds in Canada or England. At least in good old USA you get what you pay for. And if your luck, like in my state, all branded meds are covered by medicaid... go figure. Leave it up to states they know best, all
Governments are incompetent

Thats not true. I have a friend living in the west coast, very rare type of ovarian cancer. She went through all the big cancer centers in the U.S, personally visited MD Anderson and MSK. The only active clinical trial that fit her criteria in North America was at Princess Margaret Hospital (One of the best cancer hospitals in the world) in Toronto. So she is now in Canada getting the trial.

Yes I know, this is n=1. But my point is, "most of us don't have family or friends with active cancer hoping to get cutting edge branded meds in Canada or England" because people in the U.S don't even bother to seek medical help outside the States, assuming everything here is #1. I'm the one that had to prompt her to look outside the country.

The Royal Marsden in London is arguably one of the best cancer hospitals in the world, also a world leader in cancer trials.

In the Pediatrics world, the best childrens' hospitals are not even located in the U.S (Great Ormond Street London, Toronto Sick Kids and Royal Melbourne Hospital). And I've spoke to American pediatricians about this, and many do hold these 3 hospitals in high regard. No disrespect to CHOP/CHOB and other big name U.S hospitals, those are obviously very elite, excellent academic sites. But I know if my kid as a super rare condition, I'm looking outside the borders.

The point of my posts is to not say that socialized healthcare is superior to the U.S. There are obviously downsides, there is no perfect healthcare. But I just feel that people in the U.S have a very skewed, jaded view of socialized healthcare.

Just my 2 cents.

 

[Stim4me]

complete non sequitur.

Really, so making medications over the counter and reducing Med cost has no influence on healthcare costs ? Making OCPs and Celebrex and voltaren gel and neurontin ,etc OTC doesn't save healthcare resources for other expenditures? Other countries have figured that out already, but the fickle minded get lost in the logical connection I guess...

 

[VA Hopeful Dr]

Thats not true. I have a friend living in the west coast, very rare type of ovarian cancer. She went through all the big cancer centers in the U.S, personally visited MD Anderson and MSK. The only active clinical trial that fit her criteria in North America was at Princess Margaret Hospital (One of the best cancer hospitals in the world) in Toronto. So she is now in Canada getting the trial.

Yes I know, this is n=1. But my point is, "most of us don't have family or friends with active cancer hoping to get cutting edge branded meds in Canada or England" because people in the U.S don't even bother to seek medical help outside the States, assuming everything here is #1. I'm the one that had to prompt her to look outside the country.

The Royal Marsden in London is arguably one of the best cancer hospitals in the world, also a world leader in cancer trials.

In the Pediatrics world, the best childrens' hospitals are not even located in the U.S (Great Ormond Street London, Toronto Sick Kids and Royal Melbourne Hospital). And I've spoke to American pediatricians about this, and many do hold these 3 hospitals in high regard. No disrespect to CHOP/CHOB and other big name U.S hospitals, those are obviously very elite, excellent academic sites. But I know if my kid as a super rare condition, I'm looking outside the borders.

The point of my posts is to not say that socialized healthcare is superior to the U.S. There are obviously downsides, there is no perfect healthcare. But I just feel that people in the U.S have a very skewed, jaded view of socialized healthcare.

Just my 2 cents.

The point wasn't clinical trials, it was availability of newer, high-end drugs that have already been approved. The point of this thread, after all, was to discuss the committee in the UK that decides what drugs can be offered by the NHS.

 

[VA Hopeful Dr]

Really, so making medications over the counter and reducing Med cost has no influence on healthcare costs ? Making OCPs and Celebrex and voltaren gel and neurontin ,etc OTC doesn't save healthcare resources for other expenditures? Other countries have figured that out already, but the fickle minded get lost in the logical connection I guess...

Meh, those are already fairly cheap if you know how to look for them (goodrx, chain store generic lists). Making them OTC likely won't make a huge difference - look at Nexium for evidence of that. Its still $20/month (as is generic omeprazole), while prescription protonix is on the $8 list at one of my local grocery stores.

 

[Stim4me]

Yes people need to travel to third world countries, European nations and capitalist countries. Spend time and talk with the people , esp if you have never actually used the medical system. And being a resident or student really doesn't give you true insight into the healthcare market and costs. residents are deficient in most cases and most of us have learned on the fly with help from SDN...

When you have to take your grandmother to the hospital in the middle of the night, admit her, and go to the pharmacy any buy the heparin and then have to personally hang it, only then do you appreciate ones own healthcare system. And yes heparin is otc in India...

 

[Stim4me]

Meh, those are already fairly cheap if you know how to look for them (goodrx, chain store generic lists). Making them OTC likely won't make a huge difference - look at Nexium for evidence of that. Its still $20/month (as is generic omeprazole), while prescription protonix is on the $8 list at one of my local grocery stores.

Celebrex 200-400$/mo, voltaren 200$/mo. OCPs 10-400$/mo. Marked up... volt gel in Europe 5$/vial

 

[VA Hopeful Dr]

Celebrex 200-400$/mo, voltaren 200$/mo. OCPs 10-400$/mo. Marked up... volt gel in Europe 5$/vial

Sigh... https://www.goodrx.com/

Celebrex 200mg $40/month, 400mg $70/month
Voltaren $26/month
OCPs - Lots of them on the wal-mart $4 list, the most common ones that aren't:
Yaz $40/month, lo loestrin $110/month

And just to add a few others:

Crestor 10mg, $20/month
Cymbalta 60mg $20/month
Levaquin 750mg $10/week

If you get a doctor who dispenses medication from their office, you can usually get even cheaper than these prices.

Not saying that we couldn't do better, like your European example, merely that it isn't as bad as you think it is here in the US. That, and making things OTC isn't the single cure-all as my PPI example showed.

 

[Ducttape]

2 questions...

isn't "the state" a government entity? does your angst against government only extend down to the Federal level?

currently, many of the branded drugs are inaccessible to the vast majority of patients, as they cannot afford them. from the perspective of a significant proportion of US population - those without unlimited wealth -these drugs - and treatments - are out of reach.

you don't want socialized medicine, I get it. but im not seeing the free market economy and insurance based healthcare in the US providing any better access.

 

[hyperalgesia]

im not seeing the free market economy and insurance based healthcare in the US providing any better access.

We don't have a free market economy. We have crony capitalism, MediFRAUD, and Obamacare with shady deals between govt bureaucrats, insurance companies, and Big Pharma. That's why you're not seeing better access.

 

[Stim4me]

Sigh... https://www.goodrx.com/

Celebrex 200mg $40/month, 400mg $70/month
Voltaren $26/month
OCPs - Lots of them on the wal-mart $4 list, the most common ones that aren't:
Yaz $40/month, lo loestrin $110/month

And just to add a few others:

Crestor 10mg, $20/month
Cymbalta 60mg $20/month
Levaquin 750mg $10/week

If you get a doctor who dispenses medication from their office, you can usually get even cheaper than these prices.

Not saying that we couldn't do better, like your European example, merely that it isn't as bad as you think it is here in the US. That, and making things OTC isn't the single cure-all as my PPI example showed.

I'm note sure what country you live in, but out of pocket for LIDODERM is $200/mo, as well as the rest of the meds I mentioned . I believe you are either in another rural area or talking about insurance pricing of on formulary drugs, which by the way is represented in the deductible + premium cost. The true cost for non formulary or out of pocket meds are; $1000 for Epi pen, envizio narcan, etc. hence the protests by the masses and congressional hearings regarding hep c mess, hiv meds, etc.... my wife's Nuva ring costs $200/month on aetna non formulary plan.... let's get on the same pages before we debate further

 

[Stim4me]

2 questions...

isn't "the state" a government entity? does your angst against government only extend down to the Federal level?

currently, many of the branded drugs are inaccessible to the vast majority of patients, as they cannot afford them. from the perspective of a significant proportion of US population - those without unlimited wealth -these drugs - and treatments - are out of reach.

you don't want socialized medicine, I get it. but im not seeing the free market economy and insurance based healthcare in the US providing any better access.

Let's try it and reinforce it before we write it off...

 

[VA Hopeful Dr]

I'm note sure what country you live in, but out of pocket for LIDODERM is $200/mo, as well as the rest of the meds I mentioned . I believe you are either in another rural area or talking about insurance pricing of on formulary drugs, which by the way is represented in the deductible + premium cost. The true cost for non formulary or out of pocket meds are; $1000 for Epi pen, envizio narcan, etc. hence the protests by the masses and congressional hearings regarding hep c mess, hiv meds, etc.... my wife's Nuva ring costs $200/month on aetna non formulary plan.... let's get on the same pages before we debate further

You're not paying even a little bit of attention to what I'm posting.

First, I practice in in my state capital in the southeast (hardly rural, very much in the US).

Second, I run a cash-only practice so I am fairly adept at finding ways to make my patients' medication affordable. I do this in 2 major ways. 1. That website I linked to you in my previous post. 2. I dispense drugs at wholesale myself.

Thrid, if you go to the website I linked you can type in drug names and get free coupons. Literally anyone can do this: self-pay, insured, whoever. For example: I needed some ketoconazole for my golden retriever back in October. Took the script to my local grocery store pharmacy. Cash price for 30 tablets was going to be around $90. Instead, I went to the website, pulled up the free coupon on my phone, the pharmacist scanned it, and I walked out with those pills having paid just over $19. Here: https://www.goodrx.com/ketoconazole?drug-name=ketoconazole This website is for cash-pay only, it doesn't work with insurance. So the prices you see are exactly what you pay. I took it to Kroger, in case you're curious.

Let's look at the other ones you mentioned.

Epipen: if you're willing to use the off-brand, its just under $200: https://www.goodrx.com/epipen?form=...ity=1&label_override=epinephrine&days_supply=

Nuvaring: $135 https://www.goodrx.com/nuvaring?form=ring&dosage=0.12mg/0.015mg&quantity=1&label_override=

Narcan nasal spray: $132 https://www.goodrx.com/narcan?form=box&dosage=two 4mg nasal sprays&quantity=1&label_override=

Seriously, go to this website and just play around with it. I'd be willing to bet you could save many of your patients a good bit of money.

 

[Blitz2006]

Canada has a fine system- for Canadians- that will put up with mediocrity in access, lack of high tech, advances that usually lag, wait times, and a litigation system that pays very small amounts if any due to the disincentives to sue. While health outcomes are not significantly different between the US and Canada, part of that is due to lower expectations, since Canadians don't know any better. The WHO measures of outcomes are very good for Canada, in part due to the maternal care and child health care that is universally available. Longevity and overall health are not necessarily functions of the healthcare system but are due to other factors such as genetics, obesity (20.2% for Canada, 35% for US), smoking (14.6% Canada, 17% US), homicide rate 3 times higher in the US per capita, 6.5 times higher auto fatality rate in the US, physical activity rate weekly (52% Canada, 33% US), etc.

You raise good points.

And I think this is another fundamental difference. 99% of health problems can be dealt with adequately and equally in Canada. You don't need "high tech" devices to treat bread and butter issues (pneumonia, heart failure, cellulitis, kidney stones, etc.).

"Put up with mediocrity". Just because you don't get MRI/CT Scan every time you see a doctor, doesn't = mediocrity. I was a general surgery resident in the UK, and appendicitis was a clinical diagnosis. No Imaging. No CT A/P. EVER. Yet the outcomes are the same, UK vs. USA with appendicitis. The problem is here in the U.S, nobody takes a history or properly examines any patients. I have seen pain docs (while I admit this is probably/obviously the minority) that REFUSE to see a patient until they have a MRI report. Thats ridiculous. Any twinge in the back, and MRI?? But of course, this perpetuates the notion that if you don't get MRI/CT you are receiving "mediocre care". Yes, Brits and Canadians don't get as many MRI/CT scans, no doubt. Does that mean it is mediocre care? I mean there is a thread on this forum right now with NEJM and BMJ articles discussing how fusion surgeries, etc. are not that more beneficial. More "high-tech" and "expensive" doesn't necessarily equate to better care/outcomes. Of course in certain instances it does, but not always. In the UK docs are not allowed to order Lipase (Too expensive, so only Amylase) for Pancreatitis or CT A/P (Too expensive). Pancreatitis diagnosis is based on H+P. The outcomes are still the same, its not like people in the UK are dying left, right and centre from Pancreatitis. I mean according to your logic, at this rate, people coming into the ER with a cough and expecting a PET Scan to rule out Lung Ca. And if people in other countries who don't get PET Scans for cough all of a sudden are receiving "sub-par care"?.

And you discuss the WHO measures of outcome. I wasn't talking about that. I was specifically talking about healthcare outcomes, based on their care in a hospital. I wasn't talking about lifestyle stuff (weight, smoking, physical activity). Thats all irrelevant in this discussion. I'm speaking specifically about outcomes regarding medical intervention. And the studies show that Canada = USA, or perhaps even better up north.

But yes, there are obviously downsides, like the long wait times in Canada. And for very rare, subspecialized issues, USA is definitely top dog. Like if I have siamese twins, I would want Ben Carson at Hopkins to separate them. I just don't get why we can't just provide Medicaid/Medicare for everyone and still have the meccas of Brigham and Hopkins and Mayo churning out world class research/healthcare?

Its ironic because I grew up in Canada, and we are brainwashed that USA healthcare is inferior, private health care is evil (patients are not given treatment, dumped on the side of the road of a hospital if no insurance, etc.). My Canadian friends genuinely think healthcare in the U.S is garbage. I know retired people in Canada who are scared to retire in Florida because of the "bad healthcare", and would rather throw out their back shoveling 6 feet of snow at the age of 75. This is obviously not true, and a lot of it is Michael Moore liberal brainwashing (Watch the documentary "Sicko"). When I went to England, and saw the Two-Tier system in place, I was impressed by having the choice of going private if I didn't want to wait for a Hip Replacement. Then last summer, when I went to Australia and spoke to doctor friends, I was even more impressed with the 2 tier system. Australia's private sector is 100x more developed than Britain's. And the best part is, unlike the UK, Aussie doctors are pretty well paid (300-500k). Are there docs making 10 million like in the U.S? Probably not. But that doesn't make socialized healthcare "communist".

My point is, just because you are exposed to a system, doesn't make it the best without understanding other systems properly. I refrain from making comments about Scandinavia, because I'm not familiar and have never actually spoken to doctors who work in Sweden or Denmark. And Scandinavia is like Canada, 100% Socialized Healthcare, no private, unlike Two-Tiered UK and Australia. But I definitely would be very interested to see how the lifestyle is for docs and patients in places like Stockholm and Copenhagen.

 

[Stim4me]

You're not paying even a little bit of attention to what I'm posting.

First, I practice in in my state capital in the southeast (hardly rural, very much in the US).

Second, I run a cash-only practice so I am fairly adept at finding ways to make my patients' medication affordable. I do this in 2 major ways. 1. That website I linked to you in my previous post. 2. I dispense drugs at wholesale myself.

Thrid, if you go to the website I linked you can type in drug names and get free coupons. Literally anyone can do this: self-pay, insured, whoever. For example: I needed some ketoconazole for my golden retriever back in October. Took the script to my local grocery store pharmacy. Cash price for 30 tablets was going to be around $90. Instead, I went to the website, pulled up the free coupon on my phone, the pharmacist scanned it, and I walked out with those pills having paid just over $19. Here: https://www.goodrx.com/ketoconazole?drug-name=ketoconazole This website is for cash-pay only, it doesn't work with insurance. So the prices you see are exactly what you pay. I took it to Kroger, in case you're curious.

Let's look at the other ones you mentioned.

Epipen: if you're willing to use the off-brand, its just under $200: https://www.goodrx.com/epipen?form=...ity=1&label_override=epinephrine&days_supply=

Nuvaring: $135 https://www.goodrx.com/nuvaring?form=ring&dosage=0.12mg/0.015mg&quantity=1&label_override=

Narcan nasal spray: $132 https://www.goodrx.com/narcan?form=box&dosage=two 4mg nasal sprays&quantity=1&label_override=

Seriously, go to this website and just play around with it. I'd be willing to bet you could save many of your patients a good bit of money.

Like the site, interested to see if the pharmacies in my area will "honor " the contractual obligation as repeated in the website. My guess is that after insurances price fix , the pharmacies take a second swipe. My local pharmacists couldn't get me an epi pen for under 1k, let's see if the coupon works. Ditto for LIDODERM , not one pharm offers this discount. You may be on to something here... patients ordering meds from Canada can benefit from this place. But take home message is that these meds should be wholesale and otc...

 

[Aether2000]

Interesting....I saw scores of Canadian patients coming across the border into New York to obtain medical care that was unavailable in Canada when I practiced in NY. As for MRI availability- Canada has slightly over 300 MRI units for a nation of 35,000,000 people, or 1/8 the number of MRI scanners per capita compared to the US.

An acquaintance WAS treated by pain management for over a year in Canada without a MRI for facet arthropathy and musculoskeletal spasm. Turns out the spasm was a sarcoma that killed her. To Canadians, this is viva la fraternatie. To the US, this is not only fodder for litigation, but is a horrific example of how being parsimonious about the use of modern technology delayed diagnosis, if not caused an early death. To Canadians, this is acceptable as a cost containment measure. But Canada lags far behind many Western nations in technological adaptation. Canada does offer mediocre healthcare since everyone is lowered to the same common denominator. I am not saying this is wrong, since we may eventually arrive at the same place as Canada with long waits to see specialists, long waits for surgery, and a whole litany of other ills in a socialized system. http://www.city-journal.org/html/ugly-truth-about-canadian-health-care-13032.html

 

[Ducttape]

Just to chime in on pricing...

Lidocaine patches now available OTC. 4% strength. The salonpas box I bought cost 11.99 for 6.
https://www.riteaid.com/shop/salonpas-lidocaine-gel-patch-6-count-0377379
No more PA for the patches for me.


Second, you can get hospital systems and local retailers to help out. I set up the hospital pharmacy to get narcan + insufflator for $25. That is at cost in bulk.

Then again, local retailers can help out. Both Walgreens and Wegmans allow narcan 4 mg/2ml to be purchased without prescription in NY, though it costs more at $67...

Ps don't read the Details part of that page. Apparently wrong, since it discusses capsaicin and menthol. The ingredients say lidocaine tho...
Sent from my iPhone using SDN mobile

 

[Blitz2006]

Interesting....I saw scores of Canadian patients coming across the border into New York to obtain medical care that was unavailable in Canada when I practiced in NY. As for MRI availability- Canada has slightly over 300 MRI units for a nation of 35,000,000 people, or 1/8 the number of MRI scanners per capita compared to the US.

An acquaintance WAS treated by pain management for over a year in Canada without a MRI for facet arthropathy and musculoskeletal spasm. Turns out the spasm was a sarcoma that killed her. To Canadians, this is viva la fraternatie. To the US, this is not only fodder for litigation, but is a horrific example of how being parsimonious about the use of modern technology delayed diagnosis, if not caused an early death. To Canadians, this is acceptable as a cost containment measure. But Canada lags far behind many Western nations in technological adaptation. Canada does offer mediocre healthcare since everyone is lowered to the same common denominator. I am not saying this is wrong, since we may eventually arrive at the same place as Canada with long waits to see specialists, long waits for surgery, and a whole litany of other ills in a socialized system. http://www.city-journal.org/html/ugly-truth-about-canadian-health-care-13032.html

Once again you are presenting anecdotal data.

"Scores of canadians crossing the border".

Studies show that only 0.5% of Canadians come to the U.S for healthcare:

http://www.vox.com/2016/10/9/13222798/canadians-seeking-medical-care-us-trump-debate

http://content.healthaffairs.org/content/21/3/19.full

"They also tracked Canadians' behaviors by examining data from the National Population Health Survey, where 18,000 Canadians were asked if they sought medical treatment in the US. "Only 90 of those 18,000 Canadians had received care in the United States; only 20 of them had done so electively.""

Here is a great article, balanced, discussing the pros and cons of Canada healthcare:

http://motherboard.vice.com/read/fa...-swarming-the-border-to-get-better-healthcare


Just to fact check your MRI Statement:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2653696/

" For instance, Japan and the United States have 35.3 and 19.5 MRI units per million population, respectively, whereas Canada has only 4.6."

http://www.oecd-ilibrary.org/sites/...-30-en&_csp_=1bfa3f1fdc0c4d743015553f4aace77a

Canada: 8.0 MRI units per million
USA: 26.2 MRI units per million

For interest sake, Japan has 41 MRI units per million. And they have universal healthcare, right?

You also state: "But Canada lags far behind many Western nations in technological adaptation."

Well according to OECD stats, Greece and Italy have almost the same number of MRI units per million (21.7) as US (26). So I guess that means Greece and Italy's healthcare is almost on par with USA, and much better than Canada (8.0) and England (5.6) because of MRI ratio right? And that means Japan must be the BEST because they have MRIs everywhere, right? Its not. Its about outcomes. Who cares how many MRI units there?!? I mean I don't have data, but I wouldn't be surprised if places like Qatar and Dubai have MRI ratios of 100 per million. But again, that doesn't mean they are healthcare gurus either. The only people that should be concerned about MRI ratios are the dudes that make MRI machines and Radiologists ($ reasons). What patients/citizens care about is the healthcare outcome.


I am sorry to hear about your acquaintance, that is obviously terrible news. But again, thats n=1. I'm sure there are pain docs around US that miss out on stuff like that. That has nothing to do with socialized health care vs. private health care. Thats just bad medicine. I cant imagine that for 12 months the pain doc (or PMD) did not pick up on red flag symptoms of sarcoma, like weight loss, fatigue, night sweats, fevers, etc. Its not like the pain doc wanted MRI but couldn't get it. I mean, thats the thing, even in the UK/NHS (which is much "poorer" than Canadian healthcare), if you had red flag symptoms, you WILL get MRI next day. Thats my argument, when it comes to life threatening illnesses, UK and Canada are on par with USA in outcomes. With elective his replacement...not so much, I agree. So missing out on sarcoma for 1 year is just practicing bad medicine. I'm sorry. And this is why NHS/UK produce the best doctors. They focus on primary, preventative care. Primary Care doctors in the UK are actually highly respected, and highly paid. Because england realized that it is much cheaper to prevent HTN/Diabetes than to do CABGs.

Here are some stats to show USA ranking pretty low with regards to outcomes, much lower than Canada:

http://www.conferenceboard.ca/files/hcp/health/health2012_healthind_tbl_lg.png

http://www.conferenceboard.ca/hcp/details/health.aspx


http://www.usnews.com/opinion/artic...have-the-best-health-care-system-in-the-world

"About 75 percent of Americans said the health care system required fundamental changes; in contrast, 50-63 percent of Europeans were happy with their systems. Americans in fact wait longer than most Europeans to see a primary care doctor: 63-76 percent of Europeans see a doctor within one to two days, compared with 48 percent of Americans; only Canada scores worse (41 percent)."

 

[hyperalgesia]

Once again you are presenting anecdotal data.

"Scores of canadians crossing the border".

Studies show that only 0.5% of Canadians come to the U.S for healthcare:

http://www.vox.com/2016/10/9/13222798/canadians-seeking-medical-care-us-trump-debate

http://content.healthaffairs.org/content/21/3/19.full

"They also tracked Canadians' behaviors by examining data from the National Population Health Survey, where 18,000 Canadians were asked if they sought medical treatment in the US. "Only 90 of those 18,000 Canadians had received care in the United States; only 20 of them had done so electively.""

Here is a great article, balanced, discussing the pros and cons of Canada healthcare:

http://motherboard.vice.com/read/fa...-swarming-the-border-to-get-better-healthcare


Just to fact check your MRI Statement:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2653696/

" For instance, Japan and the United States have 35.3 and 19.5 MRI units per million population, respectively, whereas Canada has only 4.6."

http://www.oecd-ilibrary.org/sites/...-30-en&_csp_=1bfa3f1fdc0c4d743015553f4aace77a

Canada: 8.0 MRI units per million
USA: 26.2 MRI units per million

For interest sake, Japan has 41 MRI units per million. And they have universal healthcare, right?

You also state: "But Canada lags far behind many Western nations in technological adaptation."

Well according to OECD stats, Greece and Italy have almost the same number of MRI units per million (21.7) as US (26). So I guess that means Greece and Italy's healthcare is almost on par with USA, and much better than Canada (8.0) and England (5.6) because of MRI ratio right? And that means Japan must be the BEST because they have MRIs everywhere, right? Its not. Its about outcomes. Who cares how many MRI units there?!? I mean I don't have data, but I wouldn't be surprised if places like Qatar and Dubai have MRI ratios of 100 per million. But again, that doesn't mean they are healthcare gurus either. The only people that should be concerned about MRI ratios are the dudes that make MRI machines and Radiologists ($ reasons). What patients/citizens care about is the healthcare outcome.


I am sorry to hear about your acquaintance, that is obviously terrible news. But again, thats n=1. I'm sure there are pain docs around US that miss out on stuff like that. That has nothing to do with socialized health care vs. private health care. Thats just bad medicine. I cant imagine that for 12 months the pain doc (or PMD) did not pick up on red flag symptoms of sarcoma, like weight loss, fatigue, night sweats, fevers, etc. Its not like the pain doc wanted MRI but couldn't get it. I mean, thats the thing, even in the UK/NHS (which is much "poorer" than Canadian healthcare), if you had red flag symptoms, you WILL get MRI next day. Thats my argument, when it comes to life threatening illnesses, UK and Canada are on par with USA in outcomes. With elective his replacement...not so much, I agree. So missing out on sarcoma for 1 year is just practicing bad medicine. I'm sorry. And this is why NHS/UK produce the best doctors. They focus on primary, preventative care. Primary Care doctors in the UK are actually highly respected, and highly paid. Because england realized that it is much cheaper to prevent HTN/Diabetes than to do CABGs.

Here are some stats to show USA ranking pretty low with regards to outcomes, much lower than Canada:

http://www.conferenceboard.ca/files/hcp/health/health2012_healthind_tbl_lg.png

http://www.conferenceboard.ca/hcp/details/health.aspx


http://www.usnews.com/opinion/artic...have-the-best-health-care-system-in-the-world

"About 75 percent of Americans said the health care system required fundamental changes; in contrast, 50-63 percent of Europeans were happy with their systems. Americans in fact wait longer than most Europeans to see a primary care doctor: 63-76 percent of Europeans see a doctor within one to two days, compared with 48 percent of Americans; only Canada scores worse (41 percent)."

Are you arguing that, on an individual basis, when you have a medical issue, you will get equivalent care when your doctor is bound by "red flags" to order an MRI vs when the doc is not? Say, for example, you have a premier health plan in the US, with MRIs everywhere, you believe you will get equivalent care in Canada?

 

[Blitz2006]

Are you arguing that, on an individual basis, when you have a medical issue, you will get equivalent care when your doctor is bound by "red flags" to order an MRI vs when the doc is not? Say, for example, you have a premier health plan in the US, with MRIs everywhere, you believe you will get equivalent care in Canada?

I'm only arguing that health outcomes in Canada/UK are the same as U.S, despite the U.S having worse access, greater spending.

You are not "bound" by red flags. I used that sarcoma case as an example, of red flag symptoms. People with Back Pain/Arthirtic Pain also get MRIs, but yes, it will be a bit LONGER. I am not denying that.

Another nice read: https://www.washingtonpost.com/news...care-system-in-survey/?utm_term=.38bb34129e75

""Although the U.S. spends more on health care than any other country and has the highest proportion of specialist physicians, survey findings indicate that from the patients’ perspective, and based on outcome indicators, the performance of American health care is severely lacking," the Commonwealth Fund, a New York-based foundation that promotes improved health care"

"The U.K. diagnosed its health care system's problems and addressed them, Davis said. "They really have moved up over time. A lot of it has been systematic attention to increasing resources in the system," she said. Officials hired more specialists, gave bonuses to family physicians who meet quality targets and adopted health information systems that allow physicians to easily share information about patients. And everyone has a doctor.

The United States, on the other hand, "ranks behind most countries on many measures of health outcomes, quality, and efficiency. U.S. physicians face particular difficulties receiving timely information, coordinating care, and dealing with administrative hassles," the report concludes. The U.S. is beginning to catch up as it responds to financial incentives to improve health information systems, and Obamacare should strengthen that effort.

 

[hyperalgesia]

I'm only arguing that health outcomes in Canada/UK are the same as U.S, despite the U.S having worse access, greater spending.

You are not "bound" by red flags. I used that sarcoma case as an example, of red flag symptoms. People with Back Pain/Arthirtic Pain also get MRIs, but yes, it will be a bit LONGER. I am not denying that.

Another nice read: https://www.washingtonpost.com/news...care-system-in-survey/?utm_term=.38bb34129e75

""Although the U.S. spends more on health care than any other country and has the highest proportion of specialist physicians, survey findings indicate that from the patients’ perspective, and based on outcome indicators, the performance of American health care is severely lacking," the Commonwealth Fund, a New York-based foundation that promotes improved health care"

"The U.K. diagnosed its health care system's problems and addressed them, Davis said. "They really have moved up over time. A lot of it has been systematic attention to increasing resources in the system," she said. Officials hired more specialists, gave bonuses to family physicians who meet quality targets and adopted health information systems that allow physicians to easily share information about patients. And everyone has a doctor.

The United States, on the other hand, "ranks behind most countries on many measures of health outcomes, quality, and efficiency. U.S. physicians face particular difficulties receiving timely information, coordinating care, and dealing with administrative hassles," the report concludes. The U.S. is beginning to catch up as it responds to financial incentives to improve health information systems, and Obamacare should strengthen that effort.

Take off your politician's hat for a minute. Which would you prefer, as an INDIVIDUAL with a serious medical concern: a premier health plan in the US, with MRIs everywhere, or care in Canada, with its focus on preventative care?