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Post by stevil on May 9, 2019 14:11:13 GMT -5
All that to say, I struggle with sayhey's argument that endos are afraid of losing money if patients are well-controlled. I won't say the endo friends he's talking to are wrong or that I know more than them... I just don't understand what they're talking about. From what I understand, Afrezza would only make their job easier, not less lucrative.
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Post by stevil on May 9, 2019 14:00:46 GMT -5
Yes and no. Right now, the current guidelines call for statins and Ace inhibitors/ARBs for all patients on insulin. So any insulin dependent diabetic is a baked in level 4 billing code (out of 5). So whether the patient is well-controlled or not... Depending on how badly controlled they are, they may qualify for a level 5 code, but it's much harder to justify level 5s than 4s... In other words, it's not uncommon to get paid the same for a super complicated patient as one who is well-controlled. But you do far more work for the one that's not controlled and carry more risk as a physician for the same pay. What does the billing code level mean? Does that mean a doctor can charge more for a standard office visit if a patient is at a higher "level" regardless of what is actually done during the visit? Sort of. It all depends on how well they document the encounter. As long as they document that they addressed the issue in some way (which is not hard to do), they can justify billing for it. Reason being is it can impact medical decision making. More complicated patients require a more thoughtful approach. It doesn't have to take more time, it's just that they're more complicated so the thought is that you do spend more time reviewing labs and vitals before coming to a conclusion. I should also specify that this is for adult onset type 2s only though. You don't start kids on statins or blood pressure meds. www.aafp.org/fpm/2003/1000/fpm20031000p31-uf2.gifAs I said above, look at the HPI section (stands for history of present illness). Since an ACE/ARB (blood pressure meds that protect the kidneys) and statins (coronary artery/stroke) are indicated for all adult onset type 2 diabetes, (since it's a metabolic syndrome with high risk comorbidities) you can also bill for hypercholesterolemia and hypertension because you're treating to prevent stroke, coronary artery disease, stenosis of arteries, etc. Thus it automatically qualifies as a level 4 or higher, depending on severity. If a patient is extremely high risk, you have to document well why/how that is and why you either needed to spend more time with them or reviewing their chart to bump then up to level 5. I think I answered your question?
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Post by stevil on May 9, 2019 0:49:25 GMT -5
Yes and no. Right now, the current guidelines call for statins and Ace inhibitors/ARBs for all patients on insulin. So any insulin dependent diabetic is a baked in level 4 billing code (out of 5). So whether the patient is well-controlled or not... Depending on how badly controlled they are, they may qualify for a level 5 code, but it's much harder to justify level 5s than 4s...
In other words, it's not uncommon to get paid the same for a super complicated patient as one who is well-controlled. But you do far more work for the one that's not controlled and carry more risk as a physician for the same pay.
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Post by stevil on May 9, 2019 0:18:21 GMT -5
In other words, anyone who argues with Stevil is a "fool." Got it. Now it's really starting to feel like the old days. If that's how you chose to read my post, then I won't argue with you
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Post by stevil on May 9, 2019 0:14:51 GMT -5
Notice he did vote for its approval though! And I highly doubt he was being serious... Probably was saying it tongue in cheek. Endos do a ton more than just diabetes. They also handle the pituitary, hypothalamus, pineal gland, adrenals, reproductive organs, etc. There will always be a need for an endocrine. Would they notice a hit to their business if diabetes becomes well-managed? Absolutely. However, they'll still be managing diabetes. Not every referral is because a doctor doesn't know how to manage therapy. There is still a lot of business to share because PCP's don't want to deal with stuff. One of many reasons PCPs chose not to specialize is because they don't want to get sucked into seeing only one patient population. Someone still has to write the scripts for diabetics. Endos will be fine. I'm a non-diabetic endo patient and couldn't manage to get one for regular care under my health plan because they are all too busy and not accepting new patients. I'd look forward to some freeing up. Agree, they will do well, as all specialists tend to even with less people with uncontrolled diabetes. Sadly, there is an over abundance of patients with diabetes. Special thanks to those docs that go into primary care. Look forward to hearing where you end up Stevil. Crazy enough, if the "self-reported" income charts are to be believed, endos are actually near dead last only to peds docs on the pay scale. Reimbursement sucks for endos, despite what one might be led to believe on here. I'm sure they'd love to have the same pay for much less complicated patients. I feel bad for those guys... Always sorting out messes and getting paid squat for it.
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Post by stevil on May 9, 2019 0:08:54 GMT -5
Are you still a physical trainer, Sports? Do you ever get frustrated with people who think they know your job better than you because they have a gym membership and can lift a few weights but don't know what they're talking about? Now that you have experience, you can pretty easily spot the pretenders from the ones who know what they're talking about? That's pretty much where I'm at now. I think if I went into the gym, bad mouthed all the trainers and said they're all idiots and are horrible at their job that you'd get extremely annoyed at them and you'd try to set them straight. Am I right? I don't usually engage with those kinds of people because ignorance is hard to cure, especially when you're unable or unwilling to admit it, but when the board keeps getting littered with this kind of dialogue, again, no one else will defend it except me, so I have to engage it. You have spinned and distorted numerous posts in this thread to fit your narrative--- so much so--- that I have decided to call you out on it. I'm really disappointed by the grand level of immaturity you have demonstrated, but nonetheless, I forgive you. Anyways, maybe you will find it ironic that your medical education and training was designed, standarized and monopolized by a man from Kentucky by the name of, Abraham Flexner, who had a degree in ancient Greek literature---with no professional or educational experience in medicine whatsoever. What did you call me out on? Ha, mango, that's not how it works. You have to give me examples...
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Post by stevil on May 8, 2019 19:44:18 GMT -5
Stevil - I did not imply anything. I said it straight out and the "almost" direct quote from one of the Endo on the advisory committee board at the afrezza ADCOM point blank said "I (he) am voting for approval of afrezza even though it will probably put me(him) out of a job". I don't remember his name but I was sitting about 20feet from this guy. He understood afrezza inside and out and saw its true potential. That is from one of the top Endos in the country saying that and he is not alone. Without the uncontrolled T2s how big is an Endo's practice? Put the T2 on afrezza day 1 and most of the Endos can hang the out of business sign on the door. At this point in time there are three main groups of endos I run into. Those that do not understand afrezza and those that do and see its true potential and they are not prescribing. The third group is still waiting and seeing. Sooner or later they will do the right thing for their PWDs and prescribe but there is a lot of pressure from their BP sales friends not to. Notice he did vote for its approval though! And I highly doubt he was being serious... Probably was saying it tongue in cheek. Endos do a ton more than just diabetes. They also handle the pituitary, hypothalamus, pineal gland, adrenals, reproductive organs, etc. There will always be a need for an endocrine. Would they notice a hit to their business if diabetes becomes well-managed? Absolutely. However, they'll still be managing diabetes. Not every referral is because a doctor doesn't know how to manage therapy. There is still a lot of business to share because PCP's don't want to deal with stuff. One of many reasons PCPs chose not to specialize is because they don't want to get sucked into seeing only one patient population. Someone still has to write the scripts for diabetics. Endos will be fine.
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Post by stevil on May 8, 2019 18:58:44 GMT -5
While I am on the subject of complimenting other posters, as a side-note to Stevil's threads above, I want to add to the others in saying that I also continue to enjoy sayhey's posts and I highly regard his opinions. But, Stevil, I don't mean that to contrast your posts - thanks for explaining your stance and writing about your background - it sounds interesting. I don't want to play the role of message board guard dog. It's annoying when others do that to me. However, one thing that bothers me is when people act the authority when they have no leg to stand on. Despite this, I do not wish to silence anyone on this board. I'm a huge advocate of free speech. Everyone is entitled to their own opinion. This is probably going to sound bad, but it's not meant to be belittling or demeaning to anyone on here. People just don't know what they don't know. It's hard for people to spot the people who know what they're talking about and those who don't because they don't know any better to distinguish between the two. To be fair, there is a lot of good info shared on here... But there's equally, if not more so, bad info that gets a lot of likes. It gets a lot of likes not because it's good info, but because it usually sounds good and is what people want to hear. Look no further than just about every post by matt. He shares his experience with people and the board hates him for it because a lot of the stuff he tells them is hard to swallow at times. I'm glad he sticks around in spite of all the mocking others do of him. Sometimes he's wrong or gets his facts incorrect, but everyone makes mistakes. I wouldn't say that he's here to be sneaky or divisive. Just shares his experience and interpretations through his lens. As for me, I usually try to stay quiet. I sometimes chime in from time to time when I see new posters or feel like I have something of value to add. I post less and less because I feel like my posts are valued less and less the longer this goes on. So why waste my time? Especially when almost every post I make I have to justify or argue my position. Arguing with people on here is usually an exercise in futility. Neither side is going to relent and neither side thinks they're wrong. I try to force myself to take the great Mark Twain's advice on this board when he said, "Never argue with a fool. Onlookers may not be able to tell the difference."
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Post by stevil on May 8, 2019 18:37:56 GMT -5
stevil ... My dad was on Afrezza.. it wasn't that time consuming to get him on it and the doc didn't do most of the educating.. they actually had an RN that spent the time with him. Also if a patient comes in requesting Afrezza I believe it's the docs job to find out about it. It's not that hard. I don't think docs are in the crosshairs unfairly. I also don't ever remember someone accusing them of being malicious. And Sayhey isn't prescribing to anyone that I know of.. I'm not a disgruntled investor.. I saw years ago what the problems were. For some reason I stayed the course.. that's on me.. I understand that and I'm sorry this has been such a stressful time for you. I don't know the particular doctor your dad saw, so I can't really say I know exactly what I'm talking about. However, as a generality, the PCPs (assuming your dad saw a primary care) that I have spoken to said that greater than half of their day is spent just covering overhead. They don't start making money until they hit midday. So what does this translate into? Cramming more patients into a smaller time frame. Also, what does this mean for the doc? He's got less time to look into new medications. He/She sees insulin, looks at the data, sees more units/$ and that it's inhaled. Pretty much stops there because we're trained that insulin is insulin. There is no importance to pharmacokinetic time-action profile for insulin... cause until Afrezza, none of that was really revolutionary or mattered. Honestly, there is nothing in the published literature that distinguishes Afrezza from other RAAs other than it's inhaled. RAAs are still the standard of care. Doctors are compliant with their duties, according to their medical boards, simply by sticking to RAAs. The answers to the questions doctors may have about Afrezza are not readily accessible or do not exist at all because it has not been properly tested. It is still an unknown quantity. RAAs on the other hand, are well known. You know what you have and what you'll get out of them. There have been millions of people on them over the past couple decades compared to the thousands over the past few years with Afrezza. This is where experience comes into play. You see a busy doctor and assume he/she is lazy and/or doesn't care about his/her patients, when in reality, due to the system they're practicing in, they have to be extremely efficient with their time if they want to make money and get home at a reasonable time. The cost of medical education has been rising like college education, so it's not uncommon for your doctor to be 200,000-500,000 by the time they start residency. Then, depending on repayment, that converts to about 400,000-1,000,000 during the lifetime of the loan due to interest. It's easy for specialists to make this money up because procedures like surgeries, endoscopies, colonoscopies, percutaneous coronary intervention, laser therapy, allergy testing, etc, etc, makes a bunch of money. Primary care doesn't typically do that many well-paying procedures. So what do doctors do? They outsource and delegate the remedial stuff to their support staff... If an RN can do the job, there's no need for the doctor to do it. In essence, it's a waste of their time because there are other jobs they can be doing that only they can do. That's why you hire staff- so you can focus on the things you need to do. If I can make $100/patient, I'm not going to spend an extra 15 minutes counseling you because that extra 15 minutes would then cost me $100. If I pay an RN $10 for 15 min ($40/hr), I keep an extra $90 by moving onto the next patient. I am not condoning this behavior, but I do not fault doctors either. I can tell you I don't want to practice medicine this way, but then again, I'm just starting out and we'll see what happens. Debt sucks. Sayhey implied malicious intent to endos because they wouldn't prescribe it out of fear of being out of a job. That sounds pretty malicious to me... "I'm not going to give you the best treatment because I don't want to heal you so you won't need me anymore". In any case, look at the scenario above to see that doctors aren't afraid of being out of a job. There is a huge shortage of physicians and there are plenty of patients to go around, especially in endocrinology and primary care.
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Post by stevil on May 8, 2019 14:33:49 GMT -5
Seyhey is quite knowledgeable about. What is going on.. many of us here are.. you don't have to be in the healthcare field to see what is going on. I don't mean to be rude, but just because you are in the healthcare field doesn't make you an authority on what is going on with Afrezza. There are many healthcare professionals that obviously don't understand Afrezza and don't want to. I've been around the block with that. Docs who do understand Afrezza are having remarkable results. What Seyhey says is true.. he isn't beating any drum anymore than you are... I second that! I think someone has taken over stevil’s ID🤣 this is not how I remember him. Sayhey knows of what he speaks I’m just gonna leave it at that. Are you still a physical trainer, Sports? Do you ever get frustrated with people who think they know your job better than you because they have a gym membership and can lift a few weights but don't know what they're talking about? Now that you have experience, you can pretty easily spot the pretenders from the ones who know what they're talking about? That's pretty much where I'm at now. I think if I went into the gym, bad mouthed all the trainers and said they're all idiots and are horrible at their job that you'd get extremely annoyed at them and you'd try to set them straight. Am I right? I don't usually engage with those kinds of people because ignorance is hard to cure, especially when you're unable or unwilling to admit it, but when the board keeps getting littered with this kind of dialogue, again, no one else will defend it except me, so I have to engage it.
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Post by stevil on May 8, 2019 14:25:45 GMT -5
Wait, you were the super glucose fighting powder guy, right? So never mind on the authority part. I'm just curious why you continue to bang the Endos aren't our friends and PCP's don't know how to treat PWD's drum. What has given you that impression since you're not in the healthcare field? Seyhey is quite knowledgeable about. What is going on.. many of us here are.. you don't have to be in the healthcare field to see what is going on. I don't mean to be rude, but just because you are in the healthcare field doesn't make you an authority on what is going on with Afrezza. There are many healthcare professionals that obviously don't understand Afrezza and don't want to. I've been around the block with that. Docs who do understand Afrezza are having remarkable results. What Seyhey says is true.. he isn't beating any drum anymore than you are... Sweedee, I never said one had to work in healthcare to have knowledge of Afrezza. I do think, though, that in order to tell other people how to dose it, one should be a medical provider or be intimately involved with clinical research. I wasn't trying to be condescending to sayhey. I can see why it came across that way. Message boards are horrible means of communication, especially for me- I routinely am misunderstood because I'm a very direct communicator. I simply asked sayhey what his stance is since he is always talking as though he has authority. Personally, I don't agree with much of what he says, so I was wondering if I was in error or if he was. Since I remembered he was the glucose super powder guy, it's clear he has no experience in healthcare, so I will continue to trust my opinion over his. And yes, when it comes to the judgement of people's character, experience is required. I would imagine I have had far more encounters with medical providers than a great majority of people on this board since I have basically been living daily in hospitals and clinics for the greater part of 2 years and even a little exposure before that. So to make the claim that an entire profession of people is malicious and self-serving absolutely needs to be justified with evidence if it is to be taken seriously. Ultimately, that evidence will probably have to come in the form of personal testimony, since other evidence will be hard to find. The issue with this board is it is full of disgruntled investors who didn't understand before they placed their bets how difficult it would be for Afrezza to break into the market. This unfairly puts prescribers unfairly in the crosshairs of their frustration. I'm here to call those people out and tell them they're wrong and are unfairly judging doctors. I have heard numerous horror stories of doctors prescribing FDA approved medications, even according to the label, and have been sued (and lost) because of deleterious side effects. Money aside, doctors do have hearts (despite public opinion on here) and don't want to bring harm to their patients. To them, the devil they know (current insulin therapy) is safer than the one they don't (Afrezza), so they continue to go with the devil they know until they are given a reason not to. Mannkind hasn't given them a reason not to yet. They haven't shown them that the theoretical risk (in their mind) outweighs the benefit of current insulin therapy. That is how a doctor thinks- does the risk outweigh the benefit. Just so I'm clear and state my own beliefs, I do think the medical community thus far has gotten it wrong on Afrezza. That doesn't mean that I think they're stupid or self-serving assholes that are afraid of losing business. I have never heard a doctor tell me they feel threatened by innovation and advances in science. At the end of the day, someone needs to critically analyze the data and AI is many, many decades away, if ever from being a legitimate threat. Going back to disagreeing but understanding why adoption has been so slow... I saw this many years ago when I joined the site but I have an even greater appreciation for it now that my time is right around the corner to have people's lives in my hands. It's not as easy as you all think. Decisions matter. Consequences are real. I fully intend to practice medicine conservatively. It's an admission of my own limitations. I don't have all the answers and I don't know everything, so I will tread lightly when I'm limited in my understanding. That's the biggest issue I have with Mannkind. They're stuck between a rock and a hard place because they need money to prove to doctors that Afrezza is safe and works, but they can't get it until they convince doctors to prescribe without this evidence. Knowing all this, I used to get criticized for trying to caution people from buying this stock, but got tarred and feathered on my way out the last time I was here. This was never going to be a quick process, and I think it's still at least a couple years out for Afrezza to really gain traction, based on the time required for CGMs to break into the market and change current perceptions on insulin therapy. So to wrap up an incredibly long post, I do take issue and will call people out when they do not know of what they speak and I will continue to defend the wonderful profession I am entering into, especially since no one else will. Doctors are not the enemies. Not all of them anyway. It's just an unfortunate situation where Mannkind is trying to reinvent the wheel when one already exists. It's not an easy sell. It takes hours of time to explain the differences and that amount of time is not easy to ask for from a physician. I sure hope that Mannkind has a huge budget for dinners because that's probably going to be their best bet for capturing the attention they need. Drive by reps aren't going to work... I have seen enough interactions to be convinced of this.
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Post by stevil on May 8, 2019 0:30:35 GMT -5
Wait, you were the super glucose fighting powder guy, right? So never mind on the authority part. I'm just curious why you continue to bang the Endos aren't our friends and PCP's don't know how to treat PWD's drum. What has given you that impression since you're not in the healthcare field?
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Post by stevil on May 7, 2019 23:07:18 GMT -5
Sports - we have been saying for a long time until significant changes are made to the SOC afrezza scripts will grow but they will grow very slowly. TV ads are not going to sell afrezza but I think the TV ads worked out better than I expected as a lot of people saw them and afrezza is no longer a total unknown. When Mike gets serious about selling afrezza he will partner to open dedicated health and wellness clinics which specialize in diabetes and leverage CGM and connected care technology and afrezza. I would expect each clinic to do a minimum of 100 scripts per week which is a lot more than our current sales staff is doing. and the clinics would be profitable. Endos are not our friend and PCPs just don't have the focus to properly treat PWDs. sayhey, I must have missed it in your posting history. What is your story? You often speak with authority and I was wondering why that is...
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Post by stevil on Apr 11, 2019 20:57:04 GMT -5
I don't know why you say here's the truth as though anything I said was factually incorrect. It may be UTHR's plan to switch 100% of Tyvaso to TreT, but that doesn't always translate over. Expecting TreT to furiously outperform Tyvaso is probably a bad assumption. My exact words were "Right now, we should expect TreT to replace Tyvaso's sales, assuming UTHR pushes hard and educates doctors. Whether it will extend far beyond that is unknown. " I'm not sure how your post made that statement incorrect. Envision a scenario where a doctor prescribes Tyvaso but finds out it's discontinued. If a UTHR rep hasn't made their rounds to that doctor's office, they're not going to switch to TreT, they'll switch it to something else. That was the point of my post. UTHR is going to have to market TreT as a though it is a new drug. I won't comment too far outside of the lines but will posit this one question- if the market size is about the same, is UTHR going to aggressively market TreT to make the same amount of money (actually less since MNKD gets their cut too) they otherwise would have already? For all intents and purposes, TreT is superior to Tyvaso. But will it be indicated for more patients? Will they do another expensive superiority trial where they compare it against other medications or just let ease of use be the main driver for prescriptions? Unless I'm missing something, the studies they're doing are comparing TreT to Tyvaso as well as completing a safety trial, not comparing it to other drugs in its class. UTHR must have seen enough potential to recoup all of these costs and more, otherwise they probably wouldn't have inked the deal. I won't sit here and play armchair quarterback. Certainly UTHR has done their homework and knows how this all plays out. Just color me a little skeptical about this blowing Tyvaso out of the water for the reasons I stated above. A lot of this is riding on how aggressively UTHR markets TreT and how much they're willing to spend to ensure its success. quote: Envision a scenario where a doctor prescribes Tyvaso but finds out it's discontinued. If a UTHR rep hasn't made their rounds to that doctor's office, they're not going to switch to TreT, they'll switch it to something else. Reply: A pulmonary hypertension specialist is a physician who has been specially trained in PH by a pulmonary hypertension specialist at a pulmonary hypertension center. Most PH specialists are pulmonologists or cardiologists.IT IS THEIR JOB/Job Description TO KNOW. Specialist groups should have some in the group looking at the new drugs. We saw how badly that marketing strategy worked with Afrezza. Why repeat it with Treat? The manufacturer should promote and market their drugs, not rely on a doctor to do research to find it. Doctors have incredible time demands, which is why it's so hard for reps to get in front of them in the first place. I'm not saying UTHR won't do the job, just that they're going to have to spend more money to potentially capture the same market share. I'm curious to see how that goes and how committed they are to it.
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Post by stevil on Apr 8, 2019 17:15:25 GMT -5
Here's the truth... And the CEO of UTHR has stated that if TreT is approved they will move ~100% of patients to that platform. I don't know why you say here's the truth as though anything I said was factually incorrect. It may be UTHR's plan to switch 100% of Tyvaso to TreT, but that doesn't always translate over. Expecting TreT to furiously outperform Tyvaso is probably a bad assumption. My exact words were "Right now, we should expect TreT to replace Tyvaso's sales, assuming UTHR pushes hard and educates doctors. Whether it will extend far beyond that is unknown. " I'm not sure how your post made that statement incorrect. Envision a scenario where a doctor prescribes Tyvaso but finds out it's discontinued. If a UTHR rep hasn't made their rounds to that doctor's office, they're not going to switch to TreT, they'll switch it to something else. That was the point of my post. UTHR is going to have to market TreT as a though it is a new drug. I won't comment too far outside of the lines but will posit this one question- if the market size is about the same, is UTHR going to aggressively market TreT to make the same amount of money (actually less since MNKD gets their cut too) they otherwise would have already? For all intents and purposes, TreT is superior to Tyvaso. But will it be indicated for more patients? Will they do another expensive superiority trial where they compare it against other medications or just let ease of use be the main driver for prescriptions? Unless I'm missing something, the studies they're doing are comparing TreT to Tyvaso as well as completing a safety trial, not comparing it to other drugs in its class. UTHR must have seen enough potential to recoup all of these costs and more, otherwise they probably wouldn't have inked the deal. I won't sit here and play armchair quarterback. Certainly UTHR has done their homework and knows how this all plays out. Just color me a little skeptical about this blowing Tyvaso out of the water for the reasons I stated above. A lot of this is riding on how aggressively UTHR markets TreT and how much they're willing to spend to ensure its success.
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