Health Insurance All But Useless with High Deductibles

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“High Deductibles in Health Insurance”

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Quoting from the New York Times today, a subject often encountered daily, so rarely discussed in the media. My own colleagues cannot afford health insurance deductibles, let alone the average person who is not a medical professional. Five compounding pharmacies have closed in the last few months! Compounded medications are no longer covered! My patients cannot afford the insurance denials for medications, and how are we practicing medicine when each visit must be taken up with prior authorizations? No wonder the cost of medical care has gone up. What do we do for chronic pain or treatment resistant depression when our people have failed all drugs? Research funding never seems to go toward pain or depression.

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To the Editor:

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Re “Many Say High Deductibles Make Their Health Law Insurance All but Useless” (news article, Nov. 15):

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My self-employed husband and I have found ourselves in this predicament: affordable health care premiums but a prohibitive $5,000 yearly deductible.
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Truly accessible health care cannot be achieved when insurance companies are the primary beneficiaries of policies and when those who are “insured” still cannot afford to see a doctor.

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SUSAN A. McGREGOR

North Kingstown, R.I.
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To the Editor:

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Your article does a good job of describing cost-shifting from insurance companies to medical consumers but doesn’t explore the issue of risk-shifting.

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People pay insurance companies premiums to take on risk. Insurance companies try to avoid as much risk as they can. High deductibles and co-payments are just part of the risk-shifting.
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Other strategies being used include narrow networks of doctors and hospitals, denial of access to high-quality and often high-cost specialists, questioning and limitation of access to expensive drugs, questioning and limiting high-cost testing, and even offering free health club memberships to screen out those with high-cost disabilities.
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At a health insurance fair in San Francisco earlier this month, participants selected from various plans offered through the Affordable Care Act. Credit Jim Wilson/The New York Times
This process is about a lot more than high deductibles. But the end result is that good people are not getting the care they thought that they paid for. And the political leaders of both major parties approve these hassle factors — as our courts do — in the name of preserving America’s global competitiveness.
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BRANT S. MITTLER

San Antonio

The writer is a cardiologist and a lawyer.
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To the Editor:
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So at the end of the day, health care is no more affordable than it was before Obamacare was enacted! Why should we be surprised?
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Several decades ago, in an effort to promote “wellness,” we saw an increasing trend to encourage people to visit their doctor more regularly and more often, by offering plans that covered basic health maintenance costs. State regulations demanded coverage of some services, and the Affordable Care Act only added to the list that must now be provided without cost to the user.
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Insurance in the traditional sense provides coverage for the unforeseen event. In health care, that would be serious injury and catastrophic disease. What we have today is what the insurance industry refers to as “trading dollars.”
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Imagine if car insurance covered all basic services to reduce the risk of future damage, like oil changes, new brakes and even periodic visits to the car wash. We would see huge increases in the cost of car insurance, although we would also see policies that are offered at low premiums but with high deductibles and high co-payments.
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MICHAEL A. SMITH

Wells, Me.

The writer is a retired equity research analyst who covered the insurance industry.
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To the Editor:
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Your article about high deductibles in health insurance was accurate as far as it went, but a complete discussion of the benefits of health insurance coverage would have included the fact that insurers negotiate substantially reduced payments for in-network medical services for the insured.
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I have a high-deductible policy, but the payments I have to make to an in-network provider are usually only 40 to 50 percent of what I would have paid if I had been uninsured.
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An emergency room physicians’ bill here on my desk lists $632 as the charge, for which the insurer’s negotiated rate was $273.27, a 57 percent discount.
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My high-deductible health insurance policy is a membership in a huge discount medical services program. This is an important consideration that should be discussed more openly. The uninsured, by paying full freight, are subsidizing health care for those of us who are insured.
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DAVID MAIER

Richmond, Va.”

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Johns Hopkins Told a Patient: Unless You Want a Spinal Cord Stimulator, Don’t Schedule a Pain Appointment

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Pain Management is Taught in 3% of Medical Schools

in the United States

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Insurers Refusing to Cover Pain Medication – Morphine 100 mg per Day Maximum – Opioid Wake up Call – New Nationwide Standard? DEA Mandate

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The FDA mandated 22 manufacturers of long acting opioids

to fund a program on opioid prescribing.

FDA dictated the content.

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I attended the SCOPE of PAIN program Friday November 6, from 8 to 12:30, taught by an Addictionologist from Portland with our local Southern California DEA. Continuing education credit was given by Boston University. The first grant recipient was in 2012.  

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My take:

I think we will rapidly see a 100 mg per day

maximum morphine equivalent allowed

Could I be interpreting this wrong?

Insurers simply deny paying for high doses. They have begun already.

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I am exhausted from ICD10 diagnosis coding – complex patients !!! – that has taken away any possibility I could leave my desk until 4 AM for the last four weeks, in midst of moving office to much better place, and midst the only two computer crashes I have ever had in my pursuit of efficient tech, plus dental fracture, so much more….perfect storm. The paragraphs could be edited and rearranged, so they would be in sequence but they’re not.

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I hope others will give me their take on this. It has been getting worse since almost all university interdisciplinary pain clinics were closed in 1991. Insurers, i.e. managed care clerks, are practicing medicine mandates set forth by anonymous committees looking at spreadsheets not at our complex care. Insurers could save many billions if they invested a few billions in education. Insurers wrote Obamacare. They could write it better. Congress wants all of us to do our part. Surely business too?

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Based on this series of opioid conferences, my guess is their first step is to chop opioid prescribing down to 100 mg morphine equivalents. But what about untreated pain at the heart of the epidemic of suicide? I see it among all classes of people, because we’ve focused on opioids too long to the exclusion of research and exclusion of a whole world of medications now generic, no longer on patent therefore inexpensive, FDA approved medications. The biggest shock: Valuable compounded medications are no longer on formularies of insurers! Our most affordable FDA approved medicines are no longer covered by insurance.

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Where is the data that we must limit the dose to 100 mg per day morphine equivalent?

Is it too much pain medicine or is it untreated pain?

Is it lack of medical care?

or is it lack of affordable medical care?

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My comments arise from grave concern the Insurers and FDA are overlooking the needs of my pain patients. I must speak up now despite need to recover in the next few days.

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Where is the concern for the pain patient

in this multimillion dollar pharmaceutical-company-funded opioid conference?

FDA mandated that manufacturers of extended release opioids fund the conferences.

Where are the millions that need to be spent on

rational interdisciplinary pain management,

rather than just opioid management?

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We need more than just studies of suicides and opioid changes.

We need hospitals and insurance systems

to recognize legitimate therapies that work for real people.

Would the epidemic of addiction

go down if people could get treatment for their pain?

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I posted this week on a new study, an epidemic of suicide in Caucasian middle aged Americans. The results were a shock to Case and Deacon, the Princeton Economists who did the research that merited two articles in the New York Times.

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Epidemic of suicide

deaths as high as in the AIDS epidemic,

driven by pain, disability, loss of job, drug abuse, other.

By too many opioids or by untreated pain?

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That is why, a few days ago I posted on that epic study by Princeton economists: the suicides in middle aged Caucasians now comparable to deaths during the AIDS epidemic. I posted how that can change. In that article and for years with this blog, I post about medications that work more effectively than opioids, i.e. glial modulators, and the need for compounded and herbal medications from approved highly reputable small local pharmacies need to be covered by insurers and allowed on hospital formularies.

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Epidemic of suicide – could it be due to lack of pain treatment

not due to an epidemic of opioids?

Is it too much pain medicine or is it untreated pain?

Is it lack of medical care?

Or is it lack of affordable medical care?

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The key figure from the Case-Deaton study on epidemic of suicides in white middle-aged Americans –  bigger than deaths at the height of the AIDS epidemic. The question is why?

Andrew Gelman, statistician at Columbia University and writer for the Washington Post, argues in his blog against the rate being higher at all. His conclusion: “…death rates among middle-aged non-Hispanic whites in the U.S. slightly increased, even while corresponding death rates in other countries declined by about 30%.”

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Regardless of the argument, untreated pain is a big problem. It causes suffering and joblessness, and can lead to addiction and suicide.

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Does it matter which side of the argument is right?

Pain management is being taught in only 3% of American medical schools.

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Where is the data that we must limit the dose to 100 mg per day morphine equivalent?

Is it too much pain medicine or is it untreated pain?

Is it lack of medical care?

Or is it lack of affordable medical care?

Insurers are not willing to pay for larger doses of opioids

and deny prior authorization.

Does this lead to suicide?

Money is the root of some of this.

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The cure for suicide is not just to take a sword and slice off the top doses of morphine, and treat everyone with the same low doses, whether you have herniated discs or sprained ankle or RSD.  Sprained ankles may be already getting too much.

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Why blame it all on over-prescribing? How about suicide due to under-prescribing, or suicide from not treating pain at all because healthcare insurance and unemployment don’t mix?   

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Are they blaming high doses as cause of suicide? How about when high dose opioids fail, when all drugs fail, we see no new drugs on the horizon for pain control. That does not fill those patients with hope.

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Of course it is important to acknowledge, as the New York Time health section has followed that epidemic research with How Doctors Helped Drive the Addiction Crisis.

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Where is the data that we must limit the dose to 100 mg per day morphine equivalent?

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Someone must advocate for change. It’s not just pills, it’s not just opioids.

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We are all at risk from disabling pain, loss of jobs and suicide

—yes, doctors too become disabled—

because of substandard education in pain management in this country

focused almost universally

on opioid treatment of pain.

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Lack of funding killed the university interdisciplinary pain management centers in 1991

 

AND we need access to compounded drugs, herbs & supplements in our hospitals.

If Memorial Sloan Kettering Cancer Center can do it, why can’t my hospital?  

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Expect 100 mg oral morphine or equivalent maximum dose per day to rapidly become the standard nationwide. Insurers are refusing to cover the cost of higher doses. Even if you can afford $17,000 out of pocket each month for pain relief, your doctor will be shouldering liability if outside these rapidly evolving guidelines. Insurers rule – and they deny coverage of inexpensive compounded drugs that work better than opioids for my patients who have failed all known treatment. That’s why we need better education and more clinically focused research.

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Those who blame Obamacare for high insurance costs and business-wide practices need look no further than the price of medications, especially opioids.

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It seems everyone breezes over where Washington State came up with a maximum of 100 mg morphine (or equivalent) as a maximum daily dose of opioid. 

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This 100 mg maximum daily morphine dose became law in Washington State many years ago, initially for Workers Compensation, and will soon be adopted by Oregon.

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Of course we are all concerned about the shocking rise in deaths from prescription opioids that are occurring since opioids began to be used after Russell Portnoy published its use for chronic pain in 1991. We just didn’t know that they work for cancer pain that is usually acute pain, not for what is now tens of millions with chronic pain who are on opioids

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But opioids are still necessary for some. Those of my patients who take opioids will have a very hard time with the 100 mg morphine (or equivalent) maximum daily guideline. Informed consent is out the window. We all recognize the practice of medicine has been done by insurance companies since the late 1980’s when managed care took over. This will not change. Now insurers require the ICD10 diagnosis code before they will allow the pharmacist to refill an antidepressant that the patient has been taking for one year with much needed relief. This will give them more tools to deny paying.

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It would appear that those who govern our medication use (insurers and DEA) — and who deny coverage of even more useful, inexpensive medication –  feel that 100 mg morphine equivalent is the maximum dose that should be prescribed.   

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100 mg oral morphine is equivalent to:

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66 mg Oxycodone

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25 mg/hr Fentanyl Patch

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25 mg hydromophone (Dilaudid)

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120 mg hydrocodone (12 of the Vicodin, Norco, Lorcet 10 mg tablets)

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30 mg Oxymorphone (Opana) use not recommended

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Morphine               to                Methadone      

30-90 mg                                   One fourth the morphine dose

90-300 mg                                 One eighth (200 mg/day morphine = 25 mg methadone)

300-500 mg                               One twelfth the morphine dose

>500 mg                                    One twentieth the morphine dose

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Methadone conversion is far more complex than this guideline from University of Michigan

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Only 3% of medical schools teach pain management. That ignorance is costing us trillions in insurance and pharmaceutical fees, and right now the latter two are making war on each other by taking it out on you, the patient who is getting substandard care. They’re taking care of their financial needs that show us the symptoms of disease, pain, suffering, disability, loss of job, and the just published this week, the epidemic of suicide. We need to treat the cause, not just the symptoms. Medical education, injury prevention and treatment needs to be taught starting K-12. The cost would pay for itself but the Insurance Industry needs to pay for it there and in University Medical Schools because Congress will not pay for it. It would be a cost saving investment that would pay itself off in care for seniors when grandchildren have to spot mom and dad in the 24 hour, extended family care that strains budgets. We cannot afford not to teach trigger point basics to each kid and each physical therapist and MD. That alone could save tons of opioids and monthly visits for what never works for muscle strain that no one has found.

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I’m tired of seeing how degraded it has become. To fail to treat the cause of disability and suffering is far more in our hands now, it could happen if people were taught basics instead of opioids, K through medical school. Are we teaching only opioids? yes, it seems so. I am advocating for everything I have written about in this blog since 2009. Glial modulators, mechanical approaches, but compounded medications, in particular, are sadly becoming unaffordable because insurers have stopped coverage for them. Then we all lose one of the most important tools, the only tool, that my patients and millions of others have in treating intractable pain or treatment resistant Major Depressive Disorder, Bipolar Depression. Compounded medications often work after everything else has failed. The lives of my patients have usually either returned back to normal or  improved in ability to function. That has never been shown with opioids for chronic pain.

 

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I’m too exhausted to be in a position to edit what I’ve written just now, or write adequately. I am just furious at the direction our country for decades has pushed into opioid treatment rather than pain management. This has reached peak brewing since the DEA conference yesterday, dictated by the FDA funded by opioid manufacturers.

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It is a hope that Insurers could fund an analysis of the billions that could be saved and suicides prevented if they funded pain management. What is there to live for than a life free of pain and disability?

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The analysis could show how much is saved when training begins with the young, how to prevent and treat injury. How helpful a child can be to aging grandparents or parents when illness strikes the family. We always turn to family first, as we should. Why is something of the field of pain management not taught in K-12?

 

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The FDA just authorized two opioids for children this last week. I have a vague memory one was oxycontin in children. I do not argue against opioids, I have given opioids to tiny children when I worked in hospice. Children have crippling arthritis too and other medical needs for opioids.

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I am not arguing against opioids. I am saying that what is taught is zero pain management. The focus on drugs is completely unbalanced.

 

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If Sloan Kettering can teach herbal and supplementary medicine to cancer patients, why not begin the study of herbal medicine at K-12 since a lot of parents are taking it instead of using common sense such as exercise, weight loss, family time, relaxation. And herbal and supplementary medicine is what these young ones will teach their children when they grow up. Hopefully prevent some of the toxicity from swallowing all sorts of useless and dangerous things on the shelves.

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Rational health care must begin young in the schools. .

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Ode to ICD10

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Poll IV Bisphosphonates —- Neridronic Acid is a Bisphosphonate

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Poll

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Have you received IV Pamidronate or other IV bisphosphonate for pain?

Poll began before the neridronic acid study – please add with any comments

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 This poll is IV

not tablets or injection for osteoporosis 

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Poll Results

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Have you received IV Pamidronate or other IV bisphosphonate for pain?

Answer	Votes	Percent
1 time	19	37%
Other:	17	33%
Other	8	16%
2 times	6	12%
3 times	1	2%

Other Answer	Votes
no	4
0	3
4	2
none	1
No, not yet.	1
No	1
none to my knowledge	1
I took the tablet form	1
Ketamine	1
Never	1
Monthly for 2 years	1

Snow

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I just want

 the back mountains of Mammoth

in the snow

or

enveloped warm in my tent

under deep

in Yosemite

 complete blanket of silence.

 Bears asleep

 creatures lurk

the unspeakable silence of

snow

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Silence .   .    .    .     .     .     .         .        .

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Opioids and Deaths – If Sloan Kettering Cancer Center Can Do It, Why Can’t My Hospital OK Herbal & Compounded Medications?

 

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Gina Kolata reports in NYT

on the breaking study by two Princeton Economists    

 

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The key figure

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“The two Princeton economics professors — Angus Deaton and his wife, Anne Case — who wrote the report that is the subject of my front-page article today about rising death rates for middle-aged white Americans, have no clear answer, only speculation. But the effect is stark. Dr. Deaton and Dr. Case calculate that if the death rate among middle-aged whites had continued to decline at the rate it fell between 1979 and 1998, half a million deaths would have been avoided over the years from 1999 through 2013. That, they note, is about the same number of deaths as those caused by AIDS through 2015.”

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“…The dismal picture for middle-aged whites makes Case and Deaton wonder how much of what they are seeing might be attributed to the explosive increase in prescription narcotics.”

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“What’s interesting, Dr. Case said, is that the people who report pain in middle age are the people who report difficulty in socializing, shopping, sitting for three hours, walking for two blocks.”

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“Dr. Deaton envisions poorly educated middle-aged white Americans who feel socially isolated are out of work, suffering from chronic pain and turning to narcotics or alcohol for relief, or taking their own lives. Starting in the 1990s, he said, there was a huge emphasis on controlling pain, with pain charts going up in every doctor’s office and a concomitant increase in prescription narcotics.”

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“We don’t know which came first, were the drugs pushed so much that people are hypersensitive to pain or does overprescription of the drugs make pain worse?” Dr. Case said.”

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“Dr. Deaton noted that blacks and Hispanics may have been protected to an extent. Some pharmacies in neighborhoods where blacks and Hispanics live do not even stock those drugs, and doctors have been less likely to prescribe them for these groups. Dr. Deaton said.”

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“A black person has to be in a lot more pain to get a prescription,” Dr. Case said. “That was thought to be horrible, but now it turns out to maybe have a silver lining.”…..

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Commenter: “D. Morris 1 hour ago
“unfortunately it’s easier to get a prescription of Oxycontin, or legally buy a handgun, than it is to get affordable mental health care in…”

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My Comments are too long, need days of edits, no time to do.

We have so many inexpensive generic medications in allopathic, Ayurvedic, and complementary medicine that are never taught.

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It is cost effective for Universities to limit their instruction to Anesthesia pain that teaches procedures. Thank goodness when they work. But is that all we teach? I fear the answer is yes. That was all that was available in Santa Monica in the early and mid 1990’s, after UCLA closed the Anesthesiology Interdisciplinary Pain Management Center in 1991 – others closed nationwide. It is cost effective to teach and do procedures.

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Epidurals

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 Bread and butter epidurals have never been compared to the same steroid and local anesthetic injected to the adjacent muscle without putting a needle into the spine. It could be equally as effective, able to be done in office, without surgery and x-ray scheduling, but then it would not be a good income generator. Selective nerve root blocks and facet blocks can be very helpful. But are epidurals just flooding the area with the same effect as a local muscle injection? What are we teaching before we get to procedures? How many patients can afford to take time off from work or school for repeated costly procedures?

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Glial modulators, compounded medications

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It would help if MD’s were trained (with CME credit) in the use of generic medications to include glial modulators that mitigate the need for high doses of opioids. There is often more relief than expensive procedures and hardware can provide – which may not work or may be short lasting and unaffordable for many, either due to cost or time away from work every few weeks.

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Physical Therapy

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Good training in Physical Therapy would be the very first step, not by PhD’s who teach fine academic theory, but by certified Orthopedic Physical Therapists with decades of bedside experience are needed to teach therapists who have shown time and again that the most basic P.T. is not being done in this country. Even people with purely neuropathic pain often develop mechanical changes, splinting to avoid pain. That must also be addressed.   

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I do not mean to imply that opioids are not useful. But there is more to pain relief than opioids and I suspect it may not be taught at all. Opioids rightfully remain on the WHO list of ten most essential medications. But when you use them – and believe me I am a wimp and would not be able to tolerate pain, but when you use opioids for years and years, how effective will they be when you really need them far more?

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Opioids are essential for many of my patients and when they fail, when all drugs fail including opioids, I know one thing is on their mind, and it grieves me that this country does not care enough to fund more than a pittance for pain research. This country must do better. Nobel prizes are abundant in La Jolla, but how about translational research in the clinics where we try to keep patients functioning and able to return to work without opioids.

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Drugs do not address muscle

Trigger Points

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Any doctor can do simple trigger point injections if they knew how to identify trigger points, the classic spots on common overused muscles that mimic disabling knee pain or headache or loss of grip strength, yes a strained, shortened brachioradialis – not neurological but do MD’s know?  P.T. specialists too, I hope they know trigger points, but they are not always communicating them to me because I find them and they can be simple.

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Could they add the identification and training of doctors to know meaningful differences in types of physical therapy. They all should be taught by an Orthopedic Physical Therapist like Bruce Inniss who trained decades ago at Rancho Los Amigos, a national treasure center back then innovating care for the most difficult paralyzed, handicapped and publishing it. Not the fancy PhD theory that the newer P.T. grads know – good but not best. Why don’t all physical therapists know the basics Bruce finds every day —- the same basics that were never once treated in the 30 years that my disabled patients were forced to return to. They come from the best university specialists in the country, and they all groan when I say “P.T.” until the next day after they have seen Bruce for their “intractable pain.” Thirty years of lost life. Expensive, joyless, hoping for the worst, praying for the day you will be old enough for Medicare so you could afford care because it has cost you your life savings. I am grateful for academic researchers for their brilliance, their ability to tolerate an academic environment. Best of all I love their shiny new cardiology toys and Dr. Topol translating medicine over wi-fi. Lets not leave behind the basics.

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It shocks me to see some of the basic things were overlooked or not even considered in people who come to me, often seen by the best five pain centers in the country. Of course I rely on those centers who may be able to help my patients. But I am shocked by the omission of simple basics: physical therapy being a key ingredient. That alone could save lives and save our taxpayers billions if the investment were contemplated.

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Last week, the well respected pain specialist Joseph Shurman, MD, at Scripps, said that young Rehabilitation Pain Specialists were rare. Few are going into Pain Management from an essential field. It’s a tough field, changing daily.

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What about other things?

 Compounded medication

Botanical, Ayurvedic, Herbals

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Hospital and university pharmacy committees must begin to open their minds to highly valued compounded and herbal drugs made by respected compounding pharmacists. We all know the high volume thieves who delivered contaminated IV’s, and had  the cheapest prices that brought a bad name, but why stop beneficial interstitial cystitis infusions ordered for decades by the senior specialist in the field? This attitude against compounding and against highly recognized herbal and Ayurvedic preparations must be improved. For example, Boswellia sold by Gliacin.com points to studies by the headache specialist in Scottsdale who trained at the Mayo Migraine Clinic. His site has publications showing 7 of the most intractable Indocin-responsive headache syndromes were improved with Gliacin (Boswellia)..

Most notable in the field is the website and research by Sloan Kettering Cancer Center on herbals and botanicals. You can hardly exclude half the country from your hospital if they found relief at last?  Surely you must teach and know the effects of patient use on FDA approved medications you are prescribing.

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What happens to that patient, whose intractable pain

responds only to compounded medicine,

when they have to be admitted to hospital or rehab

for weeks where compounded medications are forbidden?

Do we make you worse to get you better?

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Hospitals and universities are run by respected seniors, whip smart, who have no experience with many tools that are essential to many in our population. They are rightfully very protective of our beloved high technology centers and want no lawsuits from unapproved drugs not sold by big pharmaceutical companies. Not all of us live in such rarefied privileged worlds in our daily lives. We already have the tools and could use many of them at home without burdening resources. I would love to see physicians on hospital pharmacy committees work side by side with compounding pharmacists and be protected by law for using such inexpensive medications. Insurers have stopped coverage for compounded medications in the last four years, finishing the job in June with Tricare no longer paying. Medicare never has.

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So goes medicine in this country. We all lose. We are reaching for bright shiny things that dazzle me too. Don’t forget to keep the basics, the first thing I learned when teaching at UCLA Epilepsy Center. Often, the basics were not omitted. Case solved.

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It’s hard to know what to trust in so-called alternative treatment, but we must begin to trust if we have evaluated the credentials of best providers. Can we not trust even your patient’s heavily documented history? 

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We must do better. It is costing too many lives. The study I mention, above, just published, is tragic and predictable. Just ask any of us who see this daily. Ask your neighbors and family.

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Politicians could give us a law to protect hospitals from law suit if they allow compounded medications from highly respected compounding pharmacists who are owners of high quality small trusted pharmacies — not those big ones without supervision, where quarterly profit is the goal. We must keep these precious resources of medicine alive so that only the upper middle class can afford them. Does everything have to have overpriced studies and FDA approval with publications by many peers? We all know what that did to colchicine pills used for 100 years for gout, taken 3 times a day. Everyone knew they worked. But if you are the 1%, you invest a little and you can charge $7 each, $21 every single day for just one pill for life, instead of pennies a day.   

 

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INTRACTABLE PAIN IS NOT INTRACTABLE

IF YOU USE THE TOOLS YOU ALREADY HAVE

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It is past time we start teaching tools for pain that many of us daily encounter. Teach to doctors and physical therapists at the very least, but bring it into middle school and even younger.

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So many people are forced to put up with lack of medical care, lack of jobs, lack of income, and disability from working in factories owned by the 1% who control care, often through worker’s compensation.

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Now insurers require ICD10 codes before pharmacy can fill an antidepressant. That feels like ICD10 prison, and this comes at the same time as 70,000 new codes – merely an extra 50 hours a week. Why is the MD not the judge of medication after due deliberation of all the details, all the failed drugs. Practicing medicine without a license has become the standard of care since 1990, out of the doctor’s hands. Now that and insurance will not accept a prior authorization for a low dose of 25 mcg patch the patient has required for the last ten years for their lupus, Sjogren’s, RSD, and painful neuropathy. We have all felt its claws.

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computer system errors may appear typing letters out of sequence – please forgive, no time to edit and finding gremlins everywhere, possibly in the opinions so dangerously passionate. We can do better America. You don’t have to take it. Step up! Vote for the ones who care about your well being.

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 , Ayurvedic, Herbal “