acne being shifted to cosmetic

Acne vulgaris is a terrible condition for teens--or anybody--to deal with. It's visible to all and afflicts many with shame, humiliation, low self esteem and confidence, etc. One of the mainstays of treatment has been benzoyl peroxide, which for decades has been proven safe and useful in controlling the pustules and papules. A big drawback is the irritation it causes, and one formulation in particular, Brevoxyl made by Stiefel Pharma, has been around since I was a resident. It had a micro-encapsulated delivery where the molecule would preferentially get into the pores and not sit on the surface of the skin leading to redness and irritation. I don't have a lab and can't attest to the biochemistry involved, but clinically speaking, it was wonderful and worked great.
A casualty of the current recession is Brevoxyl. Stiefel sold "the name" to another pharmaceutical company, apparently because it went off patent, so the product is still called Brevoxyl, but the teenagers I'm seeing have terrible flare-ups and complain that they're getting irritation and redness that they weren't before. One bright kid brought in the current Brevoxyl "kit" and pointed out that the stripes on the box are different colors and the wash runs out of the bottle like water instead of like a creamy lotion as it did before. SO-- the patients know that something is up.
I did a little sleuthing and Brevoxyl as we knew it in the past is no more. It's basically now a generic. Savvy money-hungry pharmacists are refusing to fill renewals and prescriptions and simply directing the patients to Aisle 4 where the Clearasil is located. Uh, hello, are you the doctor? Do you know what this person has and how to treat it? Do you know if the person is intolerant of Clearasil? It's absolutely appalling. Patients have been abandoned by their medication, it is simply no longer available. "Too bad, you figure it out" is the attitude.Mothers are calling me in tears.
I have heard of this happening in other fields--certain chemotherapies where the manufacturers simply ceased operations, some FDA half-hearted investigations happened, with no conclusions. I cannot imagine the hell those patients and their oncologists have been put through.
Turns out Panoxyl is the new benzoyl peroxide OTC made by Stiefel but no "wholesaler" will get it for the patients because of order minimums and that's right, it's now OTC. Patients can order it from amazon.com or drugstore.com. if they so choose.
But for the most part, now it's back to the drawing board for many patients. The nice balance they achieved and the good control has been upset. They're red, irritated, and pimply. They need to be come in, be examined by me and we need to start at square one and get them on different therapy to manage their acne.

dry winter skin

Despite the fact that my profession has me spouting off the wonders of regular emolliation of the skin, I often neglect my own needs until it's crunch time. My skin was alligator-like on my legs, rough and peeling on my fingertips from repeated hand washing with industrial strength antibacterials. I followed my own advice and have been using Cetaphil cleanser in the shower, Cetaphil cream frequently on my hands and Cetaphil cream after my shower. Amazing changes, the dry flaking itchy skin is a heck of a lot better. The stuff is wonderful and I'm glad it hasn't changed in decades. Please keep it this way, Galderma Inc.!!!!

I'm not an insurance agent

The new year, new horizons, new challenges...and a new year for pateints' copayments, deductibles, and calendar year activity. This is an especially painful time. Patients don't know what their plans cover. They don't know what they're paying for. I blame the agents and the plans themselves, for perhaps providing information, but not providing understanding. Patients also have the ostrich-head-in-the-sand attitude, they don't want to know anything until they get a bill, then they start screaming. Literally. I am the face and the bricks-and-mortar location where they can walk in and scream. One lady looked like she was going to burst a blood vessel in my waiting room she was THAT agitated. Um, your plan didn't pay anything because you have to spend $5000 first before it kicks in. There are 800-numbers on the backs of their cards but the patients do not call and verify anything. Their agents sit back and demand payment for the policy and they can't (won't) answer any questions about the products they sell. They refer them to the 800 numbers on the back of the insurance card!

I am SO BEYOND FED UP. I am not an insurance agent, adjuster, nor processor. I do not magically know what your policy will and won't cover. I resent SO MUCH being in the middle of this tug of war and being attacked for doing my job. We have now started charging a nominal fee for doing "prior authorizations".

What is a prior authorization? Well, firstly it is a complete misnomer. It sounds like it would be something you do prior to seeing the patient to authorize some service. Nope. It is an ex post facto thing that I, the "prescriber" must do when the pharmacy calls me and states that Mr. Smith's drug is not being paid for by his insurance plan. I then need to speak to someone at Mr. Smiths' pharmacy benefit office, someone normally with a minimum of a high school education, who then screens my call and a staff pharmacist will then call me back. A day or two later, the pharmacist FROM THE INSURANCE COMPANY will interview me as to why Mr. Smith needs this drug. My doctors' degree, NPI, DEA, state license, etc are not sufficient to ensure that I know what I'm doing. This all a delay tactic to NOT pay for Mr. Smith's drug. I then have to fax the records and letters to get the insurance company to pay for the drug. After all this, they usually deny it and the patient must foot the bill. Meanwhile I have spent hours with this back-and-forth and my staff has spent untold time on this issue for which we are not being paid.

A bank charges $40 for a bounced check. Medical offices need to charge for employee and staff time, faxes and the toner, paper, etc. in dealing with essentially a negotiation to try to get a drug paid for a patient. This has gone beyond the pale. I am being continually harassed by all the above involved parties--patients, pharmacies (why do they care where the money comes from, whether it's the insurance plan or the patient? aaah vested interests mesh tightly....), and insurance plans to do this thing where, as far as I am concerned, my responsibility has been vacated. I interviewed, examined, and diagnosed the patient. I discussed treatment options and recommended a plan for the patient's disease. This continual snowball of responsibility has not been curtailed by the physicians' representatives/lobbies, the AMA has done the most piss-poor job on the planet of voicing the concerns and issues of the physicians. All they care about is selling the new ICD-10 coding book.

doctor doctor

A patient identified himself as a doctor to me, the front desk, the appointment manager, etc. Everybody knew he was a "doctor" before he even set foot in the office. Today when I asked him what kind of doctor, he said he's a biochemist with a PhD. Now that may be true, but it's irrelevant and a ploy to pull rank. I find that MD's never identify themselves as such. The ones who try to pull rank are the ones without rank.

Disenfranchised

I was recently urged to join the AMA because it's the only organization that represents and battles for doctors' issues. Wrong-o. And that they've helped in getting certain things into PPACA. Wrong-o again. I have learned that the AMA secured many under-the-table promises that were denied later or flat out ignored. If you make a bargain with the Devil don't be shocked when he fails to keep his end. I just cannot relate to wanting to be part of a huge neo-fascist organization that revels in its bureaucracy and dogma. I'd rather go for a walk.

Why was I receiving nearly weekly letters in the mail to buy auto insurance through the AMA? Or more billing/coding manuals? Or phone calls from their sales dept. pushing the latest book---I got fed up long ago. Now I just view that organization the same way I view the cast of "Jersey Shore"--with benign amusement tempered by the taste of bile rising in my throat.

The recent sinking of that Italian cruiser reminded me that oftentimes, forced enjoyment may bring forced pain. I would rather read a quiet book on my recliner with my polarfleece throw and a cup of Earl Grey than be on a cruise ship anywhere in January. When asked where I go on vacation, I often say, where the people aren't. I love New York, Rome, Madrid, etc. but when I need to relax and recharge I go to the places where nobody ever goes or writes about. Of course I wouldn't divulge my secrets because then they wouldn't be secret anymore, right :-)???

Get measured for a bra

There is something I keep seeing over and over in women of all ages. They continue to wear the same bras from years past, and while that doesn't sound like such a crime, it is when considering the inexorable effects of gravity, weight gain or loss, posture changes with osteoporosis, etc. Brassieres are made to hold up that which nature hath giveth....and nylon, cotton, spandex, polyester, etc. cannot  go against Newton's postulates after the fibers have been frayed from washing machines and dryers. The problem comes when such ill-fitting bras lead to digging and tugging at the skin, which tends to accumulate sweat in the folds, and then yeast infections, generic redness/irritation, "intertrigo" (latin for "wheat in between"--yuck) and all sorts of nasties arise. No matter what drugs/powders/lotions/potions are prescribed, the problem recurs. The root of the problem is an ill fitting bra.

Getting fitted periodically for a bra is a good idea. Cup and band measurements fluctuate throughout a woman's lifetime. Most women just continually buy the same bra size they had at age 19. A properly fitting bra will not only be more comfortable, it will also relieve skin chafing and lead to happiness all around. I know Nordstrom's and Dillard's always has a bra specialist in their Lingerie departments, and Soma makes a big point of offering to measure you whenever you even walk in. So there you have it. Shop!!

Tuesday's child

The disease keeps ramping up, and the patients' stress level keeps increasing. So much is uncertain and the populace is scared, nervous, uptight. I really do empathize with my patients, for whatever tumor/rash/abscess they happen to be suffering from. A lady came in today with a retained suture from last month. It happens, I've had it happen personally. The epidermis grows a little too fast and the suture gets trapped beneath it.

ANd oh, 10 days into the new year, Medicare has gotten the notice that it's 2012 and finally posted the new fee schedule. I cannot imagine how thousands of billing offices are automatically 10 days behind on the new year if they've had patients on new years day, the federal holiday, etc. For me it's just a about 3 dozen codes. For multiple doc practices it's hundreds. What a giant hemorrhoid to deal with.

In some uplifting news, the falcons and herons are moving through to their winter hunting and breeding grounds and it's a treat to see.

http://www.allaboutbirds.org/guide/Peregrine_Falcon/id/ac

My new favorite artist is Questlove (?uestlove) not sure how he spells it but I love his vibe.