A thoughtful, factual reply to an only seemingly balanced, but really tendentious article (see New York Times cartoon accompanying it – which is what most will retain from it). Please read, redistribute and comment. The original New York times article prompting the letter that follows is here.
I will update if and when letter is printed in the NYT. For more on the Independent Doctors of New York/IDNY, please go to our web site.
>>Re: Ms. Rabin’s article “When Doctors Stop Taking Insurance” ?
The answer to why many doctors are no longer accepting health insurance payments is both simple and complex. .
The simple answer: Health insurance companies are for-profit organizations that answer to their boards and shareholders, not patients, to make sure their bottom line is a healthy, black line. The CEOs of these companies make millions in salary, and many more millions of dollar are spent on TV and print advertising needed to lure and keep patients. Each of these takes money away from the medical care they could AND should provide their patients and reasonable reimbursements to physicians.
The complex answer: If for-profit insurers paid physicians a reasonable usual and customary rate (UCR), physicians would be much more receptive to accepting insurance reimbursement. But this is not the case. The for-profit health insurance industry made up their own UCR by bankrolling the company (Ingenix) that was supposed to supply real-world UCRs. However, use of the UCRs developed by Ingenix was found to be fraudulent in New York State, and for-profit health insurers were fined $350 million and required to pay an additional $50 million to create a the new “Fair Health” UCR. Despite this ruling, the insurers found a way around this by jointly declaring that their UCRs would be a percentage of what Medicare pays–the low reimbursement rate the government provides to keep our tax burden for health care low. So, it’s acceptable for insurance companies to get together to set fees, whereas if two doctors get together and discuss fees, it’s considered an antitrust violation.
Today’s young doctors come out of medical school $150,000 to $200,000 in debt. Then there are the expenses of starting and running a medical practice, which are very high. Malpractice insurance often increases yearly in most states due to a failure to enact medical malpractice tort reform (the exceptions are Texas and California who lead the nation in this bold effort to keep medical costs down). Rent and the cost of staff also increase yearly. Yet, insurance reimbursements have not increased in years and there is no law requiring increases linked to inflation or other accepted economic indicators.
Until something is done to reign in the for-profit health insurers, more and more physicians will “opt out” and patients will have less and less access to their physician of choice.
William Rosenblatt MD
President, Independent Doctors of New York
Suite 1D
308 East 79th Street
New York, NY 10075
212-570-6100
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Of note, >>[p]atients with orthostatic hypotension, ulcerative colitis, hyperthyroidism, dementia or cognitive dysfunction, Parkinson’s disease, or cerebrovascular disorder<< were excluded. How many real-life patients with BPH also have one of the above?
Example: “Heart attack” AND “Los Angeles”
Purpose
To evaluate the efficacy and safety of solifenacin succinate as add-on therapy for overactive bladder (OAB) symptoms in men who have been treated for benign prostatic hyperplasia (BPH) with tamsulosin hydrochloride for at least 6 weeks
| Condition | Intervention | Phase |
|---|---|---|
| Benign Prostatic Hyperplasia Benign Prostatic Hypertrophy Overactive Bladder |
Drug: Tamsulosin hydrochloride Drug: Solifenacin succinate |
Phase 4 |
| Study Type: | Interventional |
| Study Design: | Allocation: Randomized Endpoint Classification: Safety/Efficacy Study Intervention Model: Parallel Assignment Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor) Primary Purpose: Treatment |
| Official Title: | A Randomized, Double-Blind, Placebo-Controlled, Parallel Group, Multicenter Study of Solifenacin Succinate as Add-on Therapy for Overactive Bladder (OAB) Symptoms in Men Treated for Benign Prostatic Hyperplasia (BPH) With Tamsulosin Hydrochloride |
| Enrollment: | 638 |
| Study Start Date: | October 2008 |
| Study Completion Date: | January 2010 |
| Primary Completion Date: | January 2010 (Final data collection date for primary outcome measure) |
| Arms | Assigned Interventions |
|---|---|
| Placebo Comparator: 1. Tamsulosin alone | Drug: Tamsulosin hydrochloride
oral
Other Names:
|
| Experimental: 2. Tamsulosin + solifenacin (low dose) | Drug: Tamsulosin hydrochloride
oral
Other Names:
Drug: Solifenacin succinate oral
Other Names:
|
| Active Comparator: 3. Tamsulosin + solifenacin (high dose) | Drug: Tamsulosin hydrochloride
oral
Other Names:
Drug: Solifenacin succinate oral
Other Names:
|
Study drugs are administered for 14 weeks in total, including a 2-week run-in period (single blind) and a 12-week treatment period (double blind). After written informed consent, study drugs for the run-in period are orally administered once daily after breakfast for two weeks to subjects who fulfill the inclusion and exclusion criteria. Then, subjects are randomized and orally treated with study drugs for the treatment period once daily after breakfast for 12 weeks
Eligibility
| Ages Eligible for Study: | 50 Years and older |
| Genders Eligible for Study: | Male |
| Accepts Healthy Volunteers: | No |
Inclusion Criteria:
Exclusion Criteria:
Contacts and Locations
| Japan | |
| Chubu, Japan | |
| Chugoku, Japan | |
| Hokkaido, Japan | |
| Kansai, Japan | |
| Kantou, Japan | |
| Kyushu, Japan | |
| Shikoku, Japan | |
| Touhoku, Japan | |
| Study Chair: | Central Contact | Astellas Pharma Inc |
More Information
| Responsible Party: | Director, Astellas Pharma Inc. |
| ClinicalTrials.gov Identifier: | NCT00771394 History of Changes |
| Other Study ID Numbers: | 905-JC-001 |
| Study First Received: | October 9, 2008 |
| Last Updated: | March 3, 2010 |
| Health Authority: | Japan: Pharmaceuticals and Medical Devices Agency |
Keywords provided by Astellas Pharma Inc:
| Vesicare Solifenacin succinate Tamsulosin Overactive Bladder BPH |
Additional relevant MeSH terms:
| Prostatic Hyperplasia Hyperplasia Hypertrophy Urinary Bladder, Overactive Prostatic Diseases Genital Diseases, Male Pathologic Processes Pathological Conditions, Anatomical Urinary Bladder Diseases Urologic Diseases Urological Manifestations Signs and Symptoms Tamsulosin |
Quinuclidin-3′-yl-1-phenyl-1,2,3,4-tetrahydroisoquinoline-2-carboxylate monosuccinate Adrenergic alpha-1 Receptor Antagonists Adrenergic alpha-Antagonists Adrenergic Antagonists Adrenergic Agents Neurotransmitter Agents Molecular Mechanisms of Pharmacological Action Pharmacologic Actions Physiological Effects of Drugs Muscarinic Antagonists Cholinergic Antagonists Cholinergic Agents |
ClinicalTrials.gov processed this record on September 30, 2012
Notice authors’ disclosures when reading this material.
Antimuscarinic drugs for overactive bladder… [J Am Geriatr Soc. 2005] – PubMed – NCBI.
Neuropsychology Division, Department of Neurology, Georgetown University School of Medicine, Washington, DC, USA. wnimail@aol.com
Antimuscarinic agents are the predominant pharmacological treatment for patients with overactive bladder (OAB). These drugs are thought to act primarily through antagonism at muscarinic M3 receptors located at neuromuscular junctions in the human bladder detrusor muscle. Several of these drugs have been shown to be efficacious in ameliorating the symptoms of OAB in older patients, but most currently available agents lack selectivity for the M3 receptor subtype, and interaction with other muscarinic receptor subtypes throughout the body may adversely affect a variety of physiological functions and result in unwanted side effects, including cognitive dysfunction. With the recent availability of antimuscarinic agents that show increased selectivity for M3 receptors relative to other muscarinic subtypes, an invitational expert panel meeting was convened to review not only the mechanisms by which antimuscarinic agents could affect cognitive function, but also the published literature on cognitive adverse events. A review of the literature shows that the cholinergic system in the central nervous system (CNS) exerts a major influence on cognitive processes, in particular memory via M1 cholinergic receptors. In addition, recent evidence suggests a role for M2 receptors in mediating cognitive function. Thus, cognitive dysfunction (including memory loss) during treatment with nonselective antimuscarinic agents for OAB is of growing concern, particularly in older patients and those with mild cognitive impairment or dementia. Increased blood-brain barrier permeability, which can occur with advanced age and certain comorbidities, may also facilitate CNS access of antimuscarinic agents (regardless of their physiochemical properties) and add to antimuscarinic burden. On the basis of available evidence, antimuscarinic agents with selectivity for M3 over M1 and M2 receptors, limited CNS penetration, or both may therefore offer a favorable balance of efficacy in treating OAB together with a reduced risk of adverse cognitive events in the older population.
Maurice Preter, MD is a European and U.S. educated psychiatrist, psychotherapist, psychopharmacologist, neurologist, and medical-legal expert in private practice in Manhattan. He is also the principal of Fifth Avenue Concierge Medicine, PLLC, a medical concierge service and health advisory for select individuals and families.
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