Except in very rural areas, it's not a monopoly in most places in the US — it's more of wrestling giants, with the uninsured getting screwed since they get stuck with the $590 "list price" that is really just supposed to start off the negotiation.
The AMA isn't a trade union (they don't negotiate pay and benefits for physicians, and only 25% of US physicians are members). The AMA contracts with the feds to develop a list of the relative values of chargeable medical procedures (which then get modified by insurance companies, who decided actual remuneration.
The AMA does come up with a code of ethics, but ensuring US physicians meet acceptable standards of competency is up to your state or territorial medical board, which are all quasi-governmental entities.
I enjoyed your comment about the "health insurance pigeon hole." I mean I get everyone hates health insurance, but what about the car insurance pigeon hole, and the fire insurance pigeon hole? The fundamental idea of insurance — spreading out risk — seems like a good one, and all insurance markets are regulated. It's a fascinating question if health insurance needs to be more regulated, or less, or simply standardized like they do in most other industrialized companies so it can be understood by mere mortals.
I agree with most of the foregoing. I am a primary care physician, and when people ask me for the prices of things —even when I'm able to spend 20 minutes downloading their formulary from some terrible website and then figure out the math of their deductible and out of pocket maximums I typically get it wrong. Every individual plan from every distinct insurance provider is structured differently, and the negotiated prices for the different billable procedures I do are considered (as I understand it) trade secrets of the insurance providers between them and each group of health care providers.
The only way of getting a menu of prices like they have posted at the Jiffy Lube is to go to a place that foregoes insurance and lets you pay cash. My group actually has a "price estimating hotline" staffed by a nice group of people who spend all day trying to tell you what your co-pay might be for a given service, but that's only good for figuring what you're in for, and not useful for comparison shopping.
This isn't a conspiracy of physicians to keep prices obscure: we really don't know. It's a side effect of the complex (expensive, inhumane) insurance system in the United States. (The same one that my Canadian colleagues love to roll their eyes at when we go to the same conferences, wondering why we put up with it.)
There's plenty of medical and insurance regulation in this country (resulting in me needing to fill out 8 page forms to get people 3 unpaid days off work for a cold, or a 20 item form to get diabetic test strips for diabetic patients). It would be nice to see more harmonized regulations, though, that didn't assume private enterprise was the perfect cure for all market problems. Health care isn't the same as oil changes and automobile repair. I'm among those who think the Affordable Care Act represented the hopeful breezes for a better future, and that its Swiss-styled system was not the unmitigated disaster my right wing friends claimed it to be.
I think this is a good point: a good primary care clinician should provide a good gatekeeping service for referrals. We should refer you only when it's likely to help, and to a competent specialist. I do think some PCP's refer more than they should because they feel pressed for time and/or think that it's simply easier to send the patient for a specialist to give a more detailed opinion. That opinion can be blinkered, though.
In my mind, competency for specialists includes knowing not just the full range of treatments, but spending time with many patients telling them they should do nothing —no fancy procedures or medications. It's not universal, but there are many specialists out there who are willing to risk making patients unhappy by not waving their magic wand, and who are willing to spend the time (and liability) to do so despite it being to their own economic disadvantage. I'm looking forward to changes in the US health care system that will encourage this, instead of encouraging simply doing as many billable procedures as possible.
It sounds like the GP had Dupuytren's contracture, a common thickening of connective tissue in the palm, with a time course of years that can result in inability fo extend (unbend) one's fingers.
As a primary care physician, I don't think I've yet referred anyone for surgery for this (in 17 years) and instead have people do stretching exercises, but surgery may make sense in severe cases. Collagenase injections (the Xiaflex referred to above)looks like it may be useful for patients who don't do well with stretching, don't want surgery, and don't have severe contractures. It doesn't look totally benign (51% bruising, 37% bleeding, 1% tendon rupture, 0.5% permanent unrelenting pain syndrome) but less invasive than surgery. It looks pretty effective.
That said, I've learned when I do referrals, one needs to be careful of who one refers to. For some specialists, given that they use a hammer a lot, most patients may start looking like a nails. I think pretty much all of these specialists genuinely want to help people, but when you specialize in something there's a risk of tunnel vision. For example, when a patient with annoying (but maybe not disabling) back pain wants to see a specialist —depending on who one sends them to — they've got a good chance of getting surgery done. Most back surgery for common spine conditions isn't clearly better than waiting a year for most patients. It's hard to tell some people you don't want to see a fancy specialist for this: you'd be better off losing weight and exercising more.
That said, though I'm pretty proud of myself for encouraging patients to avoid even seeing a surgeon until I really think it will help, and avoiding brand name medications, and decrying expensive vitamins or supplements with little evidence of effectiveness, this article in the New England Journal of Medicine gave me pause. Sure, Gawande claims with some reasoning that a lot of medical procedures have little benefit, and a lot of money is wasted. But the research leading to those conclusions was somewhat cherry-picked, and there is other research that suggests that higher spending really does improve outcomes. The author notes that "perhaps the most accurate conclusions is that sometimes less is more, sometimes more is more, and often we just don't know." Like a lot of health policy (and a lot of life in general), the issues may be more complex than they first appear.
I googled the question, and found this thread: https://www.dpreview.com/forum...
Bill_Turner Veteran Member Posts: 7,532
Re: What is relation between ISO and ASA -- found an old light meter
In reply to elbows2 Nov 5, 2006
John,
ASA is, in fact, ISO. Names have been changes to protect the innocent!
Seriously, ISO values relate directly to ASA values. Many of us "old users" still refer to ISO as "ASA."
HPV causes a lot of things (various isotypes are responsible for warts, most head and neck cancer, penile cancer); it is also the (99.7% of the time) cause of cervical cancer. HPV vaccination has been shown to prevent cervical intraepithelial neoplasia (CIN) and carcinoma in situ, the precursor lesions to invasive cervical cancer, in large randomized trials. The current 9-valent HPV vaccine is 97% effective in preventing CIN 2 (moderate) and more severe disease (CIN 3, carcinoma in situ). It also prevents the vaginal equivalent (VIN2/3) - 100% effective, in fact, among HPV naive populations, and 62% among the overall population.
Current cervical cancer prevention strategy involves Pap smears and then biopsies and surgical intervention when we find abnormalities. It's not cheap, and involves women (best case) getting an exam they don't like every 3 years from 21-29 years of age, and every 5 years from age 30-65 years of age. In the worst case, in areas and among populations that don't get Pap screening, people either can try to get to "screen and treat" centers (where we use liquid nitrogen to spots that show up on a cervix swabbed with vinegar), or, more often, simply consign a percentage of women to a miserable death. Cervical cancer is common (17.8 per 100k in countries without screening, with 9.8 of those dying), which amounts to about 266,000 deaths per year. In developed countries, cervical cancer is the eleventh most common type of cancer and ninth most common cause of cancer mortality (3.3 per 100k). In the US, that amounts of 13,000 cases per year, and 4100 deaths.
It stands to reason that HPV vaccine, since it prevents in HPV infection, and advanced pre-cancerous lesions, will likely be shown to prevent incident cancer as well when the vaccine has been around long enough. (The vaccine was first licenses in June 2006; most women get colonized with HPV around sexual debut but the cancer doesn't show up until age 35-55, a 20-40 year delay.) The tragedy of the vaccine, if any, is that it is largely available only in developed countries, where most people can get treatment rather than dying from the disease. That's not nothing: ask any woman who has to have repeated colposcopies and LEEP surgery if she would have preferred to have gotten 2 shots around age 11 and skipped all of the attended pain, expense, and risk of later preterm labor.
In fact, with the introduction of widespread HPV vaccination in the United States proposals are already afloat to change Pap screening—one proposal suggests every 10 year screening for vaccinated persons. Despite the expense of the vaccine ($240 for the two shot series) it's likely to be cheaper and less cruel than the current state of the art.
You are free to consider Gardasil to be a "scare tactic." As a family physician who gets to follow up on plenty of abnormal Paps, and not a particular fan of the pharmaceutical companies, my kids are getting vaccinated
This includes my bank, investment firms, and hospital (that's the one keyed to my specific phone).
In my primary care practice in the US, we’ve been asking about firearms since I started (in the Clinton administration). Not by government mandate or guideline, but suggestions from specialty societies, like the American Academy of Pediatrics and the American Academy of Family Physicians. We sit around in meetings and discuss this sort of stuff a couple of times a month and it gets added to the (ever lengthening) questionnaire.
This, in turn, is based on . Here’s your top 10 for 2014:
Out of 199,972 injury deaths during the last reporting year (62.6 per 100k population), 51,966 went by poisoning, 33,736 by motor vehicle accident, and 33,594 by firearms, most of that accidental. (Out of 15.872 homicides, 11,008 were by firearms, so two thirds of firearms deaths are accidents.)
So, we ask if you have a gun, and if you do, we ask if you have it properly locked up so no one accidentally shoots themselves (like your kids), just like we ask about seatbelt and carseats and smoke detectors. If it’s toward the top of the list of preventable deaths, we try to ask you about it to see if we have an opportunity to prevent you from dying—simple as that.
My use case is running for 40 minutes 4 times a week while getting my headphones soaked in a combination of sweat, rain, and lately ash blown in from nearby wildfires. I have blown through 3 prior pairs of Bluetooth wireless headphones, all of which suffered from poor reception while running, and all of which died a salt-encrusted death within several months.
My Powerbeats 3 aren't perfect (the cord sticks a bit on the back of my neck) but they are by far the only wireless headphones that ever really worked for me for running. I spent more than $200 with the other 3, which I suppose made the admittedly stiff price worth my while.
Factorials were someone's attempt to make math LOOK exciting.