Saving pennies, left and right (Kilala.nl (Cailin Coilleach)) by Cailin Coilleach

Q3 and Q4 of 2008 will see some hectic changes in our private and professional lives. We'll have our first child, Marli will possibly quit her job and I'll be geting a new job with a whole new set of responsibilities. While my new job brings a big fat paycheck (meaning "money++") the new baby and the possible loss of Marli's income will definitely mean "money--". I'm fairly sure that my increased income will be able to cover the loss of additional income and the drain formed by the baby. However, to be safe I'm scrounging left and right to make sure of it.

I just cancelled my subscription to GamesTM, which I've had for a few years. On a yearly basis it's not a big expense, but I haven't paid real attention to the mag for quite a while now anyway. At least not as much attention as I used to pay

I also called Ziggo, our ISP+Telco+Cable company, in order to consolidate our products. We currently use their Z1 TV, Z1 Phone and Z1 Internet packages, plus the extended DTV package. By rolling the three Z1 packages into their all-in-one package (and taking the 800 kbps hit in bandwidth) we'll save about ten bucks a month.

Other things we're looking at for savings are our weekly groceries (which we ought to be able to keep at sixty bucks a week once the baby's here) and our monthly utilities bill.

The one thing we can't save on and that forms a steady drain on our money are taxes and Marli's college loan. They're rather annoying insofar that we don't see the direct benefits of them, but we're still paying them :) Ah well...

Posted in: expensive , life , money , saving , scrounging

Price quotes (Punkadyne Labs (Punkwalrus))

I hate it when a vendor won't tell me a price on a web page, and says, "Call for a price quote." To me, that means, "We are ashamed how much we charge and know how expensive we are, so we hope to convince you otherwise with a lot of pushy salespeople." Can you at least give me a ballpark figure? No? You lose.

Now, I know that getting a price quote on a complex thing like, say, a server farm for a web front end and a database back end would not be easy to quote until you spoke with someone on what exactly your needs were. But if you're selling a network scanner appliance, or a firewall, or some other single purpose, single unit device, I don't want to speak to a salesperson. I am gathering price quotes and getting some ballpark figures on a commercial appliance versus something we build here. You have two models, you much have two prices. No, don't sell me on this "value" bullshit, I *trained* people to do that *only* when the unit could not sell itself and we were ashamed of the price.

I have been shocked at prices sometimes. HOW much for that device? $175,000 for mail server software??? Dude! Come on, I could buy several packages of Exchange Professional or infinite Open Source stuff and put it on the highest end commercial server HP sells for that price. "Appliances" are even worse. Most are just jacked up computers in a fancy box, like less than $2000 for parts. And those don't even include license and service fees.

I find the more expensive the item is, the harder it is to get an actual price right away. Posted in: money , work

Yay tax returns! (Kilala.nl (Cailin Coilleach)) by Cailin Coilleach

Between our mortgage, my tuition and books in college and my 20% pay cut, things are looking rather good for us. After shuffling things around a little bit we got a E 1900 tax return! o_O

Now -that- will help us fill us the savings account again! That, and it'll partially pay for next year's tuition of course. And with Marli's paycheck thrown in, we might even be able to afford a few days off, somewhere nice :)

Posted in: hooray , money , tax returns

I had no idea MS was in the imaging game (OnThePharm (Hanser)) by RJS

News to me. I'm kind of surprised that they don't have smaller products for private practices.

Come join a team of experts to design, build and ship the first version of a product that will change the world of medical imaging! We are a startup group with the goal of bringing cutting edge technology to the market in order to change the way medical image storage, distribution and interpretation happens. Our product will leverage Amalga* platform, creating a system that will enable physicians with completely new access to diagnostic images and other patient information. We have Medical imaging industry experts at the core of our team and are looking for additional expertise.

Job Description

We are looking for an expert software developer to join a team of highly experienced senior software engineers to build a solution that can seamlessly connect imaging systems from multiple departments and provide interactive visualization of up-to multi-GB datasets to physicians whether they are in the hospital or at home. You will work closely with domain experts in DICOM, imaging IT, Volume Rendering, large dataset handling and advanced image processing and you will be a key contributor to guide technology selection and strategy to solve data processing and distribution problems that have yet to be solved. You will work and collaborate with our distributed team across the globe (core team in Redmond, part of the team in D.C., supporting development team in Beijing, China and research team in Cambridge, UK).

The Health Solutions Group is the same group at MS that's responsible for their HealthVault product as well as the Amalga family.

Posted in: money

Gardasil: DTC advertising via your college bookstore (OnThePharm (Hanser)) by RJS

Merck is advertising Gardasil directly to college students that utilize Barnes and Noble's bkstore.com. For those unfamiliar, bkstore.com has a plugin structure where students log on to their college's bookstore, choose their class number (e.g. PHRM 328), and their books are loaded up, and you can either pick them up or have them shipped to you. No going to stand in lines or trying to figure out what books you need. One click shopping at it's most convenient.

So these are college bookstores inadvertently advertising prescription drugs to the entire college population. Well, more accurately, to the population that chooses to have their books shipped to their home, anyway. I don't know if the bundles that can be picked up have similar advertising info.

Merck's going about it in a strange way, though. They're sticking the prescribing information into these boxes. No fancy brochures, just the PI packet, which I find rather bizarre.

I can't say it doesn't make sense, or that it's a terrible idea — I think it's better than advertising Ambien on television — but it does make me wonder what's next… Cephalon advertising Provigil to high school and college kids? Med students? Pharmacy students?

Hey, why not?

(No discounts for having advertising in your box of books, either. )

Posted in: advertising , drugs , gardasil , marketing , money

Death and Taxes (and upgrades) (Eighty1 (Thallium)) by eighty1

I’ve had my current gaming rig for over two years now and it has served me very well in that time. Just about every game I’ve thrown at it has run quite well and the original pair of 7800GTs did their job admirably. I recently upgraded to a single 8800GT and that gave the old girl quite a bit of an extension, but the AMD 4400+ processor and DDR-3200 RAM subsystem are really starting to show their age. So I’ve decided that if I get a decent tax refund, a good chunk of that will go towards building a new beast. The best part about it is I only need a motherboard, processor and RAM; I’m going to keep the 8800GT, case, PSU and Raptor 150 (ditching my old 36GB Raptor during the upgrade) so the entire upgrade won’t technically cost too much. I am willing to spend up to $1000 though, but unless I get something like a Core 2 Extreme, I don’t foresee the price being that high. If the damned thing is even available, I’ll get the E8500; however, by the time I decide to upgrade the Q8500 might be around (and that would be just damned awesome: a 45nm quad-core successor to the Q6600!). I don’t think I’ll go to DDR3, mostly for price and latency concerns.

Speaking of taxes… I’m going to see Geri today. Mitch got a decent refund and I hope I get something back; I’m a little bit fetishistic about taxes. There’s something akin to gambling when you start running the numbers to see if you win (yay refund) or lose (boo payments). Of course, the spectre of an audit is always lurking but I don’t do anything illegal. Hopefully I get a decent sum back so I can at least buy some more pants and shirts. My favorite jeans have a hole in the left knee that just keeps getting bigger. If I’m not careful, I will inadvertantly end-up with Daisy Dukes, and that would be frightening.

Posted in: intel , money , news & such , oh god my eyes , ram , taxes , tech , upgrade

Drug advice from Consumers' Reports (OnThePharm (Hanser)) by RJS

This is going to be quick and dirty because I've got some other things to do, but I've been putting it off far longer than I've meant to. (No time like the present, right?) In the January 2008 issue, CR ran a feature on how people could save money on prescriptions meds. Generally speaking, I am in favor of this kind of thing. I like people to know the alternatives, and how they can save money.

Generally-speaking, it's not a good idea to have word-choice errors in a piece that's supposed to be professional. (See image.) Maybe they should get a medically-trained copy editor and add them to the list of peer-reviewers. Ridiculous.

I've re-created the table they have:

 

I'll go through it quickly:

Zyrtec is now available OTC, and is comparable to the cost of Claritin. Claritin doesn't work for a goodly number of folks, so Zyrtec is a better option. Zyrtec went OTC the month after this was published — and it wasn't a big secret that it was going to happen.

For ADHD, Strattera is not a popular option. It doesn't work for many people, and ADHD people have a hard time remembering to take their meds consistently, which makes this option less desirable, particularly where it takes a little while for Strattera to begin working. I'm surprised this drug was listed at all, as it's rarely a first-line choice for ADHD spectrum disorders. Even comparing atomoxetine (an NRI) to methylphenidate (a stimulant) is a bit… off, and IMO, does the consumer no favors. Strattera is usually used where someone is at risk for drug abuse or has comorbidities like hypertension or anxiety (iatrogenic or otherwise) and so cannot tolerate stimulants.

Depression… don't have much to say there. Fluoxetine tends to be more stimulating than Lexapro, and there are other subtle differences (half-life, solubility, etc.), but for most people, switching from one to the other is probably not impossible.

As for Diabetes… well. Using a biguanide is usually the first step in treating metabolic syndrome, and then you add other meds on top of that. I'd be skeptical of any doctor who used Actos before using metformin without a given reason. Diabetes treatment tends to go in stepwise fashion like most other chronic illnesses. Removing a TZD from a pre-existing diabetic regimen can be done, but it's not as simple (or desirable) as this little blurb makes it seem. And a TZD isn't normally used as monotherapy. Frankly, I think suggesting Glucotrol rather than metformin would have made more therapeutic sense. And in terms of good use of space, I think think they would have been better going after the ARBs and hypertension in general here.

Heartburn and GERD? Nexium 20mg? Who even uses the 20mg strength Nexium? I see it maybe 3 times a year. They should have done 40mg Nexium and suggested 40mg of Prilosec. (Hilarious sidenote: 40mg Prilosec caps (the one without a generic) cost ~$60 more than 40mg Nexium caps.) Generally, though, this one wasn't too bad.

Insomnia: Eh, probably okay I guess. Insomnia is a poorly-treated condition in this country, and frankly, I'd rather see other methods explored before reaching for the BZRAs at all. But the BZRAs are the easiest, and they keep patients happy. Unfortunately, not enough time is spent diagnosing the underlying causes of insomnia, resulting in a poorly quality of life. There are differences in the polysomnograms of patients on eszopiclone and zolpidem, too, which are not talked about. I'd rather see ramelteon tried before any BZRA, and also see a psychologist about diagnosing an underlying cause for the insomnia in the first place, if a primary care provider cannot take the time (due to financial considerations) to do it themselves. And 5mg of Ambien might help with sleep induction, but the relatively short half-life will do next to nothing for those with sleep maintenance problems.

I'd rather have seen trazodone suggested, since insomnia is usually secondary to some kind of other psychiatric disturbance — a type of uni- or bipolar depression.

Not much to say about arthritis, but I hardly ever see Celebrex used anymore. Now that it stands alone as a COX-2 inhibitor, it's also the most expensive anti-inflammatory in the book and insurers are loathe to use it. I'd rather see diclofenac recommended over ibuprofen, and suggesting that 400mg of ibuprofen daily is anywhere near equivalent to 200mg of celecoxib is laughable.

Schizophrenia. SCHIZO-FREAKIN-PHRENIA? CR is going to tackle SCHIZOPHRENIA in an article about how to save money?!?! I am having difficulty wrapping my brain around that one.

But okay, here goes. Schizophreniform disorders should be managed by a psychiatrist or psychiatric NP, IMNSHO. Diagnosis is tricky, and management is always tricky. All that said… while first generation antipsychotics are often as effective as their second gen counterparts, I am extremely leery of merely saying that Y could be substituted for X. At least CR has the good grace to state "The antipsychotics have major side effects and response to them is highly variable" — AKA "Take our advice with a monster grain of salt." Not the least of the worries are akathisia, tardive dyskinesia, other extrapyramidal symptoms, weight gain, and about a bazillion other possible side effects. My mind is still boggled that they even went there.

Curiously, however, discontinuation rates of perphenazine in schizophrenic patients are lower than with any second gen antipsychotic save olanzapine (Zyprexa) — though people tended to d/c Zyprexa due to its metabolic effects and weight gain, and perphenazine for its extrapyramidal symptoms. Something to consider, I suppose.

–

All things considered, it's nice to see the mainstream media promoting saving money on drugs, but it bugs me that they did it in the way that they did.

Posted in: drug pricing , money , therapeutics

Oops (OnThePharm (Hanser)) by RJS

Absolutely perfect timing with Dr Dino's Oops Meter.

Got a phonecall from an FP's office across the street from the pharmacy. Medicaid patient had brought in his Risperdal Consta injection for his bi-weekly shot. The nurse dropped the injection in the office, which broke it, resulting in some non-emergent, but non-trivial lacerations to herself in the process.

Could we get another one? Of course, it's 4pm on a Friday, and MassHealth doesn't do lost/damaged precription overrides — if they did, their budget would probably double (TAP doesn't make this shit up, you know) — but could we pleeeeeeease try. And they would, of course, call MassHealth themselves.

Risperdal Consta is about $650 per dose.

Of course the answer was no, but with both of us on the phone, MassHealth said they could do it tomorrow (that would be today, I guess) as a once-in-a-lifetime early-fill don't-ever-ask-again override.

I'm so glad it worked out, and I feel terrible for this nurse. She's probably wishing she had dropped some cyanocobalamin instead. We'd have just given it to them for nothing had it been something like that.

Based on Dino's examples on the oops meter, I'd give this a solid 8. Right next to breaking wind in front of your boss. On the elevator.

Posted in: culture , money

This pharmacist is a model for how other people should win the lottery (OnThePharm (Hanser)) by RJS

Seriously:

Sporting large sunglasses, the winner, a pharmacist, came forward, but she refused to provide her name or where she lived. An occasional player, she bought the winning ticket at a gas station at 851 S. Sutton Rd. in Streamwood.

The first step wasn't to get the money. A family member referred them to Wood Dale attorney Terry Zimmer, who assembled an advisory team, including estate planner Richard Kuenster.

"I told her get an unlisted number A.S.A.P.," Kuenster said.

The team helped the family create the JYS Family Limited Partnership and put together entities to keep the winner's identity from the public, and shield the money from some taxes, creditors and frivolous lawsuits while providing for her, her husband, children and any future grandchildren, Kuenster said.

"We're so proud of them for taking that time," said acting Illinois Lottery Superintendent Jodie Winnett. "What a sharp winner we have in Illinois and we hope that the rest of our community will hear this and that they'll take a deep breath and consider protecting themselves."

I think everyone has thought about what they'd do if they won the lottery. Most of the thought cycles probably spent on how they'd spend the money, rather than on how they'd protect themselves. I've given the collection, protection, and diversification of a large sum of money some thought in the past when Powerball has gotten up into the hundreds of millions. (It's fun to dream isn't it?) The lawyer and financial advisor seemed no-brainers to me, but an estate planner didn't occur to me. Naturally, doing everything in my power to remain anonymous is also right up there, but the third-party organization as a shield was a new one, but a smart one given her profession.

Good on her.

(The press conference is required.)

–

Anecdotally, we have a past lottery winner that comes to our store, and like this pharmacist, she is very discreet, and has managed to not blow all of her winnings in spectacular fashion. Smart people do, in fact, win the lottery sometimes.

Posted in: culture , money

Damn, I am tired. (Punkadyne Labs (Punkwalrus))

Two hours of fitful sleep started off my day. I got most of the bills done by 4am, and I have a few more to go. Then I have to balance the checkbook. Oy.

Actually, I was decided to go to bed at around 3am, but I was having a kind of mild anxiety attack over bills (even though nothing is actually worse than it's been since on average since 2000... it's weird) and didn't get to sleep until maybe around 4. I even took a shower to calm down.

I got up at 6am, like normal, and since I had only taken a shower two hours earlier, I didn't need to take one again. And I was actually awake and alert for most of the early morning like I had gotten my usual 6 hours of sleep. I wasn't tired until about 9:30, and then it hit me all at once. I drank some coffee, but my stomach had shut down again, and so coffee just sat in my stomach fermenting.

But thanks to many shifts with FanTek security back in the day, I remembered that when coffee doesn't work, try lots and lots of water (thanks Tad). At the very least, you will have to stay active to drink the water and run to the bathroom all the time to pee, but it somehow will wake you up eventually... or at least stabilize those blahs one gets when one only has a few hours of sleep. And the water is effectively neutralizing that acidic coffee.

Still... I am going to bed early tonight for sure. Posted in: bills , financies , money , sleep

No homework this week (Kilala.nl (Cailin Coilleach)) by Cailin Coilleach

Well damn. Between work, nightly work, filing my taxes and sorting out our temporary (yet rather large) monetary problems, I haven't done one single page of homework this week. :(

I'm gonna have to haul ass this weekend.

Don't worry about those money problems though: with a bit of help from my dad we'll be able to get through to Marli's first paycheck. After that, it's clear sailing. I'm just happy dad's able to help us ^_^;

Posted in: college , damn , homework , money , work

Today was awful (Kilala.nl (Cailin Coilleach)) by Cailin Coilleach

Well, today sucked.

Today was the culmination of all the bitchiness from the past week, all the anger and frustration and all the confusion. The monetary issues don't help either, making me feel quite guilty about my trip to Japan.

In the long run, we'll be okay. Especially if one of the things we're hoping on works out. However, it won't be a smooth ride.

To be honest: my bad mood even got me doubting about school today! What if all I wanted back in June was to enjoy my spare time? What if that blowout wasn't a sign that I wanted to switch jobs, but that I wanted to have fun and play games? Because right now, I'm in a position where I can play even -less- games!

We've chalked that up to my current mood though. Whatever happens, I'm going to at least finish this year properly. During summer break I'll be able to relax and get my bearings again.

Also: the fact that all of our checking accounts are maxed out landed me in some hot water today. I'd gone to the office by car and had been unable to find the free parking spaces, so I had to park for the extortionate amount of twenty euros! At the time I didn't know that I was maxed out, so I was in for a nasty surprise in the afternoon! ;_; I had to scrounge for loans among my colleagues who, cool as they are, did loan me the required bucks. That was quite embarrassing, having to fess up my brokeness to semi-strangers. :/

Luckily, I'm feeling a bit better now, all thanks to Marli. We were both feeling horrible, but we talked a lot and we're not as bad anymore.

I'd like to apologise to my colleagues though, for leaving the office so early. :(

Posted in: awful , crap , depression , fight , money

How much does Nexium cost someone on Medicare Part D? (OnThePharm (Hanser)) by RJS

One of my people — we'll call her Jane — takes two drugs. A generic SSRI, and Nexium. While sorting through the options available to her, and running two scenarios, I discovered just how much Nexium costs her per year. More specifically, how much money she will save by switching from 40mg of Nexium to 2×20mg omeprazole capsules.

$594 per year.

I asked Jane if she'd ever taken anything before the Nexium, because it looked to me like she started it in early 2006, and she told me that she hadn't. The doctor had given her samples, and then a prescription, and she'd been taking it ever since.

Here's the thing: Nexium isn't better than Prilosec. Yes, we all know it's the isolated, active enantiomer of omeprazole, and its time to acid drop is a bit better, and "studies" (paid for by AstraZeneca) have shown that Nexium beats Prilosec in squashing acid production.

Except that it doesn't, because if you look at the fine print, you'll see that those glossy, purty brochures that the big-titted drug reps bring you compare 40mg Nexium to 20mg Prilosec. In fact, when AZ did studies comparing 40mg to 40mg, they discovered that the difference was inconsequential, so they didn't include those results in their marketing materials. (My source for this is a former sales manager for AZ who used to have Nexium as a drug, and then went on to be a regional drug rep manager. He's with Forest now.)

Pretty slick. And underhanded.

Oh, and time to acid drop isn't a particularly important metric, by the way, because PPIs are maintenance meds, not Tums. And Nexium was only something like 2% better than Prilosec for the 8% of the study participants that even showed a difference. Whoopty-do. Clinically significant? Not especially.

Back to saving money. By changing from Nexium to Prilosec, Jane is able to pick a different Part D plan that has a lower premium, not to mention that when she comes to the pharmacy, her copayment will be lower, too. So Jane will be switching. And she could probably eke out a few more dollars in savings if she tried just 20mg omeprazole daily, but I thought I'd be generous by allowing for a non-standard dose in my calculations so her doctor would feel better about switching.

There is a tiny, tiny percentage of people — less than 1 in 100 — that do not respond to omeprazole that do respond to esomeprazole. No one knows why this is, and simply changing from one to the other results in marked improvement. That is no excuse for reaching right for the Nexium over the omeprazole, because sometimes the reverse is true: omeprazole works when esomeprazole does not. Sometimes neither of them work and you need to pick a different drug altogether. This phenomenon is true across all drug classes, and is another reason that having an inflexible, national formulary is a BAD idea.

[tags]healthcare, inefficiency[/tags]

Posted in: money , therapeutics

Keep up if you can, Jay Parkinson (OnThePharm (Hanser)) by RJS

Jay Parkinson has a nifty section of his blog where he details the money he has saved his patients. The timeframe spans one month (October). His total is $9,672. Pretty nice; I'll be watching to see what else you do.

I can speak for pharmacists, technicians, and patients when I say that its really, really nice to see a doctor doing the research to find out how much drugs actually cost. I see so much healthcare inefficiency on a daily basis just as it relates to drug therapy, it makes me want to start knocking heads together. Prescribers going right for the Nexium or Prevacid without EVER trying omeprazole; Lipitor when simvastatin is just as effective and has never been tried; Lescol XL, when pravastatin has never been tried; Avodart when finasteride has never been tried. Right for the ARB when an ACEi has never been tried.

Look, I don't give a fuck what your pet drug is. I don't give a damn what the drug rep shoves under your nose on a weekly basis. I don't care that you're unaware of the top-of-mind marketing that's being used on you without your knowledge or consent.

If it's going to cost an elderly person on a fixed income an extra $594/year because you "like it better", you need an ass-kicking.

And so on. I'm all for moving from one drug to another if a less expensive drug has been tried and has failed. That makes sense. But the absolute waste of money because less expensive alternatives have never been tried boggles my mind. I can truly understand why prior authorizations were invented, even if I curse them daily for wasting minutes of my precious time.

Back to the topic at hand: this time of year, people make appointments to see me, where we sit down(!), chat, review medications, and then we talk about what can be done for 2008. Most people that see me are happy with their drug therapy, except for one thing: it costs too much. The goal of their visit is to reduce the cost of their drug therapy for 2008, every single time. Without fail.

I have seen 7 people across two days. (An average appointment lasts about 45 minutes.) In that time, I have saved patients $11,831. That's an average inefficiency of ~$1700 per person. And these are people with drug coverage. The single highest total for one person was ~$3600/year.

In the next couple of days, I'll try to share some scenarios so you can see how much just one simple switch can save an average person.

Keep up the good work, Jay. Seriously. Pharmacists, technicians, and patients everywhere applaud your good sense and efforts.

[tags]healthcare, inefficiency[/tags]

Posted in: money , therapeutics

How-To: Find the best Medicare Part D prescription drug plan (OnThePharm (Hanser)) by RJS

So we’re in the open enrollment period for Medicare Part D. It started on November 15, and it ends on December 31. I’ve been doing consulting twice a week, and the scramble is in full effect. While I do quite a bit more than plunk in drugs and quantities for my consulting, there is one tool that is the backbone of what I do when running various scenarios. It’s the Medicare.gov plan finder.

This guide does not apply if you have a hybrid medicaid-medicare plan through your state. Those folks know who they are, and if you have no idea what I’m talking about, you don’t need to worry about it.

Before you begin you’ll need three things:

1. A complete drug list of the person you’re doing the research for. This means you’ll need drug names, strengths, and quantities. Calculations are done for a 30-day supply, so if you take something 3 times a day, the quantity for 30 days will be 90.
2. About five minutes
3. An Internet connection (har har)

Here’s a walk-through, so you’ll want to open the link in a new window or tab…

Click on “Find & Compare Plans” which brings you to this:

Click “Begin Personalized Search” which will bring you to this next screen. You will want to click where it says “click here.” Do NOT click the Continue button. This might trigger a browser prompt asking you if you want to continue sending this information over an unsecured connection. You’re not actually sending any information about yourself, so click Continue.

That brings you to this page:

You’ll want to mimic what I’ve done: put in the zip code of the person who you’re doing the search for, ignore the age range and health status, and then select “No” for all three of the next questions. They have no bearing on choosing the Part D plan for the average person. Click “Continue” at the bottom.

That brings you to this. Click the “Continue” button. (Top or bottom doesn’t matter.)

Get out that drug list that you put together. Click “Enter My Drugs” on this screen:

That brings you to this screen, where you can begin typing what drugs you take. I’ll fill in a couple of examples that someone might take, and run you through a couple of screens that you might run into.

So here’s my list for Bob Smith. Click “Continue” at the bottom when you are done filling in the drug names:

The next screen allows you to adjust the strength and monthly quantity. Go through the list of drugs on the left and change the strengths to reflect the drugs that you use before you start changing the quantities. Each time you select a strength other than the default, the page reloads, and you may lose any changes that you’ve made to the quantity. I learned this the hard way.

This next screenshot is the default, and the one after that reflects the changes I’ve made. Click Continue when you’re finished.

The next step is optional. You can choose a Password Date that allows you to save your drug and location information and pharmacy preferences. That means that when 2009 rolls around, you can more quickly retrieve your drug list and make changes rather than having to enter all of the information from scratch. I recommend using the person’s date of birth because it doesn’t change. I will skip this step because I’m working with a dummy profile, but it is pretty self explanatory.

If you choose to save your drug information, be sure to write down the number that medicare.gov gives you, as well as the date that you chose.

Next you can choose a pharmacy based on zip code. This doesn’t matter overmuch if you’re going to use a chain or independent pharmacy. If you’re working with a specialty pharmacy (for example, your doctor’s office has its own dispensary, or you’re a college student and use the university health office), then you may want to specify the pharmacy that you’ll be going to. Again, I’m going to skip this step since it doesn’t matter for most people.

At this point, all of the plans that cover the drugs you entered will show up. I like to display 10 on a page, but that would be a huge screenshot, so I’ll stick with 5 for demo purposes.

You can compare up to 3 plans to see an in-depth breakdown of the plan information (monthly premium, what the copays will be on various drugs and so on. Tick the checkbox for the plans you’re interested in and hit “Compare”. (On every page thus far, there has been a “Printer Friendly” link in the upper left corner. This is particularly helpful if you want to print out the plan summaries and detailed breakdowns for offline viewing and annotating. I use it regularly.)

Plans I don’t recommend

There’s one company that I would avoid right now and that is WellCare. They are the cheapest (as you can see from my screenshots), but they have been in some substantial hot water lately, thanks to some VERY shady accounting practices. Their stock recently plummetted from $130 to $27 at its lowest thanks to being raided by the FBI. They also regularly screw over their customers. Please, stay away from the them.

Enrolling

Enrolling in a plan can be done online or on the phone. Some companies, like Humana, like to send a rep to your house to sign you up. Some people love this, and some people hate it. I find it a little weird, personally. I’d rather call a phone number and do the whole process from beginning to end without having someone come into my home.

Technorati Tags: Medicare Part D, How-To, prescription drugs

Posted in: culture , medicare , money

How do you handle stepping on someone else’s toes? (OnThePharm (Hanser)) by RJS

Two recent posts of mine have dealt with bad information, and both times I’ve wondered what the accepted protocol is for addressing it. Obviously “Hey dumbass, go read some medical literature,” doesn’t cut it. I addressed one instance — the cholesterol one — quietly, after it happened. It wasn’t life-threatening misinformation, so immediate intervention didn’t seem necessary.

I didn’t bother to say anything about the antibiotic shenanigans.

The trouble with this is addressing something someone does without stepping on their toes. If I do something stupid, I’d like someone to smack me upside the head and tell me I’m wrong. Pussyfooting around the issue is for people with no self-confidence. I don’t have that problem — after all, I write on the Intarweb, and think people actually care about what I have to say, don’t I? — so just come right out and tell me I’m wrong.*

Not everyone is that resilient, however, and I’m sensitive to this.

Recently I’ve heard a pharmacist say she was going to take lots of Vitamin C and echinacea to get over a cold. I’ve seen pharmacists recommend Airborne for cold on more than one occasion. I’ve heard a pharmacist recommend a homeopathic remedy for migraine. I said nothing — these suggestions aren’t harmful, but they certainly aren’t helpful, either. In these cases, it’s just not worth the effort. Besides, Father Time and the body’s own defenses will clear these problems up on their own. (And in the case of the migraine, I suspect it was psychosomatic anyway.)

When someone says something boneheaded to a patient, how do you handle it? Especially if it’s a pharmacist colleague? I would imagine doctors and nurses run into this problem from time to time as well, even if they practice alone now.

* I’m happy to say that this hasn’t happened in a very long time, which can be viewed as either a good thing (I’m SMRT!) or a bad thing (I work with a bunch of idiots). Which one I lean towards is dependent on where and who I am working with, naturally.

Posted in: money

Genentech: an exercise in greed (OnThePharm (Hanser)) by RJS

I love the word “greed.” It’s nice and… eee-vil. Which happens to perfectly describe Genentech’s latest stunt. They’re going to try to restrict the use of Avastin so that it cannot be used for age-related wet macular degeneration — a practice that is quite common. In fact, there are several specialty pharmacies in my area that specialize in compounding Avastin for this purpose.

But wait! Genentech wants to curb this practice because Lucentis is much more expensive, despite being (basically) the same thing. Only a bit more diluted. I’ll quote from the old SFGate article:

While no rigorous studies prove Avastin’s effectiveness or safety in eye treatment, the doctors claim it can improve vision in some patients.

Now that Lucentis has been approved, Avastin may retain some share of the market because it costs a fraction of the price Genentech has set for Lucentis. That price per dose will be $1,950, company officials said Friday. Doses of Avastin are available to doctors at $50 or less from compounding pharmacies that divide up vials of the cancer drug into the much smaller amounts needed for eye treatment.

But now Genentech is going to stop providing Avastin to compounding pharmacies:

In a letter yesterday to retina specialists, Genentech said that its wholesalers would no longer provide Avastin to compounding pharmacies — companies that under sterile conditions can divide a vial of Avastin into tiny portions for use in the eye. The company said the distribution change would take effect Nov. 30.

Genentech has discovered that they are their own worst enemy. Unfortunately for them, the right course of action is to remove the compounding pharmacies as the middlemen and make an Avastin formulation specifically for ARWMD.

Genentech did not plan to compete with itself. It said it intended Lucentis specifically for use in the eye, believing that Avastin, a bigger molecule, would not work there. But while waiting for Lucentis to be approved, doctors started using Avastin and found it worked.

Instead they’ve opted for karmic seppuku for the sake of money. And this WILL bite them in the ass. It’s only a matter of time.

(Oh, and if this nonsense is allowed to stand, that’ll add $1 billion in yearly costs to Medicare. I think I speak for every US citizen that’s not employed by Genentech when I say “Go die in a fire.”)

Posted in: money

And thus it begins: Xyzal (OnThePharm (Hanser)) by RJS

The money being wasted on pointless research, that is. Xyzal (levocetirizine), is beginning to have some money spent on research proving that it’s a good drug. I have no doubt it’s a good drug. They’ve isolated the active isomer and decided to market it since the patent on Zyrtec (cetirizine) is running out.

Let’s review, SAT-style:

Zyrtec:Xyzal::Claritin:Clarinex

Expect Zyrtec to go OTC as a means of ensuring continued profitability through marketing. (More people buy brand name Tylenol than the generic — same story for Claritin.)

Here’s the bottom line: everything that Zyrtec works for, Xyzal will work for, and vice versa. Same side effects, too. And because this is so, you will never see a head-to-head study comparing Xyzal with Zyrtec, because the results will prove that it’s just a waste of money. Like Clarinex. Oh sure, there will be a few isolated cases where Xyzal is 0.5% better for 0.1% of the study population, and these studies will be trumpeted, but remember that they’re actually meaningless. You’ll also see studies that show Xyzal is effective for some obscure condition that Zyrtec was never studied for. Just remember that this is done to make Xyzal seem like something more than a me-too drug, and that if someone bothered to spend the money, Zyrtec would work just as well.

So if you like to waste your time doing PAs or you feel an insane need to throw your patients’ money away, prescribe Xyzal. Otherwise keep on using Zyrtec.

Posted in: money , therapeutic pipeline

What the GSK man asked, and what he fears (OnThePharm (Hanser)) by RJS

These were drop-shipped yesterday afternoon:

A couple of weeks ago, I was detailed by GSK. Unlike The Angry Pharmacist, I don’t hate drug reps. The GSK guy isn’t a busty blonde who brings us cannolies and only visits at lunchtime. He’s actually a genuine human being, and he’s probably old enough to be my dad.

But on his last visit, he did something that rubbed me the wrong way: he asked me to fill out these cute little forms and send them to the doctors to get them to switch to the controlled released versions of carvedilol:

Yeah okay, buddy. How about no? I like you well enough, but geeeeze. Your form is pretty, but a reversal of it would be more useful: seniors sure do like those generics that’re covered even during the donut hole…

Needless to say, I threw the stack of forms in the trash without showing anyone else. As the person who makes the most therapy recommendations, no one but me would have a use for them anyway. Even if they weren’t complete bullshit.

–

On a related note, I’m waiting for the day drug companies get a clue and make writing the original, IR version of a drug more troublesome to prescribe than the inevitable extended-release forms. Call it “Coreg IR” the first time around, and then call your extended-release, patent-protected, evergreened, overpriced bullshit version plain old “Coreg.” As though it were Coreg As It Was Meant To Be — like that marketing crap Sanofi-Aventis tried with Ambien. (Zomg, we should never have made Ambien because Ambien CR is soooooo much better. Ugh.)

That’ll work better than your fancy brochures, ridiculous therapy change forms, and formulary negotiations combined.

Technorati Tags: GSK, Coreg, carvedilol, marketing

Posted in: money

How are your potassium levels? (OnThePharm (Hanser)) by RJS

Do zey need adjusting?

Heh heh…

Posted in: money

Claritin + Singulair = ??? (OnThePharm (Hanser)) by RJS

Merck and Schering-Plough are in bed together, again. (One wonders if a merger will be the climax of their collaborations somewhere down the line?) This time it’s their new combination of loratadine (Claritin) and montelukast (Singulair) which was accepted for review by the FDA on August 28. In my opinion, it’s only a matter of time before the two companies are given the green light to start selling it.

This combo is not unlike their Vytorin arrangement, which is actually a pretty decent combination both therapeutically and financially: Vytorin is no more expensive than Zetia by itself, which makes it a good deal for consumers and insurers alike. (And there’s also the more mundane fact that there’s one less pill to take, and the fact that ezetimibe is of questionable value when prescribed alone.)

Because Claritin is now OTC, it is simultaneously more and less valuable to Schering-Plough. Less valuable because you can’t charge as much for it as you could when it was Rx-only because no one would buy it — and more valuable because you’ve got a potential market limited only by the number of people in the United States. I know I recommend (generic) Claritin pretty regularly. It works well for most people, myself included.

If the pricing is done following in the footsteps of Vytorin — which I suspect it will be — it’ll be a nice little niche drug for the two companies, and it’ll save consumers money, if not insurers. I don’t ever see it being a blockbuster like Vytorin, for obvious reasons.

The inobvious

One thing struck me about this deal after some thought, and it’s the new reciprocity between the two companies: Vytorin is inherently more valuable to Schering-Plough because their drug ezetimibe (Zetia) is still protected by patent, whereas Merck’s contribution — simvastatin — is not. With this new drug, the roles will be reversed. I don’t know what this means in terms of dollars and cents, but Merck’s got to be breathing a bit easier now that they’re on more equal footing with their partner.

Technorati Tags: Merck, Schering-Plough, Claritin, Singulair

Posted in: money , therapeutic pipeline

What goes up, must come down (Kilala.nl (Cailin Coilleach)) by Cailin Coilleach

Isn't it funny how you can go from +2100 euros to -70 euros in half an hour?

There was a big stack of bills waiting to be paid this month, including two "overdue"s. It's a weight off my shoulders each month to get rid of them, but I won't say I'm happy to see the money go ;)

Ah well! Such is life!

/me trots off, whistling Grand Prix no taka.

Posted in: bank account , down , money , up

More honesty tests (Punkadyne Labs (Punkwalrus))

So, you recall my entry about returning that wallet, right? That's not the only time I have run into this in the last week.

While walking around Lake Forest Mall with tth, I went to get some money from the ATM. The screen said, "If you'd like to cancel your withdraw, please press cancel." A few seconds later, a Visa card popped out. We returned it to the info desk.

On Saturday, at Starbucks, I saw a $50 bill on the floor. I asked a woman it was next to was that hers. She looked down, and gasped. "Yes! Oh my God, thank you!"

At work, I found a fold of $20s in a money clip. Well, the top bill was a $20, I don't know about the rest. It belonged to an employee who lost it when he got to work, and had spent the first hour of his shift looking for it in the parking lot. He was very happy.

On the Metro, a woman reached into her backpack while on the cell phone. A small roll of dollar bills fell out, and she didn't know. I handed it back to her, and she seemed shocked and hesitant; it took me three tries to convince her it was hers. She finally looked in her back pack, and realized the crazy dude on the subway wasn't trying to buy drugs off her.

These events so rarely happen to me. Now a bunch in a row. I have this fear that instead of being tested for my honesty, God is smacking his forehead going, "I am trying to help you out financially, you nimrod! DANG!" Posted in: fate , honesty , money

Three hours of sleep and stupid is no way to go through life, son. (Punkadyne Labs (Punkwalrus))

I was up until 3am doing bills. I hate bills. Luckily, American Express may be able to help me out with a consolidation at 5.99% fixed while the high credit card is 18.9%. I am going to have to ditch that card; 7 years ago it was only 11.9%.

Here's an odd one: Wachovia, which has our equity loan we used to replace the damaged deck, did not send me statements for two months. So I called them. "We didn't get your payment for July, so when that happens, we don't send you any new statements after one is missed. You are now two payments behind." I am two payments behind? "If you don't send a payment that was due August 16th..." Was due? Don't you mean "will be due?" Silence. "Sorry sir, we made a mistake, we will wave the late fee." Uh... wh... you know what? Never mind. How about I send you what I think I owe you? Like July's payment and this month's? "Okay, sure... [pause two three four...] wait, what?"

Hire the stoned: they are fun to converse with. Posted in: bills , credit cards , finances , loan , money , stoners , wachovia

Helping the out-of-towners (Punkadyne Labs (Punkwalrus))

I have a pondering: suppose you had a fairly wealthy relative who is also charitable.

Let's say his own brother is married and has a family of three kids, all of whom live in a 3-bedroom trailer in a depressed town. His brother is not well off, in fact, he's been out of work for about ten years due to an accident on the job. He gets some government support, but barely enough to live on. His wife works very hard at the local supermarket, but is working under deplorable conditions and making very little money. They can't afford to move, two of the kids have chronic health problems, and they went last Christmas without electricity because it got shut off.

On the other hand, there is a family in your relative's town who also does not have it so good. A single mom with 4 kids on welfare. There are two fathers of the kids, one in jail, and the other dead in a drug shooting. She is living with her boyfriend, who has been treated for drug addiction, and is violently abusive. Social services has gotten involved more than once. It's obvious, without passing judgement, that the family is highly unstable. One of the older kids has already been arrested for bringing a weapon on school property.

Your relative decides to give the 4 kids in the local town full college scholarships instead of his own nieces and nephews. Assume for this example, that he does not dislike his brother, but explains that his brother's kids have it better off socially than these other kids. Whereas his brother could get all kinds of assistance, grants, and whatnot, nobody will stick up for the other kids, so he decides to do so. It's his money.

How would you feel about this decision?

I ask because I often wonder about so much money going to aid in unstable foreign countries while we have so much poverty here at home. I have no presumed answer to this. Posted in: assistance , money , poverty , wealth

Maria picked up her wallet (Punkadyne Labs (Punkwalrus))

Hooray.

A few hours after that post, I got a call from some guy who sounded like he was 900 years old and in a Barcalounger. "I got sum bank call me. I heard you found mah wife's wallet?"

Yissir. So you're the husband of Maria?

A sound like the combination of a gasp and cough ended like it said, "Ayuh."

All kinds of thoughts ran through my head. Old white dude. Young Philippine wife. Stereotypes. Okay. Maybe people accuse my Uncle of the same thing, I shouldn't be so judgmental. Uncle Chuck met Aunt Angela in Taiwan in 1970 while my Uncle was doing Uncle Sam Vietnam Tour. So, maybe Mr. H was touring the Philippines and met this... man, that girl must have been 40 years his junior from the sound of that voice. Anyway, he sends his wife to come pick it up. They live right around the block in the same neighborhood, which I gathered because we found it on the local footpath on the way to the shopping center.

I met the woman, who seemed cute. Probably only in her 30s. Typical Mestizo frame: short, plump, round, and small. She was wearing casual yet professional clothing. Matched the picture on the photos. She called my cell phone twice, but I was unable to pick up because I was on the phone with work. But I saw the car out front, and so when I hung up, I walked outside with the wallet. I saw her dial her cell phone, and my phone rang. I knocked on her window.

I must have scared that poor woman to death. She at first seemed really scared of me and very mousy, but after a few sentences, she warmed up and thanked me. "I just came back from the Philippines," she said with a perfect grasp of American English with only the hint of an accent. "My sister just died, and my husband let me go and take care of things."

There was a lot of thanking and then she got back in her immaculate mid-90s car, and drove away.

I did my deed for the day. Posted in: money , wallet

Personal effects (Punkadyne Labs (Punkwalrus))

They say that Stockholm is one of the top four cities in the world where if you lose your wallet or mobile phone, you're the most likely to get it back. Being sorta Swedish, I take pride in that.

Next to my bed is the wallet of a Maria H. It's a small billfold with a cutout heart. Inside are a secured credit card, a debit card, two medical lab cards, a BJ's membership, $72 in cash, a photo, a small calendar, and 860 Philippine "Pisos" (which is like $18 USD). I think the photo is of Maria, or someone who looks a lot like her, based on the photo on her BJ's membership. It looks like a passport pose, although it's on regular photo paper. No other ID.

We found it on the way back from CR's senior photo shoot. It was on the ground, and surrounded by the US cash. I think we got it all.

I wasn't sure what to do, so I called her debit card, which is the same bank as my bank. I was on hold for 35 minutes in the "lost and stolen" queue. Luckily, when someone answered, it wasn't LaTisha the open mouthed sassy gum chewer like I usually get, but some nice lady who had a clear voice and a slight southern accent. She canceled the card, which I debated on calling the bank because of that but had to do something, and I left her my cell number so when they call Maria, they can give her my number so we can arrange a pickup.

I feel good about this. Maybe that's arrogant, but I would be FREAKED if I lost my wallet, and would pray and pray someone honest found it and gave it back, haunted by despair that people are dishonest and would steal my identity. Posted in: honesty , money , sweden , wallet

Gahvbm errrr djjmmmmfff...zzzzz ...zzzzz (Punkadyne Labs (Punkwalrus))

By Caffeine alone I set my mind in motion, by the beans of Java the thoughts acquire speed, the hands acquire shaking, the shaking is a warning. By Caffeine alone I set my mind in motion.

Jesus Christ, I am exhausted. I am running on maybe 90 minutes of sleep. The reasons behind this are basically my finances, as skimmed before in a previous entry, behind. Part of my problem stemmed from the fact I sent out some checks that were sent back because the postage rates changed and the post office returned a few bills as "postage due" for a whopping 2 cents. I have some of my bills paid online automatically, but not all of them have this feature, or they want unfettered access to my checking account and automatically withdrawing at their whim, which I find very risky at best. I had a friend who got reamed by Vepco, for instance, when a slip of a decimal point made his $83.20 bill drain his bank account with an $832.00 charge (this was later fixed, but he bounced a lot of checks that month). But the end result for me is late fees upon late fees. And the IRS claiming I owe them money (I have to find my 2005 taxes, which should be in a neat envelope). I haven't balanced my checkbook, either, because by 4am, my brain was too fried to do math. Sadly, it's too fried now to do math, but at least I got checks out this morning. I still have to balance my statements, find my 2005 Taxes, and try and find money for next month.

Sadly, a casualty of this is that TCEP is most likely not doable. This is CR's graduating year, and we have photos and stuff to get, plus his school supplies, clothes, and the usual back-to-school stuff.

I'd drink more coffee, but after 2 cups, my stomach goes sour and I get jittery. I even ate breakfast when I got to work (which I rarely do), and that didn't wake me up, either. My best hope is to drink a lot of water, a trick I learned back with FanTek security, when we realized that sometimes, your tiredness was beyond coffee, and it started to work in the opposite way (or gave you a headache and nosebleeds). Posted in: caffeine , coffee , finances , money , sleepy , tcep

I hate bills (Punkadyne Labs (Punkwalrus))

I really hate doing finances. I took them over in 1996 because takayla ran them from 1990-1996 when we had money problems the likes of which most of our current friends have never seen us with. But she was sick of doing them, and she ran them in "crisis mode," which is incredibly useful when you are shit poor, but the "pay the ones marked shutoff/final notice and toss the rest" is not a good long-term strategy. This is NOT a criticism on my part, takayla ran our money at a time when that strategy was the only option, and I am eternally and humbly grateful she did so, because I was a coward who was really sick of bill collectors.

takayla can lie, whereas I cannot.

I have run all our finances with the help of Excel spreadsheets since I took over, which has been a positive boon most of the time, but it still an incredible chore because, yes, I am one of those people who balance statements every month. Some of my friends who are more casual with their financial balances know full well that I tend to be annoying three months later when I ask them if they are every going to get around to depositing that $15 check I wrote them. I apologize for my anal-retentiveness in these matters, but it confounds me why someone may take 9 months to deposit a $150 check, and then the bank still takes it. Thank goodness I still have the money set aside.

How much did we pay for food in 1998? $6,419.06, which was 14.66% of total expenditures, second only to rent at 22.8%. There's an additional $536 in pizzas, along with $196 in Chinese delivery. I have checkbook carbons that date that far back, too, although I should really shred anything before 2000 at this point for security (if they are still legible).

But I am still really bad with money stress. Today I got a letter from the IRS stating I owe them $5000 + $2300 in late fees from my 2005 taxes, more than I paid in food, pizza, and Chinese in 1998. I can't see how this is possible, but we did them with H&R; Block and paid a $60 "if you get audited, and we goofed, we pay!" insurance.

I will let you know how that goes. Posted in: finances , money

Big career changes: talking to the experts (Kilala.nl (Cailin Coilleach)) by Cailin Coilleach

I can heartily recommend anyone considering a career switch to go and have a chat with people who work in their aspired field.

I made a little visit to my old high school this morning, to talk to their HR guy. He gave me a lot of valuable tips and suggested that a part-time study would indeed be the best and safest option for me. He indicated that it would be nigh on impossible for me to get a zij-instroom position, due to my lack of experience.

He also suggested that I go have a talk with the CWI (Centrum voor Werk en Inkomen), the part of the dutch government charged with work and job security. He reckoned that I might strike a lucky deal with them, getting a subsidy for hours I didn't spend working for Snow. In order to make time for my education I'd need to cut back on my working hours (and thus my monthly wages) by about 40%. This grant might help cover for at least part of the money I'd miss out on.

Tomorrow I'll also make a phone call with the CO of another high school. His number was given to me by my father's girlfriend who happens to work with the fellow. I'm curious if he has some other useful tips for me :)

Posted in: career change , career switch , education , money , talk to the experts