FDA Approves New Neuropathy Pain Drug

Get ready for a trip to the emergency room if you take this drug inappropriately. Also, keep this drug out of reach of children of any age less than 18. These warnings are necessary and very wise for a neuropathy pain drug just approved for use by the FDA. 

Other warnings can be found here and need to be taken seriously. For me, this will be one medication I will avoid if at all possible – FDA approval not withstanding. There are just too many potential risk hazards for me to be comfortable using this. The fact that this medication has to be doctor monitored so closely because of potential of addiction is another factor in my avoiding this medication.

The US Food and Drug Administration has approved US sales of NUCYNTA® ER (tapentadol), a twice-daily extended-release oral analgesic for the treatment of pain from diabetic peripheral neuropathy. The drug, produced by New Jersey-based Janssen Pharmaceuticals, Inc., provides around-the-clock management for moderate to severe chronic neuropathic pain. Janssen says that it is currently the only opioid on the US market that has been approved for treating the condition.

I will continue to suffer with what I considerate moderate chronic neuropathy pain rather that use this medication. I will continue to use gabapentin, which alleviates some of the pain and is not a narcotic.

While this medication may work for some people, after reading the warnings accompanying the press release and then the FDA link above, it is not a medication I wish to consider. This medication also has great potential for being abused like other controlled substances.

Contract Medicine – The Future of Medicine

As a patient that has had excellent medical insurance for most of my adult life, why would I support or advocate for another type of medicine. Quite simply – the current medical system is broken and with the government taking more power and intruding further into our lives every day, it is headed for the financial breaking point. Doctors in private practice relying on insurance and Medicare payments are finding it very uneconomical to stay in practice and live on the increasing cuts in payments, pay staff to submit insurance and Medicare claims, and meet the needs of the patients. Hospitals are seizing the opportunity to buy out these failing practices or hiring the doctors away from them, thereby increasing their monopoly.

The more exclusive the hospitals become, the higher the costs of patient care becomes. The hospitals are reimbursed for the recoding of simple procedures to complicated procedures. Does the doctor benefit, seldom, but the administration gets higher and higher salaries and bonuses. This is why we need the doctors and their preventive medicine, which is possible under contract medicine regardless of type - boutique, concierge, retainer, and direct care. These caring doctors practicing preventive medicine will decrease the probability of increases in chronic illnesses and diseases.

The current president of the American Academy of Private Physicians (AAPP), Gary M. Price, M.D., F.A.C.P., has some excellent points at the bottom of the front page of the AAPP website (sorry, this link is now broken - I suspect they rearranged site and removed some material). How long it will remain up is in doubt, but it is well worth the time to read it. I am quoting two paragraphs - “Direct practice restores the doctor-patient relationship to the lofty level it enjoyed before being constrained and degraded by government and insurance. We work only for our patients. We give them uncompromising care in an unhurried, respectful setting. Because we care, the physician becomes a trusted friend. And in direct practice we behave like any other free market: we listen to our customers and respond to their needs. Which is why we have evolved many variations of our model to serve every type of community and every income level.”

It is followed by a statement by Dr. Jordan L. Shlain, MD, San Francisco, CA - Internal Medicine. His point is well stated here - “We are building the wellness model of the future and actively critiquing the circular illness-model. The common denominator that sets us apart is our desire to listen longer, ask more questions, and take the time to work through a complex problem in the spirit of healthy living and longevity.”

Dr. Price lists contract medicine this way - “In the late 1990s a new movement was born in Seattle, Washington and Fort Myers, Florida. Creative physicians dissatisfied with the status quo opted out of the insurance-based medical system to invent a better way to care for their patients. This movement came to be known as Direct, Concierge, Boutique or Private medicine.” The last sentence is different than “boutique, concierge, retainer, and direct care” and does create some confusion as “direct” and “private” medicine are often seen as being the same. Direct primary care (DPC) may be a preferable term to direct or direct care. They are all private medicine and as a group should be considered contract medicine. All of the terms can be considered “retainer medicine”. Many doctors prefer the term “retainer” to boutique or concierge and that is the reason in my previous blog I listed the wide range of fees these doctors may charge.

Will there be a consensus about the terms? This is very doubtful, as many doctors do not like the terms “boutique” or “concierge”. They consider these terms elitist and while the fees may vary, they cannot accept the connotation that these terms may imply. This is a reason that the last sentence in the first quote from Dr. Price - Which is why we have evolved many variations of our model to serve every type of community and every income level” is so important as they are covering all aspects of contract medicine.

Back to why this is the future of medicine. Dr. Price states most of it very well and I quote, “Direct practice restores the doctor-patient relationship to the lofty level it enjoyed before being constrained and degraded by government and insurance. We work only for our patients. We give them uncompromising care in an unhurried, respectful setting. Because we care, the physician becomes a trusted friend.” This may not cover all situations; however, it does spell out the importance of restoring the doctor/patient relationship, putting the patient first and emphasizing preventive medicine instead of waiting for the illness or disease and treating these. This puts “human” back in the equation and makes the doctor and the patient be in tune with each other because the time restraints are removed and the doctor has time to be thorough.

From the AAPP website, clicking on “The Third Era of Medicine” button will bring you to one of the better discussions of the medical mess we are currently experiencing, or click on this link. I found the discussion about type 2 diabetes very informative and on target. Scroll down the page to “Trapped in the Oscillating Structure of the Second Era”, and then down some more to “To preserve the first era paradigm, the system refuses to embrace three key realities:”

1. Diabetes is in fact an escalating progression of systemic destruction set in motion by a well-understood clinical imbalance;

2. The imbalance and the resulting damage can be economically detected and measured very early in its progression; and

3. The destructive sequence can be inexpensively halted and reversed when addressed early in its progression.

This is a polite way of saying that our current doctors are so constrained that they will not attempt a diabetes diagnosis until the conditions have reached a level that requires medication. Yes, there are a few conscientious doctors that do diagnosis prediabetes, but do not usually do much further because they have no support system and if medication is required, insurance will not pay for anything. Our broken healthcare system comes to mind.

If the AAPP can state things like this, then they will be working for patients, which is more than I can say for the American Diabetes Association. Whether you consider contract medicine or not, the “The Third Era of Medicine” is very interesting and explains what the future of medicine may become. Dr. Price says. “Today, even medical schools are including direct practice in their curricula.” If potential medical students will acquaint themselves with the AAPP site and a few other sites like this one and this one, they might decide that medicine is for them. These potential doctors may be the ones to give real preventive medicine the goal of actually helping patients and preventing the development of some chronic diseases.

Of the many doctors that are wishing to retire – if they could, it is sad that they do not look to contract medicine for some enjoyment until they can retire. It is even sadder that many of these doctors will never fit in contract medicine for several reasons. Many are overly attached to the current system and are unable to rethink their situation to be able to work in contract medicine. Others have overvalued their worth and will not work in contract medicine because they cannot accept value in the Internet or using telemedicine. Still other doctors have become so ingrained in the quick appointments that having half an hour or longer appointments scares the dickens out of them, plus they cannot operate in the preventive medicine arena. To these doctors I will only say – retire, medicine may be better off without you.

Yes, I am an advocate for contract medicine and believe this may be a major part of the solution to our current broken medical system. Dr. Jordan Shlain is correct when he says, “The common denominator that sets us apart is our desire to listen longer, ask more questions, and take the time to work through a complex problem in the spirit of healthy living and longevity.” This idea is further restated in much of the AAPP website. Take time to explore the AAPP website. Just remember that some of it is for members only and not accessible to the general public, but it is better than many professional medical websites. Transparency is a term they do understand.

Affordable Contract Medicine

The more I read and research about concierge medicine, the more I become concerned that I have missed an important point. Some of this I know is me, but the rest is really muddied up in so many ways. I even made a mistake, when I wrote this blog. I used printed sources to pull together four areas of concierge medicine and there may be more definitions. I was using concierge medicine as a cover term for all types including concierge medicine. For now, I will stay with the four terms and add the term “contract medicine”. Contract medicine may be the correct cover term for the other terms that I am discussing.

Let me review the terms – boutique, concierge, retainer, and direct care (or direct primary care - DPC). All of these, by practice, are contract medicine or care. The contract is the result of a fee the patient pays at the first of each billing cycle to have access to that doctor for the coming period and if you wish to keep the doctor under contract and available to you. This does not mean that you, as the patient, will physically see the doctor that cycle, but the fee still must be paid. The fee is for only you and does not include other family members. Family members may be part of a family fee structure or handled on an individual patient basis.

There are several terms for the fee paid and include, contract fee, retainer fee, subscription fee, access fee, medical care fee, and the list goes on. Much of this naming depends on how the doctor wishes to describe it, and I will not attempt to list all possible terms. Most practices request the fee to be paid monthly, but some do collect on a yearly, semiannual, or quarterly basis.

An area that is still confusing (to me and others) is who is accepting medical insurance and who is not. Some of all types of contract medicine are accepting insurance. However, in general, doctors in direct primary care will not accept medical insurance, there are some exceptions. To protect yourself in all forms of contract medicine, be sure to ask if insurance is accepted as many doctors, of all types of contract medicine do not accept medical insurance, will not be submit insurance claims for you, and you are entirely responsible for all expenses not covered in the contract fee paid.

Boutique medicine generally has the highest fee range as could be expected. I cannot give the range, as I do not know what the highest fees are. Concierge medicine is generally considered the next highest monthly fee, but this is experiencing some lower fees. Retainer medicine is the confusing category. Some doctors do not want the label of boutique or concierge and use the term retainer medicine. The fees are broad ranging and can vary from $50 per month to several thousands of dollars per month.

Direct care medicine or direct primary care medicine is probably the lowest consistent fee. The majority range from $50 to $100 per month. No, this is not a firm range as some can be as high as $200 per month, but the $200 fee is generally considered out of the normal range. There are other terms for contract medicine, but few are mentioned or talked about and seem to be limited to certain specialties in medicine or what a few doctors are using to separate themselves from the normal forms of contract medicine. Having said that, the American Academy of Private Physicians (AAPP) does use the terms “private” and “personal” for many discussions of contract medicine.

In all types of contract medicine, patients have greater access to their doctor via phone, Internet, immediate appointment availability and some doctors are using telemedicine to meet the needs of the patients. Some doctors include house calls in the fee, but this is variable depending on the location and the time available to the doctor. Most contract medicine doctors have a patient count of 300 to approximately 1200 or slightly higher. Most, but not all, doctors will work on preventive medicine and treat illness or disease when it happens. The majority of doctors will be working hard to prevent illness and disease from happening in the first place.

Before signing any contract, check whether some or all lab tests will be covered by the contract fee. Some lab tests will probably be covered, but frequency and test costs will affect coverage. In addition, it is important to determine how hospital visits will be handled. Some may be covered by the monthly fee, but most will not. The lower the contract fee is, be alert for unusual expenses to creep into the cost factor.

The direct primary care model, especially, has drawn insurance industry opposition in part because the health insurer middleman is cut out of the equation. Insurers may benefit from direct primary medical care because patients who want insurance are still purchasing high deductible health plans for specialized care and hospitalizations. In addition, there is even talk that some insurance giants are actually talking to direct primary care pioneers MedLion of Monterey, Calif., and Seattle-based Qliance about providing patients in their practices with access to “wrap-around plans” that would cover their specialist and hospital needs. This “wrap-around plans” is gaining support in other areas of the country, particularly in areas where contract medicine is becoming more popular.

There is even some in Congress that are picking up on the contract medical care model and it is gaining momentum is a surprising bipartisan way. Even the New York Times has had stories of “concierge medicine for the masses.”

There will be more written about this in the coming months and I will blog about this when it happens. For those that want to follow a doctor in his change from group practice to a “direct primary care” practice, follow Dr. Rob Lamberts who posts about it here, here, and follow him on Facebook here or if you love twitter, he is here. On the two blogs, read the comments please as there is some excellent information in some of them.

The next blog will continue this discussion.

The @&## With Doctor's Orders

Now that my proficiency of using my left hand for the mouse has improved and I can type with my left hand (all be it slowly), I will be back to posting as I am able to complete a blog. Thank you readers for your patience!

No, my wrist is not healing, and the doctors cannot figure out why.