One of the comments in the article:

I prescribe Plaquenil extensively in patients with autoimmune conditions.The safety profile of this drug is excellent. It is also still used for malaria prophylaxis in healthy individuals .it is not a new drug. I don’t see the reason of labeling it as dangerous. The question is : does it work for Covid19 prevention and treatment? The answer is “the current limited evidence suggests that it does”. What i can tell you that I am aware of a number of doctors in the US who are currently infected or waiting for results who are taking the drug. And I cannot blame them.

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 other drugs

It's easy to make not great data look like great data to untrained eyes. And it's tempting to cut scientific corners to bring forward a drug for covid-19. But if the drug doesn't work, we should be honest about that and look for better drugs

Should at risk people take HCQ as a precaution until something better comes along? Definitely. but we need to be careful in talking about its potential

> 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.

It may be early to conclude that azithromycin has a complementary mechanism with HCQ, the study was too small and there are too many confounding factors. It is possible there is some synergy but also possible that there is not

the problem is quite simple: the virus infects your body, damages your lungs, and fucks up your immune system. Then you get an opportunistic pneumonia

The mechanism is also quite simple: administer them both together and the antimalarials kill the virus, the antibiotics kill the pneumonia.

you're not really an md, are you?

No. Now let's have a look at that bwain of yours.

Azithromycin has been shown to have some antiviral effect though it has not been characterized and the mechanism of action is unknown.

I assume they chose that as a broad spectrum prophylaxis for and opportunistic concurrent infection but perhaps they chose it specifically for this reason.

This whole incident hasn't done much to shake my impression that US doctors are interested first and foremost in making sure they get their "cut" on every prescription, even when the drug is relatively innocuous.

Like fine, we can have this discussion about chloroquine. It's behind-the-counter in the UK, so on par with sudafed in terms of access control, and OTC in a lot of countries that actually have to deal with malaria directly. But the same argument gets applied to stuff like oral contraceptives, which are straight-up OTC in a lot of countries too, and can simply be discontinued if you notice symptoms.

At the same time, we allow drugs with insanely narrow theraputic ranges like tylenol/acetaminophen/paracetamol (seriously, almost as bad as the chloroquine people are freaking out about, a normal dose is 1-4g and a lethal dose can be as low as 5g) to be sold OTC here with no questions whatsoever. We allow combination products despite obvious risks for multiple dosing, we allow combination products to "dissuade addicts" from abusing opiods (like any addict has ever been dissuaded by a risk bodily harm). And doctors don't make a peep about that, because they're not accustomed to getting their cut on that one.

That's also why the AMA resists nurse practitioners so hard. The truth is, a lot of those drugs really should be "behind the counter", a pharmacist should simply have to give you a quick rundown of possible symptoms and what to do if you notice them (discontinue and see a doctor or go to a hospital depending on urgency, same as you would do with a doctor-prescribed drug), but doctors won't allow that because they wouldn't get their cut, so we just call them "nurse practitioners" instead.

US doctors really like playing gatekeeper, to a much greater extent than other countries (where coincidentally, money doesn't come into the picture as much).

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

Chloroquine is class P (pharmacy medicines), which is effectively "behind-the-counter but the pharmacist tells you how to use it".

The idea being that if you want to take a trip to somewhere tropical, you don't have to tie up a GP with a standard, low-risk medication, but it's not quite so low-risk that you just put it on the shelf. Behind-the-counter, if you will.

https://en.wikipedia.org/wiki/Over-the-counter_drug#United_K...

> Pharmacy Medicines (P) are medicines which are legally neither a POM or GSL medication. These can be sold from a registered pharmacy but should not be available for self-selection (although directions to discuss a 'P' product may be allocated shelf space with associated GSL items). 'P' medications are reserved from the GSL list as they are either associated with a need for advice on use, or used in conditions which may require referral to a medical prescriber. Suitable trained counter assistants may sell a 'P' medication under the supervision of a pharmacist and will ask questions to determine if the customer needs to be referred for a discussion with a pharmacist.

I’ve been trying to buy some since early January and haven’t found a single pharmacist who will sell it to me. If you know of one, please let me know.

No-one carries it because they'd have hydroxychloroquine instead. Hydroxychloroquine is prescription only.

You're not going to be able to get a registered professional to give you anything for off-label experimentation, especially not something with potentially serious side effects like chloroquine.

I agree but I wanted it as a precaution. In Northern Ireland the hospital system has a vanishingly low capacity and we only test for COVID if someone is dying and we don’t know why (I think 200 tests total), so it was precautionary.

There’s a non-zero chance this virus gets into my home and a high-90’s chance the health care system will just turn us away if we got in trouble.

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

They get a couple hundred bucks for a 5 minute office visit to write the prescription, yeah.

I'm fine if there's a serious reason for a physical examination, but a lot of stuff the doctor is effectively filling the role of a pharmacist: telling you side effects and if you have this set of serious side effects then to stop it and/or go to a hospital, here's your script, pay at the front desk. A lot of stuff is unnecessarily shoehorned into Rx-only, and despite a lot of talk about "reducing costs" there is no real drive to actually do so.

A great example is oral contraceptives. You may have to try a couple different blends before you find the right mix for your body. Some of them will be uncomfortable. Some may cause dangerous bleeding and you need to go to a hospital. There is not zero risk here, or with any drug. But the doctor has no way of telling which might be which for your particular body, they are there to tell you the risks, sign the paper and let you try it out. And that's why oral contraceptives specifically are being looked at as something that could be moved out of Rx only and to either OTC or pharmacist-prescribable - but the problem is there are really a lot of drugs that don't belong there.

A pharmacist can read the risks to you just as easily and not charge you $250 for a 15 minute office visit and another $250 for a one-month followup 15 minute office visit.

I have lots of 6-month maintenance visits that are literally 5 minutes. Everything going well? "Yup!" "OK, we'll call in your prescription, pay up front". They're just using their gatekeeping power to extract a check.

They don't make a couple hundred bucks. A 99213 established outpatient visit is worth 0.96 work RVUs * $36.0391 Medicare conversion factor = $34.59 for a standard outpatient visit. Even if you add the facility RVU = 0.48 + malpractice RVU 0.08 that is $54.78 for an outpatient visit. To make a couple hundred bucks, you need to do something like placing a stent for someone who is having a heart attack: CPT code 92941 - 12.31 work RVUs = $443.64.

All this information is available online. You can look up the physician fee schedule straight from the CMS. https://www.cms.gov/apps/physician-fee-schedule/search/searc... . Here are the cardiology codes - https://myheart.net/cardiology-coding-center/coronary-interv...

To add an additional data point, doing a heart transplant is 89.50 wRVU * 36.0391 = $3225. I don't think doctors are living as well as you think. CPT code 33945.

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.

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.

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.

I get that a heart attack hospitalization is expensive, $55k on average. The physician is not pocketing all of that $55k. They aren't the ones charging that, that is the hospital. The physician will get ~$1k of that (look below for the calculation). Please try to be charitable in your evaluation of my ability to reason here.

I'm not trying to change the topic from office visit to heart attack. I provided the RVU calculation for the outpatient visits. That is how much the physicians are getting paid. You said that physicians are making a couple hundred bucks of each outpatient visit, which I don't believe is accurate, and I provided the calculation of why I don't think that is accurate. The total cost of the visit can be $250, but the physician is not getting anywhere near that.

I don't think it's accurate to say that they will be able clear $1000/hr. There is additional time needed to document each patient (often equal to the amount of time seeing the patient). I think seeing 3 visits in that time is plausible, but the physician is not getting that whole $250 (which is the point I'm trying to make). The clinic revenue may be $750 for that hour, but that needs to cover all of the overhead, and the physician will get whatever is left.

Make sure you are looking for sources that compare how much the private insurance pays physicians compared to medicare in particular vs how much they pay hospitals compared to medicare. The numbers will be different.

The $53,384 is what the hospital charges for the heart attack. The physician only gets the wRVUs for the services they provide in the hospital (if they're employed), so the 12.56 wRVU for the cardiac revascularization + the admission history and physical (2.61 wRVU CPT 99222) however many days of progress notes (2.00 wRV 1x each day - CPT 99233) in the hospital and the discharge summary (1.28 wRVU - CPT 99238) they write for the patient. So if a patient got revascularized and were in the hospital for 4 days before being discharged that's 12.56 + 2.61 (admission day) + 2 * 2.00 (2 inpatient days) + 1.28 (discharge day) = 20.45 wRVUs for the admission = $737 for the physician for that hospitalization.

I'm trying to make the distinction here between how much the hospital gets paid vs. the physician who provided the care. It's not accurate to say the physician is making $53,384 for the heart attack hospitalization, that is what the hospital is charging. The physician may make ~$1000 for an admission like that. If the physician is self-employed or in a group, they will charge for the facility RVUs and malpractice RVUs as well, because they need to cover the overhead of having a clinic to see the patient after the hospitalization.

If your bill breaks down the overhead for the clinic separate from the physician charge, then I'll agree that the physician made the $250 straight cash, but I don't think that is in any way the average amount any kind of doctor will make off an outpatient visit. Look at what you're suggesting, that a physician makes $1000/hr * 2080 workable hours in a year (not likely a physician only works 40hrs a week..) = $2+ million a year.

No, the Stark Law prevents that (self referral, referring to another business the physician has a stake in) https://en.wikipedia.org/wiki/Stark_Law . Physicians are paid according to a fee schedule that decides how much each thing they do is worth. Each procedure or office visit is assigned a work Relative Value Unit, which is multiplied by a conversion factor ($36.0391 for Medicare) to determine how much a physician gets paid. Private insurance generally follows the Medicare RVU scale, and has an adjustment ~120-150% for the conversion factor (just a guess, only a student). This conversion factor was $36.6873 in 1998, so, adjusting for inflation, Medicare values each thing a physician does at 62% of what it did in 1998. I hate that most of my posts on this site are about this topic, but so many people on this site get it so wrong when it comes to how physicians are paid.

Had a week long freak out from it. Apparently mild stimulant can magnify if your on other stimulants.

Amazing drug otherwise. My autoimmune symptoms have greatly reduced on it. Wish I could take the full dose.