The orthopod drug arsenal: 2
1. Analgesics (116 drugs)
Through what value system do we determine monetary worth in our different specialties? I have no idea. Ask the RUC
From my Tarascon Pocket Pharmacopoeia
- tylenol
- hydrocodone
1. Analgesics (116 drugs)
- antirheumatic-Immunomodulators-TNF inhibitors (2 drugs)
- Antirheumatic Agents-Immunomodulators -other (2 drugs)
- Antirheumatic Agents-other (4 drugs)
- mujscle relaxants (11 drugs)
- non-opioid analgesic combinations (12 drugs)
- NSAIDS -COX-2 inhibitors (1 drug)
- NSAIDS-salicylic acid derivatives (4 drugs)
- NSAIDS-other (17 drugs)
- opioid agonist-antagonists (4 drugs)
- opioid agonists(10 drugs)
- opioid analgesic combinations (25 drugs)
- opioid antagonists (2 drugs)
- other analgesics (3 drugs)
- anesthetics and sedatives (8 drugs)
- local anesthetics (5 drugs)
- neuromuscular blockers (6 drugs)
- aminoglycosides (4 drugs)
- antifungals (14 drugs)
- antimalarials (8 drugs)
- antimycobacterials (9 drugs)
- antiparasitics (13 drugs)
- antiviral agents-anti-CMV (4 drugs)
- antiviral agents-anti-herpetic (3 drugs)
- antiviral agents-anti-HIV-combinations (4 drugs)
- antiviral agents-anti-HIV-fusion inhibitors (1 drug)
- antiviral agents-anti-HIV-non-nucleoside reverse transcript inhibitors (2 drugs)
- antiviral agents-anti-HIV-nucleoside/necleotide reverse transcrip inhib (8 drugs)
- antiviral agents-anti-HIV- protease inhibitors (9 drugs)
- antiviral agents-anti-influenza (4 drugs)
- antiviral agents-other (10 drugs)
- carbapenems (3 drugs)
- cephalosporins-1st generation (3 drugs)
- cephalosporins-2nd generation (5 drugs)
- cephalosporins-3rd generation (10 drugs)
- cephalosporins-4th generation (1 drug)
- ketolides (1 drug)
- macrolides (6 drugs)
- penicillins-1st generation (6 drugs)
- penicillins-2nd generation (3 drugs)
- penicillins-3rd generation (5 drugs)
- penicillins-4th generation (5 drugs)
- quinolones-1st generation (1 drug)
- quinolones-2nd generation (4 drugs)
- quinolones-3rd generation (1 drug)
- quinolones-4th generation (3 drugs)
- sulfonamides (2 drugs)
- tetracyclines (3 drugs)
- other antimicrobials (15 drugs)
- ACE inhibitors (11 drugs)
- aldosterone antagonists (2 drugs)
- angiotensin receptor blockers (7 drugs)
- antiadrenergic agents (5 drugs)
- antidysrhythmics (16 drugs)
- antihyperlipidemic agents-bile acid sequestrants (3 drugs)
- antihyperlipidemic agents-HMG-CoA reductase inhibitors (9 drugs)
- antihyperlipidemic agents-other (5 drugs)
- antihypertensive combinations (41 drugs)
- antihypertensives-other (5 drugs)
- antiplatelet drugs (8 drugs)
- beta blockers (14 drugs)
- calcium channel blockers-dihydropyridines (6 drugs)
- calcium channel blockers-other (2 drugs)
- diuretics-carbonic anhydrase inhibitors (1 drug)
- diuretics-loop (4 drugs)
- diuretics-potassium sparing (1 durg)
- diuretics-thiazide type (5 drugs)
- nitrates- (9 drugs)
- pressor/inotropes (9 drugs)
- thrombolytics (5 drugs)
- volume expanders (4 drugs)
- cardiac drugs-other (4 drugs)
- acne preparations (16 drugs)
- actinic keratosis preparations (2 drugs)
- antibacterials (10 drugs)
- antifungals (12 drugs)
- antiparasitics topical (6 drugs)
- antipsoriatics (6 drugs)
- antivirals topical (6 drugs)
- atopic dermatitis drugs (2 drugs)
- topical corticosteroids of variable potency (25 drugs)
- corticosteroid/antimicrobial combinations (4 drugs)
- hemorrhoid care products (5 drugs)
- other dermatologic agents (25 drugs)
- androgens and anabolic steroids (4 drugs)
- bisphosphonates (7 drugs)
- corticosteroids (9 drugs)
- diabetes related -alphaglucosidase inhibitors (2 drugs)
- diabetes related-combinations (6 drugs)
- diabetes related-insulins (4 drugs, multiple combinations)
- diabetes related-meglitinides (2 drugs)
- diabetes related-sulfonylureas (4 drugs)
- diabetes related-other (8 drugs)
- gout related drugs (4 drugs)
- minerals (18 drugs)
- nutritionals (5 drugs)
- thyroid drugs (5 drugs)
- vitamins (21 drugs)
- endocrine-other (15 drugs)
- antihistamines-nonsedating (3 drugs)
- antihistamines-other (9 drugs)
- antitussives (3 drugs)
- decongestants (2 drugs)
- combinations of decon/antihistamine/antitussive (49 drugs)
- ear preparations (14 drugs)
- mouth and lip preparations (14 drugs)
- nasal preparations (13 drugs)
- ENT-other (1 drug)
- antidiarrheals (6 drugs)
- antiemetics-5-HT3 receptor antagonists (4 drugs)
- antiemetics-other (15 drugs)
- antiulcer-antacids (9 drugs)
- antiulcer-H2 antagonists (5 drugs)
- antiulcer-helicobacter pylori treatment (2 drugs)
- antiulcer-proton pump inhibitors (5 drugs)
- antiulcer-other (12 drugs)
- laxatives-osmotic (8 drugs)
- laxatives-stimulant (5 drugs)
- laxatives-stool softener (2 drugs)
- laxatives-other or combinations (3 drugs)
- other GI agents (21 drugs)
- anticoagulants (8 drugs)
- other hematological agents (14 drugs)
- 69 drugs
- immunizations (27 drugs)
- immunoglobulins (11 drugs)
- immunosuppression (6 drugs)
- alzheimer's disease-cholinesterase inhibitors (3 drugs)
- alzheimer's disease-NMDA receptor antagonists (1 drug)
- anticonvulsants (20 drugs)
- migraine therapy-triptans (5-HT1 receptor agonists (7 drugs)
- migraine therapy-other (4 drugs)
- multiple sclerosis drugs (4 drugs)
- myasthenia gravis drugs (3 drugs)
- parkinsonian agents-anticholinergics (3 drugs)
- parkinsonian agents-COMT inhibitors (2 drugs)
- parkinsonian agents-dopaminergic agents and combinations (10 drugs)
- other neurological (9 drugs)
- contraceptives and combinations (34 drugs)
- estrogens (16 drugs)
- GnRH agents (5 drugs)
- hormone replacement combos (12 drugs)
- labor induction/cervical ripening (3 drugs)
- ovulation stimulants (1 drug)
- progestins (7 drugs)
- selective estrogen receptor modulators (2 drugs)
- tocolytics (4 drugs)
- uterotonics (2 drugs)
- vaginitis preparations (9 drugs)
- other OB/Gyn agents (5 drugs)
- alkylating agents (14 drugs)
- antibiotics (10 drugs)
- antimetabolites (17 drugs)
- cytoprotective agents (4 drugs)
- hormones (16 drugs)
- immunomodulators (18 drugs)
- mitotic inhibitors (6 drugs)
- platinum-containing agents (3 drugs)
- radiopharmaceuticals (2 drugs)
- miscellaneous (14 drugs)
- antiallergy-decongentants and combinations (3 drugs)
- antiallergy-dual antihistamine and mast cell stabilizer (4 drugs)
- antiallergy-pure antihistamines (2 drugs)
- antiallergy-pure mast cell stabilizers (4 drugs)
- antibacterials-aminoglycosides (2 drugs)
- antibacterials-fluoroquinolones (5 drugs)
- antibacterials-other (7 drugs)
- antiviral (2 drugs)
- orticosteroid and antibacterial combinations (12 drugs)
- glaucoma agents-beta blocerks (5 drugs)
- glaucoma agents-carbonic anhydrase inhibitors (4 drugs)
- glaucoma agents-miotics (1 drug)
- glaucoma agents-prostaglindin analogs (3 drugs)
- glaucoma agents-sympathomimetics (1 drug)
- glaucoma agents-other (1 drug)
- mydriatics and cycloplegics (5 drugs)
- antidepressants-heterocyclic compounds (7 drugs)
- antidepressants-monoamine oxidase inhibitors (4 drugs)
- antidepressants-selective serotonin reuptake inhibitors (6 drugs)
- antidepressants-serotonin-norepinephrine reuptake inhibitors (2 drugs)
- antidepressants-other (4 drugs)
- antimanics (5 drugs)
- antipsychotics-atypical-serotonin dopamine receptor antagonists (5 drugs)
- antipsychotics-D2 antagonists-high potency (6 drugs)
- antipsychotics-D2 antagonists-low potency (2 drugs)
- antipsychotics-dopamine-2/serotonin-1 partial agonist and ser-2 antagonist (1 drug)
- anxiolytic/hypnotic benzodiazepines-long 1/2 life (6 drugs)
- anxiolytic/hypnotic benzodiazepines-mediume 1/2 life (3 drugs)
- anxiolytic/hypnotic benzodiazepines- short 1/2 life (3 drugs)
- anxiolytic/hypnotic-other (7 drugs)
- combination drugs (one drug)
- drug dependence therapy (12 drugs)
- stimulants/ADHD/anorexiants (9 drugs)
- other agents (2 drugs)
- beta agonists (8 drugs)
- combination inhalants (4 drugs)
- inhaled steroids (6 drugs)
- leukotriene inhibitors (3 drugs)
- other pulmonary (12 drugs)
- 16 drugs
- bph meds (6 drugs)
- bladder agents-anticholinergics and combinations (10 drugs)
- bladder agents-other (6 drugs)
- erectile dysfunction (5 drugs)
- nephrolithiasis (2 drugs)
Through what value system do we determine monetary worth in our different specialties? I have no idea. Ask the RUC
From my Tarascon Pocket Pharmacopoeia
And thanks to Anon in my comments for for this classic musical tribute. Listen 'till the end. It's a gut buster.
Love it! Check this out, you'll get a kick out of it.
ReplyDeletehttp://youtube.com/watch?v=KXROnzpsrlg
That's hilarious. I put it in my post.
ReplyDeleteHappy. Thanks!
You forgot one of the orthopod's meds: Ancef.
ReplyDeleteAnd Lovenox. However, those four probably comprise 80% of orthopod scripts.
ReplyDeleteJunkMD said...You forgot one of the orthopod's meds: Ancef.
ReplyDeleteThen there's the big Ancef versus Kefzol controversy...........
Reminds me of the old joke:
ReplyDeleteQ: What's the orthopod's definition of the heart?
A: It's that organ somewhere in the chest that pumps Ancef to the bones.
OK, wise guys, answer this: would you rather have an orthopod manage your diabetes/hypertension/arthritis, or an internist manage your open femur fracture?
ReplyDeleteI wouldn't want either scenario.
ReplyDeleteBut your open femur fracture on the orthopaedic front would be more comparable to say, septic shock. Life threatening conditions for both. Would I want an orthopod managing septic shock? My answer would still be no. But why is my hour of saving someone's life worth about pennies on the dollar that an orthopod would get paid for fixing the femur fracture. I'm back to my original question. What value system is used to determine monetary value for the different specialties?
Sorry, not buying either one of your assertions.
ReplyDeleteAn orthopod would likely remember a bit from his time in the ICU on the general surgery service. With the help of an experienced ICU nurse and a few books, he could do a passable job of managing septic shock. Not nearly as well as you would, but he could still keep someone alive. I doubt that the typical internist/medical intensivist would begin to be able to manage a femur fracture- typically they have had little or no exposure to orthopedics and are terrified of anything “procedural” beyond a jugular or arterial line. Just think how you would feel if dropped into an OR.
More disturbing is your non sequitur about “pennies on the dollar.” The medical analog of Godwin’s law is that eventually any internet discussion about medical topics devolves into a whine about how much “cognitive” docs are underpaid compared to surgeons and cardiologists and such. Were you the only one in your medical school class who did not know this when you chose your residency? In my school, we all somehow knew that you could do a relatively easy and short 3 year residency and earn less, or go for the gusto- 5 or more years of harder work and more call, with a surgical career and paycheck at the end of the tunnel.
Even giving you the benefit of this ignorance, your own example does not support your argument. The compensation for open management of a femur fracture 27507 in my state is $925. This includes a couple of hours in the OR, and 90 days of Post-op care. This might be trivial, or might be weeks of dressing changes and care of an infected wound. He would also be able to charge for the initial evaluation 99222 ($118). (All are Medicare fees).
Your septic shock patient would likely justify an initial critical care code 99291- ~$250. Every follow-up visit would be compensable at $65 (99232) or $92 (99233), and eventually a discharge 99238 ($68). Not too many days have to pass before the lines cross- if your patient is sick for a week or 10 days, you have out-earned the orthopod, especially if you have office visits after discharge. Don’t forget that these are gross numbers. The orthopod has to pay a lot more malpractice insurance.
Well said JB, I took care of septic shock as a surgical intern, I only had the comfort level to deal with an open femur as a chief resident. A closed femur would be even better, I'd take the over on 2hours for the time just to pass the guidewire for someone that has never been in the OR.
ReplyDeleteHappy knew the handwriting on the wall when he signed up for a nonsurgical residency. They didn't come up with the 80hr work rule from for overworked family practice residents. You work hard and have the grades and scores to get into a high end residency and do the extra two years you should be rewarded. We turned down two guys with 99% on their USMLE. They didn't even get an interview!
I think the government would love to pay internists a global for ICU admissions and have them be seen for 90 days for free.
jb, I'm speechless. Orthopods are great at what they do. Internists and primary care are great at what they do. To attempt to imply that an orthopod can manage septic shock with is like me trying to convince you I could manage an open femur fracture. Stopping before you look any sillier would do you well.
ReplyDeleteBTW, I have no problem earning less than specialties that have trainined longer. I absolutely love my job, my lifestyle and my field of practice. I have no quarlm with earning less. I have a big problem with the process used to pay primary care and cognitive care in general. The process of WIN-LOSE where in the payment of primary care is wholly dependent on the RVU system and the RUC controlled specialty organizations that fight tooth and nail to keep the RVU value of their procedures intact. It's a political game through and through. Back scratching and hi-fives. Because the bugdet neutral nature of the RVU process, for every winner there is a loser. RUC devalues the time factor for cognitive care when compared with procedural medicine. If you try and argue that, you'll look silly.
Sure, specialists deserve to make more. But they don't deserve to make more at the expense of cognitive medicine. Hell, I put lots of central lines in (36556) I am appalled that this 15 minute procedure pays me almost $110 dollars, double what a 99232 hospital follow up visit pays ($60), which is supposed to take me 25 minutes.
Trying to argue that global fees result in an evening of the time factor, again, makes you look silly. We both know that for a vast majority of uncomplicated orthopaedic surgeries the global fee consists of the surgery and a post op visit in 10-14 daya. The post op care routinely managed by an PA or NP.
When I'm managing a daily 99232 visit at 30 minutes each for relative fee of $120 an hour, the orthopod is out earning another $1200 (or more) for a total knee arthoplasy (27447) that takes an hour or two of operative time, maybe a generous 20 minutes of post operative follow up notes by a PA and a 15 minute visit in the office in 2 weeks.
If you throw in a generous 45 minutes of post operative doc time you're looking at a tops of 3 hours for a surgery that pays $1200. That's $400 an hour, generously calculated.
Now, I understand you trained longer, but do you really think your $400 an hour should come at the expense of primary care's $120 an hour? If you do, then there in lies the problem. You believe your skills make you monetarily worth 3X's the value of primary care.
Unfortunately, you are worth that much more because of the system of RUC has determined your time is worth that much more. Not because you trained an extra 2 years, or your skills are so much more special. And guess who controls the RUC. If you believe you are worth that much more than primary care, I can't help you understand why you're not. You are worth that much more because primary care is worth less. If primary care is suddenly worth more in RVU, then your time will be worth less. Such is the WIN-LOSE of RUC. It;s the F*ked up system of WIN-LOSE RUC style.
It's politics my man. Nothing more than that. You practice orthopaedics. I practice internal medicine. I wouldn't want you managing anthing outside of your skill set, any more than you would want me managing your broken bones. But to value your broken bones at 3 times my medical management has nothing to do with a special skill set you have, and everything to do with the political RUC You are worth that much more because the politics say you are. I think you already know that.
Primary care is great at what they do. Ortho is great at what they do. Should ortho be rewarded at the expense of primary care? No. Is it? Absolultely, as are all procedurally driven specialties.
One last thing, Of course, I hope you know my comparison with medications between ortho and primary care was all tongue in cheek. I respect all physicians for the expertise in their respective fields. Including the hammers and chisels. The payment rates are not something they control. Only something they seek. To think otherwise would be myopic.
anon 0236, please. When I was an intern I wrote my own TPN orders by hand. What does that have to do with me today?
ReplyDeleteAbsolutely nothing. Extrapolate that to a practicing orthopod managing sepsis.
You imply that good USMLE scores go into "high end residency" By high end, I assume you mean money. Which brings you back to the RUC. It pays higher because of the political RUC. Not because orthopaedics is harder. They are both hard in their own respective ways.
If primary care paid better, I can assure you that more medical students would suddenly shift their thinking into primary care tracts. Suddenly orthopaedics isn't so "high end" anymore, and the competition would shift to primary care. So, if you are trying to imply orthopaedics is high end because it's harder, would that arguement still hold if both paid the same. I think you know the answer.
Circular logic doesn't work with me.
Love the song. Here's another.
ReplyDeletewww.garageband.com/song?|pe1|S8LTM0LdsaSlYFezYm0