[adam_arthur]

Should cut out the doctors for most of these too...

Or at least allow people to continue to renew their medications after prescribed one time, rather than requiring further doctor's visits.

Most things in medicine are expensive due to legal monopolies/improper regulations. e.g. no reason you shouldn't be able to buy prescription glasses for $10-20 dollars off the shelf. The main problem with medical costs is that it's not a free enough market, with sufficient competition.

[bobthepanda]

Some medications are not renewed like this for good reason.

Some medications require regular monitoring to ensure that bad side effects aren't happening; PrEP requires checkups every 90 days to make sure kidney function is not getting impacted.

[adam_arthur]

That's fine but many don't require it for good reason, thus should be exempted.

People can easily seek out prescriptions as it is today, they just need to find a doctor and say the right things. This is common with TRT, Modafinil, Cannabis etc the barrier as it exists today is mostly artificial.

We allow people to drink alcohol, so any drug less dangerous than that shouldn't be gated

[Terry_Roll]

Its cost, losing kidney function and the subsequent dialysis is more expensive than a 90day check up. Besides you dont want to lose kidney function if all it took to avoid it was a 90day check.

Saying that kidney function usually involves Estimated Glomular Filtration Rate which means they measure the creatinine. Now if you happen to supplement with creatine, creatinine being the metabolised form will alter the eGFR! So if a dr doesnt ask you if you are supplementing with vitamins, minerals and other supplements, you could skew some medical tests and end up with a medical condition that doesnt exist!

You can also get quite alot off your pharmacy, but you need to know what to say, so some online pharmacys are better to use to work out what to say.

For example, if you want to get hold of Testogel here in the UK, for males its a nice pick me up and its being used in South Africa for dementia treatment, you need to say your T levels are below a certain amount. If you get rejected, you lower the amount on another website and then you can eventually work out what the level is that lets you have a testogel prescription!

Its not too hard to game the medical system for low risk drugs, for everything else you have various people who already qualify and through word of mouth have been known to sell on their meds because the Dr might sometimes up the dose if there is no response or told there is no response. SSRI's are like this. In theory a blood test measuring the 5-Hydroxyindoleacetic acid from the jugular vein will test if someone is taking SSRI's but they also do other things which go undocumented until some published scientific study highlights it.

To be honest though, the best drugs are vitamins and supplements, the number of medical studies I've read highlighting negative effects is quite shocking. Take https://en.wikipedia.org/wiki/Bisphosphonate#History It was first used for bone problems in the 1960's but the technology wasnt around to explain exactly what it was doing until the 1990's! Loads of studies slate the use of Bisphonates but these are recent like post millennium studies.

In fact you go through Google Scholar, you can see a trend from the first studies published in the 1800's where medicine was largely using what was found in the body, so B12 deficiency was eating raw liver, then from WW1 to WW2 patented drugs started to appear and thats when modern medicine started, but it is a case of medicine is restricted by the technology so AI in medicine is big business.

This gives you an idea of how the medical profession work, drug companies develop something run a battery of tests and then see if they can get it licenced and sold as a treatment.

https://en.wikipedia.org/wiki/Bupropion#History This is another drug designed for one thing but they noticed it had smoking cessation properties so it got relicensed.

Painkillers even the common ones like ibuprofen and paracetamol are also dangerous drugs. Paracetamol will destroy your bones and your kidneys dont like ibuprofen.

This is the history of Ecstasy aka molly aka mdma TLDR,

1912 German pharma Merck developed the compound for blood clotting, didnt work so got shelved.

1950's US Army dust off the compound and get university of Michigan to study it.

1973 results declassified.

1978 https://twitter.com/DrAShulgin a former Dow chemicals chemist into his psychoactive drugs looks at it and publishes a report "the drug appears to evoke an easily controlled altered state of consciousness with emotional and sensual overtones. It can be compared in its effects to marijuana, to psilocybin devoid of the hallucinatory component, or to low levels of MDA"

Psychotherapists start using it.

1980's its getting popular and DEA start to take notice.

1985 DEA get it banned, people having too much fun! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3931692/

Medicine is like chemical hacking of the body.

[Auracle]

I’m prescribed 3 controlled substance medications. I need to go online and send a message to my doctor every time I need them refilled, and I go through them all at different rates. I can’t get them especially early and if the doctor isn’t in I might need to wait, though I think he sometimes does it remotely. It’s insane.

My clinic’s backend used to have a slightly easier ‘refill prescription’ form but they changed it to only work with their integrated pharmacies. The closest one is an hour away.

[weird-eye-issue]

Most medications don't require this. Blacklist the ones that do

[adrr]

What drugs are those? Looking at the list of most common drugs prescribed, I can't see any that shouldn't require a doctor. Maybe finasteride, viagra and retin a but those are available with a usually are available with usually free telemedicine visit at one the many telemedicine startups.

https://www.goodrx.com/drug-guide

[weird-eye-issue]

I've taken several over the years where nothing was needed except telling the doctor or psychiatrist that "yep things are still the same". Adderall, Ritalin, Lexapro, Trazadone, Xanax, Gabapentin, and more all fit in this category for me personally

[danachow]

I’m not saying freer markets in some aspects of medicine would be better - but the libertarian dream in medicine is probably very naive and fails to learn from history to boot (medicine, especially pharm was much freer 120 years ago - it didn’t work out too well).

And of the big problems in medicine - a prescription for glasses (which isn’t really a medical service in the US - optometry is not a medical profession) just doesn’t register for me - you can order glasses online without a prescription if you are so inclined.

Meanwhile there isn’t any realistic libertarian solution to allocation or access to complex medical care - and just hand waving “free markets” doesn’t make it so.

[adam_arthur]

You can't order corrective lenses online without a prescription. You can order frames, or reading glasses. You need a prescription for both contacts or the lenses themselves.

Contacts would certainly be much cheaper without that hurdle.

And I bring up vision, because it's a common problem and for less well off folk with families it can be a big expense, basically entirely unnecessarily so. Imagine making 20k/year and you have to pay $500-$1000 a year for vision correction for your family. That's 2.5-5% of your pretax compensation

There's no handwaving here. Competitive markets require complete information. Information about costs to the consumer is basically entirely opaque. Over 90% of medical costs are non emergency, so if people could comparison shop, costs would go down. Also requires skin in the game (e.g. marginal cost per visit).

Look at plastic surgery for a good example of how free market/non insurance based medicine can fare. Many procedures are quite cheap, and while many are still expensive, much cheaper than necessary medical care covered by insurance. Also the number of doctors is still limited by the AMA, so even this is not fully competitive. There's an arbitrary cap on number of providers

[danachow]

> Also the number of doctors is still limited by the AMA, so even this is not fully competitive. There's an arbitrary cap on number of providers

This is an old trope but hasn’t even been superficially true for years. The AMA does not have the authority to limit the number of doctors. In any event their political influence has become less and less relevant for decades now, so even their ability to influence the number of docs is quite limited - I am not even am AMA member - I was only during medical school to get discounts on test prep. I don’t believe most of my peers are AMA members either - they belong to their specialist groups. Meanwhile the number of medical schools and students in the US has increased substantially in part due to AMA and AAMC. Meanwhile internal medicine residencies still have to fill their ranks with imported talent (foreign medical graduates) - only the lucrative subspecialties are the ones that remain limited and competitive. There are also forces at work to limit the number of MD jobs available that have nothing to do with the supply of MDs (replacement of positions with midlevels). The limit on residency positions is a partisan federal funding issue going on for years and only recently has much headway been made.

On eye care, I can of course self prescribe but even so for contact lenses I usually end up purchasing overseas from reputable retailers because of the price fixing of contact lenses - and I’ve never been asked for a prescription. It’s not that hard to get eyewear without a prescription.

[weird-eye-issue]

No you don't need a prescription for corrective lenses. I've ordered them without and just had to confirm there would be no returns and such

[adam_arthur]

I'm pretty confident it's not possible, as I was specifically looking for this recently.

But please link me to a US site where I can legally buy contacts without providing proof of prescription, if there is one!

[InvaderFizz]

I looked into this, apparently it is a legal requirement in the US for contacts.

That said, for normal eyeglasses, there are many sites that offer eyeglasses without proof of prescription. I've been buying eyeglasses from Zenni Optical for almost a decade for my whole family. Most recently in 2021. I have never once even been asked for proof of prescription, I just punch in my numbers and hit order.

[Scoundreller]

Dunno if they ship to USA, but all of the Canadian online shops shipped to me without sending over any proof.

One province de-regulated dispensing of corrective lenses and anyone could get in the game, and many did!

[adam_arthur]

Oh, well yeah, other countries have less regulation. It's not possible in the US right now.

But good to hear you can in Canada!

[weird-eye-issue]

I used framesdirect.com. I didn't say I bought contacts though, it might be different

[beaconstudios]

isn't forcing hospitals to post prices a form of regulation? In a free market (I'm interpreting this to mean laissez-faire - a market setup maximise competition and consumer choice must be regulated) nobody will post prices unless they have to or the procedures are elective, like plastic surgery is.

[adam_arthur]

Yes, I'm not advocating a free market, but a competitive market.

Fully free markets can lead to negative externalities like monopolies, pollution etc.

What leads to good societal outcomes is competitive markets. It just happens that free and competitive overlap a lot of the time. Information hiding makes a market less competitive, but is permitted under a full free market mentality. This is an area where regulations are warranted and useful.

Competitive capitalism should be the goal for most areas in modern society. Which in almost all cases only requires light regulation.

[mchusma]

I actually think requiring to give prices is consistent with libertarian approaches. I like good clear contract law. I think being able to give prices is basically required for good contracts. This is why every other industry does this, and nobody just says "we will charge you whatever we like".

If you were in another industry, and went to a judge and said "this person defaulted on their agreement to pay me whatever I want." Then I think the judge would basically tell you to get lost. And that is a good thing. The only oddness here is that somehow the medical industry has been getting away with this for a long time.

That is what the fix should be too, IMO. Basically, legislation that states unless someone expressly agrees to a price for a medical procedure, they are not liable for it.

[adam_arthur]

Yup, there's a lot that can be done to foster more competition in the medical space. Important that consumers have some skin in the game too. Another big problem is that the structure of insurance plans often warp incentives such that people either under or over-consume care.

Certainly there's a good case to be made for having safety nets for those that can't afford, but for the vast majority of people, a competitive system would bring down costs substantially. The US actually pays the most for healthcare per capita than any other country, I believe. Largely goes to inefficiencies rather than health outcomes. A truly well structured and competitively designed healthcare system could greatly improve QOL for the public.

Whether it's "libertarian" or not is a matter of semantics. The free market extreme would have no regulations at all... but clearly that can lead to certain negative outcomes (monopoly being classic example). Certainly there are different flavors of libertarian... and I would consider myself one, but am in favor of regulations that encourage competition between businesses. However, not needed in most spaces, healthcare in particular seems very warped/not rationally structured.

A rule of thumb for whether a sector is competitive/efficient are whether margins are broadly high across the board. I'm definitely a capitalist and not anti-business, but in a competitive market you should expect margins to be relatively constrained in the long run. Of course first movers, and those that truly out compete the rest can attain high margins... but over time these advantages should erode as new and better players come along.

Certain SaaS is pretty interesting example, because cost of switching can be high, creating "utility-like" businesses. DocuSign, for example, is really easy to dump for a competitor, low cost of switching. But something like AWS is much more difficult... need to invest potentially millions of dollars and months of time to rewrite your systems/design learn a new cloud environment, very high and painful costs of switching. It's often cheap to choose one of many competitors, but then you're entrenched in that environment.

Anyway, long tangent, but I expect law to recognize these kind of things eventually...

[robbedpeter]

Where's the "didn't work out too well" come from? Prohibition never works, whether it's restricting coffee or cocaine.

Combine education and free access to everything with reasonable daily unit limits and per-substance licensing. You want meth, you go through meth safety training and get a yearlong endorsement allowing you to buy up to the daily limit at a pharmacy, no prescription involved.

Set up due process that limits or eliminates legal access to substances based on criminal or medical situations.

Drug abuse - using in inappropriate situations leading to misbehavior - can be treated as a medical issue. Misbehavior that rises to the level of criminality is already handled.

It's absurd to think that any adult in a free country has any business whatsoever telling other adults what they can ingest or do in private.

Some variation on these notions are already demonstrated across the world. The current schedule system and drug laws in America serve only the bad guys, whether it's commercial prison slave labor, drug cartels, big Pharma, or the alphabet jackboots.

[claudiulodro]

> Where's the "didn't work out too well" come from?

I believe they were referring to the snake oil craze of the 19th century, not prohibition:

> The term comes from the "snake oil" that used to be sold as a cure-all elixir for many kinds of physiological problems. Many 19th-century United States and 18th-century European entrepreneurs advertised and sold mineral oil (often mixed with various active and inactive household herbs, spices, drugs, and compounds, but containing no snake-derived substances whatsoever) as "snake oil liniment", making claims about its efficacy as a panacea. Patent medicines that claimed to be a panacea were extremely common from the 18th century until the 20th, particularly among vendors masking addictive drugs such as cocaine, amphetamine, alcohol and opium-based concoctions or elixirs, to be sold at medicine shows as medication or products promoting health.

> https://en.wikipedia.org/wiki/Snake_oil