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Income how can i buy viagra Limits &. Rules and Household Size 3. The Three MSP Programs - What are they and how are they Different?. 4 how can i buy viagra.

FOUR Special Benefits of MSP Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment how can i buy viagra &. Applications for People who Have Medicare What is Application Process?.

6. Enrolling in an MSP for People age 65+ how can i buy viagra who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!.

Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources how can i buy viagra can qualify for an MSP. 1.A. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium how can i buy viagra if did not have enough work quarters and meets citizenship requirement.

See “Part A Buy-In” YES YES Pays Part A &. B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application? how can i buy viagra. Yes - Benefits begin the month after the month of the MSP application.

18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro how can i buy viagra for January application). See GIS 07 MA 027. Can Enroll in MSP and Medicaid at Same Time?.

YES YES how can i buy viagra NO!. Must choose between QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down. 2 how can i buy viagra.

INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). 2019 how can i buy viagra FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below. NOTE.

There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost how can i buy viagra of living adjustment). Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA. See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples.

367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include. (a) The first $20 of your &.

Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc.

For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. (c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart. As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher.

The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2. See DAB Household Size Chart.

Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE. Bob's Social Security is $1300/month. He is age 67 and has Medicare.

His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO. DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010.

This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?. Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP.

In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). 3. The Three Medicare Savings Programs - what are they and how are they different?.

1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations.

Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The program’s benefits will begin the month after the month in which your client is found eligible. ** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center).

2. Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months.

3. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only. QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months.

However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid. They cannot be in both.

It is their choice. DOH MRG p. 19. In contrast, one may receive Medicaid and either QMB or SLIMB.

4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1. Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable.

They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit.

People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application.

Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03. Also see CMS "Dear State Medicaid Director" letter dated Feb.

18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability. An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center. If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP).

Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life.. Even if one later ceases to be eligible for the MSP.

AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer. Benefit 3. No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55.

Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010. The federal government made this change in order to eliminate barriers to enrollment in MSPs.

See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium.

Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?. And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?.

The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification.

Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits.

See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply. The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment.

See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below. WHO IS AUTOMATICALLY ENROLLED IN AN MSP.

Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York State’s Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B. Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid. (NYS DOH 2000-ADM-7 and GIS 05 MA 033).

Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP. Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason.

SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive. Note. The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application.

As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. Applying for MSP Directly with Local Medicaid Program. Those who do not have Medicaid already must apply for an MSP through their local social services district. (See more in Section D.

Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare. If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available). Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid.

See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &. Back), and proof of residency/address. See the application form for other instructions.

One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person.

Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district.

The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare.

IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test. For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare.

People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down. If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP.

08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE. Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016.

He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund.

This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district. Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP.

(Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown. MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply.

The letters are. · Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium. See Step-by-Step Guide by the Medicare Rights Center).

This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as.

SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums. In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period.

(The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid. The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health – that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiary’s Social Security check.

SSA also refunds any amounts owed to the recipient. (Note. This process can take awhile!. !.

!. ) CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS). ​Can the MSP be retroactive like Medicaid, back to 3 months before the application?. ​The answer is different for the 3 MSP programs.

QMB -No Retroactive Eligibility – Benefits begin the month after the month of the MSP application. 18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application. QI-1 - YES up to 3 months but only in the same calendar year. No retroactive eligibility to the previous year.

7. QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance. However, there are limitations.

First, co-insurance will only be paid if the provide accepts Medicaid. Not all Medicare provides accept Medicaid. Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider. But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance.

Click here for an article that explains all of these rules. This article was authored by the Empire Justice Center.THE PROBLEM. Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB). His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations.

Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay. Now Joe has a bill that he can’t pay. Read below to find out -- SHORT ANSWER.

QMB or Medicaid will pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all. This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service.

However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers. Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them.

These rights and the ramifications of these QMB rules are explained in this article. CMS is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections. Download the 2020 Medicare Handbook here.

See pp. 53, 86. 1. To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?.

"Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance. 2. How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?.

If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid. Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining. 42 U.S.C.

§ 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan. 3. For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?.

The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov. Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further. The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans.

The answer also differs based on the type of service. Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments are reduced if the beneficiary has a Medicaid spend-down.

For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200). See more on spend-down here. Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020.

For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $198. Medicaid pays the entire $198, meeting the deductible. If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down.

In the 2019 proposed state budget, Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature. Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage.

If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate. Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate.

ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32). SSL 367-a, subd. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is.

This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case. This would have deterred doctors and other providers from being willing to treat them. SSL 367-a, subd. 1(d)(iv), added 2016.

EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules. The Medicare rate for Mary's specialist visit is $185.

The Medicaid rate for the same service is $120. Current rules (since 2016). Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50.

The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment. Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37. Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148).

For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget. . 4.

May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No. Balance billing is banned by the Balanced Budget Act of 1997. 42 U.S.C.

§ 1396a(n)(3)(A). In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider. If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules.

This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at. CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm.

QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions. Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018. CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals.

See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5. How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue.

If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016. Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN.

The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider. Justice in Aging has posted samples of what the new MSNs look like here. They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services.

CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb.

2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays. Unfortunately, the Medicaid card dos not indicate QMB eligibility.

Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB. See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly.

6. If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec.

16, 2016. Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.​​​ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters. Include a link to the CMS Medicare Learning Network Notice. Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised June 26.

2018) In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing. A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372. TTY/TDD users can call 1-855-729-2372. Medicare Advantage members should complain to their Medicare Advantage plan.

In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R.

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A broadly neutralising antibody to viagra for the brain prevent HIV transmissionTwo HIV prevention viagra for womens where to buy trials (HVTN 704/HPTN 085. HVTN 703/HPTN 081) enrolled 2699 at-risk cisgender men and transgender persons in the Americas and Europe and 1924 at-risk women in sub-Saharan Africa who were randomly assigned to receive the broadly neutralising antibody (bnAb) VRC01 or placebo (10 infusions at an interval of 8 weeks). Moderate-to-severe adverse events related viagra for the brain to VRC01 were uncommon.

In a prespecified pooled analysis, over 20 months, VRC01 offered an estimated prevention efficacy of ~75% against VRC01-sensitive isolates (30% of viagraes circulating in the trial regions). However, VRC01 did not prevent with other HIV isolates viagra for the brain and overall HIV acquisition compared with placebo. The data provide proof of concept that bnAb can prevent HIV acquisition, although the approach is limited by viral diversity and potential selection of resistant isolates.Corey L, Gilbert PB, Juraska M, et al.

Two randomized trials of neutralizing viagra for the brain antibodies to prevent HIV-1 acquisition. N Engl J Med. 2021;384:1003–1014.Seminal cytokine profiles are associated with the risk of HIV transmissionInvestigators analysed a panel of 34 cytokines/chemokines in blood and semen of men (predominantly men who have sex with men) with HIV, comparing 21 who transmitted HIV viagra for the brain to their partners and 22 who did not.

Overall, 47% of men had a recent HIV , 19% were on antiretroviral therapy and 84% were viraemic. The cytokine profile in seminal fluid, but not in blood, differed significantly between transmitters and non-transmitters, with transmitters showing higher seminal concentrations of interleukin 13 (IL-13), IL-15 and IL-33, viagra for the brain and lower concentrations of interferon‐gamma, IL-15, macrophage colony-stimulating factor (M-CSF), IL-17, granulocyte-macrophage CSF (GM-CSF), IL-4, IL-16 and eotaxin. Although limited, the findings suggest that the seminal milieu modulates the risk of HIV transmission, providing a potential development opportunity for HIV prevention strategies.Vanpouille C, Frick A, Rawlings SA, et al.

Cytokine network and sexual HIV transmission in men viagra for the brain who have sex with men. Clin Infect Dis. 2020;71:2655–2662.The challenge of estimating global treatment eligibility for chronic viagra for the brain hepatitis B from incomplete datasetsWorldwide, over 250 million people are estimated to live with chronic hepatitis B (CHB), although only ~11% is diagnosed and a minority receives antiviral therapy.

An estimate of the global proportion eligible for treatment was not previously available. A systematic review analysed studies of CHB populations done between 2007 and 2018 to estimate the prevalence of cirrhosis, abnormal alanine aminotransferase, hepatitis B viagra DNA >2000 or >20 000 IU/mL, hepatitis B e-antigen, and overall eligibility viagra for the brain for treatment as per WHO and other guidelines. The pooled treatment eligibility estimate was 19% (95% CI 18% to 20%), with about 10% requiring urgent treatment due to cirrhosis.

However, the viagra for the brain estimate should be interpreted with caution due to incomplete data acquisition and reporting in available studies. Standardised reporting is needed to improve global and regional estimates of CHB treatment eligibility and guide effective policy formulation.Tan M, Bhadoria AS, Cui F, et al. Estimating the proportion of people with chronic hepatitis B viagra eligible for viagra for the brain hepatitis B antiviral treatment worldwide.

A systematic review and meta-analysis. Lancet Gastroenterol Hepatol, 2021 viagra for the brain. 6:106–119.Broad geographical disparity in the contribution of HIV to the burden of cervical cancerThis systematic review and meta-analysis estimated the contribution of HIV to the global and regional burden of cervical cancer using data from 24 studies which included 236 127 women with HIV.

HIV markedly increased the risk of cervical viagra for the brain cancer (pooled relative risk 6.07. 95% CI 4.40 to 8.37). In 2018, 4.9% (95% CI 3.6% to 6.4%) of cervical cancers were attributable to HIV globally, although the population-attributable fraction for HIV varied geographically, reaching 21% (95% CI 15.6% to 26.8%) viagra for the brain in the African region.

Cervical cancer is preventable and treatable. Efforts are needed to expand viagra for the brain access to HPV vaccination in sub-Saharan Africa. More immediately, there is an urgent need to integrate cervical cancer screening within HIV services.Stelzle D, Tanaka LF, Lee KK, et al.

Estimates of the global burden of cervical cancer associated viagra for the brain with HIV. Lancet Glob Health. 2020.

9:e161–69.The complex relationship between serum vitamin D and persistence of high-risk human papilloma viagra Most cervical high-risk human papilloma viagra (hrHPV) s are transient and those that persist are more likely to progress to cancer. Based on the proposed immunomodulatory properties of vitamin D, a longitudinal study examined the association between serum concentrations of five vitamin D biomarkers and short-term persistent (vs transient or sporadic) detection of hrHPV in 72 women who collected monthly cervicovaginal swabs over 6 months. No significant associations were detected in the primary analysis.

In sensitivity analyses, after multiple adjustments, serum concentrations of multiple vitamin D biomarkers were positively associated with the short-term persistence of 14 selected hrHPV types. The relationship between vitamin D and hrHPV warrants closer examination. Studies should have longer follow-up, include populations with more diverse vitamin D concentrations and account for vitamin D supplementation.Troja C, Hoofnagle AN, Szpiro A, et al.

Understanding the role of emerging vitamin D biomarkers on short-term persistence of high-risk HPV among mid-adult women. J Infect Dis 2020. Online ahead of printPublished in STI—the editor’s choice.

One in five cases of with Neisseria gonorrhoeae clear spontaneouslyStudies have indicated that Neisseria gonorrhoeae (NG) s can resolve spontaneously without antibiotic therapy. A substudy of a randomised trial investigated 405 untreated subjects (71% men) who underwent both pretrial and enrolment NG testing at the same anatomical site (genital, pharyngeal and rectal). Based on nuclear acid amplification tests, 83 subjects (20.5%) showed clearance of the anatomical site within a median of 10 days (IQR 7–15) between tests.

Those with spontaneous clearance were less likely to have concurrent chlamydia (p=0.029) and dysuria (p=0.035), but there were no differences in age, gender, sexual orientation, HIV status, number of previous NG episodes, and symptoms other than dysuria between those with and without clearance. Given the high rate of spontaneous resolution, point-of-care NG testing should be considered to reduce unnecessary antibiotic treatment.Mensforth S, Ayinde OC, Ross J. Spontaneous clearance of genital and extragenital Neisseria gonorrhoeae.

Data from GToG. STI 2020. 96:556–561.BackgroundReproductive aged women are at risk of both pregnancy and sexually transmitted s (STI).

The modern contraceptive prevalence among married and unmarried women in South Africa is 54% and 64%, respectively, with injectable progestins being most widely used.1 Moreover, current global efforts aim towards all women having access to a range of reliable contraceptives options.2 The prevalences of chlamydia and gonorrhoea are high among women in Africa, particularly among younger women. A recent meta-analysis of over 37 000 women estimated prevalences for chlamydia and gonorrhoea by region and population type (South Africa clinic/community-based, Eastern Africa higher-risk and Southern/Eastern Africa clinic community-based). High chlamydia and gonorrhoea prevalences were found among 15–24 year-old South African women and high risk populations in East Africa.3 Both chlamydia and gonorrhoea are associated with numerous comorbidities including pelvic inflammatory disease (PID), ectopic pregnancy, infertility, increased risk of HIV and other STIs, as well as significant social harm.4While STIs are a significant global health burden, data on STI prevalence by gender and drivers of are limited, hindering an effective public health response.5 Moreover, data on the association between contraceptive use and risk of non-HIV STIs are limited.

The WHO recently reported stagnation in efforts to decrease global STI incidence.5 Understanding drivers of STI acquisition, including any possible associations with widely used contraceptive methods, is necessary to effectively target public health responses that reduce STI incidence and associated comorbidities.The ECHO Trial (ClinicalTrials.gov Identifier. NCT02550067) was a multicentre, open-label randomised trial of 7829 HIV-seronegative women seeking effective contraception in Eswatini, Kenya, South Africa and Zambia. Detailed trial methods and results have been published.6 7 We conducted a secondary analysis of ECHO trial data to evaluate absolute and relative chlamydia and gonorrhoea final visit prevalences among women randomised to intramuscular depot medroxyprogesterone acetate (DMPA-IM), a copper intrauterine device (IUD) and a levonorgestrel (LNG) implant.MethodsStudy design, participants and ethicsWomen were enrolled in the ECHO trial from December 2015 through September 2017.

Institutional review boards at each site approved the study protocol and women provided written informed consent before any study procedures. In brief, women who were not pregnant, HIV-seronegative, aged 16–35 years, seeking effective contraception, without medical contraindications, willing to use the assigned method for 18 months, reported not using injectable, intrauterine or implantable contraception for the previous 6 months and reported being sexually active, were enrolled. At every visit, participants received HIV risk reduction counselling, HIV testing and STI management, condoms and, as it became a part of national standard of care, HIV pre-exposure prophylaxis.

Counselling messages related to HIV risk were implemented consistently across the three groups throughout the trial.6The trial was implemented in accordance with the Declaration of Helsinki and Good Clinical Practice. Informed consent was obtained from participants or their parents/guardians and human experimentation guidelines of the United States Department of Health and Human Services and those of the authors' institution(s) were followed.Contraceptive exposureAt enrolment, women were randomly assigned (1:1:1) to DMPA-IM, copper IUD or LNG implant.6 Participants received an injection of 150 mg/mL DMPA-IM (Depo Provera. Pfizer, Puurs, Belgium) at enrolment and every 3 months until the final visit at 18 months after enrolment, a copper IUD (Optima TCu380A.

Injeflex, Sao Paolo, Brazil) or a LNG implant (Jadelle. Bayer, Turku, Finland) at enrolment. Women returned for follow-up visits at 1 month after enrolment to address initial contraceptive side-effects and every 3 months thereafter, for up to 18 months with later enrolling participants contributing 12 to 18 months of follow-up.

Visits included HIV serological testing, contraceptive counselling, syndromic STI management and safety monitoring.STI outcomesThe primary outcomes of this secondary analysis were prevalent chlamydia and gonorrhoea at the final visit. Syndromic STI management was provided at screening and all follow-up visits. Nucleic acid amplification testing (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae was conducted at screening and final visits, at the visit of HIV detection for participants who became HIV infected and at clinical discretion.

Any untreated participants with positive NAAT results were contacted to return to the study clinic for treatment.CovariatesAt baseline (inclusive of screening and enrolment visits), we collected demographic, sexual and reproductive risk behaviour and reproductive and contraceptive history data. Baseline risk factors evaluated as covariates included age, whether the participant earned her own income, chlamydia and gonorrhoea status, herpes simplex viagra type 2 (HSV-2) sero-status and suspected PID. Final visit factors evaluated as covariates included number of sex partners in the past 3 months, number of new sex partners in the past 3 months, HIV serostatus, HSV-2 serostatus, condom use in the past 3 months, sex exchanged for money/gifts, sex during vaginal bleeding, follow-up time and number of pelvic examinations during follow-up.

Age and HSV-2 serostatus were evaluated for effect measure modification.Statistical analysisWe conducted analyses using R V.3.5.3 (Vienna, Austria), and log-binomial regression to estimate chlamydia and gonorrhoea prevalences within each contraceptive group and pairwise prevalence ratios (PR) between each arm in as-randomised and consistent use analyses.In the as-randomised analysis, we analysed participants by the contraceptive method assigned at randomisation independent of method adherence. We estimated crude point prevalences by arm and study site and pairwise adjusted PRs.In the consistent use analysis, we only included women who initiated use of their randomised contraceptive method and maintained randomised method adherence throughout follow-up. We estimated crude point prevalences by arm and pairwise adjusted PRs, with evaluation of age and HSV-2 status first as potential effect measure modifiers, and all covariates above as potential confounders.

Study site http://www.em-centre-bischheim.ac-strasbourg.fr/les-parcours/decloisonnement/ and age were retained in the final model. Other covariates were retained if their inclusion in the base model led to a 10% change in the effect estimate through backwards selection.Supplementary analysesAdditional supporting analyses to assess postrandomisation potential sources of bias were conducted to inform interpretation of results. These include evaluation of recent sexual behaviour at enrolment, month 9 and the final visit.

Cohort participation (ie, follow-up time, early discontinuation and timing of randomised method discontinuation) and health outcomes (ie, final visit HIV and HSV-2 status) and frequency and results of pelvic examinations by STI status, site and visit month by randomised arm.ResultsA total of 7829 women were randomly assigned as follows. 2609 to the DMPA-IM group, 2607 to the copper IUD group and 2613 to the LNG implant group (figure 1). Participants were excluded if they were HIV positive at enrolment, did not have at least one HIV test or did not have chlamydia and gonorrhoea test results at the final visit.

Overall, 90%, 94% and 93% from the DMPA-IM, copper IUD and LNG implant groups, respectively, were included in analyses.Study profile. DMPA-IM, depot medroxy progesterone acetate. IUD, intrauterine device.

LNG, levonorgestrel." data-icon-position data-hide-link-title="0">Figure 1 Study profile. DMPA-IM, depot medroxy progesterone acetate. IUD, intrauterine device.

LNG, levonorgestrel.Participant characteristicsBaseline characteristics were similar across groups (table 1). Nearly two-third of enrolled women (63%) were aged 24 and younger and 5768 (74%) of the study population resided in South Africa.View this table:Table 1 Participant baseline and final visit characteristicsThe duration of participation averaged 16 months with no differences between randomised groups (table 1). A total of 1468 (19%) women either did not receive their randomised method or discontinued use during follow-up.

Overall method continuation rates were high with minimal differences between randomised groups when measured by person-years.6 The proportion, however, of method non-adherence as defined in this analysis (ie, did not receive randomised method at baseline or discontinued randomised method at any point during follow-up), was greater in the DMPA-IM group (26%), followed by the copper IUD (18%) and LNG implant (12%) groups. Timing of discontinuation also differed across methods. During the first 6 months, method discontinuation was highest in the copper IUD group (7%) followed closely by DMPA-IM (6%) and LNG implant (4%) groups.

Between 7 and 12 months of follow-up, it was highest in DMPA-IM group (15%), with equivalent proportions in the LNG implant (5%) and copper IUD (5%) groups.Point prevalences of chlamydia and gonorrhoea at baseline and final visitsIn total, 18% of women had chlamydia at baseline (figure 2A) and 15% at the final visit. Among women 24 years and younger, 22% and 20% had chlamydia at baseline and final visits, respectively. Women aged 25–35 at baseline were less likely to have chlamydia at both baseline (12%) and final visits (8%) compared with younger women.

Baseline chlamydia prevalence ranged from 5% in Zambia to 28% in the Western Cape, South Africa (figure 2B).Point prevalence (per 100 persons) of chlamydia and gonorrhoea at baseline and final visit by age category and study site region. Y-axis scale differs for chlamydia and gonorrhoea figures." data-icon-position data-hide-link-title="0">Figure 2 Point prevalence (per 100 persons) of chlamydia and gonorrhoea at baseline and final visit by age category and study site region. Y-axis scale differs for chlamydia and gonorrhoea figures.Among all women, 5% had gonorrhoea at baseline and the final visit (figure 2C).

Women aged 24 and younger were more likely to have gonorrhoea compared with women aged 25 and older at both baseline (5% vs 4%, respectively) and the final visit (6% vs 3%, respectively). Baseline gonorrhoea prevalence ranged from 3% in Zambia and Kenya to 9% in the Western Cape, South Africa (figure 2D). Similar prevalences were observed at the final visit.Point prevalences of chlamydia and gonorrhoea at final visit by randomised contraceptive methodFourteen per cent of women randomised to DMPA-IM, 15% to copper IUD and 17% to LNG implant had chlamydia at the final visit (table 2).View this table:Table 2 Chlamydia trachomatis and Neisseria gonorrhoeae prevalence at final visitThe prevalence of chlamydia did not significantly differ between DMPA-IM and copper IUD groups (PR 0.90, 95% CI (0.79 to 1.04)) or between copper IUD and LNG implant groups (PR 0.92, 95% CI (0.81 to 1.04)).

Women in the DMPA-IM group, however, had a significantly lower risk of chlamydia compared with the LNG implant group (PR. 0.83, 95% CI (0.72 to 0.95)). Findings from the consistent use analysis were similar, and neither age nor HSV-2 status modified the observed associations.Four per cent of women randomised to DMPA-IM, 6% to copper IUD and 5% to LNG implant had gonorrhoea at the final visit (table 2).

Gonorrhoea prevalence did not significantly differ between DMPA-IM and LNG implant groups (PR. 0.79, 95% CI (0.61 to 1.03)) or between copper IUD and LNG implant groups (PR. 1.18, 95% CI (0.93 to 1.49)).

Women in the DMPA-IM group had a significantly lower risk of gonorrhoea compared with women in the copper IUD group (PR. 0.67, 95% CI (0.52 to 0.87)). Results from as randomised and continuous use analyses did not differ.

And again, neither age nor HSV-2 status modified the observed associations.Clinical assessment by randomised contraceptive methodTo assess the potential for outcome ascertainment bias, we evaluated the frequency of pelvic examinations and abdominal/pelvic pain and discharge by study arm. Women in the copper IUD group were generally more likely to receive a pelvic examination during follow-up as compared with women in the DMPA-IM and LNG implant groups (online supplemental appendix 1). Similarly, abdominal/pelvic pain on examination or abnormal discharge was observed most frequently in the copper IUD group.

The number of pelvic examinations met the prespecified criteria for retention in the adjusted gonorrhoea model but not in the chlamydia model.Supplemental materialFrequency of syndromic symptoms and potential reAmong women who had chlamydia at baseline, 23% were also positive at the final visit (online supplemental appendix 2, figure 3A). Nine per cent of gonorrhoea-positive women at baseline were also positive at the final visit (online supplemental appendix 2, figure 3B). Across both baseline and final visits, a minority of women with chlamydia or gonorrhoea presented with signs and/or symptoms.

Among chlamydia-positive women, only 12% presented with either abnormal vaginal discharge and/or abdominal/pelvic pain at their test-positive visit (online supplemental appendix 2, figure 3C). Similarly, only 15% of gonorrhoea-positive women presented with abnormal vaginal discharge and/or abdominal/pelvic pain at their test-positive visit (online supplemental appendix 2, figure 3D).Potential re and symptoms among women with chlamydia or gonorrhoea. Data are pooled across the screening and final visits in figures (C) and (D).

Symptomatic is defined as presenting with abnormal vaginal discharge and/or abdominal/pelvic pain. Final visit is described as potential re because test of cure was not conducted following baseline diagnosis and treatment." data-icon-position data-hide-link-title="0">Figure 3 Potential re and symptoms among women with chlamydia or gonorrhoea. Data are pooled across the screening and final visits in figures (C) and (D).

Symptomatic is defined as presenting with abnormal vaginal discharge and/or abdominal/pelvic pain. Final visit is described as potential re because test of cure was not conducted following baseline diagnosis and treatment.DiscussionWe observed differences in final prevalences of chlamydia and gonorrhoea by contraceptive group in both as-randomised and consistent-use analyses. The DMPA-IM group had lower final visit chlamydia and gonorrhoea prevalences as compared with copper IUD and LNG implant groups, though only the DMPA-IM versus the copper IUD comparison of gonorrhoea and DMPA-IM versus LNG implant comparison of chlamydia reached statistical significance.

These are novel findings that have not previously been reported to our knowledge and were determined in a randomised trial setting with high participant retention, robust biomarker testing and high randomised method adherence. Interestingly, the copper IUD group had higher gonorrhoea and lower chlamydia prevalence compared with the LNG implant group, though neither finding was statistically significant.Two recent systematic reviews of the association between contraceptives and STIs found inconsistent and insufficient evidence on the association between the contraceptive methods under study in ECHO and chlamydia and gonorrhoea.8 9 Neither systematic review identified any randomised studies or any direct comparative evidence for DMPA-IM, copper IUD and LNG implant, thus enabling a unique scientific contribution from this secondary trial analysis. Nonetheless, these findings should be interpreted in light of biological plausibility, as well as the design strengths and limitations of this analysis.The emerging science on the biological mechanisms underlying HIV susceptibility demonstrates the complex relationship between the infectious pathogen, the host innate and adaptive immune response and the interaction of both with the vaginal microbiome and other -omes.

Data on these factors in relationship to chlamydia and gonorrhoea acquisition are much more limited but can be assumed to be equally complex. Vaginal microbiome composition, including microbial metabolic by-products, have been shown to significantly modify risk of HIV acquisition and to vary with exogenous hormone exposure, menstrual cycle phase, ethnicity and geography.10–12 These same biological principles likely apply to chlamydia and gonorrhoea susceptibility. While DMPA-IM has been associated with decreased bacterial vaginosis (BV), initiation of the copper IUD has been associated with increased BV prevalence, and BV is associated with chlamydia and gonorrhoea acquisition.13 14 Moreover, Lactobacillus crispatus, which is less abundant in BV, has been shown to inhibit HeLa cell by Chlamydia trachomatis and inhibits growth of Neisseria gonorrhoeae in animal models.15 16 In addition, microbial community state types that are deficient in Lactobacillus crispatus and/or dominated by dysbiotic species are associated with inflammation, which is a driver of both STI and HIV susceptibility.

Thus, while the exact mechanisms of chlamydia and gonorrhoea in the presence of exogenous hormones and varying host microbiomes are unknown, it is biologically plausible that these complex factors may result in differential susceptibility to chlamydia and gonorrhoea among DMPA-IM, copper IUD and LNG implant users.An alternative explanation for these findings may be postrandomisation differences in clinical care and/or sexual behaviour. Participants in the copper IUD arm were more likely to have pelvic examinations and more likely to have discharge compared with women in the DMPA-IM and LNG implant groups. While interim STI testing and/or treatment were not documented, women in the copper IUD arm may have been more likely to receive syndromic STI treatment during follow-up due to more examination and observed discharge.

More frequent STI treatment in the copper IUD group would theoretically lower the final visit point prevalence relative to women in the DMPA-IM and LNG implant arms, suggesting that the observed lower risk of STI in the DMPA-IM arm is not due to differential examination, testing and treatment. Differential sexual risk behaviour may also have influenced the results. As reported previously, women in the DMPA-IM group less frequently reported condomless sex and multiple partners than women in the other groups, and both DMPA-IM and LNG implant users less frequently reported new partners and sex during menses than copper IUD users.6 Statistical control of self-reported sexual risk behaviour in the consistent-use analysis may have been inadequate if self-reported sexual behaviour was inaccurately or insufficiently reported.A second alternative explanation may be differences in randomised method non-adherence, which was greater in the DMPA-IM group, compared with copper IUD and LNG implant groups.

Yet, the consistency of findings in the as-randomised and continuous use analyses suggests that method non-adherence had minimal effect on study outcomes. Taken as a whole, these findings indicate that there may be real differences in chlamydia and gonorrhoea risk associated with use of DMPA-IM, the copper IUD and LNG implant. However, any true differential risk by method must be evaluated in light of the holistic benefits and risks of each method.The high observed chlamydia and gonorrhoea prevalences, despite intensive counselling and condom provision, warrants attention, particularly among women ages 24 years and younger and among women in South Africa and Eswatini.

While the ECHO study was conducted in settings of high HIV/STI incidence, enrolment criteria did not purposefully target women at highest risk of HIV/STI in the trial communities, suggesting that the observed prevalences may be broadly applicable to women seeking effective contraception in those settings. Improved approaches are needed to prevent STIs, including options for expedited partner treatment, to prevent re.As expected, few women testing positive for chlamydia or gonorrhoea presented with symptoms (12% and 15%, respectively), and a substantial proportion of women who were positive and treated at baseline were infected at the final visit despite syndromic management during the follow-up. Given that syndromic management is the standard of care within primary health facilities in most trial settings, these data suggest that a large proportion of among reproductive aged women is missed, exacerbating the burden of curable STIs and associated morbidities.

Routine access to more reliable diagnostics, like NAAT and novel point-of-care diagnostic tests, will be key to managing asymptomatic STIs and reducing STI prevalence and related morbidities in these settings.17This secondary analysis of the ECHO trial has strengths and limitations. Strengths include the randomised design with comparator groups of equal STI baseline risk. Participants had high adherence to their randomised contraceptive method.6 While all participants received standardised clinical care and counselling, the unblinded randomisation may have allowed postrandomisation differences in STI risk over time by method.

It is possible that participants modified their risk-taking behaviour based on study counselling messages regarding the potential association between DMPA-IM and HIV.In conclusion, our analyses suggest that DMPA-IM users may have lower risk of chlamydia and gonorrhoea compared with LNG implant and copper IUD users, respectively. Further investigation is warranted to better understand the mechanisms of chlamydia and gonorrhoea susceptibility in the context of contraceptive use. Moreover, the high chlamydia and gonorrhoea prevalences in this population, independent of contraceptive method, warrants urgent attention.Key messagesThe prevalence of chlamydia and gonorrhoea varied by contraceptive method in this randomised trial.High chlamydia and gonorrhoea prevalences, despite intensive counselling and condom provision, warrants attention, particularly among young women in South Africa and Eswatini.Most chlamydia and gonorrhoea s were asymptomatic.

Therefore, routine access to reliable diagnostics are needed to effectively manage and prevent STIs in African women..

A broadly how can i buy viagra neutralising antibody to prevent HIV http://www.ec-rene-schickele-mutzig.ac-strasbourg.fr/2020/04/07/sauras-tu-defier-la-maitresse/ transmissionTwo HIV prevention trials (HVTN 704/HPTN 085. HVTN 703/HPTN 081) enrolled 2699 at-risk cisgender men and transgender persons in the Americas and Europe and 1924 at-risk women in sub-Saharan Africa who were randomly assigned to receive the broadly neutralising antibody (bnAb) VRC01 or placebo (10 infusions at an interval of 8 weeks). Moderate-to-severe adverse events related how can i buy viagra to VRC01 were uncommon.

In a prespecified pooled analysis, over 20 months, VRC01 offered an estimated prevention efficacy of ~75% against VRC01-sensitive isolates (30% of viagraes circulating in the trial regions). However, VRC01 how can i buy viagra did not prevent with other HIV isolates and overall HIV acquisition compared with placebo. The data provide proof of concept that bnAb can prevent HIV acquisition, although the approach is limited by viral diversity and potential selection of resistant isolates.Corey L, Gilbert PB, Juraska M, et al.

Two randomized trials of neutralizing how can i buy viagra antibodies to prevent HIV-1 acquisition. N Engl J Med. 2021;384:1003–1014.Seminal cytokine how can i buy viagra profiles are associated with the risk of HIV transmissionInvestigators analysed a panel of 34 cytokines/chemokines in blood and semen of men (predominantly men who have sex with men) with HIV, comparing 21 who transmitted HIV to their partners and 22 who did not.

Overall, 47% of men had a recent HIV , 19% were on antiretroviral therapy and 84% were viraemic. The cytokine profile in seminal fluid, but not in blood, differed significantly between transmitters and non-transmitters, with transmitters showing higher seminal concentrations of interleukin 13 (IL-13), IL-15 and IL-33, and lower concentrations of interferon‐gamma, IL-15, macrophage colony-stimulating how can i buy viagra factor (M-CSF), IL-17, granulocyte-macrophage CSF (GM-CSF), IL-4, IL-16 and eotaxin. Although limited, the findings suggest that the seminal milieu modulates the risk of HIV transmission, providing a potential development opportunity for HIV prevention strategies.Vanpouille C, Frick A, Rawlings SA, et al.

Cytokine network how can i buy viagra and sexual HIV transmission in men who have sex with men. Clin Infect Dis. 2020;71:2655–2662.The challenge how can i buy viagra of estimating global treatment eligibility for chronic hepatitis B from incomplete datasetsWorldwide, over 250 million people are estimated to live with chronic hepatitis B (CHB), although only ~11% is diagnosed and a minority receives antiviral therapy.

An estimate of the global proportion eligible for treatment was not previously available. A systematic review analysed studies of CHB populations done between 2007 and 2018 to estimate the prevalence of cirrhosis, abnormal alanine aminotransferase, hepatitis B viagra DNA >2000 or how can i buy viagra >20 000 IU/mL, hepatitis B e-antigen, and overall eligibility for treatment as per WHO and other guidelines. The pooled treatment eligibility estimate was 19% (95% CI 18% to 20%), with about 10% requiring urgent treatment due to cirrhosis.

However, the estimate should be interpreted with caution due to incomplete data acquisition and reporting in available studies how can i buy viagra. Standardised reporting is needed to improve global and regional estimates of CHB treatment eligibility and guide effective policy formulation.Tan M, Bhadoria AS, Cui F, et al. Estimating the proportion of people with how can i buy viagra chronic hepatitis B viagra eligible for hepatitis B antiviral treatment worldwide.

A systematic review and meta-analysis. Lancet Gastroenterol how can i buy viagra Hepatol, 2021. 6:106–119.Broad geographical disparity in the contribution of HIV to the burden of cervical cancerThis systematic review and meta-analysis estimated the contribution of HIV to the global and regional burden of cervical cancer using data from 24 studies which included 236 127 women with HIV.

HIV markedly increased the risk of cervical cancer how can i buy viagra (pooled relative risk 6.07. 95% CI 4.40 to 8.37). In 2018, 4.9% (95% CI 3.6% to 6.4%) of cervical cancers were attributable to HIV globally, although the population-attributable fraction for HIV varied geographically, how can i buy viagra reaching 21% (95% CI 15.6% to 26.8%) in the African region.

Cervical cancer is preventable and treatable. Efforts are needed to expand access to HPV vaccination in sub-Saharan how can i buy viagra Africa. More immediately, there is an urgent need to integrate cervical cancer screening within HIV services.Stelzle D, Tanaka LF, Lee KK, et al.

Estimates of how can i buy viagra the global burden of cervical cancer associated with HIV. Lancet Glob Health. 2020.

9:e161–69.The complex relationship between serum vitamin D and persistence of high-risk human papilloma viagra Most cervical high-risk human papilloma viagra (hrHPV) s are transient and those that persist are more likely to progress to cancer. Based on the proposed immunomodulatory properties of vitamin D, a longitudinal study examined the association between serum concentrations of five vitamin D biomarkers and short-term persistent (vs transient or sporadic) detection of hrHPV in 72 women who collected monthly cervicovaginal swabs over 6 months. No significant associations were detected in the primary analysis.

In sensitivity analyses, after multiple adjustments, serum concentrations of multiple vitamin D biomarkers were positively associated with the short-term persistence of 14 selected hrHPV types. The relationship between vitamin D and hrHPV warrants closer examination. Studies should have longer follow-up, include populations with more diverse vitamin D concentrations and account for vitamin D supplementation.Troja C, Hoofnagle AN, Szpiro A, et al.

Understanding the role of emerging vitamin D biomarkers on short-term persistence of high-risk HPV among mid-adult women. J Infect Dis 2020. Online ahead of printPublished in STI—the editor’s choice.

One in five cases of with Neisseria gonorrhoeae clear spontaneouslyStudies have indicated that Neisseria gonorrhoeae (NG) s can resolve spontaneously without antibiotic therapy. A substudy of a randomised trial investigated 405 untreated subjects (71% men) who underwent both pretrial and enrolment NG testing at the same anatomical site (genital, pharyngeal and rectal). Based on nuclear acid amplification tests, 83 subjects (20.5%) showed clearance of the anatomical site within a median of 10 days (IQR 7–15) between tests.

Those with spontaneous clearance were less likely to have concurrent chlamydia (p=0.029) and dysuria (p=0.035), but there were no differences in age, gender, sexual orientation, HIV status, number of previous NG episodes, and symptoms other than dysuria between those with and without clearance. Given the high rate of spontaneous resolution, point-of-care NG testing should be considered to reduce unnecessary antibiotic treatment.Mensforth S, Ayinde OC, Ross J. Spontaneous clearance of genital and extragenital Neisseria gonorrhoeae.

Data from GToG. STI 2020. 96:556–561.BackgroundReproductive aged women are at risk of both pregnancy and sexually transmitted s (STI).

The modern contraceptive prevalence among married and unmarried women in South Africa is 54% and 64%, respectively, with injectable progestins being most widely used.1 Moreover, current global efforts aim towards all women having access to a range of reliable contraceptives options.2 The prevalences of chlamydia and gonorrhoea are high among women in Africa, particularly among younger women. A recent meta-analysis of over 37 000 women estimated prevalences for chlamydia and gonorrhoea by region and population type (South Africa clinic/community-based, Eastern Africa higher-risk and Southern/Eastern Africa clinic community-based). High chlamydia and gonorrhoea prevalences were found among 15–24 year-old South African women and high risk populations in East Africa.3 Both chlamydia and gonorrhoea are associated with numerous comorbidities including pelvic inflammatory disease (PID), ectopic pregnancy, infertility, increased risk of HIV and other STIs, as well as significant social harm.4While STIs are a significant global health burden, data on STI prevalence by gender and drivers of are limited, hindering an effective public health response.5 Moreover, data on the association between contraceptive use and risk of non-HIV STIs are limited.

The WHO recently reported stagnation in efforts to decrease global STI incidence.5 Understanding drivers of STI acquisition, including any possible associations with widely used contraceptive methods, is necessary to effectively target public health responses that reduce STI incidence and associated comorbidities.The ECHO Trial (ClinicalTrials.gov Identifier. NCT02550067) was a multicentre, open-label randomised trial of 7829 HIV-seronegative women seeking effective contraception in Eswatini, Kenya, South Africa and Zambia. Detailed trial methods and results have been published.6 7 We conducted a secondary analysis of ECHO trial data to evaluate absolute and relative chlamydia and gonorrhoea final visit prevalences among women randomised to intramuscular depot medroxyprogesterone acetate (DMPA-IM), a copper intrauterine device (IUD) and a levonorgestrel (LNG) implant.MethodsStudy design, participants and ethicsWomen were enrolled in the ECHO trial from December 2015 through September 2017.

Institutional review boards at each site approved the study protocol and women provided written informed consent before any study procedures. In brief, women who were not pregnant, HIV-seronegative, aged 16–35 years, seeking effective contraception, without medical contraindications, willing to use the assigned method for 18 months, reported not using injectable, intrauterine or implantable contraception for the previous 6 months and reported being sexually active, were enrolled. At every visit, participants received HIV risk reduction counselling, HIV testing and STI management, condoms and, as it became a part of national standard of care, HIV pre-exposure prophylaxis.

Counselling messages related to HIV risk were implemented consistently across the three groups throughout the trial.6The trial was implemented in accordance with the Declaration of Helsinki and Good Clinical Practice. Informed consent was obtained from participants or their parents/guardians and human experimentation guidelines of the United States Department of Health and Human Services and those of the authors' institution(s) were followed.Contraceptive exposureAt enrolment, women were randomly assigned (1:1:1) to DMPA-IM, copper IUD or LNG implant.6 Participants received an injection of 150 mg/mL DMPA-IM (Depo Provera. Pfizer, Puurs, Belgium) at enrolment and every 3 months until the final visit at 18 months after enrolment, a copper IUD (Optima TCu380A.

Injeflex, Sao Paolo, Brazil) or a LNG implant (Jadelle. Bayer, Turku, Finland) at enrolment. Women returned for follow-up visits at 1 month after enrolment to address initial contraceptive side-effects and every 3 months thereafter, for up to 18 months with later enrolling participants contributing 12 to 18 months of follow-up.

Visits included HIV serological testing, contraceptive counselling, syndromic STI management and safety monitoring.STI outcomesThe primary outcomes of this secondary analysis were prevalent chlamydia and gonorrhoea at the final visit. Syndromic STI management was provided at screening and all follow-up visits. Nucleic acid amplification testing (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae was conducted at screening and final visits, at the visit of HIV detection for participants who became HIV infected and at clinical discretion.

Any untreated participants with positive NAAT results were contacted to return to the study clinic for treatment.CovariatesAt baseline (inclusive of screening and enrolment visits), we collected demographic, sexual and reproductive risk behaviour and reproductive and contraceptive history data. Baseline risk factors evaluated as covariates included age, whether the participant earned her own income, chlamydia and gonorrhoea status, herpes simplex viagra type 2 (HSV-2) sero-status and suspected PID. Final visit factors evaluated as covariates included number of sex partners in the past 3 months, number of new sex partners in the past 3 months, HIV serostatus, HSV-2 serostatus, condom use in the past 3 months, sex exchanged for money/gifts, sex during vaginal bleeding, follow-up time and number of pelvic examinations during follow-up.

Age and HSV-2 serostatus were evaluated for effect measure modification.Statistical analysisWe conducted analyses using R V.3.5.3 (Vienna, Austria), and log-binomial regression to estimate chlamydia and gonorrhoea prevalences within each contraceptive group and pairwise prevalence ratios (PR) between each arm in as-randomised and consistent use analyses.In the as-randomised analysis, we analysed participants by the contraceptive method assigned at randomisation independent of method adherence. We estimated crude point prevalences by arm and study site and pairwise adjusted PRs.In the consistent use analysis, we only included women who initiated use of their randomised contraceptive method and maintained randomised method adherence throughout follow-up. We estimated crude point prevalences by arm and pairwise adjusted PRs, with evaluation of age and HSV-2 status first as potential effect measure modifiers, and all covariates above as potential confounders.

Study site and age were retained in the final model. Other covariates were retained if their inclusion in the base model led to a 10% change in the effect estimate through backwards selection.Supplementary analysesAdditional supporting analyses to assess postrandomisation potential sources of bias were conducted to inform interpretation of results. These include evaluation of recent sexual behaviour at enrolment, month 9 and the final visit.

Cohort participation (ie, follow-up time, early discontinuation and timing of randomised method discontinuation) and health outcomes (ie, final visit HIV and HSV-2 status) and frequency and results of pelvic examinations by STI status, site and visit month by randomised arm.ResultsA total of 7829 women were randomly assigned as follows. 2609 to the DMPA-IM group, 2607 to the copper IUD group and 2613 to the LNG implant group (figure 1). Participants were excluded if they were HIV positive at enrolment, did not have at least one HIV test or did not have chlamydia and gonorrhoea test results at the final visit.

Overall, 90%, 94% and 93% from the DMPA-IM, copper IUD and LNG implant groups, respectively, were included in analyses.Study profile. DMPA-IM, depot medroxy progesterone acetate. IUD, intrauterine device.

LNG, levonorgestrel." data-icon-position data-hide-link-title="0">Figure 1 Study profile. DMPA-IM, depot medroxy progesterone acetate. IUD, intrauterine device.

LNG, levonorgestrel.Participant characteristicsBaseline characteristics were similar across groups (table 1). Nearly two-third of enrolled women (63%) were aged 24 and younger and 5768 (74%) of the study population resided in South Africa.View this table:Table 1 Participant baseline and final visit characteristicsThe duration of participation averaged 16 months with no differences between randomised groups (table 1). A total of 1468 (19%) women either did not receive their randomised method or discontinued use during follow-up.

Overall method continuation rates were high with minimal differences between randomised groups when measured by person-years.6 The proportion, however, of method non-adherence as defined in this analysis (ie, did not receive randomised method at baseline or discontinued randomised method at any point during follow-up), was greater in the DMPA-IM group (26%), followed by the copper IUD (18%) and LNG implant (12%) groups. Timing of discontinuation also differed across methods. During the first 6 months, method discontinuation was highest in the copper IUD group (7%) followed closely by DMPA-IM (6%) and LNG implant (4%) groups.

Between 7 and 12 months of follow-up, it was highest in DMPA-IM group (15%), with equivalent proportions in the LNG implant (5%) and copper IUD (5%) groups.Point prevalences of chlamydia and gonorrhoea at baseline and final visitsIn total, 18% of women had chlamydia at baseline (figure 2A) and 15% at the final visit. Among women 24 years and younger, 22% and 20% had chlamydia at baseline and final visits, respectively. Women aged 25–35 at baseline were less likely to have chlamydia at both baseline (12%) and final visits (8%) compared with younger women.

Baseline chlamydia prevalence ranged from 5% in Zambia to 28% in the Western Cape, South Africa (figure 2B).Point prevalence (per 100 persons) of chlamydia and gonorrhoea at baseline and final visit by age category and study site region. Y-axis scale differs for chlamydia and gonorrhoea figures." data-icon-position data-hide-link-title="0">Figure 2 Point prevalence (per 100 persons) of chlamydia and gonorrhoea at baseline and final visit by age category and study site region. Y-axis scale differs for chlamydia and gonorrhoea figures.Among all women, 5% had gonorrhoea at baseline and the final visit (figure 2C).

Women aged 24 and younger were more likely to have gonorrhoea compared with women aged 25 and older at both baseline (5% vs 4%, respectively) and the final visit (6% vs 3%, respectively). Baseline gonorrhoea prevalence ranged from 3% in Zambia and Kenya to 9% in the Western Cape, South Africa (figure 2D). Similar prevalences were observed at the final visit.Point prevalences of chlamydia and gonorrhoea at final visit by randomised contraceptive methodFourteen per cent of women randomised to DMPA-IM, 15% to copper IUD and 17% to LNG implant had chlamydia at the final visit (table 2).View this table:Table 2 Chlamydia trachomatis and Neisseria gonorrhoeae prevalence at final visitThe prevalence of chlamydia did not significantly differ between DMPA-IM and copper IUD groups (PR 0.90, 95% CI (0.79 to 1.04)) or between copper IUD and LNG implant groups (PR 0.92, 95% CI (0.81 to 1.04)).

Women in the DMPA-IM group, however, had a significantly lower risk of chlamydia compared with the LNG implant group (PR. 0.83, 95% CI (0.72 to 0.95)). Findings from the consistent use analysis were similar, and neither age nor HSV-2 status modified the observed associations.Four per cent of women randomised to DMPA-IM, 6% to copper IUD and 5% to LNG implant had gonorrhoea at the final visit (table 2).

Gonorrhoea prevalence did not significantly differ between DMPA-IM and LNG implant groups (PR. 0.79, 95% CI (0.61 to 1.03)) or between copper IUD and LNG implant groups (PR. 1.18, 95% CI (0.93 to 1.49)).

Women in the DMPA-IM group had a significantly lower risk of gonorrhoea compared with women in the copper IUD group (PR. 0.67, 95% CI (0.52 to 0.87)). Results from as randomised and continuous use analyses did not differ.

And again, neither age nor HSV-2 status modified the observed associations.Clinical assessment by randomised contraceptive methodTo assess the potential for outcome ascertainment bias, we evaluated the frequency of pelvic examinations and abdominal/pelvic pain and discharge by study arm. Women in the copper IUD group were generally more likely to receive a pelvic examination during follow-up as compared with women in the DMPA-IM and LNG implant groups (online supplemental appendix 1). Similarly, abdominal/pelvic pain on examination or abnormal discharge was observed most frequently in the copper IUD group.

The number of pelvic examinations met the prespecified criteria for retention in the adjusted gonorrhoea model but not in the chlamydia model.Supplemental materialFrequency of syndromic symptoms and potential reAmong women who had chlamydia at baseline, 23% were also positive at the final visit (online supplemental appendix 2, figure 3A). Nine per cent of gonorrhoea-positive women at baseline were also positive at the final visit (online supplemental appendix 2, figure 3B). Across both baseline and final visits, a minority of women with chlamydia or gonorrhoea presented with signs and/or symptoms.

Among chlamydia-positive women, only 12% presented with either abnormal vaginal discharge and/or abdominal/pelvic pain at their test-positive visit (online supplemental appendix 2, figure 3C). Similarly, only 15% of gonorrhoea-positive women presented with abnormal vaginal discharge and/or abdominal/pelvic pain at their test-positive visit (online supplemental appendix 2, figure 3D).Potential re and symptoms among women with chlamydia or gonorrhoea. Data are pooled across the screening and final visits in figures (C) and (D).

Symptomatic is defined as presenting with abnormal vaginal discharge and/or abdominal/pelvic pain. Final visit is described as potential re because test of cure was not conducted following baseline diagnosis and treatment." data-icon-position data-hide-link-title="0">Figure 3 Potential re and symptoms among women with chlamydia or gonorrhoea. Data are pooled across the screening and final visits in figures (C) and (D).

Symptomatic is defined as presenting with abnormal vaginal discharge and/or abdominal/pelvic pain. Final visit is described as potential re because test of cure was not conducted following baseline diagnosis and treatment.DiscussionWe observed differences in final prevalences of chlamydia and gonorrhoea by contraceptive group in both as-randomised and consistent-use analyses. The DMPA-IM group had lower final visit chlamydia and gonorrhoea prevalences as compared with copper IUD and LNG implant groups, though only the DMPA-IM versus the copper IUD comparison of gonorrhoea and DMPA-IM versus LNG implant comparison of chlamydia reached statistical significance.

These are novel findings that have not previously been reported to our knowledge and were determined in a randomised trial setting with high participant retention, robust biomarker testing and high randomised method adherence. Interestingly, the copper IUD group had higher gonorrhoea and lower chlamydia prevalence compared with the LNG implant group, though neither finding was statistically significant.Two recent systematic reviews of the association between contraceptives and STIs found inconsistent and insufficient evidence on the association between the contraceptive methods under study in ECHO and chlamydia and gonorrhoea.8 9 Neither systematic review identified any randomised studies or any direct comparative evidence for DMPA-IM, copper IUD and LNG implant, thus enabling a unique scientific contribution from this secondary trial analysis. Nonetheless, these findings should be interpreted in light of biological plausibility, as well as the design strengths and limitations of this analysis.The emerging science on the biological mechanisms underlying HIV susceptibility demonstrates the complex relationship between the infectious pathogen, the host innate and adaptive immune response and the interaction of both with the vaginal microbiome and other -omes.

Data on these factors in relationship to chlamydia and gonorrhoea acquisition are much more limited but can be assumed to be equally complex. Vaginal microbiome composition, including microbial metabolic by-products, have been shown to significantly modify risk of HIV acquisition and to vary with exogenous hormone exposure, menstrual cycle phase, ethnicity and geography.10–12 These same biological principles likely apply to chlamydia and gonorrhoea susceptibility. While DMPA-IM has been associated with decreased bacterial vaginosis (BV), initiation of the copper IUD has been associated with increased BV prevalence, and BV is associated with chlamydia and gonorrhoea acquisition.13 14 Moreover, Lactobacillus crispatus, which is less abundant in BV, has been shown to inhibit HeLa cell by Chlamydia trachomatis and inhibits growth of Neisseria gonorrhoeae in animal models.15 16 In addition, microbial community state types that are deficient in Lactobacillus crispatus and/or dominated by dysbiotic species are associated with inflammation, which is a driver of both STI and HIV susceptibility.

Thus, while the exact mechanisms of chlamydia and gonorrhoea in the presence of exogenous hormones and varying host microbiomes are unknown, it is biologically plausible that these complex factors may result in differential susceptibility to chlamydia and gonorrhoea among DMPA-IM, copper IUD and LNG implant users.An alternative explanation for these findings may be postrandomisation differences in clinical care and/or sexual behaviour. Participants in the copper IUD arm were more likely to have pelvic examinations and more likely to have discharge compared with women in the DMPA-IM and LNG implant groups. While interim STI testing and/or treatment were not documented, women in the copper IUD arm may have been more likely to receive syndromic STI treatment during follow-up due to more examination and observed discharge.

More frequent STI treatment in the copper IUD group would theoretically lower the final visit point prevalence relative to women in the DMPA-IM and LNG implant arms, suggesting that the observed lower risk of STI in the DMPA-IM arm is not due to differential examination, testing and treatment. Differential sexual risk behaviour may also have influenced the results. As reported previously, women in the DMPA-IM group less frequently reported condomless sex and multiple partners than women in the other groups, and both DMPA-IM and LNG implant users less frequently reported new partners and sex during menses than copper IUD users.6 Statistical control of self-reported sexual risk behaviour in the consistent-use analysis may have been inadequate if self-reported sexual behaviour was inaccurately or insufficiently reported.A second alternative explanation may be differences in randomised method non-adherence, which was greater in the DMPA-IM group, compared with copper IUD and LNG implant groups.

Yet, the consistency of findings in the as-randomised and continuous use analyses suggests that method non-adherence had minimal effect on study outcomes. Taken as a whole, these findings indicate that there may be real differences in chlamydia and gonorrhoea risk associated with use of DMPA-IM, the copper IUD and LNG implant. However, any true differential risk by method must be evaluated in light of the holistic benefits and risks of each method.The high observed chlamydia and gonorrhoea prevalences, despite intensive counselling and condom provision, warrants attention, particularly among women ages 24 years and younger and among women in South Africa and Eswatini.

While the ECHO study was conducted in settings of high HIV/STI incidence, enrolment criteria did not purposefully target women at highest risk of HIV/STI in the trial communities, suggesting that the observed prevalences may be broadly applicable to women seeking effective contraception in those settings. Improved approaches are needed to prevent STIs, including options for expedited partner treatment, to prevent re.As expected, few women testing positive for chlamydia or gonorrhoea presented with symptoms (12% and 15%, respectively), and a substantial proportion of women who were positive and treated at baseline were infected at the final visit despite syndromic management during the follow-up. Given that syndromic management is the standard of care within primary health facilities in most trial settings, these data suggest that a large proportion of among reproductive aged women is missed, exacerbating the burden of curable STIs and associated morbidities.

Routine access to more reliable diagnostics, like NAAT and novel point-of-care diagnostic tests, will be key to managing asymptomatic STIs and reducing STI prevalence and related morbidities in these settings.17This secondary analysis of the ECHO trial has strengths and limitations. Strengths include the randomised design with comparator groups of equal STI baseline risk. Participants had high adherence to their randomised contraceptive method.6 While all participants received standardised clinical care and counselling, the unblinded randomisation may have allowed postrandomisation differences in STI risk over time by method.

It is possible that participants modified their risk-taking behaviour based on study counselling messages regarding the potential association between DMPA-IM and HIV.In conclusion, our analyses suggest that DMPA-IM users may have lower risk of chlamydia and gonorrhoea compared with LNG implant and copper IUD users, respectively. Further investigation is warranted to better understand the mechanisms of chlamydia and gonorrhoea susceptibility in the context of contraceptive use. Moreover, the high chlamydia and gonorrhoea prevalences in this population, independent of contraceptive method, warrants urgent attention.Key messagesThe prevalence of chlamydia and gonorrhoea varied by contraceptive method in this randomised trial.High chlamydia and gonorrhoea prevalences, despite intensive counselling and condom provision, warrants attention, particularly among young women in South Africa and Eswatini.Most chlamydia and gonorrhoea s were asymptomatic.

Therefore, routine access to reliable diagnostics are needed to effectively manage and prevent STIs in African women..

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When Kayla Kjelshus gave birth to her first child, the viagra side effects alcohol infant spent seven days in the how to order viagra neonatal intensive care unit, known as the NICU. This stressful medical experience was followed by an equally stressful financial one. Because of an obscure health insurance policy called the “birthday rule,” Kjelshus and her husband, Mikkel, were viagra side effects alcohol hit with an unexpected charge of more than $200,000 for the NICU stay. Now, seven months after KHN and NPR published a story about the Kjelshus family’s experience, new parents may be spared this kind of financial uncertainty if lawmakers pass a bill that would give parents more control when it’s time to pick a health insurance policy for their child.

The new proposed law would eliminate the birthday rule. That rule dictates how viagra side effects alcohol insurance companies pick the primary insurer for a child when both parents have coverage. The parent whose birthday comes first in the calendar year covers the new baby with their plan first. For the Kjelshuses of Olathe, Kansas, that meant the insurance held by Mikkel, whose birthday is two weeks before his wife’s, was primary, even though his policy was much less generous and based in a different state.

€œIt’s an viagra side effects alcohol outdated policy,” Mikkel Kjelshus said. €œNowadays both parents typically have to work just to make ends meet.” Two jobs often means two offers of health insurance — and while double coverage should be a good thing, in practice, it can lead to a bureaucratic nightmare like the one the Kjelshuses faced. U.S. Rep.

Sharice Davids (D-Kansas) introduced “Empowering Parents’ Healthcare Choices Act,” a bill that would do away with “the birthday rule” and a “coordination of benefits policy” that trips up first-time parents up when it’s time to sign up a new baby for insurance. €œWhen I heard about the Kjelshus family’s story, I knew there had to be a way to help,” Davids said. €œParents should have the power when it comes to their new baby’s health care coverage.” For Charlie Kjelshus, the birthday rule meant her dad’s plan — with a $12,000 deductible, a high coinsurance obligation and a network focused in a different state — was deemed her primary coverage. Her mom’s more generous plan was secondary.

Confusion over the two plans caused a tangle of red tape for the family that took almost two years and national media attention to resolve. This model regulation was set by the National Association of Insurance Commissioners and adopted by most states, including Kansas, said Lee Modesitt, director of public affairs with the Kansas Insurance Department. It is a somewhat arbitrary rule that could be fair if all jobs offered health plans with similar coverage. But for many families, one partner’s plan is much more generous.

€œIt feels awesome,” Mikkel Kjelshus said of the news that a change has been proposed. €œWe really didn’t want this to happen to anyone else.” To be enacted, the bill would need to pass the House and Senate before receiving the president’s signature. Davids was elected to Congress in 2018, flipping a seat in Overland Park, Kansas, that had been held by a Republican for a decade. She was reelected in 2020 and is the only Democrat in Kansas’ House delegation.

Ellie Turner, a spokesperson for the congresswoman, said Davids is talking with colleagues in the House to garner additional support. €œIt’s becoming clear that the Kjelshus family is not alone in this experience,” Turner wrote in an email. €œWe are going to continue working to raise awareness and gain momentum for a birthday rule fix, because every family deserves a choice when it comes to their child’s health.” As they await the arrival of their second child, this time around the Kjelshus family has a better idea of how the health insurance will work. And, much like the first time, they feel prepared.

€œWe’ve got the crib. We’ve got the baby stuff. It’s a lot less stress this time around,” Mikkel Kjelshus said. €œWe kind of know what we’re doing.” Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills.

Do you have an interesting medical bill you want to share with us?. Tell us about it!. Cara Anthony. canthony@kff.org, @CaraRAnthony Related Topics Contact Us Submit a Story TipSAN BERNARDINO, Calif.

€” A few months ago, the boxy, teal truck parked outside a McDonald’s in this Inland Empire city might have drawn hundreds of people willing to stand in line for hours under the scorching sun. The truck is San Bernardino County’s mobile treatment unit, which brings erectile dysfunction treatments directly to people. But on July 15, only 22 people got a erectile dysfunction treatment shot during the four hours it sat there. Roughly 12 feet away, more people were often seen waiting by a red canopy for free, government-subsidized smartphones, intended for low-income people, than were stepping up for the potentially lifesaving shots.

Barry Luque, a 37-year-old car wash worker who visited the red canopy that day for a free phone, was lured by the truck. He had been eligible for a erectile dysfunction treatment since April but never got around to making an appointment. Had he not seen the truck in the parking lot on his day off, “this wouldn’t have gotten done,” he said. It’s Luque’s job to guide drivers into the car wash, but his boss won’t let him take his mask off unless he can show proof he’s vaccinated.

€œPeople come in from different lives, different styles, different moods at different times,” he said after getting his first dose of the Pfizer-BioNTech treatment. €œI’ve got to guide them carefully and gently, and it’s kinda hard for them to see the smile on my face.” Car wash worker Barry Luque got a erectile dysfunction treatment because his boss requires employees to wear masks unless they can show proof of vaccination. After months of guiding people into the car wash with a mask on, Luque wanted people to see his smile.(Anna Almendrala / KHN) Luque and the other 21 people who got vaccinated that day — in addition to the scores of others who drove by or waited in the McDonald’s drive-thru line without seeking a shot — offer a snapshot of California’s stalling vaccination effort. Some who finally got the shot, like Luque, were motivated by mandates from employers or are tired of wearing masks.

Others want to visit other countries, and vaccinations may help ease travel or quarantine requirements. Some were persuaded, at long last, by family and friends. Those who continued to hold out primarily cited potential side effects and distrust of the medical system. Recent polling shows that no matter which tactics are used, a strong majority of unvaccinated people are unlikely to budge on getting a shot, creating an increasingly dangerous scenario as the highly contagious delta variant burns through the country.

In California, about 2,800 people were hospitalized for erectile dysfunction treatment or suspected erectile dysfunction treatment — more than twice the number six weeks earlier — as of Wednesday. About 61% of Californians age 12 and up were fully vaccinated by then, according to the U.S. Centers for Disease Control and Prevention, ranking the state 18th among other states and the District of Columbia. But the overall rate masks deep disparities among, and even within, regions.

In geographically and ethnically diverse San Bernardino County, about 47% of eligible residents were fully vaccinated as of Wednesday, with the lowest rates among young people, men, Latinos, Blacks and those who live in the poorest and unhealthiest communities. Statewide, the profile of unvaccinated people is largely the same. San Bernardino County’s pop-up erectile dysfunction treatment clinic in the parking lot of a McDonald’s in San Bernardino, California, on July 15 was open to walk-ups and those who made appointments. During the four-hour event, 22 people received shots.(Anna Almendrala / KHN) One way local and state leaders are trying to get shots into residents’ arms is by hosting pop-up clinics that make erectile dysfunction treatments more convenient and accessible for those who can’t or won’t sign up for an appointment.

San Bernardino County is organizing pop-up events at supermarkets, schools, churches and community centers. The state is also funding treatment clinics, including 155 events at more than 80 McDonald’s restaurants in 11 counties as of Wednesday. The pop-ups require significant resources and are showing diminishing returns. About 2,500 doses have been administered at the McDonald’s clinics so far — an average of 16 shots per event.

The California Department of Public Health declined to say how much these events cost, saying it varies. At the McDonald’s in San Bernardino, a city of more than 200,000 that serves as the county seat, eight staffers were on hand to check people in, administer shots and watch for side effects from 9 a.m. To 1 p.m. They also scheduled the necessary second dose for another local pop-up event.

Nancy Garcia, a San Bernardino County employee who managed the July 15 pop-up treatment clinic in San Bernardino, California, says she works a “crazy schedule” to get people vaccinated. Garcia, who lost her mother and a cousin to erectile dysfunction treatment, says she’s deep in the throes of grief. (Anna Almendrala / KHN) Jeisel Estabillo, 36, hadn’t been vaccinated, even though she is a registered nurse who sometimes cares for erectile dysfunction treatment patients at a hospital. She was one of the first people in the county to become eligible for treatments, in December, but avoided getting a shot because she wanted to wait and see how it would affect others.

She also tested positive for erectile dysfunction treatment during the winter surge. But Estabillo changed her mind and visited the treatment clinic with her father and teenage son because they plan to vacation in the Philippines next year and hope vaccination will reduce travel restrictions or quarantines. Estabillo also likes that vaccinated people can forgo masks in most public places, although that perk may slip away as more California counties respond to the delta surge by calling on residents to mask up again indoors. But Jasmine Woodson continued to hold out against the treatment even though she was hired to provide security and direct traffic for the clinic.

Woodson, 24, is studying to become a pharmacy technician and has been tracking treatment news. She said she was alarmed by the brief pause in the administration of the one-shot Johnson &. Johnson treatment over concern about blood clots, and reports of rare heart inflammation linked to the Moderna and Pfizer treatments. She also knows that no erectile dysfunction treatment has been fully approved by the Food and Drug Administration, which puts her on high alert.

Woodson, who is Black, is also wary because these mobile treatment events seem to take place only in low-income Black and Latino neighborhoods — a tactic public health officials say is meant to increase uptake in these communities. €œEvery day there’s always something new. You’re not meant to live that long, so if you get it, you get it, and if you don’t, you don’t,” Woodson said of erectile dysfunction treatment. Jasmine Woodson provided security for the San Bernardino County pop-up erectile dysfunction treatment clinic on July 15 in San Bernardino, California, but hasn’t gotten vaccinated herself.

Woodson says she is cautious about the new treatments because of the blood clots linked to the Johnson &. Johnson shot, as well as the rare heart inflammation side effects linked to the mRNA treatments. (Anna Almendrala / KHN) Maxine Luna, 69, who came to the nearby red canopy to get a phone, also was not swayed. A longtime smoker whose doctor has been pleading with her to get a erectile dysfunction treatment shot, she fears side effects, mentioning a friend who battled two weeks of headaches, diarrhea and vomiting after getting vaccinated.

To mitigate her risk, Luna sticks close to her home, which she shares with her brother, who is vaccinated, and her sister and brother-in-law, who are not. €œWe’re not out and about, we don’t go to shows, and we don’t go to crowded places,” she said. Concern about side effects is the most common reason holdouts cite for not getting a erectile dysfunction treatment, said Ashley Kirzinger, associate director of public opinion and survey research for KFF. (The KHN newsroom is an editorially independent program of KFF.) This is followed by fear that the treatment is too new or hasn’t been tested enough.

Kirzinger said it’s important to acknowledge that some people simply can’t be persuaded. €œThey don’t see themselves at risk for erectile dysfunction treatment, they think that the treatment is a greater risk to their health than the viagra itself, and there’s really no incentive, no stick, no message, no messenger that’s going to convince these populations,” she said. €œIt’s going to be really hard to reach the goals set by public health officials, with the decreasing enthusiasm around the treatment that we have seen in the past several weeks.” Maxine Luna says she hasn’t gotten a erectile dysfunction treatment because a friend experienced two weeks of unpleasant side effects afterward. Still, she’s scared of the delta variant and mostly stays at home to reduce her risk.

(Anna Almendrala / KHN) This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation. This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Anna Almendrala. aalmendrala@kff.org, @annaalmendrala Related Topics Contact Us Submit a Story TipAURORA, Colo. €” Fatumo Osman, a 65-year-old Somali refugee who speaks limited English, was in a bind. She made too much money at a meal prep service job so she no longer qualified for Medicaid.

But knee pain kept her from working, so her income had dropped. She could reapply for Medicaid, get her knee fixed and return to work, at which point she’d lose that safety-net health coverage. Her first step was getting a note from a doctor so she wouldn’t lose her job. So, Osman came to Mango House, a clinic in this eastern suburb of Denver that caters primarily to refugees and turns no one away, regardless of their ability to pay.

Dr. P.J. Parmar designed the clinic to survive on the Medicaid payments that many doctors across the U.S. Reject as too low.

The clinic is just one part of a broader refugee ecosystem that Parmar has built. Mango House provides food and clothing assistance, after-school programs, English classes, legal help — and Parmar even leads a Boy Scout troop there. He leases space to nine stores and six restaurants, all owned and run by refugees. Mango House hosts a dozen religious groups, plus community meetings, weddings and other celebrations.

When Parmar needs an interpreter for a patient from any of a dozen languages spoken in the building, he can easily grab one of his tenants. €œThis is what I call a medical home,” Parmar said. Although it’s not part of the formal U.S. Refugee resettlement program, Mango House is in many ways emblematic of refugee health care in the U.S.

It’s a less-than-lucrative field of medicine that often relies on individual physicians willing to eke out a living caring for an underserved and under-resourced population. Parmar finds creative ways, often flouting norms or skirting rules, to fit his patients’ needs. As a result, Mango House looks nothing like the rest of the U.S. Health care system and, at times, draws the ire of the medical establishment.

€œHow do you deliver the quality of care necessary, and that they deserve, while still keeping the lights on?. It’s a struggle for sure,” said Jim Sutton, executive director of the Society of Refugee Healthcare Providers. €œIt’s these heroes, these champions out there, these cowboys that are taking this on.” Dr. P.J.

Parmar examines Johnny Lun Ring at the Mango House clinic on June 24. His father, Khang Pang (right), a Kachin Rawang refugee, is a pastor of one of the churches that meets at Mango House. At far right is another of Pang’s children, Noel Nang Shan Dvbe. The clinic caters primarily to refugees and turns no one away, regardless of their ability to pay.

Parmar designed the clinic to survive on the Medicaid payments that many doctors across the U.S. Reject as too low. (Ross Taylor for KHN) Osman brought her son, Jabarti Yussef, 33, to interpret for her. They have been coming to Mango House for 10 years and said that Parmar opens doors for them when they have trouble accessing care.

€œIf we ask for an appointment to get Medicaid, P.J. Makes the call,” Yussef said. €œIf we call, we’re on hold for an hour, and then it hangs up. If we go to the ER, it’s a three-hour wait.

Here, the majority of people walk in and sit for 30 minutes. It’s good for the community.” As for Osman’s knee pain, Yussef asked Parmar, could they pay cash to get an MRI at the hospital?. “I can almost guarantee it’s arthritis,” Parmar replied. €œYou could do an X-ray.

That will cost $100. An MRI will cost $500. And if it shows a bigger problem, what are you going to do?. It will cost you $100,000.” Parmar said he would connect them with someone who could help Osman enroll in Medicaid but that it’s an imperfect solution.

€œMost orthopedists don’t take Medicaid,” Parmar said. Older immigrants need to have worked the equivalent of 10 years in the U.S. To qualify for Medicare. Dr.

P.J. Parmar must navigate a host of obstacles while working to overcome financial and language barriers with the patients he treats at Mango House. Many of them are refugees and he offers them treatment even when they don’t have insurance to cover the cost. Here, he checks the wrist of Dhan Ghishing, a refugee from Nepal who had come to see him on June 24 for various medical issues.

(Ross Taylor for KHN) Medicaid, which covers low-income people, generally pays primary health care providers a third less than Medicare, which covers seniors and the disabled. And both pay even less than commercial insurance plans. Some doctors paint Medicaid patients as more difficult and less likely to follow instructions, show up on time or speak English. Parmar said he realized back in medical school that few doctors were motivated to treat Medicaid patients.

If he limited his practice to just Medicaid, he said dryly, he’d have guaranteed customers and no competition. So how does he survive on Medicaid rates?. By keeping his overhead low. There are no appointments, so no costs for a receptionist or scheduling software.

He said his patients often like that they can drop in anytime and be seen on a first-come, first-served basis, much like an urgent care clinic, and similar to the way things worked in their native countries. Because he takes only Medicaid, he knows how to bill the program and doesn’t have to hire billing specialists to deal with 10 insurance companies. It’s also more cost-efficient for the health system. Many of his patients would otherwise go to the emergency room, sometimes avoiding care altogether until their problems get much worse and more expensive to fix.

€œReally none of our innovations are new or unique. We just put them together in a unique way to help low-income folks, while making money,” Parmar said. €œAnd then, instead of taking that money home, I put it back into the refugee community.” Mango House leases out space to nine stores and six restaurants, all owned and run by refugees. When Dr.

P.J. Parmar needs an interpreter for a patient from any of a dozen languages spoken in the building, he often grabs one of his tenants to help, an unorthodox practice. Parmar talks with Doug Adams (left) and Eric Solem who were eating in the food court of Mango House on June 24. (Ross Taylor for KHN) The son of Indian immigrants, Parmar, 46, was born in Canada but grew up in Chicago and moved to Colorado after college in 1999, where he did his medical training at the University of Colorado School of Medicine.

He opened Mango House 10 years ago, buying a building and renting out space to refugees to cover the cost. Two years ago, he expanded into a vacant J.C. Penney building across the street. €œThere’s a good three-, four-year dip in the red here, intentionally, as we move from there to here,” Parmar said.

€œBut that red is going to go away soon.” The erectile dysfunction treatment viagra has helped shore up his finances, as federal incentives and payment increases boosted revenue and allowed him to pay down his debt faster. Parmar must navigate a host of obstacles while working to overcome financial and language barriers. A Muslim Somali woman needs dental care but is uncomfortable seeing a male dentist. A Nepalese woman needs a prescription refill, but she lives in Denver and so has been assigned by Medicaid to the safety-net hospital, Denver Health.

Parmar won’t get paid but sees her anyway. Another patient brings paperwork showing he’s being sued by a local health system for a year-old emergency room bill he has no way to pay. A Nepalese man with psoriasis doesn’t want creams or ointments. Good medicine, he believes, comes through a needle.

€œA lot of this is, basically, geriatrics,” Parmar said. €œYou have to add 20 years to get their age in refugee years.” When one patient turns away momentarily, Parmar discreetly throws away her bottle of meloxicam, a strong anti-inflammatory he said she shouldn’t be taking because of her kidney problems. He began stocking over-the-counter medications after realizing his patients got overwhelmed amid 200 varieties of cough and cold medicines at the drugstore. Some couldn’t find what he told them to get, even after he printed flyers showing pictures of the products.

Parmar’s creative solutions, however, often rub many in health care the wrong way. Some balk at his use of family members or others as informal interpreters. Best practices call for the use of trained interpreters who understand medicine and patient privacy rules. But billing for interpretation isn’t possible, so hospitals and clinics must pay interpreters themselves.

And that’s beyond the capabilities of most refugee clinics, unless they’re affiliated with a larger health system that can absorb those costs. Dr. P.J. Parmar talks with Tabarak Saed, Saja Saed and Feryal Saddek, who are refugees from Palestine, on June 24 in the waiting room.

Saddek came to see him about a foot issue. Patients are seen on a first-come, first-served basis, much like an urgent care clinic, and similar to the way things worked in many of the patients’ native countries. This also helps minimize the clinic’s costs, with no need for a receptionist or scheduling software.(Ross Taylor for KHN) “It’s a good thing to have the standards, but it’s another thing altogether to implement them,” said Dr. Pat Walker, an expert on refugee health at the University of Minnesota.

When Mango House began providing erectile dysfunction treatments, residents of more affluent areas of town started showing up. Parmar tried to limit vaccinations only to those patients living in the immediate area, checking ZIP codes on their IDs. The state stepped in to say he could neither require IDs nor turn away any patients, regardless of his refugee-focused mission. During a recent lull at the clinic, Parmar took stock of that day’s inventory of patients.

Six were assigned to Denver Health, one patient’s Medicaid coverage had expired, and two had high-deductible commercial plans. Chances are he wouldn’t get paid for seeing any of them. Of the 25 patients he had seen that day, 14 had Medicaid coverage that Parmar could bill. €œWe see the rest of them anyway,” he said.

Markian Hawryluk. MarkianH@kff.org, @MarkianHawryluk Related Topics Contact Us Submit a Story TipKathi Arbini said she felt elated when Missouri finally caught up to the other 49 states and approved a statewide prescription drug monitoring program this June in an attempt to curb opioid addiction. The hairstylist turned activist estimated she made 75 two-hour trips in the past decade from her home in Fenton, a St. Louis suburb, to the state capital, Jefferson City, to convince Republican lawmakers that monitoring how doctors and pharmacists prescribe and dispense controlled substances could help save people like her son, Kevin Mullane.

He was a poet and skateboarder who she said turned to drugs after she and his dad divorced. He started “doctor-shopping” at about age 17 and was able to obtain multiple prescriptions for the pain medication OxyContin. He died in 2009 at 21 from a heroin overdose. If the state had had a monitoring program, doctors might have detected Mullane’s addiction and, Arbini thinks, her son might still be alive.

She said it’s been embarrassing that it’s taken Missouri so long to agree to add one. €œAs a parent, you would stand in front of a train. You would protect your child forever — and if this helps, it helps,” said Arbini, 61. €œIt can’t kill more people, I don’t think.” But even though Missouri was the lone outlier, it had not been among the states with the highest opioid overdose death rates.

Missouri had an average annual rank of 16th among states from 2010 through 2019, as the country descended into an opioid epidemic, according to a KHN analysis of Centers for Disease Control and Prevention data compiled by KFF. Some in public health now argue that when providers use such monitoring programs to cut off prescription opiate misuse, people who have an addiction instead turn to heroin and fentanyl. That means Missouri’s new toll could cause more people to overdose and leave the state with buyer’s remorse. €œIf we can take any benefit from being last in the country to do this, my hope would be that we have had ample opportunity to learn from others’ mistakes and not repeat them,” said Rachel Winograd, a psychologist who leads NoMODeaths, a state program aimed at reducing harm from opioid misuse.

Before Missouri’s monitoring program was approved, lawmakers and health and law enforcement officials warned that the absence made it easier for Missouri patients to doctor-shop to obtain a particular drug, or for providers to overprescribe opiates in what are known as pill mills. State Sen. Holly Rehder, a Republican with family members who have struggled with opioid addiction, spent almost a decade pushing legislation to establish a monitoring program but ran into opposition from state Sen. Rob Schaaf, a family physician and fellow Republican who expressed concerns about patient privacy and fears about hacking.

In 2017, Schaaf agreed to stop filibustering the legislation and support it if it required that doctors check the database for other prescriptions before writing new ones for a patient. That, though, sparked fresh opposition from the Missouri State Medical Association, concerned the requirement could expose physicians to malpractice lawsuits if patients overdosed. The new law does not include such a requirement for prescribers. Pharmacists who dispense controlled substances will be required to enter prescriptions into the database.

Dr. Silvia Martins, an epidemiologist at Columbia University who has studied monitoring programs, said it’s important to mandate that prescribers review a patient’s information in the database. €œWe know that the ones that are most effective are the ones where they check it regularly, on a weekly basis, not just on a monthly basis,” she said. But Stephen Wood, a nurse practitioner and visiting substance abuse bioethics researcher at Harvard Law School, said the tool is often punitive because it cuts off access to opioids without offering viable treatment options.

He and his colleagues in the intensive care unit at Carney Hospital in Boston don’t use the Massachusetts monitoring program nearly as often as they once did. Instead, he said, they rely on toxicology screens, signs such as injection marks or the patients themselves, who often admit they are addicted. €œRather than pulling out a piece of paper and being accusatory, I find it’s much better to present myself as a caring provider and sit down and have an honest discussion,” Wood said. When Kentucky in 2012 became the first state to require prescribers and dispensers to use the system, the number of opioid prescriptions and overdoses from prescription opioids initially decreased slightly, according to a state study.

But the number of opioid overdose deaths — with the exception of a slight dip in 2018 and 2019 — has since consistently ticked upward, according to a KFF analysis of CDC data. In 2020, Kentucky was estimated to have had the nation’s second-largest increase in drug overdose deaths. When efforts to establish Missouri’s statewide monitoring program stalled, St. Louis County established one in 2017 that 75 local jurisdictions agreed to participate in, covering 85% of the state, according to the county health department.

The county now plans to move its program into the state one, which is scheduled to launch in 2023. Dr. Faisal Khan, director of the county department, said he has no doubt that the St. Louis program has “saved lives across the state.” Opioid prescriptions decreased dramatically once the county established the monitoring program.

In 2016, Missouri averaged 80.4 opioid prescriptions per 100 people. In 2019, it was down to 58.3 prescriptions, according to the CDC. The overall drug overdose death rate in Missouri has steadily increased since 2016, though, with the CDC reporting an initial count of 1,921 people dying from overdoses of all kinds of drugs in 2020. Khan acknowledged that a monitoring program can lead to an increase in overdose deaths in the years immediately following its establishment because people addicted to prescription opioids suddenly can’t obtain them and instead buy street drugs that are more potent and contain impurities.

But he said a monitoring program can also help a physician intervene before someone becomes addicted. Doctors who flag a patient using the monitoring program must then also be able to easily refer them to treatment, Khan and others said. €œWe absolutely are not prepared for that in Missouri,” said Winograd, of NoMODeaths. €œSubstance use treatment providers will frequently tell you that they are at max capacity.” Uninsured people in rural areas may have to wait five weeks for inpatient or outpatient treatment at state-funded centers, according to PreventEd, a St.

Louis-based nonprofit that aims to reduce harm from alcohol and drug use. For example, the waiting list for residential treatment at the Preferred Family Healthcare clinic in Trenton is typically two weeks during the summer and one month in winter, according to Melanie Tipton, who directs clinical services at the center, which mostly serves uninsured clients in rural northern Missouri. Tipton, who has worked at the clinic for 17 years, said that before the erectile dysfunction treatment viagra, people struggling with opioid addiction mainly used prescription pills. Now it’s mostly heroin and fentanyl, because they are cheaper.

Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine, according to the National Institute on Drug Abuse. Still, Tipton said her clients continue to find providers who overprescribe opiates, so she thinks a statewide monitoring program could help. Inez Davis, diversion program manager for the Drug Enforcement Administration’s St. Louis division, also said in an email that the program will benefit Missouri and neighboring states because “doctor shoppers and those who commit prescription fraud now have one less avenue.” Winograd said it’s possible that if the state had more opioid prescription pill mills, it would have a lower overdose death rate.

€œI don’t think that’s the answer,” she said. €œWe need to move in the direction of decriminalization and a regulated drug supply.” Specifically, she’d rather Missouri decriminalize possession of small amounts of hard drugs, even heroin, and institute regulations to ensure the drugs are safe. State Rep. Justin Hill, a Republican from St.

Charles and former narcotics detective, opposed the monitoring program legislation because of his concerns over patient privacy and evidence that the lack of a program has not made Missouri’s opioid problem any worse than many other states’. He also worries the monitoring program will lead to an increase in overdose deaths. €œI would love the people that passed this bill to stand by the numbers,” Hill said. €œAnd if we see more deaths from overdose, scrap the monitoring program and go back to the drawing board.” Related Topics Contact Us Submit a Story Tip[embedded content] The vast majority of the viagra’s 4.1 million erectile dysfunction treatment s in children have been mild.

However, doctors are concerned about a growing number of long-haul erectile dysfunction treatment cases and a rare but dangerous inflammatory disease, particularly among Black and Latino children. KHN correspondent Sarah Varney, in collaboration with PBS NewsHour, reports on the phenomena. This story aired on July 23, 2021. Sarah Varney.

svarney@kff.org, @SarahVarney4 Related Topics Contact Us Submit a Story Tip.

When Kayla Kjelshus gave birth to her first child, the infant spent seven days in the neonatal intensive visit this website care how can i buy viagra unit, known as the NICU. This stressful medical experience was followed by an equally stressful financial one. Because of an obscure health insurance policy called the “birthday rule,” Kjelshus and her husband, Mikkel, were hit with an unexpected charge of more than $200,000 for the how can i buy viagra NICU stay. Now, seven months after KHN and NPR published a story about the Kjelshus family’s experience, new parents may be spared this kind of financial uncertainty if lawmakers pass a bill that would give parents more control when it’s time to pick a health insurance policy for their child.

The new proposed law would eliminate the birthday rule. That rule dictates how insurance companies pick the primary insurer for a how can i buy viagra child when both parents have coverage. The parent whose birthday comes first in the calendar year covers the new baby with their plan first. For the Kjelshuses of Olathe, Kansas, that meant the insurance held by Mikkel, whose birthday is two weeks before his wife’s, was primary, even though his policy was much less generous and based in a different state.

€œIt’s an outdated policy,” Mikkel Kjelshus how can i buy viagra said. €œNowadays both parents typically have to work just to make ends meet.” Two jobs often means two offers of health insurance — and while double coverage should be a good thing, in practice, it can lead to a bureaucratic nightmare like the one the Kjelshuses faced. U.S. Rep.

Sharice Davids (D-Kansas) introduced “Empowering Parents’ Healthcare Choices Act,” a bill that would do away with “the birthday rule” and a “coordination of benefits policy” that trips up first-time parents up when it’s time to sign up a new baby for insurance. €œWhen I heard about the Kjelshus family’s story, I knew there had to be a way to help,” Davids said. €œParents should have the power when it comes to their new baby’s health care coverage.” For Charlie Kjelshus, the birthday rule meant her dad’s plan — with a $12,000 deductible, a high coinsurance obligation and a network focused in a different state — was deemed her primary coverage. Her mom’s more generous plan was secondary.

Confusion over the two plans caused a tangle of red tape for the family that took almost two years and national media attention to resolve. This model regulation was set by the National Association of Insurance Commissioners and adopted by most states, including Kansas, said Lee Modesitt, director of public affairs with the Kansas Insurance Department. It is a somewhat arbitrary rule that could be fair if all jobs offered health plans with similar coverage. But for many families, one partner’s plan is much more generous.

€œIt feels awesome,” Mikkel Kjelshus said of the news that a change has been proposed. €œWe really didn’t want this to happen to anyone else.” To be enacted, the bill would need to pass the House and Senate before receiving the president’s signature. Davids was elected to Congress in 2018, flipping a seat in Overland Park, Kansas, that had been held by a Republican for a decade. She was reelected in 2020 and is the only Democrat in Kansas’ House delegation.

Ellie Turner, a spokesperson for the congresswoman, said Davids is talking with colleagues in the House to garner additional support. €œIt’s becoming clear that the Kjelshus family is not alone in this experience,” Turner wrote in an email. €œWe are going to continue working to raise awareness and gain momentum for a birthday rule fix, because every family deserves a choice when it comes to their child’s health.” As they await the arrival of their second child, this time around the Kjelshus family has a better idea of how the health insurance will work. And, much like the first time, they feel prepared.

€œWe’ve got the crib. We’ve got the baby stuff. It’s a lot less stress this time around,” Mikkel Kjelshus said. €œWe kind of know what we’re doing.” Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills.

Do you have an interesting medical bill you want to share with us?. Tell us about it!. Cara Anthony. canthony@kff.org, @CaraRAnthony Related Topics Contact Us Submit a Story TipSAN BERNARDINO, Calif.

€” A few months ago, the boxy, teal truck parked outside a McDonald’s in this Inland Empire city might have drawn hundreds of people willing to stand in line for hours under the scorching sun. The truck is San Bernardino County’s mobile treatment unit, which brings erectile dysfunction treatments directly to people. But on July 15, only 22 people got a erectile dysfunction treatment shot during the four hours it sat there. Roughly 12 feet away, more people were often seen waiting by a red canopy for free, government-subsidized smartphones, intended for low-income people, than were stepping up for the potentially lifesaving shots.

Barry Luque, a 37-year-old car wash worker who visited the red canopy that day for a free phone, was lured by the truck. He had been eligible for a erectile dysfunction treatment since April but never got around to making an appointment. Had he not seen the truck in the parking lot on his day off, “this wouldn’t have gotten done,” he said. It’s Luque’s job to guide drivers into the car wash, but his boss won’t let him take his mask off unless he can show proof he’s vaccinated.

€œPeople come in from different lives, different styles, different moods at different times,” he said after getting his first dose of the Pfizer-BioNTech treatment. €œI’ve got to guide them carefully and gently, and it’s kinda hard for them to see the smile on my face.” Car wash worker Barry Luque got a erectile dysfunction treatment because his boss requires employees to wear masks unless they can show proof of vaccination. After months of guiding people into the car wash with a mask on, Luque wanted people to see his smile.(Anna Almendrala / KHN) Luque and the other 21 people who got vaccinated that day — in addition to the scores of others who drove by or waited in the McDonald’s drive-thru line without seeking a shot — offer a snapshot of California’s stalling vaccination effort. Some who finally got the shot, like Luque, were motivated by mandates from employers or are tired of wearing masks.

Others want to visit other countries, and vaccinations may help ease travel or quarantine requirements. Some were persuaded, at long last, by family and friends. Those who continued to hold out primarily cited potential side effects and distrust of the medical system. Recent polling shows that no matter which tactics are used, a strong majority of unvaccinated people are unlikely to budge on getting a shot, creating an increasingly dangerous scenario as the highly contagious delta variant burns through the country.

In California, about 2,800 people were hospitalized for erectile dysfunction treatment or suspected erectile dysfunction treatment — more than twice the number six weeks earlier — as of Wednesday. About 61% of Californians age 12 and up were fully vaccinated by then, according to the U.S. Centers for Disease Control and Prevention, ranking the state 18th among other states and the District of Columbia. But the overall rate masks deep disparities among, and even within, regions.

In geographically and ethnically diverse San Bernardino County, about 47% of eligible residents were fully vaccinated as of Wednesday, with the lowest rates among young people, men, Latinos, Blacks and those who live in the poorest and unhealthiest communities. Statewide, the profile of unvaccinated people is largely the same. San Bernardino County’s pop-up erectile dysfunction treatment clinic in the parking lot of a McDonald’s in San Bernardino, California, on July 15 was open to walk-ups and those who made appointments. During the four-hour event, 22 people received shots.(Anna Almendrala / KHN) One way local and state leaders are trying to get shots into residents’ arms is by hosting pop-up clinics that make erectile dysfunction treatments more convenient and accessible for those who can’t or won’t sign up for an appointment.

San Bernardino County is organizing pop-up events at supermarkets, schools, churches and community centers. The state is also funding treatment clinics, including 155 events at more than 80 McDonald’s restaurants in 11 counties as of Wednesday. The pop-ups require significant resources and are showing diminishing returns. About 2,500 doses have been administered at the McDonald’s clinics so far — an average of 16 shots per event.

The California Department of Public Health declined to say how much these events cost, saying it varies. At the McDonald’s in San Bernardino, a city of more than 200,000 that serves as the county seat, eight staffers were on hand to check people in, administer shots and watch for side effects from 9 a.m. To 1 p.m. They also scheduled the necessary second dose for another local pop-up event.

Nancy Garcia, a San Bernardino County employee who managed the July 15 pop-up treatment clinic in San Bernardino, California, says she works a “crazy schedule” to get people vaccinated. Garcia, who lost her mother and a cousin to erectile dysfunction treatment, says she’s deep in the throes of grief. (Anna Almendrala / KHN) Jeisel Estabillo, 36, hadn’t been vaccinated, even though she is a registered nurse who sometimes cares for erectile dysfunction treatment patients at a hospital. She was one of the first people in the county to become eligible for treatments, in December, but avoided getting a shot because she wanted to wait and see how it would affect others.

She also tested positive for erectile dysfunction treatment during the winter surge. But Estabillo changed her mind and visited the treatment clinic with her father and teenage son because they plan to vacation in the Philippines next year and hope vaccination will reduce travel restrictions or quarantines. Estabillo also likes that vaccinated people can forgo masks in most public places, although that perk may slip away as more California counties respond to the delta surge by calling on residents to mask up again indoors. But Jasmine Woodson continued to hold out against the treatment even though she was hired to provide security and direct traffic for the clinic.

Woodson, 24, is studying to become a pharmacy technician and has been tracking treatment news. She said she was alarmed by the brief pause in the administration of the one-shot Johnson &. Johnson treatment over concern about blood clots, and reports of rare heart inflammation linked to the Moderna and Pfizer treatments. She also knows that no erectile dysfunction treatment has been fully approved by the Food and Drug Administration, which puts her on high alert.

Woodson, who is Black, is also wary because these mobile treatment events seem to take place only in low-income Black and Latino neighborhoods — a tactic public health officials say is meant to increase uptake in these communities. €œEvery day there’s always something new. You’re not meant to live that long, so if you get it, you get it, and if you don’t, you don’t,” Woodson said of erectile dysfunction treatment. Jasmine Woodson provided security for the San Bernardino County pop-up erectile dysfunction treatment clinic on July 15 in San Bernardino, California, but hasn’t gotten vaccinated herself.

Woodson says she is cautious about the new treatments because of the blood clots linked to the Johnson &. Johnson shot, as well as the rare heart inflammation side effects linked to the mRNA treatments. (Anna Almendrala / KHN) Maxine Luna, 69, who came to the nearby red canopy to get a phone, also was not swayed. A longtime smoker whose doctor has been pleading with her to get a erectile dysfunction treatment shot, she fears side effects, mentioning a friend who battled two weeks of headaches, diarrhea and vomiting after getting vaccinated.

To mitigate her risk, Luna sticks close to her home, which she shares with her brother, who is vaccinated, and her sister and brother-in-law, who are not. €œWe’re not out and about, we don’t go to shows, and we don’t go to crowded places,” she said. Concern about side effects is the most common reason holdouts cite for not getting a erectile dysfunction treatment, said Ashley Kirzinger, associate director of public opinion and survey research for KFF. (The KHN newsroom is an editorially independent program of KFF.) This is followed by fear that the treatment is too new or hasn’t been tested enough.

Kirzinger said it’s important to acknowledge that some people simply can’t be persuaded. €œThey don’t see themselves at risk for erectile dysfunction treatment, they think that the treatment is a greater risk to their health than the viagra itself, and there’s really no incentive, no stick, no message, no messenger that’s going to convince these populations,” she said. €œIt’s going to be really hard to reach the goals set by public health officials, with the decreasing enthusiasm around the treatment that we have seen in the past several weeks.” Maxine Luna says she hasn’t gotten a erectile dysfunction treatment because a friend experienced two weeks of unpleasant side effects afterward. Still, she’s scared of the delta variant and mostly stays at home to reduce her risk.

(Anna Almendrala / KHN) This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation. This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Anna Almendrala. aalmendrala@kff.org, @annaalmendrala Related Topics Contact Us Submit a Story TipAURORA, Colo. €” Fatumo Osman, a 65-year-old Somali refugee who speaks limited English, was in a bind. She made too much money at a meal prep service job so she no longer qualified for Medicaid.

But knee pain kept her from working, so her income had dropped. She could reapply for Medicaid, get her knee fixed and return to work, at which point she’d lose that safety-net health coverage. Her first step was getting a note from a doctor so she wouldn’t lose her job. So, Osman came to Mango House, a clinic in this eastern suburb of Denver that caters primarily to refugees and turns no one away, regardless of their ability to pay.

Dr. P.J. Parmar designed the clinic to survive on the Medicaid payments that many doctors across the U.S. Reject as too low.

The clinic is just one part of a broader refugee ecosystem that Parmar has built. Mango House provides food and clothing assistance, after-school programs, English classes, legal help — and Parmar even leads a Boy Scout troop there. He leases space to nine stores and six restaurants, all owned and run by refugees. Mango House hosts a dozen religious groups, plus community meetings, weddings and other celebrations.

When Parmar needs an interpreter for a patient from any of a dozen languages spoken in the building, he can easily grab one of his tenants. €œThis is what I call a medical home,” Parmar said. Although it’s not part of the formal U.S. Refugee resettlement program, Mango House is in many ways emblematic of refugee health care in the U.S.

It’s a less-than-lucrative field of medicine that often relies on individual physicians willing to eke out a living caring for an underserved and under-resourced population. Parmar finds creative ways, often flouting norms or skirting rules, to fit his patients’ needs. As a result, Mango House looks nothing like the rest of the U.S. Health care system and, at times, draws the ire of the medical establishment.

€œHow do you deliver the quality of care necessary, and that they deserve, while still keeping the lights on?. It’s a struggle for sure,” said Jim Sutton, executive director of the Society of Refugee Healthcare Providers. €œIt’s these heroes, these champions out there, these cowboys that are taking this on.” Dr. P.J.

Parmar examines Johnny Lun Ring at the Mango House clinic on June 24. His father, Khang Pang (right), a Kachin Rawang refugee, is a pastor of one of the churches that meets at Mango House. At far right is another of Pang’s children, Noel Nang Shan Dvbe. The clinic caters primarily to refugees and turns no one away, regardless of their ability to pay.

Parmar designed the clinic to survive on the Medicaid payments that many doctors across the U.S. Reject as too low. (Ross Taylor for KHN) Osman brought her son, Jabarti Yussef, 33, to interpret for her. They have been coming to Mango House for 10 years and said that Parmar opens doors for them when they have trouble accessing care.

€œIf we ask for an appointment to get Medicaid, P.J. Makes the call,” Yussef said. €œIf we call, we’re on hold for an hour, and then it hangs up. If we go to the ER, it’s a three-hour wait.

Here, the majority of people walk in and sit for 30 minutes. It’s good for the community.” As for Osman’s knee pain, Yussef asked Parmar, could they pay cash to get an MRI at the hospital?. “I can almost guarantee it’s arthritis,” Parmar replied. €œYou could do an X-ray.

That will cost $100. An MRI will cost $500. And if it shows a bigger problem, what are you going to do?. It will cost you $100,000.” Parmar said he would connect them with someone who could help Osman enroll in Medicaid but that it’s an imperfect solution.

€œMost orthopedists don’t take Medicaid,” Parmar said. Older immigrants need to have worked the equivalent of 10 years in the U.S. To qualify for Medicare. Dr.

P.J. Parmar must navigate a host of obstacles while working to overcome financial and language barriers with the patients he treats at Mango House. Many of them are refugees and he offers them treatment even when they don’t have insurance to cover the cost. Here, he checks the wrist of Dhan Ghishing, a refugee from Nepal who had come to see him on June 24 for various medical issues.

(Ross Taylor for KHN) Medicaid, which covers low-income people, generally pays primary health care providers a third less than Medicare, which covers seniors and the disabled. And both pay even less than commercial insurance plans. Some doctors paint Medicaid patients as more difficult and less likely to follow instructions, show up on time or speak English. Parmar said he realized back in medical school that few doctors were motivated to treat Medicaid patients.

If he limited his practice to just Medicaid, he said dryly, he’d have guaranteed customers and no competition. So how does he survive on Medicaid rates?. By keeping his overhead low. There are no appointments, so no costs for a receptionist or scheduling software.

He said his patients often like that they can drop in anytime and be seen on a first-come, first-served basis, much like an urgent care clinic, and similar to the way things worked in their native countries. Because he takes only Medicaid, he knows how to bill the program and doesn’t have to hire billing specialists to deal with 10 insurance companies. It’s also more cost-efficient for the health system. Many of his patients would otherwise go to the emergency room, sometimes avoiding care altogether until their problems get much worse and more expensive to fix.

€œReally none of our innovations are new or unique. We just put them together in a unique way to help low-income folks, while making money,” Parmar said. €œAnd then, instead of taking that money home, I put it back into the refugee community.” Mango House leases out space to nine stores and six restaurants, all owned and run by refugees. When Dr.

P.J. Parmar needs an interpreter for a patient from any of a dozen languages spoken in the building, he often grabs one of his tenants to help, an unorthodox practice. Parmar talks with Doug Adams (left) and Eric Solem who were eating in the food court of Mango House on June 24. (Ross Taylor for KHN) The son of Indian immigrants, Parmar, 46, was born in Canada but grew up in Chicago and moved to Colorado after college in 1999, where he did his medical training at the University of Colorado School of Medicine.

He opened Mango House 10 years ago, buying a building and renting out space to refugees to cover the cost. Two years ago, he expanded into a vacant J.C. Penney building across the street. €œThere’s a good three-, four-year dip in the red here, intentionally, as we move from there to here,” Parmar said.

€œBut that red is going to go away soon.” The erectile dysfunction treatment viagra has helped shore up his finances, as federal incentives and payment increases boosted revenue and allowed him to pay down his debt faster. Parmar must navigate a host of obstacles while working to overcome financial and language barriers. A Muslim Somali woman needs dental care but is uncomfortable seeing a male dentist. A Nepalese woman needs a prescription refill, but she lives in Denver and so has been assigned by Medicaid to the safety-net hospital, Denver Health.

Parmar won’t get paid but sees her anyway. Another patient brings paperwork showing he’s being sued by a local health system for a year-old emergency room bill he has no way to pay. A Nepalese man with psoriasis doesn’t want creams or ointments. Good medicine, he believes, comes through a needle.

€œA lot of this is, basically, geriatrics,” Parmar said. €œYou have to add 20 years to get their age in refugee years.” When one patient turns away momentarily, Parmar discreetly throws away her bottle of meloxicam, a strong anti-inflammatory he said she shouldn’t be taking because of her kidney problems. He began stocking over-the-counter medications after realizing his patients got overwhelmed amid 200 varieties of cough and cold medicines at the drugstore. Some couldn’t find what he told them to get, even after he printed flyers showing pictures of the products.

Parmar’s creative solutions, however, often rub many in health care the wrong way. Some balk at his use of family members or others as informal interpreters. Best practices call for the use of trained interpreters who understand medicine and patient privacy rules. But billing for interpretation isn’t possible, so hospitals and clinics must pay interpreters themselves.

And that’s beyond the capabilities of most refugee clinics, unless they’re affiliated with a larger health system that can absorb those costs. Dr. P.J. Parmar talks with Tabarak Saed, Saja Saed and Feryal Saddek, who are refugees from Palestine, on June 24 in the waiting room.

Saddek came to see him about a foot issue. Patients are seen on a first-come, first-served basis, much like an urgent care clinic, and similar to the way things worked in many of the patients’ native countries. This also helps minimize the clinic’s costs, with no need for a receptionist or scheduling software.(Ross Taylor for KHN) “It’s a good thing to have the standards, but it’s another thing altogether to implement them,” said Dr. Pat Walker, an expert on refugee health at the University of Minnesota.

When Mango House began providing erectile dysfunction treatments, residents of more affluent areas of town started showing up. Parmar tried to limit vaccinations only to those patients living in the immediate area, checking ZIP codes on their IDs. The state stepped in to say he could neither require IDs nor turn away any patients, regardless of his refugee-focused mission. During a recent lull at the clinic, Parmar took stock of that day’s inventory of patients.

Six were assigned to Denver Health, one patient’s Medicaid coverage had expired, and two had high-deductible commercial plans. Chances are he wouldn’t get paid for seeing any of them. Of the 25 patients he had seen that day, 14 had Medicaid coverage that Parmar could bill. €œWe see the rest of them anyway,” he said.

Markian Hawryluk. MarkianH@kff.org, @MarkianHawryluk Related Topics Contact Us Submit a Story TipKathi Arbini said she felt elated when Missouri finally caught up to the other 49 states and approved a statewide prescription drug monitoring program this June in an attempt to curb opioid addiction. The hairstylist turned activist estimated she made 75 two-hour trips in the past decade from her home in Fenton, a St. Louis suburb, to the state capital, Jefferson City, to convince Republican lawmakers that monitoring how doctors and pharmacists prescribe and dispense controlled substances could help save people like her son, Kevin Mullane.

He was a poet and skateboarder who she said turned to drugs after she and his dad divorced. He started “doctor-shopping” at about age 17 and was able to obtain multiple prescriptions for the pain medication OxyContin. He died in 2009 at 21 from a heroin overdose. If the state had had a monitoring program, doctors might have detected Mullane’s addiction and, Arbini thinks, her son might still be alive.

She said it’s been embarrassing that it’s taken Missouri so long to agree to add one. €œAs a parent, you would stand in front of a train. You would protect your child forever — and if this helps, it helps,” said Arbini, 61. €œIt can’t kill more people, I don’t think.” But even though Missouri was the lone outlier, it had not been among the states with the highest opioid overdose death rates.

Missouri had an average annual rank of 16th among states from 2010 through 2019, as the country descended into an opioid epidemic, according to a KHN analysis of Centers for Disease Control and Prevention data compiled by KFF. Some in public health now argue that when providers use such monitoring programs to cut off prescription opiate misuse, people who have an addiction instead turn to heroin and fentanyl. That means Missouri’s new toll could cause more people to overdose and leave the state with buyer’s remorse. €œIf we can take any benefit from being last in the country to do this, my hope would be that we have had ample opportunity to learn from others’ mistakes and not repeat them,” said Rachel Winograd, a psychologist who leads NoMODeaths, a state program aimed at reducing harm from opioid misuse.

Before Missouri’s monitoring program was approved, lawmakers and health and law enforcement officials warned that the absence made it easier for Missouri patients to doctor-shop to obtain a particular drug, or for providers to overprescribe opiates in what are known as pill mills. State Sen. Holly Rehder, a Republican with family members who have struggled with opioid addiction, spent almost a decade pushing legislation to establish a monitoring program but ran into opposition from state Sen. Rob Schaaf, a family physician and fellow Republican who expressed concerns about patient privacy and fears about hacking.

In 2017, Schaaf agreed to stop filibustering the legislation and support it if it required that doctors check the database for other prescriptions before writing new ones for a patient. That, though, sparked fresh opposition from the Missouri State Medical Association, concerned the requirement could expose physicians to malpractice lawsuits if patients overdosed. The new law does not include such a requirement for prescribers. Pharmacists who dispense controlled substances will be required to enter prescriptions into the database.

Dr. Silvia Martins, an epidemiologist at Columbia University who has studied monitoring programs, said it’s important to mandate that prescribers review a patient’s information in the database. €œWe know that the ones that are most effective are the ones where they check it regularly, on a weekly basis, not just on a monthly basis,” she said. But Stephen Wood, a nurse practitioner and visiting substance abuse bioethics researcher at Harvard Law School, said the tool is often punitive because it cuts off access to opioids without offering viable treatment options.

He and his colleagues in the intensive care unit at Carney Hospital in Boston don’t use the Massachusetts monitoring program nearly as often as they once did. Instead, he said, they rely on toxicology screens, signs such as injection marks or the patients themselves, who often admit they are addicted. €œRather than pulling out a piece of paper and being accusatory, I find it’s much better to present myself as a caring provider and sit down and have an honest discussion,” Wood said. When Kentucky in 2012 became the first state to require prescribers and dispensers to use the system, the number of opioid prescriptions and overdoses from prescription opioids initially decreased slightly, according to a state study.

But the number of opioid overdose deaths — with the exception of a slight dip in 2018 and 2019 — has since consistently ticked upward, according to a KFF analysis of CDC data. In 2020, Kentucky was estimated to have had the nation’s second-largest increase in drug overdose deaths. When efforts to establish Missouri’s statewide monitoring program stalled, St. Louis County established one in 2017 that 75 local jurisdictions agreed to participate in, covering 85% of the state, according to the county health department.

The county now plans to move its program into the state one, which is scheduled to launch in 2023. Dr. Faisal Khan, director of the county department, said he has no doubt that the St. Louis program has “saved lives across the state.” Opioid prescriptions decreased dramatically once the county established the monitoring program.

In 2016, Missouri averaged 80.4 opioid prescriptions per 100 people. In 2019, it was down to 58.3 prescriptions, according to the CDC. The overall drug overdose death rate in Missouri has steadily increased since 2016, though, with the CDC reporting an initial count of 1,921 people dying from overdoses of all kinds of drugs in 2020. Khan acknowledged that a monitoring program can lead to an increase in overdose deaths in the years immediately following its establishment because people addicted to prescription opioids suddenly can’t obtain them and instead buy street drugs that are more potent and contain impurities.

But he said a monitoring program can also help a physician intervene before someone becomes addicted. Doctors who flag a patient using the monitoring program must then also be able to easily refer them to treatment, Khan and others said. €œWe absolutely are not prepared for that in Missouri,” said Winograd, of NoMODeaths. €œSubstance use treatment providers will frequently tell you that they are at max capacity.” Uninsured people in rural areas may have to wait five weeks for inpatient or outpatient treatment at state-funded centers, according to PreventEd, a St.

Louis-based nonprofit that aims to reduce harm from alcohol and drug use. For example, the waiting list for residential treatment at the Preferred Family Healthcare clinic in Trenton is typically two weeks during the summer and one month in winter, according to Melanie Tipton, who directs clinical services at the center, which mostly serves uninsured clients in rural northern Missouri. Tipton, who has worked at the clinic for 17 years, said that before the erectile dysfunction treatment viagra, people struggling with opioid addiction mainly used prescription pills. Now it’s mostly heroin and fentanyl, because they are cheaper.

Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine, according to the National Institute on Drug Abuse. Still, Tipton said her clients continue to find providers who overprescribe opiates, so she thinks a statewide monitoring program could help. Inez Davis, diversion program manager for the Drug Enforcement Administration’s St. Louis division, also said in an email that the program will benefit Missouri and neighboring states because “doctor shoppers and those who commit prescription fraud now have one less avenue.” Winograd said it’s possible that if the state had more opioid prescription pill mills, it would have a lower overdose death rate.

€œI don’t think that’s the answer,” she said. €œWe need to move in the direction of decriminalization and a regulated drug supply.” Specifically, she’d rather Missouri decriminalize possession of small amounts of hard drugs, even heroin, and institute regulations to ensure the drugs are safe. State Rep. Justin Hill, a Republican from St.

Charles and former narcotics detective, opposed the monitoring program legislation because of his concerns over patient privacy and evidence that the lack of a program has not made Missouri’s opioid problem any worse than many other states’. He also worries the monitoring program will lead to an increase in overdose deaths. €œI would love the people that passed this bill to stand by the numbers,” Hill said. €œAnd if we see more deaths from overdose, scrap the monitoring program and go back to the drawing board.” Related Topics Contact Us Submit a Story Tip[embedded content] The vast majority of the viagra’s 4.1 million erectile dysfunction treatment s in children have been mild.

However, doctors are concerned about a growing number of long-haul erectile dysfunction treatment cases and a rare but dangerous inflammatory disease, particularly among Black and Latino children. KHN correspondent Sarah Varney, in collaboration with PBS NewsHour, reports on the phenomena. This story aired on July 23, 2021. Sarah Varney.

svarney@kff.org, @SarahVarney4 Related Topics Contact Us Submit a Story Tip.

Adderall and viagra reddit

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The erectile dysfunction viagra has brought to public attention a variety of questions long debated in medical ethics, but now daily viagra dosage given both added urgency and wider publicity. Among these is triage, with its origins in deciding which individual lives are to be saved on a battlefield, but now also concerned with the allocation of scarce resources more generally. On the historical battlefield, decisions about whom to treat first – neither those who would survive without treatment, nor those who would not survive even with treatment, but those who needed treatment to survive – was facilitated by military discipline and the limited effectiveness of treatments available. In the daily viagra dosage allocation of scarce resources today, by contrast, such decisions are subject to intense public and political scrutiny, and the range of effective treatments available has immeasurably diminished the proportion of ‘those who would not survive even with treatment’. If triage decisions are to be made, they now need to be justified in the arena of public opinion by moral arguments which are also politically persuasive.A number of different aspects of what is required for this endeavour are examined in the first five contributions to this issue of the Journal.

In ‘Should age matter in erectile dysfunction treatment triage?. A deliberative study’1, Kuylen and colleagues report on a deliberative study of public views in the UK, in which participants ‘generally accepted daily viagra dosage the need for triage but strongly rejected ’fair innings’ and ’life projects’ principles as justifications for age-based allocation,…preferring to maximise the number of lives rather than life years saved’. And concerned that in any resolution ‘utilitarian considerations of efficiency should be tempered with a concern for equality and vulnerability’.A similar concern to temper utilitarian considerations, in this case with an Aristotelian view of the common good as ‘the good life for each and every member of the community’ is expressed in ‘Public health decisions in the erectile dysfunction treatment viagra require more than ‘follow the science’’ by de Campos-Rudinsky and Undurraga.2 Public health decisions, they argue, ‘always involve layers of complexity, coupled with uncertainty’. €˜the implication of the incommensurability of basic human goods… is that when tensions between them arise (such as happened during this viagra, when preservation of health required the adaptation of how we experience work, education, leisure, family and friendships), the solution cannot be readily determined by a simple balancing test’. €˜Good decision-making in public health policy’ daily viagra dosage they conclude.

€˜does depend on the availability of reliable data and rigorous analyses, but depends above all on sound ethical reasoning that ascribes value and normative judgement to empirical facts.’Triage decisions actually made during the viagra are the subject of ‘National health system cuts and triage decisions during the erectile dysfunction treatment viagra in Italy and Spain. Ethical implications’ by Faggioni and colleagues.3 Analysing ‘the most important documents establishing the criteria for the treatment and exclusion of erectile dysfunction treatment patients, especially in regard to the giving of respiratory support, in Italy and Spain’, they discover ‘a tension that stems from limited healthcare resources which are insufficient to save lives that, under normal conditions, could have been saved, or at least could have received the best possible treatment’. In response, they ‘set forth a series of concrete ethical proposals with which to face the successive waves of erectile dysfunction treatment , as well as daily viagra dosage other future viagras’. These include the duty of health authorities ‘to plan for foreseeable ethical challenges during a health emergency’, and the duty of ‘public organisms at the national level, such as national committees on ethics…to prepare the protocols for care and treatment that would help physicians and healthcare workers to manage the predictable uncertainty and distress in healthcare emergencies’.Turning to a currently pressing international aspect of resource allocation, Jecker and colleagues, in ‘treatment ethics. An ethical framework for global distribution of erectile dysfunction treatments’4 marshal an impressive amount of empirical research and ethical theory to argue that ‘in order to accelerate development and fair, efficient treatment allocation…treatments should be distributed globally, with priority to frontline and essential workers worldwide’.

€˜ethical values to guide treatment distribution’, they conclude, should ‘highlight values of helping the neediest, reducing health disparities, saving lives and keeping society daily viagra dosage functioning’.A further important resource often found to be all too scarce during the viagra was personal protective equipment (PPE). In ‘Balancing health worker well-being and duty to care. An ethical approach to staff safety in erectile dysfunction treatment and beyond’5, McDougall and colleagues ‘articulate some of the specific ethical challenges around PPE currently being faced by front-line clinicians, and develop an approach to staff safety that involves balancing duty to care and personal well-being’. This includes ‘a five-step structured…decision-making framework that facilitates ‘ethical reflection and/or decision-making that is systematic, specific and transparent’ and ‘guides the decision maker to characterise the degree of risk to staff, articulate feasible options for staff protection in that specific setting and identify the option that ensures any decrease in patient care is proportionate to the increase in staff well-being’.Because of the viagra and the fear of health services being overwhelmed by it, research daily viagra dosage on and treatment of other conditions, no less serious for the individual patient, have lacked resources which urgently require to be restored. Issues in medical ethics not directly related to erectile dysfunction treatment equally call for renewed attention, not least because analysis of ethical questions raised by the viagra largely relies on intellectual tools forged in earlier debates on other subjects.

Three papers in this issue of the Journal return to subjects often discussed in medical ethics, but with fresh thinking on these, while a fourth examines a question which for many may be genuinely new.The role and functioning of research ethics committees (RECs) was one of the earliest concerns of twentieth century medical ethics and as these committees grew both in number and in the complexity of their deliberations, they have continued to receive ethical attention. In ‘Process of risk assessment by research ethics daily viagra dosage committees. Foundations, shortcomings and open questions’6 Rudra observes that ‘there is currently no uniform and solid theoretical approach to risk assessment by RECs’ and in response develops a detailed ‘concept of aggregate risk definition’ designed to ‘strengthen the coherence of REC decisions and therefore the trust between researchers and the institution of the REC as such’.‘Imperfect by design. The problematic ethics of surgical training’7 by Das, again addresses a familiar but difficult ethical question. €˜How do we ethically validate the current training model for surgeons, in which trainees are often given operative duties that could daily viagra dosage likely be better handled by a staff physician?.

€™ Admitting that the ‘deontological responsibilities of individual surgeons are incommensurable with the fundamentally utilitarian nature of the medical system’ the author argues that surgeons ‘as individuals must be willing to accept that they are knowingly foregoing optimal patient care on a small scale, and navigate the trade-offs which exist at the interface of two (possibly irreconcilable) philosophical system’.One of the most familiar of all subjects in medical ethics, that of consent, is discussed by Giordano and colleagues in ‘Gender dysphoria in adolescents. Can adolescents or parents give valid consent to puberty blockers?. €™8 The occasion for this discussion is a recent English judgement suggesting ‘that adolescents cannot give valid consent to treatment that temporarily suspends puberty’ - a claim which appears to contradict what hitherto was generally considered settled law on adolescent consent daily viagra dosage to medical treatment. The authors, while not commenting on the specific case in question, carefully examine ‘four reasons why consent may be deemed invalid’ in cases of this kind. €˜the decision is too complex, the decision-makers are too emotionally involved, the decision-makers are on a ‘conveyor belt and ’the possibility of detransitioning’.

They argue that ‘none of these stand up to scrutiny’ and conclude that ‘accepting these claims at face value could have serious negative implications, not daily viagra dosage just for gender diverse youth, but for many other minors and families and in a much broader range of healthcare settings.’While much has been written on whether patients can trust their doctors, whether doctors can trust their computers has been until recently a less familiar question in medical ethics. This month’s Feature Article, ‘Who is afraid of black box algorithms?. On the epistemological and ethical basis of trust in medical AI’9 by Durán and Jongsma, together with four critical Commentaries, addresses this question with specific reference to the use in medicine of ‘black box’ algorithms, that is, algorithms whose ‘computational processes…do not follow well understood rules’ and are ‘methodologically opaque to humans’. In order to trust such algorithms, the authors argue, doctors do not necessarily need to understand their computational processes, provided their reliability is supported by ‘computational reliabilism’, evidence, daily viagra dosage that is, that the algorithm is ‘a reliable process…that yields, most of the time, trustworthy results’. On the other hand, even if the results are trustworthy, the authors warn, that is not sufficient to justify doctors in acting on them.

€˜clinical findings and evidence need to be interpreted and contextualised, regardless of the methods used for analysis (ie, opaque or not), in order to determine how these should be acted on in clinical practice…even if recommendations provided by the medical AI system are trusted because the algorithm itself is reliable, these should not be followed blindly without further assessment. Instead, we must keep humans in the loop of decision making by algorithms.’IntroductionThe first wave of the erectile dysfunction treatment viagra put a large daily viagra dosage burden on many healthcare systems. Fears arose that demand for resources would exceed supply, necessitating triage in critical care, for example, when allocating intensive care unit (ICU) beds. The role of age in resource allocation was an especially salient issue given the proclivity of erectile dysfunction to cause excess mortality in older groups. Several erectile dysfunction treatment triage guidelines included age as an explicit factor,1–4 and practices of both triage and ‘anticipatory triage’ likely limited access to hospital care for elderly patients, especially those daily viagra dosage in care homes.5–8 This raised ethical and societal questions about the role of age in triage decision making.9–11In medical ethics literature, different principles for resource allocation exist.

Following a scoping review, we identified four that have explicit implications for the use of age as a deciding factor in triage:(1) the ‘fair innings’ principle, (2) the ‘life projects’ principle, (3) the ‘egalitarian principle’ and (4) the ‘maximise life years’ principle. (1) The ‘fair innings’ principle prioritises younger over older people so that younger people also get the chance to reach later life stages.12 (2) The ‘life projects’ principle prioritises young to middle-aged people so that everyone gets the chance to complete their life projects (eg, raising children and making a career).13 (3) The egalitarian principle calls for equal treatment of all and does not permit discrimination on the basis of age, meaning we must take a ‘lottery’ or ‘first come, first served’ approach.14 15 (4) Finally, the ‘maximise life years’ principle, a utilitarian approach, permits indirect discrimination on the basis of age insofar as this maximises the amount of life years saved.16These principles have conflicting implications. Our study aimed to explore general public views on the role of age in triage decision making daily viagra dosage during the erectile dysfunction treatment viagra. Specifically, we wanted to understand attitudes to the aforementioned four allocation principles, as well as on related factors such as quality of life and frailty. We also sought to understand, and elicit, participants’ considered recommendations on triage, with a view to developing ethical guidelines that are sensitive to public thinking.MethodsWe held deliberative workshops with members of the general public following the general method of deliberative democracy,17–19 in collaboration with UK market research company Ipsos MORI, which has expertise in deliberative workshops.

We requested them to recruit 25 participants daily viagra dosage from South East London, so as to inform clinical ethics forums in hospitals associated with King’s College London. Participants were guided through a deliberative process so they could arrive at an informed and considered opinion on topics that may have been new or unfamiliar to them. Four workshops, each lasting 2 hours, took place during 3 weeks across August and September 2020, in a particular social window between the first and second wave of erectile dysfunction treatment. This was an opportunity for participants to discuss the complex daily viagra dosage ethical questions on triage in a context in which its importance was pertinent. Three participants dropped out before the first session for personal reasons.

Nineteen participants took part in all four sessions. The three remaining participants each took part in three out of four sessions.Deliberative democracy offers medical daily viagra dosage ethics a promising way to consult public preferences while ensuring these are adequately informed and considered. The sessions met the three standards for deliberation set out by Blacksher et al.20 First, sessions included informative presentations to provide ‘balanced, factual information that improves participant’s knowledge of the issue’. Second, we ensured ‘the inclusion of diverse perspectives’ through strategic sampling. Participants reflected the demographics of the demographically diverse boroughs of Lambeth and Southwark (see table 1 for sample daily viagra dosage characteristics).

We made particular effort to include participants over 60 years. Third, participants were given ‘the opportunity to reflect on and discuss freely a wide spectrum of viewpoints and to challenge and test competing moral claims’. The sessions included plenary discussions daily viagra dosage and discussions in smaller breakout groups, which were facilitated by experienced qualitative research staff from Ipsos MORI. Facilitation was non-directive and neutral with respect to content but active in promotion of an engaged, inclusive process among participants.View this table:Table 1 Participant demographicsThe research team (GO, MNIK, ARK) observed sessions and held discussion with the facilitators between workshops. The sessions were transcribed by professional note takers, and transcriptions were thematically analysed in two stages.

First, general themes were daily viagra dosage identified in the raw data by Ipsos MORI and the research team and summarised in the report. In a second step, the research team analysed the raw data again with particular focus on the ethical reasoning underlying discussions.Ahead of the study, we worked with Ipsos MORI to develop a detailed but accessible discussion guide for the workshops and survey questions to be answered by participants after each session. We also developed information materials to present to participants. A presentation on how resource allocation and treatment escalation works in England’s National Health Service, an overview of relevant data on how erectile dysfunction treatment affects the elderly, video presentations spelling out the four allocation principles, materials explaining the concepts of frailty and quality daily viagra dosage of life and case vignettes showing how triage dilemmas may arise. These materials and further details of the methods are reported elsewhere.21During session 1, the information materials were presented to participants, and initial reactions to the four principles were briefly explored in breakout groups.

During session 2, case study examples were discussed in breakout groups to examine the practical implications of the respective principles. During session 3, participants were introduced daily viagra dosage to the notions of frailty and quality of life and explored these in breakout groups through one further hypothetical triage dilemma. Participants also deliberated further on the four principles and were asked to spell out their concerns about them. During session 4, participants were asked to formulate final recommendations and caveats in breakout groups. They also discussed how daily viagra dosage recommendations should be implemented and communicated to the public.Given viagra safety measures, the workshops were conducted online on Zoom.

This was a relatively novel approach to deliberative democracy. Benefits of this approach were that participants felt more comfortable expressing opinions about sensitive subjects, carers or family members could more easily support older or vulnerable participants to contribute to the deliberations, and there was more time between sessions for reflection than with face-to-face sessions, which usually take place within 1 day. Downsides were that some participants experienced minor technical difficulties.All participants gave informed daily viagra dosage consent before taking part.Findings‘Fair innings’ and ‘life projects’ principlesThe ‘fair innings’ and ‘life projects’ principle were strongly rejected from the outset and throughout the deliberative process. Participants found the ‘fair innings’ principle arbitrary and unnuanced, as well as unfair. They felt that age alone does not provide sufficient information about someone’s medical condition and that the lives of older people are important too.

€˜We should get all equal daily viagra dosage treatment, young or old, we’re all the same’. Some participants also mentioned the contributions of the elderly to society, stating that ‘older people have just as much to give to society as younger people do’. The ‘life projects’ principle was equally firmly rejected, on the basis that it was normalising, favouring existing societal norms that not everyone meets. €˜It’s very daily viagra dosage discriminatory and not right. There are late developers.

There are people who bloom later or earlier in life’. It was also daily viagra dosage emphasised that retirement was a time in which, after a life of work, people are finally free to start and pursue their life projects. €˜When you get older, that’s when you want to start projects. […] There are a lot of people almost having second lives doing all the things they couldn’t do previously’. Dismissing this period, therefore, seemed daily viagra dosage counterintuitive.Egalitarian principleThe egalitarian principle was accepted, though a number of concerns about it were raised throughout the study.

Initially, this principle was received as the most straightforward and fairest principle, but as discussion progressed, worries emerged about its practical application. First of all, participants rejected a randomised ‘lottery’ approach, preferring a ‘first come, first served’ version of this principle. €˜lottery doesn’t feel like a daily viagra dosage good system when it’s people lives. It’s inappropriate’. But even the latter approach raised concerns.

Participants were mostly worried about hidden inequalities, stating this approach would not redress, and even risk reinforcing, existing inequalities (eg, people with better access to the hospital may get there daily viagra dosage sooner). One participant said that ‘first come, first served isn’t egalitarian and you have the socio-economic challenges because, if you are in a particular class, you’re in a better position to be able to take care of yourself and get to the doctors first’. There were further concerns that a ‘first come, first served’ approach would waste valuable resources, when patients with a worse prognosis happen to arrive earlier. Finally, some participants felt uneasy that, on this approach, resources would not necessarily go to those who need them daily viagra dosage most. €˜On the face of it, it looks good, but I think means that those that come in later who are in greater need haven’t got access’.

A few participants remained in favour of an egalitarian approach, though all accepted that, if a patient’s prognosis is extremely poor, they should not be escalated for treatment. €˜if you were following the egalitarian principle but you have someone in front of you who the evidence would suggest is highly unlikely to survive treatment and you’ve got someone who is highly daily viagra dosage likely to survive, as unfair as it may seem, it feels like it would be an important consideration […] I’m only thinking about extreme cases where you’ve got someone who is extremely frail and therefore extremely unlikely to survive’.‘Maximise life years’ principleWhen the ‘maximise life years’ principle was introduced, immediate concerns were raised about the accuracy of medical judgments about life expectancy. €˜Nobody knows how long anybody is going to live for. There are some assumptions, even if you’ve got two people in front of you, one who is 40 and one who is 60’. Furthermore, in discussing this principle, participants spontaneously distinguished survival chance daily viagra dosage from life expectancy in the deliberations and strongly favoured the former.

They supported maximising the number of lives saved, rather than the amount of life years saved. €˜There’s a logic in maximum number of lives you save irrespective of the number of life years they have’. The underlying reasoning seemed to be that every life is of daily viagra dosage equal value. A majority of participants agreed that ‘a life is a life’.It was thus widely felt that a patient’s immediate medical condition was a very important factor in triage, insofar as this informed their chances of survival. In this context, participants recognised frailty as a key factor.

Though it was not initially understood as a medical term, it was eventually accepted as a relevant prognostic variable for predicting daily viagra dosage survival chances.Some participants questioned the survival chance-based approach, though. For example, a small number of participants expressed concern about the disproportionate effects it could have on groups that may be more vulnerable to erectile dysfunction treatment. €˜By virtue of prioritising survival of the fittest, it will discriminate and people are uncomfortable with this because it means older people will be less likely to be escalated, people in wheelchairs, people in BAME communities’. Another more widespread worry was that this approach failed to allocate resources in daily viagra dosage accordance with need. These concerns led some participants to formulate a new, vulnerability-based allocation principle, which is discussed further below.Quality of lifeThe notion of quality of life was initially treated with suspicion, seen as inviting unconscious bias and too subjective.

€˜I don’t know if professionals can really confirm how somebody’s well-being is’. Throughout the study, it was increasingly accepted, though mostly daily viagra dosage as a secondary factor when patients’ medical conditions are highly similar, in which case those with a higher quality of life would be prioritised. Caveats were that it should only be applied in extreme cases and that quality of life assessments should, where possible, involve ‘input of the person, their family, carers and that kind of stuff’ to avoid biased assessments.However, one participant said those with a lower quality of life should be prioritised, so that their quality of life may be improved. Some also noted that quality of life may be strongly influenced by socioeconomic factors, indicating a danger of exacerbating existing inequalities. €˜I do worry with quality of life, the more money you have, the better quality daily viagra dosage of life you tend to have […] your health is defined by your class and how much money you have’.VulnerabilityThroughout the study, concerns were expressed about vulnerability, especially in reaction to the utilitarian approach.

In these discussions, participants struggled to formulate an additional allocation principle. This had two aspects, though these were not always clearly differentiated. One aspect concerned vulnerable groups (eg, age, disability or ethnic groups) who may be disproportionately affected by daily viagra dosage the viagra itself or the social response to it (eg, unconscious bias). One participant said. €˜we know it affects the elderly at higher rates than the youth.

[…] It daily viagra dosage makes the most sense to prioritise the elderly over the young, just on the basis of the percentages of old people vs young people dying. Young people are more likely to survive’. There was, however, some disagreement over whether positive action for these groups should indeed be taken to mitigate the vulnerability or whether this was itself a form of discrimination.The other aspect concerned individuals in need (eg, those presenting to hospital as sicker) and whether a humane principle was to prioritise those in greatest medical need. €˜The more help daily viagra dosage somebody needs, the more they should get’. Some suggested to prioritise those least likely to survive.

€˜I think the most vulnerable should be prioritised. […] If daily viagra dosage you think you can save them, then prioritise them’. Reasons given for such an approach were that ‘the true measure of any society is how it treats its most vulnerable members’. But, again, it was accepted that if treatment was unlikely to succeed, patients should not be escalated. €˜you give the resources to the people that most need it, in my opinion, up until the point where the giving of resources is next to useless, where it’s ascertained that they will die anyway’.Other participants rejected this need-based daily viagra dosage approach altogether, out of a concern for efficiency.

€˜Does that mean, if those people are most likely to die, you’re directing your resources at people who are weaker?. So resources could be going to a group who stand the least chance of surviving?. That doesn’t daily viagra dosage feel like a great use of resources’.ImplementationDuring the final workshop, participants were asked how their recommendations should be implemented. We found strong support for discretion (applying recommendations as guidance rather than a mandatory policy), and participants felt groups of doctors, not individuals, should make decisions as this could reduce burden and bias. Thus, guidelines should not be binding but instead guide expert deliberation, and this deliberation is ideally executed by teams rather than individuals, so that different perspectives can be considered.DiscussionIn summary, we observed a strong rejection of the two explicitly age-based principles.

A tolerance for an egalitarian ‘first come, first served’ principle, though with doubts about daily viagra dosage sufficiency. Wide support for a newly formulated approach based on survival chances, with some consideration of frailty and quality of life. Concerns about group vulnerability and individual need. And a preference daily viagra dosage for discretion and deliberation in triage decision making.These findings raise important questions regarding existing guidelines and expert recommendations, when and where they do not align with them. Fallucchi et al22 have observed similar public intuitions, which digress from US triage guidelines, but conclude that the public requires more education.

We found, however, that these public moral intuitions persist even after a robust process of reflection and deliberation. We think this warrants serious consideration of public preferences.A first preference deserving serious consideration is the stark rejection of direct discrimination on the basis of age, as well as the use of randomised ‘lottery’ approaches, both of which have been observed in similar studies.22 23A daily viagra dosage second focal point is the preference for survival chance over life expectancy, which also has been observed elsewhere.19 22 Savulescu et al24 have criticised the UK’s NICE guidelines on resource allocation during erectile dysfunction treatment25 for including considerations of survival chance but not life expectancy. The NICE guidelines reject the latter as it results in indirect discrimination on the basis of age. According to Savulescu et al, however, the guidelines already tolerate indirect discrimination since basing triage on survival chance will also disproportionally affect the elderly. The authors thus assume daily viagra dosage both factors operate on the same logic.

However, we suspect our participants may have highlighted an ethically relevant distinction between survival chance and life expectancy. In fact, there are at least two ways in which these factors may be different. First, considering life expectancy in triage seems closer to direct age-based discrimination daily viagra dosage. While survival chance is closely linked to age specifically in the context of erectile dysfunction treatment, life expectancy has a closer (indeed almost conceptual) link to age. To be older simply is to be closer to death.

A similar distinction between survival chance and life expectancy has been made by Mello et al,26 who argue that daily viagra dosage only the latter results in disability-based discrimination. Second, a live saved and a life year saved seem to produce a different kind of value. A life saved is a categorical outcome, whereas a life year saved is a scalar outcome. This conceptual difference seems ethically relevant because most participants considered any life daily viagra dosage saved of inherent value, regardless of its predicted length. It is ‘about saving as many people as possible, even if they have a shorter life’.

On this logic, saving more of a life does not produce additional value.A third finding deserving of consideration is the concern about vulnerability. The core values of equality and efficiency, and the question of how to balance both, are central to daily viagra dosage discussions about resource allocation. During our study, however, a third relevant principle spontaneously emerged from the discussions. Vulnerability. Though this notion was not unpacked in much detail during the deliberations, it alludes to values of antidiscrimination and protection, in line with emerging debates in the literature.27 28How can these public intuitions be daily viagra dosage incorporated into triage decisions?.

Participants generally accepted the need for triage but did not arrive at a unified recommendation of one principle. Indeed, in the final survey, recommendations included a mixture of principles and factors. However, a concern for three core principles daily viagra dosage and values emerged. As mentioned, deliberation resulted in the formulation of three broad, but distinguishable, allocation principles. An egalitarian ‘first come, first served’ principle, a utilitarian principle (but based mainly on survival chance and frailty) and a ‘vulnerability’ principle.

The underlying daily viagra dosage core values of each of these principles could be described as equality, efficiency and vulnerability, respectively. In other words, a ‘triad’ of ethical values emerged. While these remain very hard to fully respect at once, they captured a considered, multifaceted consensus. All three principles were daily viagra dosage embedded in caveats and raised their own set of concerns. Notably, for each principle, these caveats and concerns can be linked back to the two other values of the triad:The egalitarian ‘equality’ principle raised concerns about efficiency and vulnerability.

If treatment was likely futile, it was agreed that patients should forgo it (efficiency concern). Participants worried strongly about hidden inequalities (vulnerability concern).The ‘efficiency’ principle raised concerns about equality and vulnerability daily viagra dosage. Most agreed that if there was a ‘close call’ between patients, an egalitarian approach should be adopted instead (equality concern). Some worried about groups more vulnerable to erectile dysfunction treatment and about individuals with greater clinical need (vulnerability concerns).The ‘vulnerability’ principle raised concerns about equality and efficiency. Many participants resisted daily viagra dosage the notion of positive discrimination for vulnerable groups (equality concern).

Many also worried that scarce resources would be ‘wasted’ on vulnerable individuals as they may not survive or take up more time in ICU (efficiency concerns).We are hopeful, therefore, that this ‘triad’ of ethical principles may be a useful structure to guide ethical deliberation as societies negotiate the conflicting ethical demands of triage.This links to our finding that participants favoured discretion and group deliberation in triage decisions. In light of this, the triad may offer a useful framework, as it does not prescribe one single principle but rather a balancing exercise among three core values, ideally performed by a team of deliberators. In sum, rather than inviting moral paralysis, we hope this triad could guide fruitful case discussion for doctors, reduce moral distress and give them more confidence that the triage decisions they arrive at have public acceptability.Strengths and limitationsStrengthsWe achieved a purposeful sample, there was a high level of participant engagement, participants showed they could think through complex ethical topics, a triad consensus emerged from a very diverse South-East London group, indicating daily viagra dosage a degree of robustness and there was the ecological validity of doing this study in the social window in between two erectile dysfunction treatment waves.LimitationsThe South-East London sample may not generalise to other areas, findings may not generalise to other triage contexts (eg, viagras effecting children) and some elements, for example, vulnerability, remained underexplored, indicating a need for further research.ConclusionTo ensure the legitimacy of triage guidelines, which affect the public, it is important to engage the public’s moral intuitions, as they do not always align with expert recommendations. Guiding the public through a process of deliberation ensures that public intuitions do not stem from ignorance or misunderstanding but rather express genuine and considered preferences. We found that (widespread) utilitarian considerations of efficiency should be tempered with a concern for equality and vulnerability.Data availability statementNo data are available.Ethics statementsPatient consent for publicationNot required.Ethics approvalThe study was approved under the Ipsos MORI research ethics committee.AcknowledgmentsWe are grateful to Suzanne Hall, Chloe Juliette, Paul Carroll and Tom Cooper at Ipsos MORI, and to Bobby Duffy, Benedict Wilkinson, Alexandra Pollitt and Lucy Strang at the Policy Institute for their input.

The erectile dysfunction viagra http://www.em-erables-horbourg-wihr.site.ac-strasbourg.fr/2019/10/18/collation-du-matin/ has brought to public attention a variety of questions long debated in medical ethics, but now given both added how can i buy viagra urgency and wider publicity. Among these is triage, with its origins in deciding which individual lives are to be saved on a battlefield, but now also concerned with the allocation of scarce resources more generally. On the historical battlefield, decisions about whom to treat first – neither those who would survive without treatment, nor those who would not survive even with treatment, but those who needed treatment to survive – was facilitated by military discipline and the limited effectiveness of treatments available.

In the allocation of how can i buy viagra scarce resources today, by contrast, such decisions are subject to intense public and political scrutiny, and the range of effective treatments available has immeasurably diminished the proportion of ‘those who would not survive even with treatment’. If triage decisions are to be made, they now need to be justified in the arena of public opinion by moral arguments which are also politically persuasive.A number of different aspects of what is required for this endeavour are examined in the first five contributions to this issue of the Journal. In ‘Should age matter in erectile dysfunction treatment triage?.

A deliberative study’1, Kuylen and colleagues report on a deliberative study of public views in the UK, in which participants ‘generally accepted the need for triage but strongly rejected ’fair innings’ and ’life projects’ principles as justifications for age-based allocation,…preferring to maximise the number of how can i buy viagra lives rather than life years saved’. And concerned that in any resolution ‘utilitarian considerations of efficiency should be tempered with a concern for equality and vulnerability’.A similar concern to temper utilitarian considerations, in this case with an Aristotelian view of the common good as ‘the good life for each and every member of the community’ is expressed in ‘Public health decisions in the erectile dysfunction treatment viagra require more than ‘follow the science’’ by de Campos-Rudinsky and Undurraga.2 Public health decisions, they argue, ‘always involve layers of complexity, coupled with uncertainty’. €˜the implication of the incommensurability of basic human goods… is that when tensions between them arise (such as happened during this viagra, when preservation of health required the adaptation of how we experience work, education, leisure, family and friendships), the solution cannot be readily determined by a simple balancing test’.

€˜Good decision-making in public health policy’ they how can i buy viagra conclude. €˜does depend on the availability of reliable data and rigorous analyses, but depends above all on sound ethical reasoning that ascribes value and normative judgement to empirical facts.’Triage decisions actually made during the viagra are the subject of ‘National health system cuts and triage decisions during the erectile dysfunction treatment viagra in Italy and Spain. Ethical implications’ by Faggioni and colleagues.3 Analysing ‘the most important documents establishing the criteria for the treatment and exclusion of erectile dysfunction treatment patients, especially in regard to the giving of respiratory support, in Italy and Spain’, they discover ‘a tension that stems from limited healthcare resources which are insufficient to save lives that, under normal conditions, could have been saved, or at least could have received the best possible treatment’.

In response, they ‘set forth a series of concrete ethical proposals with which to face how can i buy viagra the successive waves of erectile dysfunction treatment , as well as other future viagras’. These include the duty of health authorities ‘to plan for foreseeable ethical challenges during a health emergency’, and the duty of ‘public organisms at the national level, such as national committees on ethics…to prepare the protocols for care and treatment that would help physicians and healthcare workers to manage the predictable uncertainty and distress in healthcare emergencies’.Turning to a currently pressing international aspect of resource allocation, Jecker and colleagues, in ‘treatment ethics. An ethical framework for global distribution of erectile dysfunction treatments’4 marshal an impressive amount of empirical research and ethical theory to argue that ‘in order to accelerate development and fair, efficient treatment allocation…treatments should be distributed globally, with priority to frontline and essential workers worldwide’.

€˜ethical values to guide treatment distribution’, they conclude, should ‘highlight values of helping the neediest, reducing health disparities, saving lives and keeping society functioning’.A further important resource often found to be all too scarce during the how can i buy viagra viagra was personal protective equipment (PPE). In ‘Balancing health worker well-being and duty to care. An ethical approach to staff safety in erectile dysfunction treatment and beyond’5, McDougall and colleagues ‘articulate some of the specific ethical challenges around PPE currently being faced by front-line clinicians, and develop an approach to staff safety that involves balancing duty to care and personal well-being’.

This includes ‘a five-step structured…decision-making framework that facilitates ‘ethical how can i buy viagra reflection and/or decision-making that is systematic, specific and transparent’ and ‘guides the decision maker to characterise the degree of risk to staff, articulate feasible options for staff protection in that specific setting and identify the option that ensures any decrease in patient care is proportionate to the increase in staff well-being’.Because of the viagra and the fear of health services being overwhelmed by it, research on and treatment of other conditions, no less serious for the individual patient, have lacked resources which urgently require to be restored. Issues in medical ethics not directly related to erectile dysfunction treatment equally call for renewed attention, not least because analysis of ethical questions raised by the viagra largely relies on intellectual tools forged in earlier debates on other subjects. Three papers in this issue of the Journal return to subjects often discussed in medical ethics, but with fresh thinking on these, while a fourth examines a question which for many may be genuinely new.The role and functioning of research ethics committees (RECs) was one of the earliest concerns of twentieth century medical ethics and as these committees grew both in number and in the complexity of their deliberations, they have continued to receive ethical attention.

In ‘Process of risk assessment how can i buy viagra by research ethics committees. Foundations, shortcomings and open questions’6 Rudra observes that ‘there is currently no uniform and solid theoretical approach to risk assessment by RECs’ and in response develops a detailed ‘concept of aggregate risk definition’ designed to ‘strengthen the coherence of REC decisions and therefore the trust between researchers and the institution of the REC as such’.‘Imperfect by design. The problematic ethics of surgical training’7 by Das, again addresses a familiar but difficult ethical question.

€˜How do we ethically validate the current training model for surgeons, in which trainees are often given operative duties that could likely be better handled by how can i buy viagra a staff physician?. €™ Admitting that the ‘deontological responsibilities of individual surgeons are incommensurable with the fundamentally utilitarian nature of the medical system’ the author argues that surgeons ‘as individuals must be willing to accept that they are knowingly foregoing optimal patient care on a small scale, and navigate the trade-offs which exist at the interface of two (possibly irreconcilable) philosophical system’.One of the most familiar of all subjects in medical ethics, that of consent, is discussed by Giordano and colleagues in ‘Gender dysphoria in adolescents. Can adolescents or parents give valid consent to puberty blockers?.

€™8 The occasion for this discussion is a recent how can i buy viagra English judgement suggesting ‘that adolescents cannot give valid consent to treatment that temporarily suspends puberty’ - a claim which appears to contradict what hitherto was generally considered settled law on adolescent consent to medical treatment. The authors, while not commenting on the specific case in question, carefully examine ‘four reasons why consent may be deemed invalid’ in cases of this kind. €˜the decision is too complex, the decision-makers are too emotionally involved, the decision-makers are on a ‘conveyor belt and ’the possibility of detransitioning’.

They argue that ‘none of these stand up to scrutiny’ and conclude that ‘accepting these claims at face value could have serious negative implications, not just for gender diverse youth, but for many other minors and families and in a much broader range of healthcare settings.’While much has been written on whether patients can trust their doctors, whether doctors can trust their computers has been until recently a less familiar question in medical how can i buy viagra ethics. This month’s Feature Article, ‘Who is afraid of black box algorithms?. On the epistemological and ethical basis of trust in medical AI’9 by Durán and Jongsma, together with four critical Commentaries, addresses this question with specific reference to the use in medicine of ‘black box’ algorithms, that is, algorithms whose ‘computational processes…do not follow well understood rules’ and are ‘methodologically opaque to humans’.

In order to trust such algorithms, the authors argue, doctors do not necessarily need to understand their computational processes, provided their reliability is supported by ‘computational reliabilism’, evidence, that is, that the algorithm is ‘a reliable process…that yields, most of the time, how can i buy viagra trustworthy results’. On the other hand, even if the results are trustworthy, the authors warn, that is not sufficient to justify doctors in acting on them. €˜clinical findings and evidence need to be interpreted and contextualised, regardless of the methods used for analysis (ie, opaque or not), in order to determine how these should be acted on in clinical practice…even if recommendations provided by the medical AI system are trusted because the algorithm itself is reliable, these should not be followed blindly without further assessment.

Instead, we must keep humans in the loop of decision making by algorithms.’IntroductionThe first wave of the erectile dysfunction treatment viagra put a large burden how can i buy viagra on many healthcare systems. Fears arose that demand for resources would exceed supply, necessitating triage in critical care, for example, when allocating intensive care unit (ICU) beds. The role of age in resource allocation was an especially salient issue given the proclivity of erectile dysfunction to cause excess mortality in older groups.

Several erectile dysfunction treatment triage guidelines included age as an explicit factor,1–4 and practices of both triage and ‘anticipatory triage’ likely limited access to hospital care for elderly patients, especially those how can i buy viagra in care homes.5–8 This raised ethical and societal questions about the role of age in triage decision making.9–11In medical ethics literature, different principles for resource allocation exist. Following a scoping review, we identified four that have explicit implications for the use of age as a deciding factor in triage:(1) the ‘fair innings’ principle, (2) the ‘life projects’ principle, (3) the ‘egalitarian principle’ and (4) the ‘maximise life years’ principle. (1) The ‘fair innings’ principle prioritises younger over older people so that younger people also get the chance to reach later life stages.12 (2) The ‘life projects’ principle prioritises young to middle-aged people so that everyone gets the chance to complete their life projects (eg, raising children and making a career).13 (3) The egalitarian principle calls for equal treatment of all and does not permit discrimination on the basis of age, meaning we must take a ‘lottery’ or ‘first come, first served’ approach.14 15 (4) Finally, the ‘maximise life years’ principle, a utilitarian approach, permits indirect discrimination on the basis of age insofar as this maximises the amount of life years saved.16These principles have conflicting implications.

Our study aimed to explore general public views on the role of age in triage decision making how can i buy viagra during the erectile dysfunction treatment viagra. Specifically, we wanted to understand attitudes to the aforementioned four allocation principles, as well as on related factors such as quality of life and frailty. We also sought to understand, and elicit, participants’ considered recommendations on triage, with a view to developing ethical guidelines that are sensitive to public thinking.MethodsWe held deliberative workshops with members of the general public following the general method of deliberative democracy,17–19 in collaboration with UK market research company Ipsos MORI, which has expertise in deliberative workshops.

We requested how can i buy viagra them to recruit 25 participants from South East London, so as to inform clinical ethics forums in hospitals associated with King’s College London. Participants were guided through a deliberative process so they could arrive at an informed and considered opinion on topics that may have been new or unfamiliar to them. Four workshops, each lasting 2 hours, took place during 3 weeks across August and September 2020, in a particular social window between the first and second wave of erectile dysfunction treatment.

This was an opportunity for participants to discuss the complex ethical questions on triage in a context in which its importance how can i buy viagra was pertinent. Three participants dropped out before the first session for personal reasons. Nineteen participants took part in all four sessions.

The three remaining participants each took part in three out of four sessions.Deliberative democracy offers medical ethics a promising way how can i buy viagra to consult public preferences while ensuring these are adequately informed and considered. The sessions met the three standards for deliberation set out by Blacksher et al.20 First, sessions included informative presentations to provide ‘balanced, factual information that improves participant’s knowledge of the issue’. Second, we ensured ‘the inclusion of diverse perspectives’ through strategic sampling.

Participants reflected how can i buy viagra the demographics of the demographically diverse boroughs of Lambeth and Southwark (see table 1 for sample characteristics). We made particular effort to include participants over 60 years. Third, participants were given ‘the opportunity to reflect on and discuss freely a wide spectrum of viewpoints and to challenge and test competing moral claims’.

The sessions included plenary discussions and discussions in smaller breakout groups, which were facilitated by how can i buy viagra experienced qualitative research staff from Ipsos MORI. Facilitation was non-directive and neutral with respect to content but active in promotion of an engaged, inclusive process among participants.View this table:Table 1 Participant demographicsThe research team (GO, MNIK, ARK) observed sessions and held discussion with the facilitators between workshops. The sessions were transcribed by professional note takers, and transcriptions were thematically analysed in two stages.

First, general themes were identified how can i buy viagra in the raw data by Ipsos MORI and the research team and summarised in the report. In a second step, the research team analysed the raw data again with particular focus on the ethical reasoning underlying discussions.Ahead of the study, we worked with Ipsos MORI to develop a detailed but accessible discussion guide for the workshops and survey questions to be answered by participants after each session. We also developed information materials to present to participants.

A presentation on how resource allocation and treatment escalation works in England’s National Health Service, an overview of relevant data on how erectile dysfunction treatment affects the elderly, video presentations spelling out the four allocation principles, materials explaining the concepts of frailty and quality of life and case vignettes showing how triage dilemmas how can i buy viagra may arise. These materials and further details of the methods are reported elsewhere.21During session 1, the information materials were presented to participants, and initial reactions to the four principles were briefly explored in breakout groups. During session 2, case study examples were discussed in breakout groups to examine the practical implications of the respective principles.

During session 3, participants were introduced to the notions of frailty and quality of life and how can i buy viagra explored these in breakout groups through one further hypothetical triage dilemma. Participants also deliberated further on the four principles and were asked to spell out their concerns about them. During session 4, participants were asked to formulate final recommendations and caveats in breakout groups.

They also discussed how recommendations should how can i buy viagra be implemented and communicated to the public.Given viagra safety measures, the workshops were conducted online on Zoom. This was a relatively novel approach to deliberative democracy. Benefits of this approach were that participants felt more comfortable expressing opinions about sensitive subjects, carers or family members could more easily support older or vulnerable participants to contribute to the deliberations, and there was more time between sessions for reflection than with face-to-face sessions, which usually take place within 1 day.

Downsides were that some participants experienced minor technical difficulties.All participants gave informed consent before taking part.Findings‘Fair innings’ and ‘life projects’ principlesThe ‘fair innings’ and ‘life projects’ principle were strongly rejected from the how can i buy viagra outset and throughout the deliberative process. Participants found the ‘fair innings’ principle arbitrary and unnuanced, as well as unfair. They felt that age alone does not provide sufficient information about someone’s medical condition and that the lives of older people are important too.

€˜We should get all equal how can i buy viagra treatment, young or old, we’re all the same’. Some participants also mentioned the contributions of the elderly to society, stating that ‘older people have just as much to give to society as younger people do’. The ‘life projects’ principle was equally firmly rejected, on the basis that it was normalising, favouring existing societal norms that not everyone meets.

€˜It’s very how can i buy viagra discriminatory and not right. There are late developers. There are people who bloom later or earlier in life’.

It was also emphasised that retirement was a time in how can i buy viagra which, after a life of work, people are finally free to start and pursue their life projects. €˜When you get older, that’s when you want to start projects. […] There are a lot of people almost having second lives doing all the things they couldn’t do previously’.

Dismissing this period, therefore, seemed counterintuitive.Egalitarian principleThe egalitarian principle was accepted, though a number of concerns about it how can i buy viagra were raised throughout the study. Initially, this principle was received as the most straightforward and fairest principle, but as discussion progressed, worries emerged about its practical application. First of all, participants rejected a randomised ‘lottery’ approach, preferring a ‘first come, first served’ version of this principle.

€˜lottery doesn’t how can i buy viagra feel like a good system when it’s people lives. It’s inappropriate’. But even the latter approach raised concerns.

Participants were mostly worried about hidden inequalities, how can i buy viagra stating this approach would not redress, and even risk reinforcing, existing inequalities (eg, people with better access to the hospital may get there sooner). One participant said that ‘first come, first served isn’t egalitarian and you have the socio-economic challenges because, if you are in a particular class, you’re in a better position to be able to take care of yourself and get to the doctors first’. There were further concerns that a ‘first come, first served’ approach would waste valuable resources, when patients with a worse prognosis happen to arrive earlier.

Finally, some participants felt uneasy that, on this approach, resources would not necessarily go to those who need how can i buy viagra them most. €˜On the face of it, it looks good, but I think means that those that come in later who are in greater need haven’t got access’. A few participants remained in favour of an egalitarian approach, though all accepted that, if a patient’s prognosis is extremely poor, they should not be escalated for treatment.

€˜if you were following the how can i buy viagra egalitarian principle but you have someone in front of you who the evidence would suggest is highly unlikely to survive treatment and you’ve got someone who is highly likely to survive, as unfair as it may seem, it feels like it would be an important consideration […] I’m only thinking about extreme cases where you’ve got someone who is extremely frail and therefore extremely unlikely to survive’.‘Maximise life years’ principleWhen the ‘maximise life years’ principle was introduced, immediate concerns were raised about the accuracy of medical judgments about life expectancy. €˜Nobody knows how long anybody is going to live for. There are some assumptions, even if you’ve got two people in front of you, one who is 40 and one who is 60’.

Furthermore, in discussing this principle, participants how can i buy viagra spontaneously distinguished survival chance from life expectancy in the deliberations and strongly favoured the former. They supported maximising the number of lives saved, rather than the amount of life years saved. €˜There’s a logic in maximum number of lives you save irrespective of the number of life years they have’.

The underlying reasoning seemed to be how can i buy viagra that every life is of equal value. A majority of participants agreed that ‘a life is a life’.It was thus widely felt that a patient’s immediate medical condition was a very important factor in triage, insofar as this informed their chances of survival. In this context, participants recognised frailty as a key factor.

Though it how can i buy viagra was not initially understood as a medical term, it was eventually accepted as a relevant prognostic variable for predicting survival chances.Some participants questioned the survival chance-based approach, though. For example, a small number of participants expressed concern about the disproportionate effects it could have on groups that may be more vulnerable to erectile dysfunction treatment. €˜By virtue of prioritising survival of the fittest, it will discriminate and people are uncomfortable with this because it means older people will be less likely to be escalated, people in wheelchairs, people in BAME communities’.

Another more widespread worry how can i buy viagra was that this approach failed to allocate resources in accordance with need. These concerns led some participants to formulate a new, vulnerability-based allocation principle, which is discussed further below.Quality of lifeThe notion of quality of life was initially treated with suspicion, seen as inviting unconscious bias and too subjective. €˜I don’t know if professionals can really confirm how somebody’s well-being is’.

Throughout the study, it was increasingly accepted, though mostly as how can i buy viagra a secondary factor when patients’ medical conditions are highly similar, in which case those with a higher quality of life would be prioritised. Caveats were that it should only be applied in extreme cases and that quality of life assessments should, where possible, involve ‘input of the person, their family, carers and that kind of stuff’ to avoid biased assessments.However, one participant said those with a lower quality of life should be prioritised, so that their quality of life may be improved. Some also noted that quality of life may be strongly influenced by socioeconomic factors, indicating a danger of exacerbating existing inequalities.

€˜I do worry with quality of life, the more money you have, the better quality of life you tend to have […] your health is defined by your class and how much money you have’.VulnerabilityThroughout the study, concerns were expressed about how can i buy viagra vulnerability, especially in reaction to the utilitarian approach. In these discussions, participants struggled to formulate an additional allocation principle. This had two aspects, though these were not always clearly differentiated.

One aspect concerned vulnerable groups (eg, age, disability or ethnic how can i buy viagra groups) who may be disproportionately affected by the viagra itself or the social response to it (eg, unconscious bias). One participant said. €˜we know it affects the elderly at higher rates than the youth.

[…] It makes the most sense to prioritise the elderly over the young, how can i buy viagra just on the basis of the percentages of old people vs young people dying. Young people are more likely to survive’. There was, however, some disagreement over whether positive action for these groups should indeed be taken to mitigate the vulnerability or whether this was itself a form of discrimination.The other aspect concerned individuals in need (eg, those presenting to hospital as sicker) and whether a humane principle was to prioritise those in greatest medical need.

€˜The more help somebody needs, the more they should how can i buy viagra get’. Some suggested to prioritise those least likely to survive. €˜I think the most vulnerable should be prioritised.

[…] If you how can i buy viagra think you can save them, then prioritise them’. Reasons given for such an approach were that ‘the true measure of any society is how it treats its most vulnerable members’. But, again, it was accepted that if treatment was unlikely to succeed, patients should not be escalated.

€˜you give the resources to the people that most need it, in my opinion, how can i buy viagra up until the point where the giving of resources is next to useless, where it’s ascertained that they will die anyway’.Other participants rejected this need-based approach altogether, out of a concern for efficiency. €˜Does that mean, if those people are most likely to die, you’re directing your resources at people who are weaker?. So resources could be going to a group who stand the least chance of surviving?.

That doesn’t feel like a great use how can i buy viagra of resources’.ImplementationDuring the final workshop, participants were asked how their recommendations should be implemented. We found strong support for discretion (applying recommendations as guidance rather than a mandatory policy), and participants felt groups of doctors, not individuals, should make decisions as this could reduce burden and bias. Thus, guidelines should not be binding but instead guide expert deliberation, and this deliberation is ideally executed by teams rather than individuals, so that different perspectives can be considered.DiscussionIn summary, we observed a strong rejection of the two explicitly age-based principles.

A tolerance how can i buy viagra for an egalitarian ‘first come, first served’ principle, though with doubts about sufficiency. Wide support for a newly formulated approach based on survival chances, with some consideration of frailty and quality of life. Concerns about group vulnerability and individual need.

And a preference for discretion and deliberation in triage how can i buy viagra decision making.These findings raise important questions regarding existing guidelines and expert recommendations, when and where they do not align with them. Fallucchi et al22 have observed similar public intuitions, which digress from US triage guidelines, but conclude that the public requires more education. We found, however, that these public moral intuitions persist even after a robust process of reflection and deliberation.

We think this warrants serious consideration of public preferences.A first preference deserving serious consideration is the stark rejection of direct how can i buy viagra discrimination on the basis of age, as well as the use of randomised ‘lottery’ approaches, both of which have been observed in similar studies.22 23A second focal point is the preference for survival chance over life expectancy, which also has been observed elsewhere.19 22 Savulescu et al24 have criticised the UK’s NICE guidelines on resource allocation during erectile dysfunction treatment25 for including considerations of survival chance but not life expectancy. The NICE guidelines reject the latter as it results in indirect discrimination on the basis of age. According to Savulescu et al, however, the guidelines already tolerate indirect discrimination since basing triage on survival chance will also disproportionally affect the elderly.

The authors thus assume both factors operate on how can i buy viagra the same logic. However, we suspect our participants may have highlighted an ethically relevant distinction between survival chance and life expectancy. In fact, there are at least two ways in which these factors may be different.

First, considering life expectancy in how can i buy viagra triage seems closer to direct age-based discrimination. While survival chance is closely linked to age specifically in the context of erectile dysfunction treatment, life expectancy has a closer (indeed almost conceptual) link to age. To be older simply is to be closer to death.

A similar distinction between survival chance and life expectancy has been made by Mello et al,26 who argue that only the latter results in how can i buy viagra disability-based discrimination. Second, a live saved and a life year saved seem to produce a different kind of value. A life saved is a categorical outcome, whereas a life year saved is a scalar outcome.

This conceptual difference seems ethically relevant because most participants considered any life saved of inherent value, regardless of its how can i buy viagra predicted length. It is ‘about saving as many people as possible, even if they have a shorter life’. On this logic, saving more of a life does not produce additional value.A third finding deserving of consideration is the concern about vulnerability.

The core values of equality and efficiency, and how can i buy viagra the question of how to balance both, are central to discussions about resource allocation. During our study, however, a third relevant principle spontaneously emerged from the discussions. Vulnerability.

Though this notion was not unpacked in much detail during the deliberations, it alludes to values of antidiscrimination how can i buy viagra and protection, in line with emerging debates in the literature.27 28How can these public intuitions be incorporated into triage decisions?. Participants generally accepted the need for triage but did not arrive at a unified recommendation of one principle. Indeed, in the final survey, recommendations included a mixture of principles and factors.

However, a how can i buy viagra concern for three core principles and values emerged. As mentioned, deliberation resulted in the formulation of three broad, but distinguishable, allocation principles. An egalitarian ‘first come, first served’ principle, a utilitarian principle (but based mainly on survival chance and frailty) and a ‘vulnerability’ principle.

The underlying core how can i buy viagra values of each of these principles could be described as equality, efficiency and vulnerability, respectively. In other words, a ‘triad’ of ethical values emerged. While these remain very hard to fully respect at once, they captured a considered, multifaceted consensus.

All three principles were embedded in caveats and raised their own how can i buy viagra set of concerns. Notably, for each principle, these caveats and concerns can be linked back to the two other values of the triad:The egalitarian ‘equality’ principle raised concerns about efficiency and vulnerability. If treatment was likely futile, it was agreed that patients should forgo it (efficiency concern).

Participants worried strongly about hidden how can i buy viagra inequalities (vulnerability concern).The ‘efficiency’ principle raised concerns about equality and vulnerability. Most agreed that if there was a ‘close call’ between patients, an egalitarian approach should be adopted instead (equality concern). Some worried about groups more vulnerable to erectile dysfunction treatment and about individuals with greater clinical need (vulnerability concerns).The ‘vulnerability’ principle raised concerns about equality and efficiency.

Many participants resisted the notion of positive how can i buy viagra discrimination for vulnerable groups (equality concern). Many also worried that scarce resources would be ‘wasted’ on vulnerable individuals as they may not survive or take up more time in ICU (efficiency concerns).We are hopeful, therefore, that this ‘triad’ of ethical principles may be a useful structure to guide ethical deliberation as societies negotiate the conflicting ethical demands of triage.This links to our finding that participants favoured discretion and group deliberation in triage decisions. In light of this, the triad may offer a useful framework, as it does not prescribe one single principle but rather a balancing exercise among three core values, ideally performed by a team of deliberators.

In sum, rather than inviting moral paralysis, we hope this triad could guide fruitful case discussion for doctors, reduce moral distress and give them more confidence that the triage decisions they arrive at have public acceptability.Strengths and limitationsStrengthsWe achieved a purposeful sample, there was a high level of participant engagement, participants showed they could think through complex ethical topics, a triad consensus emerged from a very diverse South-East London group, indicating a degree of robustness and there was the ecological validity of doing this study in how can i buy viagra the social window in between two erectile dysfunction treatment waves.LimitationsThe South-East London sample may not generalise to other areas, findings may not generalise to other triage contexts (eg, viagras effecting children) and some elements, for example, vulnerability, remained underexplored, indicating a need for further research.ConclusionTo ensure the legitimacy of triage guidelines, which affect the public, it is important to engage the public’s moral intuitions, as they do not always align with expert recommendations. Guiding the public through a process of deliberation ensures that public intuitions do not stem from ignorance or misunderstanding but rather express genuine and considered preferences. We found that (widespread) utilitarian considerations of efficiency should be tempered with a concern for equality and vulnerability.Data availability statementNo data are available.Ethics statementsPatient consent for publicationNot required.Ethics approvalThe study was approved under the Ipsos MORI research ethics committee.AcknowledgmentsWe are grateful to Suzanne Hall, Chloe Juliette, Paul Carroll and Tom Cooper at Ipsos MORI, and to Bobby Duffy, Benedict Wilkinson, Alexandra Pollitt and Lucy Strang at the Policy Institute for their input.

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If stakeholders wish to continue importing foods for a special dietary purpose once the transition regulations come into force, they would be required to go through the normal regulatory process. Next stepsHealth Canada will consult with industry stakeholders, health system partners and other government departments beginning in January. This notice will be updated and provide links to information on these consultations and any related measures, as required.

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