Coronavirus: What questions do you have?

[afadeev]

Question for the forum: Is telemedicine's resurgence here to stay? The reason physicians have not grasped this technology is a lack of compensation for providing it. Do you think that will change?

Not if the Dr's can help it - who wants competition from mid-west telemedicine providers when you are paying Manhattan rents ?!

As an illustrative example (not a direct telemedicine use-case): our dentist runs two practices across NY and NJ, and was particularly talkative on the recent visit.
His rent for his NJ office in $3K/month, for a much smaller Manhattan office is $20K/month. Three months of enforced down-time have consumed all of his savings and then some, and PPP loans were of marginal help (only covered assistants salaries, not rent, nor equipment lease payments - which are substantial).
He took out a personal loan to stay in business. A few of his dentist friends couldn't, and went under.

If you think NJ vs. Manhattan example is too geographically limited, visualize the opportunity for outsourced medical visits from your favorite international destination. I bet patient outcomes will be similar, but the cost competition will be intolerable for the US Dr's, who will fight telemedicine proliferation tooth and nail. And succeed in stifling it.

BTW, Dr's are already compensated for the tele-consultations as much as physical visits. I have bills from the past three months that show up as regular visits.

 

[cwbullet]

Not if the Dr's can help it - who wants competition from mid-west telemedicine providers when you are paying Manhattan rents ?!

As an illustrative example (not a direct telemedicine use-case): our dentist runs two practices across NY and NJ, and was particularly talkative on the recent visit.
His rent for his NJ office in $3K/month, for a much smaller Manhattan office is $20K/month. Three months of enforced down-time have consumed all of his savings and then some, and PPP loans were of marginal help (only covered assistants salaries, not rent or equipment lease payments - which are substantial).
He took out a personal loan to stay in business. A few of his dentist friends couldn't, and went under.

If you think NJ vs. Manhattan example is too geographically limited, visualize the opportunity for outsourced medical visits from your favorite international destination. I bet patient outcomes will be similar, but the cost competition will be intolerable for the US Dr's. Who will fight telemedicine proliferation tooth and nail. And succeed in stifling it.

BTW, Dr's are already compensated for the tele-consultations as much as physical visits. I have bills from the past three months that show up as regular visits.

That is simply not the complete truth. They might be fighting it in metropolitan areas but must rural physicians would welcome the ability to do telemedicine. The only reasons telemedicine has nto become more relevant prior to COVID is compensation (not funded as highly by insurance) and technical (Bandwidth and Training). To be honest, I do not think John Q public will put up with not having it in the future so any physicians who don't want it are going to have to get out of the way or they gonna get mowed over by the train. Telemedicine is a part of the new norm.

 

[blackwing94]

To be honest, I do not think John Q public will put up with not having it in the future so any physicians who don't want it are going to have to get out of the way or they gonna get mowed over by the train. Telemedicine is a part of the new norm.

And when Amazon offers Telemedicine..... Be careful what you ask for.

Back to COVID questions. Is pulling the CDC out of the loop going to provide better COVID data so we have a better idea what's going on?

 

[NateB]

Not if the Dr's can help it - who wants competition from mid-west telemedicine providers when you are paying Manhattan rents ?!

It doesn't have to be that way. Our family practice group which is owned by my hospital has an app where we can schedule telehealth services. Insurance (also owned by the hospital) covers it and the providers are the same providers in the group. They are all local enough and licensed in Indiana.

 

[RobCamele]

Have you read this editorial from the NEJM. What, if any, implications does it have for untrained individuals wearing masks in public?

 

[CalebJ]

Have you read this editorial from the NEJM. What, if any, implications does it have for untrained individuals wearing masks in public?

I'll try to find the link, but the authors of that article wrote one afterwards to significantly clarify their position (and support for) mask wearing as a measure to prevent disease spread.

Edit- this is it:
https://www.nejm.org/doi/full/10.1056/NEJMc2020836

We understand that some people are citing our Perspective article (published on April 1 at NEJM.org)1 as support for discrediting widespread masking. In truth, the intent of our article was to push for more masking, not less. It is apparent that many people with SARS-CoV-2 infection are asymptomatic or presymptomatic yet highly contagious and that these people account for a substantial fraction of all transmissions.2,3 Universal masking helps to prevent such people from spreading virus-laden secretions, whether they recognize that they are infected or not.4

We did state in the article that “wearing a mask outside health care facilities offers little, if any, protection from infection,” but as the rest of the paragraph makes clear, we intended this statement to apply to passing encounters in public spaces, not sustained interactions within closed environments. A growing body of research shows that the risk of SARS-CoV-2 transmission is strongly correlated with the duration and intensity of contact: the risk of transmission among household members can be as high as 40%, whereas the risk of transmission from less intense and less sustained encounters is below 5%.5-7 This finding is also borne out by recent research associating mask wearing with less transmission of SARS-CoV-2, particularly in closed settings.8 We therefore strongly support the calls of public health agencies for all people to wear masks when circumstances compel them to be within 6 ft of others for sustained periods.

Michael Klompas, M.D., M.P.H.
Harvard Medical School, Boston, MA

Charles A. Morris, M.D., M.P.H.
Brigham and Women’s Hospital, Boston, MA

Erica S. Shenoy, M.D., Ph.D.
Massachusetts General Hospital, Boston, MA

[/quote/

 

[BABAR]

Not if the Dr's can help it - who wants competition from mid-west telemedicine providers when you are paying Manhattan rents ?!

As an illustrative example (not a direct telemedicine use-case): our dentist runs two practices across NY and NJ, and was particularly talkative on the recent visit.
His rent for his NJ office in $3K/month, for a much smaller Manhattan office is $20K/month. Three months of enforced down-time have consumed all of his savings and then some, and PPP loans were of marginal help (only covered assistants salaries, not rent or equipment lease payments - which are substantial).
He took out a personal loan to stay in business. A few of his dentist friends couldn't, and went under.

If you think NJ vs. Manhattan example is too geographically limited, visualize the opportunity for outsourced medical visits from your favorite international destination. I bet patient outcomes will be similar, but the cost competition will be intolerable for the US Dr's. Who will fight telemedicine proliferation tooth and nail. And succeed in stifling it.

BTW, Dr's are already compensated for the tele-consultations as much as physical visits. I have bills from the past three months that show up as regular visits.

Fortunately for U.S. physicians, Medicare will only pay if the provider is located in a U.S. state or territory. Some medical specialties like Diagnostic Radiology lend themselves extremely well to telemedicine, good internet connections when combined with the right software make it almost seamless, in fact provides most hospitals with 24 hour coverage with reasonably quick turnarounds.

For primary care? A lot of stuff would work well (med refills, some problems that don’t require a physical examination such as sleep disorders.). Home blood pressure cuffs that also do a pulse rate and home pulse oximeters are also relatively cheap, so following up hypertension and some other problems may be done remotely as well. For some specialties would work well for follow up visits but not initial diagnosis. As Medicare and Insurance coverage money gets tighter, things are going to change, not all for the better.

 

[BABAR]

Practical question.

I have to travel somewhere by commercial air. Should I try and get an N95 mask and a face shield for the whole trip?

 

[RobCamele]

R

 

[cwbullet]

Practical question.

I have to travel somewhere by commercial air. Should I try and get an N95 mask and a face shield for the whole trip?

Yes as long as the airline will allow it.

 

[ether]

Fortunately for U.S. physicians, Medicare will only pay if the provider is located in a U.S. state or territory. Some medical specialties like Diagnostic Radiology lend themselves extremely well to telemedicine, good internet connections when combined with the right software make it almost seamless, in fact provides most hospitals with 24 hour coverage with reasonably quick turnarounds.

For primary care? A lot of stuff would work well (med refills, some problems that don’t require a physical examination such as sleep disorders.). Home blood pressure cuffs that also do a pulse rate and home pulse oximeters are also relatively cheap, so following up hypertension and some other problems may be done remotely as well. For some specialties would work well for follow up visits but not initial diagnosis. As Medicare and Insurance coverage money gets tighter, things are going to change, not all for the better.

Its not a preset negative change, there is the opportunity to improvement to care people will get. There are certain barriers that are obstacles from a patient perspective. Currently an MD has to licensed in the state you reside in, hence a doctor from say Kansas can not practice tele-medicine on a patient that resides in California. Some states don't allow for MDs to prescribe presciptions via telemedicine unless its an already established patient. The next one is the ownership of patient records, last time i checked only in 1 or 2 states does the patient own their records. These barriers, as they come down, will hopefully increase the pool of MDs one could have a virtual visit and allow patients to use their data to find the best doctor. Then virtual visits can certainly lead to better and lower cost care. One of the reasons medical costs in the US is so expensive is the local nature of health care, coupled with capitalist system that allows extreme leverage to be exerted by participants. Not saying capitalism is bad, just that health care is one segment where the extremes are easily found, its extremely fragmented and small niche markets bubble up where participants extract significant rewards (by that I mean the rewards distribution is very high for a given activity)

 

[BABAR]

Its not a preset negative change, there is the opportunity to improvement to care people will get. There are certain barriers that are obstacles from a patient perspective. Currently an MD has to licensed in the state you reside in, hence a doctor from say Kansas can not practice tele-medicine on a patient that resides in California. Some states don't allow for MDs to prescribe presciptions via telemedicine unless its an already established patient. The next one is the ownership of patient records, last time i checked only in 1 or 2 states does the patient own their records. These barriers, as they come down, will hopefully increase the pool of MDs one could have a virtual visit and allow patients to use their data to find the best doctor. Then virtual visits can certainly lead to better and lower cost care. One of the reasons medical costs in the US is so expensive is the local nature of health care, coupled with capitalist system that allows extreme leverage to be exerted by participants. Not saying capitalism is bad, just that health care is one segment where the extremes are easily found, its extremely fragmented and small niche markets bubble up where participants extract significant rewards (by that I mean the rewards distribution is very high for a given activity)

For the most part correct. For telemedicine most states require the doc to have a license both in the state he or she is practicing from AND in the state where the patient’s care is taking place. Humongous teleradiology groups are now practicing nationwide, they basically license their rads in numerous if not all states,

Hawaii is particularly popular as they can cover “live” night call for the Eastern seaboard at a slightly better time interval. Guam is about the best you can get from a time perspective, but not considered a great place to live by many.

 

[cwbullet]

For the most part correct. For telemedicine most states require the doc to have a license both in the state he or she is practicing from AND in the state where the patient’s care is taking place. Humongous teleradiology groups are now practicing nationwide, they basically license their rads in numerous if not all states,

Hawaii is particularly popular as they can cover “live” night call for the Eastern seaboard at a slightly better time interval. Guam is about the best you can get from a time perspective, but not considered a great place to live by many.

I some states it is a license in one state (patient location) or the other (Provider location). Provider licensing is a racket. We need federal licensing and take the states out of this money making racket.

 

[cwbullet]

Update: 3900 new positive tests in GA yesterday and 7 of the last 8 days had over 3k. I think it is starting to peak but who knows.

 

[afadeev]

That is simply not the complete truth. They might be fighting it in metropolitan areas but must rural physicians would welcome the ability to do telemedicine.

Completely agree on the above observation. Low-fixed cost physicians will definitely have, and exploit, a competitive edge over higher-cost metro practices.
From the consumer's perspective - this will be great - competition improves the breed!
But this would also go against the core business principles (not to be confused with ethics) of the US healthcare industry:

1. Avoid and minimize direct competition among providers
2. Constrain and manage physicians and services supply availability (see #1)
3. Opaque and not publicly disclosed pricing (see #1)
4. Legislate against competitive international services, pharma supply options, and payment optimization attempts (see #1)
5. Maximize the income stream for the medical ecosystem participants by pursuing #1, #2, #3, and #4.

I don't believe the above is much of a secret, though we can debate the motivations and relative priorities of each item.
For the sake of fair disclosure: my broader family has benefited from the above arrangement, so I'm not dismissing the virtues for its participants. But those benefits are accumulated at the expense of milking the US customers with maximum ingenuity and proficiency.

The only reasons telemedicine has nto become more relevant prior to COVID is compensation (not funded as highly by insurance) and technical (Bandwidth and Training). To be honest, I do not think John Q public will put up with not having it in the future so any physicians who don't want it are going to have to get out of the way or they gonna get mowed over by the train. Telemedicine is a part of the new norm.

Personally, I would welcome telemedicine for 90+% of the non-emergency visits (hard to draw blood or get shots over video).
Emergency, specialty, and pediatric care may trend closer to ~50%, as they require more frequent in-person interactions.
A good subset of medical services may not be good candidates for telemedicine at all (dentistry, OBGYN, surgery, etc).

Don't get me wrong, I love the idea and convenience of telemedicine, and would welcome it, as an option, with open arms.

However, for the overall medical ecosystem, and the physicians in particular, it's a massive competitive threat.
What's more, many will (correctly) perceive it as a slippery-slope enabler of medical services outsourcing. Once a person is comfortable receiving medical advice over video - who will notice if the person on the other end of the video chat is in Canada? UK? India? Eastern Europe?
Feel free to guess what that will do to the income potential of the US physicians?!!

 

[NOLA_BAR]

The Moderna trial is taking volunteers in my area due to my location being a “hot-spot” and likely to get infected. I would seriously consider volunteering but half will be injected with saline as placebo control. The highest doses have been eliminated from the the trial due to lower doses achieve an immune response, and adverse effects from the higher dose. I’m wondering if the placebo is administered in each area, or would more likely be placed in areas that are less likely to have a volunteer get infected?

 

[NateB]

Shoot, just connect cheap Ai and cut Doctors out of the loop.

AI is helpful in many healthcare applications, but we still need human oversight and that includes doctors. There are certain nuances that AI doesn't catch and a human can.

 

[cwbullet]

AI is helpful in many healthcare applications, but we still need human oversight and that includes doctors. There are certain nuances that AI doesn't catch and a human can.

100% true. Medicine is art with a science background. Even the top Doc misses some disease and computers have not been found to be superior.

 

[rharshberger]

100% true. Medicine is art with a science background. Even the top Doc misses some disease and computers have not been found to be superior.

When I was in the service, the Army medics at the TMC's used to have a book they used like a flow chart to determine what the person could have, after a few questions they had enough info to narrow the issue down to a few choices and could ask further questions, of course the Doc (a real doctor) still had to agree they had the right answer, but it seemed to be a way to maximize the use of the doctors time when it was busy in the clinic. Today we med tech basically foing the same thing via tele-medicine.

 

[cwbullet]

When I was in the service, the Army medics at the TMC's used to have a book they used like a flow chart to determine what the person could have, after a few questions they had enough info to narrow the issue down to a few choices and could ask further questions, of course the Doc (a real doctor) still had to agree they had the right answer, but it seemed to be a way to maximize the use of the doctors time when it was busy in the clinic. Today we med tech basically foing the same thing via tele-medicine.

That is ADTMC and it is still used. It will work for 40-50% of medicine. The problem is determining when it does not. I had a medic and PA that followed ever algorithm in Iraq. They came to me to review a case in which they were sold the patient was malingering. The patient came in a bunch to times with odd sumptoms that did make medical or neurologic sense. I reviewed it and almost came to the same conclusion. I asked them to bring me the Soldier. After running 4 laps around the parking lot. The Soldier had Guillain-Barre. It is important to have physicians as a part of medicine.

 

[Cl(VII)]

The Moderna trial is taking volunteers in my area due to my location being a “hot-spot” and likely to get infected. I would seriously consider volunteering but half will be injected with saline as placebo control. The highest doses have been eliminated from the the trial due to lower doses achieve an immune response, and adverse effects from the higher dose. I’m wondering if the placebo is administered in each area, or would more likely be placed in areas that are less likely to have a volunteer get infected?

The placebo will absolutely be administered at all sites. All sites will run very close to 50:50, any deviation is just noise of +/- a couple. The degree of deviation from 50:50 will depend largely on what their product packaging/dose delivery form is.

For a trial like this to work the placebo group has to get sick more than the active group. If the placebo group doesn’t have an equal chance of infection you are making it harder to show a treatment effect. You are comparing the number of infections in both groups. The company, the patient or the physician have no idea what group a person is until they unblind the data. There is always a 3rd party unblinded data safety monitoring committee that watches for toxicity signals in the active group. That committee, or a separate unblinded group, can also stop the trial if the effect is so unambiguous that continuing to have a placebo group would be unethical. I would die of shock if there isn’t an unblinded group watching the infection data in near real time given how time sensitive the answer is. This would not be from Moderna, but a 3rd party. There are many companies that do this kind of thing, but my guess would be the NIH, NIAID, a group of immunology KOLs (key opinion leaders), or likely a combo of those.

As I said previously, I submitted my info to the clinical site in DFW, haven’t heard back though.

 

[cwbullet]

Guys, let stay on the COVID topic. Any questions?

 

[ksaves2]

I some states it is a license in one state (patient location) or the other (Provider location). Provider licensing is a racket. We need federal licensing and take the states out of this money making racket.

One more quick OT comment on this. I just retired after 32.5 years of geriatric practice and for a doc to retire or change positions one has to pay a “tail” malpractice insurance fee. That is to cover for any malpractice claims that might occur from the prior two years of “discovery” of a possible case. If a doc is switching jobs and is really wanted by a new employer, said employer usually covers the “tail”. In the case of retirement as I was in, since I was with the same malpractice insurance provider for greater than 10 years, the insurance provider covered the tail. In my case the tail costs roughly $30,000.00. If I was a specialty doc, the tail might have been higher.

The proviso is I had to promise not to practice medicine ever again which in my case was easy to do as I would never want to do primary care medicine again and am 63.5 years old. If I went back, I’d be on the hook for the $30k.

Another thing is if I or “one” wanted to sentimentally maintain a medical license, the out of pocket price is ridiculous. State fees, DEA fees and Maintenance of Certification fees is a sizable chunk of change so once
one is done, it’s best to walk away..................... And fly more rockets which is what I intend to do once I clean up my house and two little shops. One in the basement and one in the garage. Gosh I’m glad I’m done with work! Kurt Savegnago

 

[cwbullet]

One more quick OT comment on this. I just retired after 32.5 years of geriatric practice and for a doc to retire or change positions one has to pay a “tail” malpractice insurance fee. That is to cover for any malpractice claims that might occur from the prior two years of “discovery” of a possible case. If a doc is switching jobs and is really wanted by a new employer, said employer usually covers the “tail”. In the case of retirement as I was in, since I was with the same malpractice insurance provider for greater than 10 years, the insurance provider covered the tail. In my case the tail costs roughly $30,000.00. If I was a specialty doc, the tail might have been higher.

The proviso is I had to promise not to practice medicine ever again which in my case was easy to do as I would never want to do primary care medicine again and am 63.5 years old. If I went back, I’d be on the hook for the $30k.

Another thing is if I or “one” wanted to sentimentally maintain a medical license, the out of pocket price is ridiculous. State fees, DEA fees and Maintenance of Certification fees is a sizable chunk of change so once
one is done, it’s best to walk away..................... And fly more rockets which is what I intend to do once I clean up my house and two little shops. One in the basement and one in the garage. Gosh I’m glad I’m done with work! Kurt Savegnago

I feel for you. I really am toying with hanging it up and I am 52. My retirement is not enough to live on but I am looking at other streams of income. I am 2 years from my military retirement and will have 24 years. I might work another 10 years as a civilian for the military. I might not.

Have you thought about a civilian position as a geriatrician with the military? We are always looking for one and 10 years and you can have a second retirement.

 

[BABAR]

I feel for you. I really am toying with hanging it up and I am 52. My retirement is not enough to live on but I am looking at other streams of income. I am 2 years from my military retirement and will have 24 years. I might work another 10 years as a civilian for the military. I might not.

Have you thought about a civilian position as a geriatrician with the military? We are always looking for one and 10 years and you can have a second retirement.

24? You a USUHS grad?

 

[cwbullet]

24? You a USUHS grad?

No. HPSP. Just a little tired.

 

[blackwing94]

Covid numbers question. Will the new hospital reporting guidelines change how the number are counted? What is the effect of bypassing the CDC? I don't understand what the change means to me, John Q Public. Thanks.

 

[cwbullet]

Covid numbers question. Will the new hospital reporting guidelines change how the number are counted? What is the effect of bypassing the CDC? I don't understand what the change means to me, John Q Public. Thanks.

No change yet. I will keep you up to date. I do no think that bypassing the CDC will have any effect other than have the information sent to a higher level directly. You should notice no change at the public level. The discussions are all politics.

 

[Tech 68]

Thought folks might find this site useful, or at least interesting...

https://ourworldindata.org/coronavirus

 

[cwbullet]

Some of the data is suspect. Most notably - China.

Thought folks might find this site useful, or at least interesting...

https://ourworldindata.org/coronavirus