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Chloroquine, past and present

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Re: Chloroquine, past and present

#261

Post by paulmd »

jac241 wrote: post #256
paulmd wrote: post #228

Earlier quoted context omitted.

They get a couple hundred bucks for a 5 minute office visit to write the prescription, yeah. I'm fine if there's a serious reason for a physical examination, but a lot of stuff the doctor is effectively filling the role of a pharmacist: telling you side effects and if you have this set of serious side effects then to stop it and/or go to a hospital, here's your script, pay at the front desk. A lot of stuff is unneces…

They don't make a couple hundred bucks. A 99213 established outpatient visit is worth 0.96 work RVUs * $36.0391 Medicare conversion factor = $34.59 for a standard outpatient visit. Even if you add the facility RVU = 0.48 + malpractice RVU 0.08 that is $54.78 for an outpatient visit. To make a couple hundred bucks, you need to do something like placing a stent for someone who is having a heart attack: CPT code 92941 -…

Providers don't bill Medicare rates to normal patients, so none of that is valid.

Providers in fact make a point that they lose a significant amount of money at Medicare rates and have to limit the number of Medicare/Medicaid patients they see as a result.

I can confirm that a "45 minute" (5 minutes with nurse taking vitals, 25 minutes waiting in office exam room, 15 minutes with doctor) specialist "new" office visit was just billed to me for $246. They didn't charge me half the rate they charge a heart attack, they charge the heart attack patient 100x as much.

I don't think you understand how US billing works. Probably not from the US, or probably not subject to the system due to age (child or senior) or privilege (an engineer on a cadillac PPO plan perhaps).

Anyone who has ever experienced the US system knows that's absolutely normal.

Re: Chloroquine, past and present

#262

Post by cogntive_elite »

gumby wrote: post #91
cameldrv wrote: post #62

We definitely want more studies, but IMO we're reaching a tipping point. We have anecdotal evidence from China and South Korea, and this quite flawed, but at least data-containing study from France. Chloroquine's safety profile isn't great, but the safety profile of COVID is way worse. If you look at Chemotherapy for example, one would never take any of those drugs unless you had cancer. COVID isn't quite as bad as c…

> Chloroquine's safety profile isn't great, but the safety profile of COVID is way worse. If you look at Chemotherapy for example, one would never take any of those drugs unless you had cancer. The FDA's Office of new drugs is split into divisions (dermatology, oncology etc) and the different divisions have different approval criteria as you mention. From my Onco friends' PoV, cancer patients are pretty much assumed…

Please qualify the "very" in "very hepatotoxic."

I hear beer and wine are hepatotoxic too.

That's why I take milk thistle (silymarin).

I assume the Koreans are all taking silymarin with their chloroquine, which is why they aren't dying en masse from liver failure, right?

Re: Chloroquine, past and present

#263

Post by jac241 »

paulmd wrote: post #261
jac241 wrote: post #256

Earlier quoted context omitted.

They don't make a couple hundred bucks. A 99213 established outpatient visit is worth 0.96 work RVUs * $36.0391 Medicare conversion factor = $34.59 for a standard outpatient visit. Even if you add the facility RVU = 0.48 + malpractice RVU 0.08 that is $54.78 for an outpatient visit. To make a couple hundred bucks, you need to do something like placing a stent for someone who is having a heart attack: CPT code 92941 -…

Providers don't bill Medicare rates to normal patients, so none of that is valid. Providers in fact make a point that they lose a significant amount of money at Medicare rates and have to limit the number of Medicare/Medicaid patients they see as a result. I can confirm that a "45 minute" (5 minutes with nurse taking vitals, 25 minutes waiting in office exam room, 15 minutes with doctor) specialist "new" office visit…

You said physicians get paid a couple hundred bucks for each visit. I provided the source that says how much a physician gets paid by medicare for an established outpatient visit. An outpatient visit for a new patient (99203) is 1.42 wRVU + 1.48 facility RVU + 0.13 malpractice RVU = 2.14 RVUs = $109 for Medicare. A complex new visit (99205) is 3.17 wRVU + 2.40 facility RVU + 0.28 malpractice RVU = 5.85*36.06 = 210 dollars. The facility RVU is the amount given to pay for staff, rent, and other overhead. In general, if a physician is employed, they are getting just the wRVU for the visit.

For outpatient visits, this source says medicare pays 92% of what private insurance pays for established outpatient visits, and 80% overall https://money.cnn.com/2014/04/21/news/economy/medicare-docto... .

I am a US citizen who used to be a software engineer who now attends a US MD Medical school and I have student health insurance.

For the heart attack patient, it isn't the physician who is charging the huge amount. It's the hospital. The physician is only going to get a certain factor (somewhere between 1x - maybe 3x on the extreme end) of that $440 for the wRVUs.

Re: Chloroquine, past and present

#264

Post by paulmd »

jac241 wrote: post #263
paulmd wrote: post #261

Earlier quoted context omitted.

Providers don't bill Medicare rates to normal patients, so none of that is valid. Providers in fact make a point that they lose a significant amount of money at Medicare rates and have to limit the number of Medicare/Medicaid patients they see as a result. I can confirm that a "45 minute" (5 minutes with nurse taking vitals, 25 minutes waiting in office exam room, 15 minutes with doctor) specialist "new" office visit…

You said physicians get paid a couple hundred bucks for each visit. I provided the source that says how much a physician gets paid by medicare for an established outpatient visit. An outpatient visit for a new patient (99203) is 1.42 wRVU + 1.48 facility RVU + 0.13 malpractice RVU = 2.14 RVUs = $109 for Medicare. A complex new visit (99205) is 3.17 wRVU + 2.40 facility RVU + 0.28 malpractice RVU = 5.85*36.06 = 210 do…

And like I said, billing for normal patients isn't determined on medicare/medicaid rates and those are widely noted to be far lower than break-even let alone private billing rates.

> The researchers found the gap between the prices Medicare and private insurers pay hospitals increased from 2015 to 2017. Specifically, the researchers found private insurers in 2015 on average paid 236% of Medicare rates, and by 2017 that grew to 241% of Medicare rates.

https://www.advisory.com/daily-briefing/2019/05/13/hospital-...

Again, I just provided you an example of me getting billed $250 for 15 minutes of physician time during an office literally this month. Right now. Just paid it today. Will seeing the bill solve this discussion for you?

> For the heart attack patient, it isn't the physician who is charging the huge amount. It's the hospital. The physician is only going to get a certain factor (somewhere between 1x - maybe 3x on the extreme end) of that $440 for the wRVUs.

That's not what we were discussing, you're changing the topic from an office visit to a heart attack. A doctor's office visit is mostly doctor time, there's no surgical ampitheatre necessary for an office visit. No recovery time in a hospital bed. Completely different situation.

$1000 an hour net billing rate for a specialist office visit sounds about right. That's what I just got billed.

And yes, student insurance is unusually generous and usually subsidized by the university in terms of provider reimbursement as well as direct rates. You are not paying the full freight there.

Furthermore, you are far, far off the reservation suggesting the normal billing for a heart attack is $3200. You are underneath the Dunning-Kruger curve here, you don't even know what you don't know and you think you are informed for it.

> Heart attack hospitalizations cost a median $53,384 and strokes cost $31,218, according to the study. The resulting catastrophic costs make it difficult for uninsured patients to keep up with basic living expenses such as transportation and housing, according to researchers.

https://newsarchive.heart.org/uninsured-patients-faced-devas...

Feel free to tell the American Heart Association that they're wrong by a factor of 15. Let me know when they update the article. You're wrong, it's no longer worth continuing the debate with you.

Again, like I said, I mean this in the gentlest possible way: if you think an average heart attack billing (not just for the doctor, the whole thing) is $3200, you're too privileged to have been exposed to the realities of the American system. You are more incorrect than you have the worldview to even grasp. Even the doctors' association themselves think you are wrong.

Re: Chloroquine, past and present

#265

Post by easytiger »

spion wrote: post #244
easytiger wrote: post #206

Earlier quoted context omitted.

We have a pretty good idea in Italy how many cases are asymptomatic or very mild and it is enormous. Traveling right now but if you are interested I'll update tomorrow

Yes, please.

https://www.sanitainformazione.it/salute/scovare-i-positivi-...

In English:

https://mobile.twitter.com/andreamatranga/status/12397748625...

> According to Crisanti, the director of the virology lab of U Padua, as little as 10% of #COVID2019 carriers show any symptoms at all. He sampled repeatedly the entire 3k+ population of Vo ', one of the initial clusters.

https://grapevine.is/news/2020/03/15/first-results-of-genera...

> 700 have been tested. Kári says that about half of those who tested positive have shown no symptoms, and the other half show symptoms have having a regular cold.

https://www.repubblica.it/salute/medicina-e-ricerca/2020/03/...

> "The vast majority of people infected with Covid-19, between 50 and 75%, are completely asymptomatic but represent a formidable source of contagion". The Professor of Clinical Immunology of the University of Florence Sergio Romagnani writes

Re: Chloroquine, past and present

#266

Post by postalrat »

paulmd wrote: post #239
drstewart wrote: post #235

Earlier quoted context omitted.

Thinking the entire world will quarantine for 12-18 months is a pipe dream. That will never happen.

US DHHS: "18 months or longer" https://int.nyt.com/data/documenthelper/6819-covid-19-respon... UK government: "at least a year." https://news.sky.com/story/coronavirus-social-distancing-nee... Modelling: "2 months on 1 month off until a vaccine is developed". https://www.imperial.ac.uk/media/imperial-college/medicine/s... /shrug It's unprecedented and I tend to agree with you that at some point the economic carnage i…

http://www.euromomo.eu/

The all-cause mortality rate in Europe has been dropping in the past few weeks and is now well below normal levels. To me this looks like people have been overdoing the whole stay indoors and avoid any sort of risky behavior.

Re: Chloroquine, past and present

#267

Post by [deleted] »

jac241 wrote: post #256
paulmd wrote: post #228

Earlier quoted context omitted.

They get a couple hundred bucks for a 5 minute office visit to write the prescription, yeah. I'm fine if there's a serious reason for a physical examination, but a lot of stuff the doctor is effectively filling the role of a pharmacist: telling you side effects and if you have this set of serious side effects then to stop it and/or go to a hospital, here's your script, pay at the front desk. A lot of stuff is unneces…

They don't make a couple hundred bucks. A 99213 established outpatient visit is worth 0.96 work RVUs * $36.0391 Medicare conversion factor = $34.59 for a standard outpatient visit. Even if you add the facility RVU = 0.48 + malpractice RVU 0.08 that is $54.78 for an outpatient visit. To make a couple hundred bucks, you need to do something like placing a stent for someone who is having a heart attack: CPT code 92941 -…

[deleted]

Re: Chloroquine, past and present

#268

Post by red-indian »

zamalek wrote: post #259
aaavl2821 wrote: post #232

Earlier quoted context omitted.

Fwiw, Plaquenil is hydroxychloroquine, a less toxic derivative of chloroquine. It has a different safety profile than chloroquine The French study of HCQ had several limitations. Including that it was very small and some patients who got HCQ and progressed to go to the ICU were excluded from the study. Thus making the drug look better than it is HCQ is not likely to be a miracle cure. It may be useful in combo with o…

> It may be useful in combo with other drugs Weren't the first studies done in combination with azithromycin (which is bizzare, as that's an antibiotic)?

The azithromycin was given to some of the patients with viral pneumonia as there is a chance of reinfection with bacterial pneumonia. Astonishing and unexpectedly, the covid19 virus was completely wiped out in all the HCQ+azithromycin patients but only in a bit over half the HCQ alone patients. So just as an antiparasite drug surprisingly once was found to also work as an antiviral, azithromycin has unexpectedly been found to have some sort of a complementary amplifying or catalyzing effect with the hydrochloroquine. Of unknown mechanism and no doubt this will be explored in great detail in future research. For now it's known that putting the two together looks to be a good thing to do.

Re: Chloroquine, past and present

#269

Post by Munky-Necan »

icelancer wrote: post #52
Munky-Necan wrote: post #46

Until there's a double blind placebo trial I will take this type of report with a truck load of salt. We want randomized control trials in medicine. We want highly vetted research in medicine. Lacking either is a bad idea. I am also not holding my breath about a vaccine. We tried making a vaccine with SARS-CoV with a significant amount of the animal models dying from cytokine storm after viral exposure. Drug trials a…

>> Until there's a double blind placebo trial I will take this type of report with a truck load of salt. You're welcome to. The remainder of the world should have the choice. Some people can't - or don't - want to wait for an RCT with a sample size in the thousands before taking a cheap and well-known drug with well-tolerated side effects.

Do no harm. This is the first line for a reason and when we deviate from strong evidence we will always find regret. If you've talked with your physician and understand the risks, be my guest.

Until we've done a double blind placebo trial we won't even be able to demonstrate efficacy.

Re: Chloroquine, past and present

#270

Post by Munky-Necan »

jki275 wrote: post #101
icelancer wrote: post #52

Earlier quoted context omitted.

>> Until there's a double blind placebo trial I will take this type of report with a truck load of salt. You're welcome to. The remainder of the world should have the choice. Some people can't - or don't - want to wait for an RCT with a sample size in the thousands before taking a cheap and well-known drug with well-tolerated side effects.

To be fair, I don't think that he's saying it should be banned -- he's saying that we need a lot more testing before claiming this is a cure based on one study with a tiny number of participants. His statement is accurate. And the quinine derivatives have some very subtle neurological effects that last a lifetime. Suicidal ideations -- for life and incurable -- are a well known side effect of mefloquine at least. May…

Bingo, we need nonbiased blinded drug trials otherwise the data could be seriously flawed. There's drug trials for reasons, and even in this pandemic we should respect the rationale for why we established those trials.

Also, I'm finding that this forum is full of incredibly intelligent individuals who demonstrate the a little knowledge is a dangerous thing. It amazes me how often y'all will talk about medicine like you're experts but miss fundamental concepts. May points, like the other poster, sound awesome to lay people, but under the scrutiny of any medical professional would be laughed at.

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