Lasix cost per pill

How to cite this article:Singh Recommended Site OP lasix cost per pill. Mental health in diverse India. Need for lasix cost per pill advocacy.

Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of. We have diversity in terms of geography – From lasix cost per pill the Himalayas to the deserts to the seas. Every region has its own distinct culture and food.

There are so many varieties of dress and language. There is lasix cost per pill huge difference between the states in terms of development, attitude toward women, health infrastructure, child mortality, and other sociodemographic development indexes. There is now ample evidence that sociocultural factors influence mental health.

Compton and Shim[1] have described in their model of gene environment interaction how public policies lasix cost per pill and social norms act on the distribution of opportunity leading to social inequality, exclusion, poor environment, discrimination, and unemployment. This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low access to health care leads lasix cost per pill to poor mental health, disease, and morbidity.When we come to the field of mental health, we find huge differences between different states of India.

The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern lasix cost per pill states had more of childhood onset disorders.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates of depression and anxiety were found in lasix cost per pill females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms.

Marriage was found to be a negative prognostic indicator contrary to the western norms.[3]Cultural lasix cost per pill influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders. The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions.

Apart from culture bound syndromes, the role of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of lasix cost per pill 1–5 lakhs, it was 41,197, and in higher income group, it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy aimed at promoting rights lasix cost per pill of mentally ill persons and reducing stigma and discriminations.

It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population. Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be lasix cost per pill to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done at institutional level, organizational level, and individual level.

There has been huge work done in this regard at institution level. Important research work done in this regard includes the National Mental Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden lasix cost per pill of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.

Similarly, at organizational level, lasix cost per pill the Indian Psychiatric Society (IPS) has filed a case for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality. The IPS has also started helplines at different levels and media interactions.

The Indian Journal of Psychiatry has lasix cost per pill also come out with editorials highlighting the need of care of marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, our weapon is research highlighting lasix cost per pill the role of these factors on mental health.

References 1.Compton MT, Shim RS. The social determinants of lasix cost per pill mental health. Focus 2015;13:419-25.

2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental Health lasix cost per pill Survey of India, 2015-16. Prevalence, Patterns and Outcomes.

Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No. 129.

2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India.

The Global Burden of Disease Study 1990–2017. Lancet Psychiatry 2020;7:148-61. 4.National Crime Records Bureau, 2019.

Accidental Deaths and Suicides in India. 2019. Available from.

Https://ncrb.gov.in. [Last accessed on 2021 Jun 24]. 5.Machado DB, Rasella D, dos Santos DN.

Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/indianjpsychiatry.indianjpsychiatry_635_21Abstract Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, and cultural factors on the one hand and while on the other hand, biological aspects, genetic predisposition, and associated mental and physical illnesses. Sexual health is a neglected area, even though it influences mortality, morbidity, and disability. Dhat syndrome (DS), the term coined by Dr.

N. N. Wig, has been at the forefront of advancements in understanding and misunderstanding.

The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as “a culturally determined idiom of distress.” It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments. Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients.

The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature.

It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.Keywords. Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome.

A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr. President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020.

I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr. Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research.

His name carries the reverence in the corridors of the current National Institute of Mental Health and Neuro Sciences (NIMHANS) at Bangalore which was All India Institute of Mental Health, when he served as Head and the Medical Superintendent. Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS).

Even though Dr. Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore – Dr.

Abraham Varghese, the first Editor of the Indian Journal of Psychological Medicine and Dr. K. Kuruvilla, Past Editor of Indian Journal of Psychiatry whose legacies I carried forward for both the journals.

I must place on record that my journey in the field of Sexual Medicine was sown by Dr. K. Kuruvilla and subsequent influence of Dr.

Ajit Avasthi from Postgraduate Institute of Medical Education and Research from Chandigarh as my role model in the field. There are many more who have shaped and nurtured my interest in the field of sex and sexuality.The term “Dhat” was taken from the Sanskrit language, which is an important word “Dhatu” and has known several meanings such as “metal,” a “medicinal constituent,” which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for “loss of semen”, and the DS is a well-known “culture-bound syndrome (CBS).”[4] The DS leads to several psychosexual disorders such as physical weakness, tiredness, anxiety, appetite loss, and guilt related to the loss of semen through nocturnal emission, in urine and by masturbation as mentioned in many studies.[4],[5],[6] Conventionally, Charaka Samhita mentions “waste of bodily humors” being linked to the “loss of Dhatus.”[5] Semen has even been mentioned by Aristotle as a “soul substance” and weakness associated with its loss.[6] This has led to a plethora of beliefs about “food-blood-semen” relationship where the loss of semen is considered to reduce vitality, potency, and psychophysiological strength. People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions.

Several past studies have emphasized that CBS leads to “anxiety for loss of semen” is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area. Tiwari et al.[22] mentioned in their study that “culture is closely associated with mental disorders through social and psychological activities.” With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome.

A Separate Entity or a “Cultural Variant” of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved. It has mostly been conceptualized as a multidimensional psychosomatic entity consisting of anxiety, depressive, somatic, and sexual phenomenology. Most importantly, abnormal and erroneous attributions are considered to be responsible for the genesis of DS.

The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?.

There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders. Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue.

Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively. Depression continued to be reported as the most common association of DS in many studies.[25],[26] This “cause-effect” dilemma can never be fully resolved. Whether “loss of semen” and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument.

However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness. Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management. He also mentions that the underlying “emotional distress and cultural contexts” are not unique to DS but can be related to any psychiatric syndrome for that matter.

On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of “mood disorders” can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a “cultural phenotype” of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.

Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent.

The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners. A psychiatric referral occurs much later, if at all. This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder.

Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders. The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being.

Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS. That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome.

The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as “semen loss syndrome” by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with “semen loss anxiety” suffer from a myriad of psychosexual symptoms, which have been attributed to “loss of vital essence through semen” (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale.

The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms. Most commonly associated symptoms were found as per score ≥1. This study reported several parameters such as the “sense of being unhealthy” (99%), worry (99%), feeling “no improvement despite treatment” (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%).

The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness. Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic.

Most of them have sexual neurosis (Shen-K'uei syndrome).[7] More than one-third of the patients belonged to lower social class and symptoms of depression, somatization, anxiety, masturbation, and nocturnal emissions. Other bodily complaints as reported were sleep disturbances, fatigue, dizziness, backache, and weakness. Nearly 80% of them considered that all of their problems were due to masturbatory practices.De Silva and Dissanayake[8] investigated several manifestations on semen loss syndrome in the psychiatric clinic of Colombo General Hospital, Sri Lanka.

Beliefs regarding effects of semen loss and help-seeking sought for DS were explored. 38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years.

Every participant reported excessive loss of semen and was preoccupied with it. The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss.

Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing “Dhat” in urine. They were assessed for a period of 6 months.

More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety. All the participants felt that their symptoms were due to loss of “dhat” in urine, attributed to excessive masturbation, extramarital and premarital sex.

Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan. About 600 educated patients were included as per Bradford Somatic Inventory (BSI).

Men with DS reported greater symptoms on BSI than those without DS. 60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for “Dhat” items on BSI.

The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness. This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire.

Nearly one-third of the patients were passing “Dhat” multiple times a week. Among them, nearly 60% passed almost a spoonful of “Dhat” each time during a loss. This work on sexual disorders reported that the passage of “Dhat” was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%).

Mostly, the participants experienced passage of Dhat as “night falls” (60.1%) and “while passing stools” (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the “loss of Dhat.” The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure. Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%.

It was found that 57.5% were suffering either from comorbid depression or anxiety disorders. The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban).

One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction. The psychosexual symptoms were found among 113 patients who had DS. The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%).

In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice.

The view of participants was that semen is very “precious,” needs preservation, and masturbation is a malpractice. Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders. Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively.

The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments. About 66% of the patients met the DSM-IV diagnostic criteria of depression.

They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety. The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through “nocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.” The assessment was done based on several indices, namely “Somatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.” Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis.

Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia).

Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India. They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic.

Clinical assessments were done apart from detailed sexual history. The patients were 15–50 years of age, educated up to mid-school and mostly from a rural background. Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age.

There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16–23 years).

The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill. It was assumed in the study that semen loss is considered synonymous to “loss of something precious”, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and “Dhat” in urine (40%) were the common complaints observed.

Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache. More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia.

About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders). Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse.

67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%). Hypochondriasis, sexually transmitted diseases, and depression were the associated comorbidities.

Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms. DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains.

The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation. Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas.

In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%–66.7%) were from rural areas, belonged to “conservative families and posed rigid views about sex” (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class. Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss.

They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment.

The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class. Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%).

The subjects were single or unmarried (51.0%) and married (46.7%). About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes.

Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%). About 45.80% of the study subjects were illiterates and very few had completed postgraduation. The subjects were both married and single.

Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).

Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16–20 years (34%) followed by 21–25 years (28%), greater than 30 years (26%), 26–30 years (10%), and 11–15 years (2%).

Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively. Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine. In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years.

The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%). Priyadarshi and Verma[43] performed a study in 110 male patients with DS.

The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18–25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years.

Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively.

Two-third patients belonged to rural areas of residence. Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata.

The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset. Only a few patients received higher education.

Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training.

Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%). Most of those who had comorbid DS symptoms received minimal formal education. Management.

A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks. As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal “supplements,” etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help.

The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals. Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone.

Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality. This needs to be tailored to the local terminology and beliefs.

Biofeedback has also been proposed as a treatment modality.[4] Individual stress factors that might have precipitated DS need to be addressed. A detailed outline of assessment, evaluation, and management of DS is beyond the scope of this article and has already been reported in the IPS Clinical Practice Guidelines.[56] The readers are referred to these important guidelines for a comprehensive read on management. Probably, the most important factor is to understand and resolve the sociocultural contexts in the genesis of DS in each individual.

Adequate debunking of the myths related to sexuality and culturally appropriate sexual education is vital both for the prevention and treatment of DS.[56] Adequate treatment of comorbidities such as depression and anxiety often helps in reduction of symptoms, more so when the DS is considered to be a manifestation of the same. Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary.

CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization. Sameer et al.[23] followed up DS patients for 6.0 ± 3.5 years and concluded that the “pure” variety of DS is not a stable diagnostic entity.

The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right “place” for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different.

While ICD-10 considers DS under “other nonpsychotic mental disorders” (F48), DSM-V mentions it only in appendix section as “cultural concepts of distress” not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a “true syndrome.”[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural “idiom” of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification. However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the “niche” of DS in the near future.

It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader “narrative” of depression. In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric “construct” which is equally interesting and controversial.

Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality. Beyond the traditional debate about its “separate” existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health. It is also treatable, and hence, the detection, understanding, and awareness become vital to its management.

This oration attempts a “bird's eye” view of this CBS taking into account a holistic perspective of the available evidence so far. The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr.

Debanjan Banerjee (Senior Resident, Department of Psychiatry, NIMHANS, Bangalore) for his constant selfless support, rich academic discourse, and continued collaboration that helped me condense years of research and ideas into this paper.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.2.3.Srinivasa Murthy R, Wig NN. A man ahead of his time.

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27.Balhara YP. Culture-bound syndrome. Has it found its right niche?.

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A review and update. J Psychosexual Health 2019;1:241-5. 30.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al.

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31.Dhikav V, Aggarwal N, Gupta S, Jadhavi R, Singh K. Depression in Dhat syndrome. J Sex Med 2008;5:841-4.

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35.Kar SK, Sarkar S. Dhat syndrome. Evolution of concept, current understanding, and need of an integrated approach.

J Hum Reprod Sci 2015;8:130-4. [PUBMED] [Full text] 36.World Health Organisation. The ICD-10, Classification of Mental and Behavioural Disorders.

Diagnostic Criteria for Research. Geneva. World Health Organisation.

1992. 37.Perme B, Ranjith G, Mohan R, Chandrasekaran R. Dhat (semen loss) syndrome.

A functional somatic syndrome of the Indian subcontinent?. Gen Hosp Psychiatry 2005;27:215-7. 38.Wig NN.

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A study on its prevalence in an outpatient setting. Indian J Psychiatry 1997:Suppl 39:53. 42.Bhatia MS, Thakkur KN, Chadda RK, Shome S.

Koro in Dhat syndrome. Indian J Soc Psychiatry 1992;8:74-5. 43.Priyadarshi S, Verma A.

Dhat syndrome and its social impact. Urol Androl Open J 2015;1:6-11. 44.Nakra BR, Wig NN, Verma VK.

A study of male potency disorders. Indian J Psychiatry 1977;19:13-8. [Full text] 45.Behere PB, Natraj GS.

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[PUBMED] [Full text] 47.Bhatia MS, Malik SC. Dhat syndrome – A useful diagnostic entity in Indian culture. Br J Psychiatry 1991;159:691-5.

48.Bhatia MS, Choudhry S, Shome S. Dhat syndrome - Is it a syndrome of Dhat only?. J Ment Health Hum Behav1997;2:17-22.

49.Bhatia MS. An analysis of 60 cases of culture bound syndromes. Indian J Med Sci 1999;53:149-52.

[PUBMED] [Full text] 50.Morrone A, Nosotti L, Tumiati Mc, Cianconi P, Casadei F, Franco G. Dhat Syndrome. An Analysis of 18 Cases.

Paper Presented in 11th Congress of the European Academy of Dermatology &. Venerology. Prague.

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[PUBMED] [Full text] 55.Prakash O, Rao TS. Sexuality research in India. An update.

Indian J Psychiatry 2010;52:S260-3. 56.Avasthi A, Grover S, Rao TS. Clinical practice guidelines for management of sexual dysfunction.

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Indian J Soc Psychiatry 2018;34 Suppl S1:1-4. Correspondence Address:T S Sathyanarayana RaoDepartment of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka IndiaSource of Support. None, Conflict of Interest.

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Research also needs to recognise the diverse range of different people, with different needs and vulnerabilities, who are grouped under the multidimensional term BAME, including people from different generations, first-time migrants, people from Africa, India, the Caribbean and, more recently, migrants from Eastern Europe. Application of a race equality impact assessment to all research questions and methodology has recently been proposed as a lasix cost per pill first step in this process.2 At this early stage, the guidance for assessing risks of hypertension medications for health professionals is also useful for patients, until more refined decision support and prediction tools are developed. A recent Public Health England report on ethnic minorities and hypertension medications9 recommends better recording of ethnicity data in health and social care, and goes further to suggest this should also apply to death certificates. Furthermore, the report recommends more participatory and experience-based research to understand causes and consequences of pre-existing multimorbidity and hypertension medications , integrated care systems that work well for susceptible and marginalised groups, culturally competent health promotion, lasix cost per pill prevention and occupational risk assessments, and recovery strategies to mitigate the risks of widening inequalities as we come out of restrictions.Primary data collection will need to cover not only hospital admissions but also data from primary care, linking information on mental health, hypertension medications and ethnicity. We already have research and specific guidance emerging on other risk factors, such as age and gender.

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Modern Healthcare Senior Hospital Operations Reporter Alex Kacik and Finance Reporter lasix name Tara Bannow talk about Lloyd Dean's retirement and CommonSpirit Health.Subscribe to Beyond the BylineSubscribe to Modern Healthcare Follow us on buy lasix online no prescription TwitterMusic Credit. Coffee by CamboAlex Kacik. Hello, and welcome to Modern Healthcare's Beyond the Byline, where we offer behind the scenes lasix name looks into our reporting. I'm Alex Kacik, senior operations reporter. Senior finance reporter Tara Bannow is joining me today to talk about CommonSpirit Health, the largest not-for-profit health system in the country behind Kaiser Permanente.

Thanks for joining lasix name me, Tara.Tara Bannow. Thanks for having me.Alex Kacik. So Lloyd Dean is retiring in the summer of 2022, 3 years after Dignity Health merged with Catholic Health Initiatives to form CommonSpirit Health. This is a sprawling 140 hospital health system that spans over 20 states and has 33 lasix name billion in annual revenue. When you're talking to folks who have watched him over the years lead various health systems and how CommonSpirit Health is faring, what do they say about his departure?.

Tara Bannow. Yeah. And personally, I was surprised to hear this, so I kind of went into it through that lens. I thought that Lloyd was going to be the one to kind of stay and lead CommonSpirit for the long run, especially after Kevin Lofton, who was the co-CEO, retired in 2020. But, you know, I talked to a number of analysts, a number of folks who cover CommonSpirit, and they pointed out, "Look, you know, he's 71.

He's been doing this for decades," and, you know, capping off his career by putting together what we know was a very difficult merger and then getting CommonSpirit off the ground, getting it on what appears to be relatively stable footing, that's all really hard to do. And it makes sense that now he wants to hand off this enterprise to a new leader.Actually, I talked to a guy from Korn Ferry and he kind of compared it to the Advocate Aurora merger that was in 2018. So they also started out with a co-CEO model, like CommonSpirit, but this analyst said, you know, "Jim Schogsburg, he's the CEO, he said that if Jim were to retire now, that would be surprising, because he's in his early sixties, has a lot of career left, but 71 is a different place to be."Alex Kacik. Yeah. And there was a lot of anticipation.

I remember you and I covered this when it was nearing completion, the CommonSpirit deal, Dignity and CHI, and I think it was our first co-byline for the magazine. There was a lot of talk about that co-CEO model and how that was going to work as the system's integrated, you know. And what we've come to see now, and in most cases that's usually like a two-year arrangement at tops and one of them steps down or retires. And, you know, like you said, I think Lloyd Dean was expected to lead it over the long haul after Kevin Lofton stepped down.But there was other complicating issues aside from the massive scale of these two organizations, predominantly CHI, but, you know, the Vatican had to green light the merger. Whenever you have the Catholic doctrines that come into play and those directives, and you have to get these, you know, extra layers of approval and ensure, you know, what expectations are for certain types of procedures, like abortion or gender affirming care.

And so, you know, you reported for the first two years, since 2019, they've posted some pretty significant operating losses. And since then, it sounds like over the past year or so, they've been able to get a better clamp down on expenses and find ways to operate in the black.Tara Bannow. Yeah, that's right. I think, to be fair, early credit ratings that came out suggested, you know, the agencies were writing, you know, we understand that it takes a while to get your footing as a merged entity. There's a lot of risk involved.

So the executives with CommonSpirit were talking about all these cost savings they were going to get, but initially it is a very expensive thing to do when you're merging two systems of this size. So S&P wrote in its initial report on CommonSpirit that its finances will decline initially, and then they'll ultimately improve. So I think that's kind of starting to bear out. So the financial losses in the first years as a system were pretty alarming. I mean, $602 million in fiscal 2019, which was the first year as a system, and then $550 million in the subsequent year.And that's with more than $800 million in stimulus grants.

So it would've been much steeper without those. And in late 2020, what was interesting on investor calls, you had analysts asking the system if it expected to violate its debt covenants, which that's not exactly a show of confidence to have people asking you that. But yeah, I mean things have started to turn around. It's too soon to say whether this will be permanent, but CommonSpirit did generate almost a billion in operating income in fiscal 2021, a 3% margin. Would've been 1% without stimulus grants.

So it's not amazing, but it's much better than they had been doing.Alex Kacik. So hospital executives claim that it takes at least a year or two to fully integrate. Like you were saying, there's a lot of moving parts, you have to combine IT systems, and, you know, you manage supply chains through different operating processes and different ERP platforms. You often have different cultures when it comes to day-to-day management, especially when it comes to your physicians and whether you're, you know, more hands on or hands off there, but ultimately they say you'll save money through bundled purchasing, through other economies of scale. And then, you know, you have the critics on the other side of mergers saying that those efficiencies don't often pan out, because it's really hard to integrate large organizations, given some of the executive redundancies.We've seen in various reports that efficiencies are harder to glean when organizations are spread out.

It's harder to bundle purchasing across multiple states. And that's similar when it comes negotiations with insurers. Dignity had a more regional presence in the West, while CHI is spread out across more than a dozen states. And, you know, we talked to them a few times independently and then, you know, talked about their expansion and how they purchased dozens, hundreds of doctors over their growth. And that's hard to integrate into the system.

You always take a little bit of risk as you pay for the compensation and try to ensure that referrals stay within the system. But yeah, I mean it seemed like there was a pattern of regional partnerships over the past four or five years and less of some of these sprawling, spread out ones. But what did you make of that dichotomy between trying to go big for that and trying to gain efficiencies of scale, versus, you know, others that have taken a different approach?. Tara Bannow. Yeah.

I mean, I think that's a really reasonable question to ask. I mean and I think another complicating factor with CommonSpirit in particular is they had different operating structures, with Dignity being more centralized and CHI being kind of led by these regional arms. So I imagine that was kind of difficult to navigate culturally as a larger system. CommonSpirit ... I mean, analysts have kind of pointed to the fact that CommonSpirit is trying to sort of refine its profile.

They added Virginia Mason in Seattle, which was a really good get for them. They tried unsuccessfully to sell some hospitals in the Midwest to Essentia. So you can tell they're kind of trying to, you know, give themselves a better overall platform. So whether that will work sort of remains to be seen.I think what was interesting too with CommonSpirit is in Texas when we saw CHI St. Luke's raise this contract dispute with Blue Cross Blue Shield of Texas mid-contract and said, "Our rates aren't high enough.

We want more money or we're out." And that's very unusual to do. I mean, usually that kind of stuff comes up at the end of a contract, but, you know, I think this shows that CommonSpirit isn't afraid to use its market power and flex its very large muscles when it comes to contracting. And then they did actually reach a new contract agreement. So I guess it worked. And also, interesting from a branding perspective, Lloyd Dean told me that they are keeping things pretty much separate indefinitely.

So CHI will stay CHI. Dignity will stay Dignity. Lloyd said that CommonSpirit is kind of a house of brands, so it makes sense to harness this local recognition that CHI Franciscan has, for example.Alex Kacik. Yeah. And that's interesting too, because you always get to a point of when you're talking with these analysts on how thorough is their integration, and one of the things at least from just a optics perspective is when you're not sharing the same name and you kind of remain as a separate institution, maybe you keep those silos up too, depending on whether you have more of a centralized, you know, governance structure or one that's a hub and spoke model.

And so yeah, I mean that factors into it too. And you mentioned the contract dispute. I know Dignity had one come up with Anthem, Blue Shield in their California region and they resolved that, but it's always interesting to see that back and forth and how much negotiating leverage each party thinks they have. But, you know, when it comes to CEO tenures, they were already getting shorter prior to the lasix and it's a competitive market for CEOs, and many would get poached away by other systems that would pay more, but it seems like the lasix has maybe even expedited some of that CEO turnover.Tara Bannow. Yeah.

I mean, there's been a lot of CEO retirement announcements since the start of the lasix. It's impossible to say if these were entirely lasix driven. I mean, it could be a number of factors. Maybe the lasix was the straw that broke the camel's back, but some big ones were Baylor Scott &. Whites, Jim Hinton, and Acadia Healthcare's Debbie Ostein, Alina Health's Dr.

Penny Wheeler, Sutter Health's Sarah Krevens. One analyst I talked to about this said, "The world has changed a lot since early 2020. We're kind of operating in a new paradigm in healthcare and every area of our lives." So for many, maybe the next five years or so, is the appropriate time to hand off the baton to somebody who wants to kind of work and lead systems in this new world.Alex Kacik. Sounds good. So what's the outlook for CommonSpirit?.

You know, when you're talking to analysts, what are they keeping an eye on as they look at, you know, what their next steps are as a system?. I know they are seemingly selling some operations off the non-core markets of their business. You mentioned, you know, a couple mergers that were proposed out in the West with CHI Franciscan. And yeah, what's their gauge on what are they going to be keeping an eye on moving forward to see if CommonSpirit progresses?. Tara Bannow.

Analysts are cautiously optimistic. I think they're encouraged by the financial improvement they've seen so far, but they want to definitely get a sense for how CommonSpirit plans to keep that momentum going and improve the finances further. You know, I think it's impossible to say at this point what exactly will happen there. Lloyd Dean said that CommonSpirit is currently being re-evaluated, re-rated by all three credit rating agencies. And he said he expects better ratings this time around.

I think he's hoping things will look good. The credit rating agencies for their part were a little bit more mum on that point.But I think people, you know, analysts and others are also looking hard at that $2 billion cost savings goal that CommonSpirit has talked a lot about, and they want to see, you know, more detail around that, around how they plan to get there and when they'll get there. I think the lasix has sort of slowed that down a little bit. They're not exactly at the pace that they wanted to be initially, because obviously preparing for and treating hypertension medications patients and rolling out the vaccinations and getting adequate labor during the lasix has been a really big challenge for CommonSpirit and others. But yeah, I think once we have more progress and detail toward the cost savings goal, that will improve the margins as well.Alex Kacik.

All right, Tara, thank you so much for breaking this down for us.Tara Bannow. Yeah, thanks for having me. This was fun.Alex Kacik. All right. Thank you all for listening.

If you'd like to subscribe and support our work, there's a link in the show notes. You can subscribe to Beyond the Byline on Spotify or wherever you listen to your podcast, and you can stay connected with our work by following Tara and I at Modern Healthcare on Twitter and LinkedIn. We appreciate your support..

Modern Healthcare Senior Hospital Operations Reporter Alex Kacik and lasix cost per pill Finance Reporter Tara Bannow talk about Lloyd Dean's retirement and http://stephaniehosford.com/?post_type=wpcf7_contact_form&p=54 CommonSpirit Health.Subscribe to Beyond the BylineSubscribe to Modern Healthcare Follow us on TwitterMusic Credit. Coffee by CamboAlex Kacik. Hello, and welcome to Modern Healthcare's Beyond the Byline, where we lasix cost per pill offer behind the scenes looks into our reporting.

I'm Alex Kacik, senior operations reporter. Senior finance reporter Tara Bannow is joining me today to talk about CommonSpirit Health, the largest not-for-profit health system in the country behind Kaiser Permanente. Thanks for joining me, lasix cost per pill Tara.Tara Bannow.

Thanks for having me.Alex Kacik. So Lloyd Dean is retiring in the summer of 2022, 3 years after Dignity Health merged with Catholic Health Initiatives to form CommonSpirit Health. This is a sprawling 140 hospital health system that lasix cost per pill spans over 20 states and has 33 billion in annual revenue.

When you're talking to folks who have watched him over the years lead various health systems and how CommonSpirit Health is faring, what do they say about his departure?. Tara Bannow. Yeah.

And personally, I was surprised to hear this, so I kind of went into it through that lens. I thought that Lloyd was going to be the one to kind of stay and lead CommonSpirit for the long run, especially after Kevin Lofton, who was the co-CEO, retired in 2020. But, you know, I talked to a number of analysts, a number of folks who cover CommonSpirit, and they pointed out, "Look, you know, he's 71.

He's been doing this for decades," and, you know, capping off his career by putting together what we know was a very difficult merger and then getting CommonSpirit off the ground, getting it on what appears to be relatively stable footing, that's all really hard to do. And it makes sense that now he wants to hand off this enterprise to a new leader.Actually, I talked to a guy from Korn Ferry and he kind of compared it to the Advocate Aurora merger that was in 2018. So they also started out with a co-CEO model, like CommonSpirit, but this analyst said, you know, "Jim Schogsburg, he's the CEO, he said that if Jim were to retire now, that would be surprising, because he's in his early sixties, has a lot of career left, but 71 is a different place to be."Alex Kacik.

Yeah. And there was a lot of anticipation. I remember you and I covered this when it was nearing completion, the CommonSpirit deal, Dignity and CHI, and I think it was our first co-byline for the magazine.

There was a lot of talk about that co-CEO model and how that was going to work as the system's integrated, you know. And what we've come to see now, and in most cases that's usually like a two-year arrangement at tops and one of them steps down or retires. And, you know, like you said, I think Lloyd Dean was expected to lead it over the long haul after Kevin Lofton stepped down.But there was other complicating issues aside from the massive scale of these two organizations, predominantly CHI, but, you know, the Vatican had to green light the merger.

Whenever you have the Catholic doctrines that come into play and those directives, and you have to get these, you know, extra layers of approval and ensure, you know, what expectations are for certain types of procedures, like abortion or gender affirming care. And so, you know, you reported for the first two years, since 2019, they've posted some pretty significant operating losses. And since then, it sounds like over the past year or so, they've been able to get a better clamp down on expenses and find ways to operate in the black.Tara Bannow.

Yeah, that's right. I think, to be fair, early credit ratings that came out suggested, you know, the agencies were writing, you know, we understand that it takes a while to get your footing as a merged entity. There's a lot of risk involved.

So the executives with CommonSpirit were talking about all these cost savings they were going to get, but initially it is a very expensive thing to do when you're merging two systems of this size. So S&P wrote in its initial report on CommonSpirit that its finances will decline initially, and then they'll ultimately improve. So I think that's kind of starting to bear out.

So the financial losses in the first years as a system were pretty alarming. I mean, $602 million in fiscal 2019, which was the first year as a system, and then $550 million in the subsequent year.And that's with more than $800 million in stimulus grants. So it would've been much steeper without those.

And in late 2020, what was interesting on investor calls, you had analysts asking the system if it expected to violate its debt covenants, which that's not exactly a show of confidence to have people asking you that. But yeah, I mean things have started to turn around. It's too soon to say whether this will be permanent, but CommonSpirit did generate almost a billion in operating income in fiscal 2021, a 3% margin.

Would've been 1% without stimulus grants. So it's not amazing, but it's much better than they had been doing.Alex Kacik. So hospital executives claim that it takes at least a year or two to fully integrate.

Like you were saying, there's a lot of moving parts, you have to combine IT systems, and, you know, you manage supply chains through different operating processes and different ERP platforms. You often have different cultures when it comes to day-to-day management, especially when it comes to your physicians and whether you're, you know, more hands on or hands off there, but ultimately they say you'll save money through bundled purchasing, through other economies of scale. And then, you know, you have the critics on the other side of mergers saying that those efficiencies don't often pan out, because it's really hard to integrate large organizations, given some of the executive redundancies.We've seen in various reports that efficiencies are harder to glean when organizations are spread out.

It's harder to bundle purchasing across multiple states. And that's similar when it comes negotiations with insurers. Dignity had a more regional presence in the West, while CHI is spread out across more than a dozen states.

And, you know, we talked to them a few times independently and then, you know, talked about their expansion and how they purchased dozens, hundreds of doctors over their growth. And that's hard to integrate into the system. You always take a little bit of risk as you pay for the compensation and try to ensure that referrals stay within the system.

But yeah, I mean it seemed like there was a pattern of regional partnerships over the past four or five years and less of some of these sprawling, spread out ones. But what did you make of that dichotomy between trying to go big for that and trying to gain efficiencies of scale, versus, you know, others that have taken a different approach?. Tara Bannow.

Yeah. I mean, I think that's a really reasonable question to ask. I mean and I think another complicating factor with CommonSpirit in particular is they had different operating structures, with Dignity being more centralized and CHI being kind of led by these regional arms.

So I imagine that was kind of difficult to navigate culturally as a larger system. CommonSpirit ... I mean, analysts have kind of pointed to the fact that CommonSpirit is trying to sort of refine its profile.

They added Virginia Mason in Seattle, which was a really good get for them. They tried unsuccessfully to sell some hospitals in the Midwest to Essentia. So you can tell they're kind of trying to, you know, give themselves a better overall platform.

So whether that will work sort of remains to be seen.I think what was interesting too with CommonSpirit is in Texas when we saw CHI St. Luke's raise this contract dispute with Blue Cross Blue Shield of Texas mid-contract and said, "Our rates aren't high enough. We want more money or we're out." And that's very unusual to do.

I mean, usually that kind of stuff comes up at the end of a contract, but, you know, I think this shows that CommonSpirit isn't afraid to use its market power and flex its very large muscles when it comes to contracting. And then they did actually reach a new contract agreement. So I guess it worked.

And also, interesting from a branding perspective, Lloyd Dean told me that they are keeping things pretty much separate indefinitely. So CHI will stay CHI. Dignity will stay Dignity.

Lloyd said that CommonSpirit is kind of a house of brands, so it makes sense to harness this local recognition that CHI Franciscan has, for example.Alex Kacik. Yeah. And that's interesting too, because you always get to a point of when you're talking with these analysts on how thorough is their integration, and one of the things at least from just a optics perspective is when you're not sharing the same name and you kind of remain as a separate institution, maybe you keep those silos up too, depending on whether you have more of a centralized, you know, governance structure or one that's a hub and spoke model.

And so yeah, I mean that factors into it too. And you mentioned the contract dispute. I know Dignity had one come up with Anthem, Blue Shield in their California region and they resolved that, but it's always interesting to see that back and forth and how much negotiating leverage each party thinks they have.

But, you know, when it comes to CEO tenures, they were already getting shorter prior to the lasix and it's a competitive market for CEOs, and many would get poached away by other systems that would pay more, but it seems like the lasix has maybe even expedited some of that CEO turnover.Tara Bannow. Yeah. I mean, there's been a lot of CEO retirement announcements since the start of the lasix.

It's impossible to say if these were entirely lasix driven. I mean, it could be a number of factors. Maybe the lasix was the straw that broke the camel's back, but some big ones were Baylor Scott &.

Whites, Jim Hinton, and Acadia Healthcare's Debbie Ostein, Alina Health's Dr. Penny Wheeler, Sutter Health's Sarah Krevens. One analyst I talked to about this said, "The world has changed a lot since early 2020.

We're kind of operating in a new paradigm in healthcare and every area of our lives." So for many, maybe the next five years or so, is the appropriate time to hand off the baton to somebody who wants to kind of work and lead systems in this new world.Alex Kacik. Sounds good. So what's the outlook for CommonSpirit?.

You know, when you're talking to analysts, what are they keeping an eye on as they look at, you know, what their next steps are as a system?. I know they are seemingly selling some operations off the non-core markets of their business. You mentioned, you know, a couple mergers that were proposed out in the West with CHI Franciscan.

And yeah, what's their gauge on what are they going to be keeping an eye on moving forward to see if CommonSpirit progresses?. Tara Bannow. Analysts are cautiously optimistic.

I think they're encouraged by the financial improvement they've seen so far, but they want to definitely get a sense for how CommonSpirit plans to keep that momentum going and improve the finances further. You know, I think it's impossible to say at this point what exactly will happen there. Lloyd Dean said that CommonSpirit is currently being re-evaluated, re-rated by all three credit rating agencies.

And he said he expects better ratings this time around. I think he's hoping things will look good. The credit rating agencies for their part were a little bit more mum on that point.But I think people, you know, analysts and others are also looking hard at that $2 billion cost savings goal that CommonSpirit has talked a lot about, and they want to see, you know, more detail around that, around how they plan to get there and when they'll get there.

I think the lasix has sort of slowed that down a little bit. They're not exactly at the pace that they wanted to be initially, because obviously preparing for and treating hypertension medications patients and rolling out the vaccinations and getting adequate labor during the lasix has been a really big challenge for CommonSpirit and others. But yeah, I think once we have more progress and detail toward the cost savings goal, that will improve the margins as well.Alex Kacik.

All right, Tara, thank you so much for breaking this down for us.Tara Bannow. Yeah, thanks for having me. This was fun.Alex Kacik.

All right. Thank you all for listening. If you'd like to subscribe and support our work, there's a link in the show notes.

You can subscribe to Beyond the Byline on Spotify or wherever you listen to your podcast, and you can stay connected with our work by following Tara and I at Modern Healthcare on Twitter and LinkedIn. We appreciate your support..

When should lasix be taken

Before that date, people enrolled in a Medicaid managed care plan obtained all of their health care through the plan, but used their regular Medicaid card to access any drug available on the state formulary on a "fee for service" when should lasix be taken basis without needing to utilize a restricted pharmacy network or comply with managed care plan rules. COMING IN April 2021 - In the NYS Budget enacted in April 2020, the pharmacy benefit was "carved out" of "mainstream" Medicaid managed care plans. That means that members of managed care plans will access their drugs outside their plan, unlike the rest of their medical care, which is accessed from in-network providers. How when should lasix be taken Prescription Drugs are Obtained through Managed Care plans No - Until April 2020 HOW DO MANAGED CARE PLANS DEFINE THE PHARMACY BENEFIT FOR CONSUMERS?. The Medicaid pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies.

Under Medicaid managed care. Plan formularies will when should lasix be taken be comparable to but not the same as the Medicaid formulary. Managed care plans are required to have drug formularies that are “comparable” to the Medicaid fee for service formulary. Plan formularies do not have to include all drugs covered listed on the fee for service formulary, but they must include generic or therapeutic equivalents of all Medicaid covered drugs. The Pharmacy Benefit will vary by when should lasix be taken plan.

Each plan will have its own formulary and drug coverage policies like prior authorization and step therapy. Pharmacy networks can also differ from plan to plan. Prescriber Prevails applies when should lasix be taken in certain drug classes. Prescriber prevails applys to medically necessary precription drugs in the following classes. atypical antipsychotics, anti-depressants, anti-retrovirals, anti-rejection, seizure, epilepsy, endocrine, hemotologic and immunologic therapeutics.

Prescribers will need to demonstrate reasonable profession judgment and supply plans witht requested information and/or clinical documentation when should lasix be taken. Pharmacy Benefit Information Website -- http://mmcdruginformation.nysdoh.suny.edu/-- This website provides very helpful information on a plan by plan basis regarding pharmacy networks and drug formularies. The Department of Health plans to build capacity for interactive searches allowing for comparison of coverage across plans in the near future. Standardized Prior Autorization (PA) when should lasix be taken Form -- The Department of Health worked with managed care plans, provider organizations and other state agencies to develop a standard prior authorization form for the pharmacy benefit in Medicaid managed care. The form will be posted on the Pharmacy Information Website in July of 2013.

Mail Order Drugs -- Medicaid managed care members can obtain mail order/specialty drugs at any retail network pharmacy, as long as that retail network pharmacy agrees to a price that is comparable to the mail order/specialty pharmacy price. CAN CONSUMERS SWITCH PLANS IN ORDER when should lasix be taken TO GAIN ACCESS TO DRUGS?. Changing plans is often an effective strategy for consumers eligible for both Medicaid and Medicare (dual eligibles) who receive their pharmacy service through Medicare Part D, because dual eligibles are allowed to switch plans at any time. Medicaid consumers will have this option only in the limited circumstances during the first year of enrollment in managed care. Medicaid when should lasix be taken managed care enrollees can only leave and join another plan within the first 90 days of joining a health plan.

After the 90 days has expired, enrollees are “locked in” to the plan for the rest of the year. Consumers can switch plans during the “lock in” period only for good cause. The pharmacy benefit changes are not considered good when should lasix be taken cause. After the first 12 months of enrollment, Medicaid managed care enrollees can switch plans at any time. STEPS CONSUMERS CAN TAKE WHEN A MANAGED CARE PLAM DENIES ACCESS TO A NECESSARY DRUG As a first step, consumers should try to work with their providers to satisfy plan requirements for prior authorization or step therapy or any other utilization control requirements.

If the plan still denies access, consumers can pursue review processes specific to managed care while at the same time pursuing a fair hearing when should lasix be taken. All plans are required to maintain an internal and external review process for complaints and appeals of service denials. Some plans may develop special procedures for drug denials. Information on these when should lasix be taken procedures should be provided in member handbooks. Beginning April 1, 2018, Medicaid managed care enrollees whose plan denies prior approval of a prescription drug, or discontinues a drug that had been approved, will receive an Initial Adverse Determination notice from the plan - See Model Denial IAD Notice and IAD Notice to Reduce, Suspend or Stop Services The enrollee must first request an internal Plan Appeal and wait for the Plan's decision.

An adverse decision is called a 'FInal Adverse Determination" or FAD. See model Denial FAD Notice and FAD when should lasix be taken Notice to Reduce, Suspend or Stop Services. The enroll has the right to request a fair hearing to appeal an FAD. The enrollee may only request a fair hearing BEFORE receiving the FAD if the plan fails to send the FAD in the required time limit, which is 30 calendar days in standard appeals, and 72 hours in expedited appeals. The plan may extend the time to decide both standard and expedited appeals by up to 14 days if more information is needed and it when should lasix be taken is in the enrollee's interest.

AID CONTINUING -- If an enrollee requests a Plan Appeal and then a fair hearing because access to a drug has been reduced or terminated, the enrollee has the right to aid continuing (continued access to the drug in question) while waiting for the Plan Appeal and then the fair hearing. The enrollee must request the Plan Appeal and then the Fair Hearing before the effective date of the IAD and FAD notices, which is a very short time - only 10 days including mailing time. See more about the changes in Managed Care when should lasix be taken appeals here. Even though that article is focused on Managed Long Term Care, the new appeals requirements also apply to Mainstream Medicaid managed care. Enrollees who are in the first 90 days of enrollment, or past the first 12 months of enrollment also have the option of switching plans to improve access to their medications.

Consumers who experience problems with access to prescription drugs should always file a complaint when should lasix be taken with the State Department of Health’s Managed Care Hotline, number listed below. ACCESSING MEDICAID'S PHARMACY BENEFIT IN FEE FOR SERVICE MEDICAID For those Medicaid recipients who are not yet in a Medicaid Managed Care program, and who do not have Medicare Part D, the Medicaid Pharmacy program covers most of their prescription drugs and select non-prescription drugs and medical supplies for Family Health Plus enrollees. Certain drugs/drug categories require the prescribers to obtain prior authorization. These include brand name drugs that have a generic alternative under New York's mandatory generic drug when should lasix be taken program or prescribed drugs that are not on New York's preferred drug list. The full Medicaid formulary can be searched on the eMedNY website.

Even in fee for service Medicaid, prescribers must obtain prior authorization before prescribing non-preferred drugs unless otherwise indicated. Prior authorization is when should lasix be taken required for original prescriptions, not refills. A prior authorization is effective for the original dispensing and up to five refills of that prescription within the next six months. Click here for more information on NY's prior authorization process. The New York State Board of Pharmacy publishes an annual list of the 150 most frequently prescribed when should lasix be taken drugs, in the most common quantities.

The State Department of Health collects retail price information on these drugs from pharmacies that participate in the Medicaid program. Click here to search for a specific drug from the most frequently prescribed drug list and this site can also provide you with the locations of pharmacies that provide this drug as well as their costs. Click here to view New York State when should lasix be taken Medicaid’s Pharmacy Provider Manual. WHO YOU CAN CALL FOR HELP Community Health Advocates Hotline. 1-888-614-5400 NY State Department of Health's Managed Care Hotline.

1-800-206-8125 (Mon when should lasix be taken. - Fri. 8:30 am - 4:30 pm) NY State Department of Insurance. 1-800-400-8882 NY State Attorney General's Health Care Bureau when should lasix be taken. 1-800-771-7755Haitian individuals and immigrants from some other countries who have applied for Temporary Protected Status (TPS) may be eligible for public health insurance in New York State.

2019 updates - The Trump administration has taken steps to end TPS status. Two courts have temporarily enjoined the termination of TPS, one in New York State in when should lasix be taken April 2019 and one in California in October 2018. The California case was argued in an appeals court on August 14, 2019, which the LA Times reported looked likely to uphold the federal action ending TPS. See US Immigration Website on TPS - General TPS website with links to status in all countries, including HAITI. See also Pew Research March when should lasix be taken 2019 article.

Courts Block Changes in Public charge rule- See updates on the Public Charge rule here, blocked by federal court injunctions in October 2019. Read more about this change in public charge rules here. What is Temporary when should lasix be taken Protected Status?. TPS is a temporary immigration status granted to eligible individuals of a certain country designated by the Department of Homeland Security because serious temporary conditions in that country, such as armed conflict or environmental disaster, prevents people from that country to return safely. On January 21, 2010 the United States determined that individuals from Haiti warranted TPS because of the devastating earthquake that occurred there on January 12.

TPS gives undocumented Haitian residents, who when should lasix be taken were living in the U.S. On January 12, 2010, protection from forcible deportation and allows them to work legally. It is important to note that the U.S. Grants TPS when should lasix be taken to individuals from other countries, as well, including individuals from El Salvador, Honduras, Nicaragua, Somalia and Sudan. TPS and Public Health Insurance TPS applicants residing in New York are eligible for Medicaid and Family Health Plus as long as they also meet the income requirements for these programs.

In New York, applicants for TPS are considered PRUCOL immigrants (Permanently Residing Under Color of Law) for purposes of medical assistance eligibility and thus meet the immigration status requirements for Medicaid, Family Health Plus, and the Family Planning Benefit Program. Nearly all children in New York remain eligible when should lasix be taken for Child Health Plus including TPS applicants and children who lack immigration status. For more information on immigrant eligibility for public health insurance in New York see 08 GIS MA/009 and the attached chart. Where to Apply What to BringIndividuals who have applied for TPS will need to bring several documents to prove their eligibility for public health insurance. Individuals will need to bring when should lasix be taken.

1) Proof of identity. 2) Proof of residence in New York. 3) when should lasix be taken Proof of income. 4) Proof of application for TPS. 5) Proof that U.S.

Citizenship and Immigration Services (USCIS) has received the application for when should lasix be taken TPS. Free Communication Assistance All applicants for public health insurance, including Haitian Creole speakers, have a right to get help in a language they can understand. All Medicaid offices and enrollers are required to offer free translation and interpretation services to anyone who cannot communicate effectively in English. A bilingual worker or an interpreter, whether in-person or over the telephone, must be provided in all interactions with the office when should lasix be taken. Important documents, such as Medicaid applications, should be translated either orally or in writing.

Interpreter services must be offered free of charge, and applicants requiring interpreter services must not be made to wait unreasonably longer than English speaking applicants. An applicant when should lasix be taken must never be asked to bring their own interpreter. Related Resources on TPS and Public Health Insurance o The New York Immigration Coalition (NYIC) has compiled a list of agencies, law firms, and law schools responding to the tragedy in Haiti and the designation of Haiti for Temporary Protected Status. A copy of the list is posted at the NYIC’s website at http://www.thenyic.org. o USCIS TPS website with links to status in all countries, including HAITI.

O For information on eligibility for public health insurance programs call The Legal Aid Society’s Benefits Hotline 1-888-663-6880 Tuesdays, Wednesdays and Thursdays. 9:30 am - 12:30 pm FOR IMMIGRATION HELP. CONTACT THE New York State New Americans Hotline for a referral to an organization to advise you. 212-419-3737 Monday-Friday, from 9:00 a.m. To 8:00 p.m.Saturday-Sunday, from 9:00 a.m.

To 5:00 p.m. Or call toll-free in New York State at 1-800-566-7636 Please see these fact sheets and web sites of national organizations for more information about the new PUBLIC CHARGE rules. Printable Fact Sheets for Distribution This article was co-authored by the New York Immigration Coalition, Empire Justice Center and the Health Law Unit of the Legal Aid Society.

Heads Up - Changes Coming April 2021 Once again, NYS is changing the way people without Medicare access prescription lasix cost per pill drugs. Since October 2011, most people who do not have Medicare obtained their drugs throug their Medicaid managed care plan. At that time, this drug benefit was "carved into" the Medicaid managed care benefit package.

Before that date, people enrolled in a Medicaid managed care plan obtained all of their health care through the plan, but used their regular Medicaid card to access any drug available lasix cost per pill on the state formulary on a "fee for service" basis without needing to utilize a restricted pharmacy network or comply with managed care plan rules. COMING IN April 2021 - In the NYS Budget enacted in April 2020, the pharmacy benefit was "carved out" of "mainstream" Medicaid managed care plans. That means that members of managed care plans will access their drugs outside their plan, unlike the rest of their medical care, which is accessed from in-network providers.

How Prescription Drugs are Obtained through Managed Care lasix cost per pill plans No - Until April 2020 HOW DO MANAGED CARE PLANS DEFINE THE PHARMACY BENEFIT FOR CONSUMERS?. The Medicaid pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies. Under Medicaid managed care.

Plan formularies will lasix cost per pill be comparable to but not the same as the Medicaid formulary. Managed care plans are required to have drug formularies that are “comparable” to the Medicaid fee for service formulary. Plan formularies do not have to include all drugs covered listed on the fee for service formulary, but they must include generic or therapeutic equivalents of all Medicaid covered drugs.

The Pharmacy lasix cost per pill Benefit will vary by plan. Each plan will have its own formulary and drug coverage policies like prior authorization and step therapy. Pharmacy networks can also differ from plan to plan.

Prescriber Prevails applies in lasix cost per pill certain drug classes. Prescriber prevails applys to medically necessary precription drugs in the following classes. atypical antipsychotics, anti-depressants, anti-retrovirals, anti-rejection, seizure, epilepsy, endocrine, hemotologic and immunologic therapeutics.

Prescribers will lasix cost per pill need to demonstrate reasonable profession judgment and supply plans witht requested information and/or clinical documentation. Pharmacy Benefit Information Website -- http://mmcdruginformation.nysdoh.suny.edu/-- This website provides very helpful information on a plan by plan basis regarding pharmacy networks and drug formularies. The Department of Health plans to build capacity for interactive searches allowing for comparison of coverage across plans in the near future.

Standardized Prior Autorization (PA) Form -- The Department lasix cost per pill of Health worked with managed care plans, provider organizations and other state agencies to develop a standard prior authorization form for the pharmacy benefit in Medicaid managed care. The form will be posted on the Pharmacy Information Website in July of 2013. Mail Order Drugs -- Medicaid managed care members can obtain mail order/specialty drugs at any retail network pharmacy, as long as that retail network pharmacy agrees to a price that is comparable to the mail order/specialty pharmacy price.

CAN CONSUMERS SWITCH PLANS IN ORDER TO GAIN ACCESS TO lasix cost per pill DRUGS?. Changing plans is often an effective strategy for consumers eligible for both Medicaid and Medicare (dual eligibles) who receive their pharmacy service through Medicare Part D, because dual eligibles are allowed to switch plans at any time. Medicaid consumers will have this option only in the limited circumstances during the first year of enrollment in managed care.

Medicaid managed care enrollees can only leave and lasix cost per pill join another plan within the first 90 days of joining a health plan. After the 90 days has expired, enrollees are “locked in” to the plan for the rest of the year. Consumers can switch plans during the “lock in” period only for good cause.

The pharmacy benefit lasix cost per pill changes are not considered good cause. After the first 12 months of enrollment, Medicaid managed care enrollees can switch plans at any time. STEPS CONSUMERS CAN TAKE WHEN A MANAGED CARE PLAM DENIES ACCESS TO A NECESSARY DRUG As a first step, consumers should try to work with their providers to satisfy plan requirements for prior authorization or step therapy or any other utilization control requirements.

If the plan still denies lasix cost per pill access, consumers can pursue review processes specific to managed care while at the same time pursuing a fair hearing. All plans are required to maintain an internal and external review process for complaints and appeals of service denials. Some plans may develop special procedures for drug denials.

Information on these procedures lasix cost per pill should be provided in member handbooks. Beginning April 1, 2018, Medicaid managed care enrollees whose plan denies prior approval of a prescription drug, or discontinues a drug that had been approved, will receive an Initial Adverse Determination notice from the plan - See Model Denial IAD Notice and IAD Notice to Reduce, Suspend or Stop Services The enrollee must first request an internal Plan Appeal and wait for the Plan's decision. An adverse decision is called a 'FInal Adverse Determination" or FAD.

See model Denial FAD Notice and lasix cost per pill FAD Notice to Reduce, Suspend or Stop Services. The enroll has the right to request a fair hearing to appeal an FAD. The enrollee may only request a fair hearing BEFORE receiving the FAD if the plan fails to send the FAD in the required time limit, which is 30 calendar days in standard appeals, and 72 hours in expedited appeals.

The plan may extend the time to decide both standard and expedited appeals by up to 14 days if more lasix cost per pill information is needed and it is in the enrollee's interest. AID CONTINUING -- If an enrollee requests a Plan Appeal and then a fair hearing because access to a drug has been reduced or terminated, the enrollee has the right to aid continuing (continued access to the drug in question) while waiting for the Plan Appeal and then the fair hearing. The enrollee must request the Plan Appeal and then the Fair Hearing before the effective date of the IAD and FAD notices, which is a very short time - only 10 days including mailing time.

See more lasix cost per pill about the changes in Managed Care appeals here. Even though that article is focused on Managed Long Term Care, the new appeals requirements also apply to Mainstream Medicaid managed care. Enrollees who are in the first 90 days of enrollment, or past the first 12 months of enrollment also have the option of switching plans to improve access to their medications.

Consumers who experience problems with access to prescription drugs should always file a lasix cost per pill complaint with the State Department of Health’s Managed Care Hotline, number listed below. ACCESSING MEDICAID'S PHARMACY BENEFIT IN FEE FOR SERVICE MEDICAID For those Medicaid recipients who are not yet in a Medicaid Managed Care program, and who do not have Medicare Part D, the Medicaid Pharmacy program covers most of their prescription drugs and select non-prescription drugs and medical supplies for Family Health Plus enrollees. Certain drugs/drug categories require the prescribers to obtain prior authorization.

These include brand name drugs lasix cost per pill that have a generic alternative under New York's mandatory generic drug program or prescribed drugs that are not on New York's preferred drug list. The full Medicaid formulary can be searched on the eMedNY website. Even in fee for service Medicaid, prescribers must obtain prior authorization before prescribing non-preferred drugs unless otherwise indicated.

Prior authorization is required lasix cost per pill for original prescriptions, not refills. A prior authorization is effective for the original dispensing and up to five refills of that prescription within the next six months. Click here for more information on NY's prior authorization process.

The New lasix cost per pill York State Board of Pharmacy publishes an annual list of the 150 most frequently prescribed drugs, in the most common quantities. The State Department of Health collects retail price information on these drugs from pharmacies that participate in the Medicaid program. Click here to search for a specific drug from the most frequently prescribed drug list and this site can also provide you with the locations of pharmacies that provide this drug as well as their costs.

Click here to view New York lasix cost per pill State Medicaid’s Pharmacy Provider Manual. WHO YOU CAN CALL FOR HELP Community Health Advocates Hotline. 1-888-614-5400 NY State Department of Health's Managed Care Hotline.

1-800-206-8125 lasix cost per pill (Mon. - Fri. 8:30 am - 4:30 pm) NY State Department of Insurance.

1-800-400-8882 NY State Attorney General's Health Care Bureau lasix cost per pill. 1-800-771-7755Haitian individuals and immigrants from some other countries who have applied for Temporary Protected Status (TPS) may be eligible for public health insurance in New York State. 2019 updates - The Trump administration has taken steps to end TPS status.

Two lasix cost per pill courts have temporarily enjoined the termination of TPS, one in New York State in April 2019 and one in California in October 2018. The California case was argued in an appeals court on August 14, 2019, which the LA Times reported looked likely to uphold the federal action ending TPS. See US Immigration Website on TPS - General TPS website with links to status in all countries, including HAITI.

See also Pew Research March lasix cost per pill 2019 article. Courts Block Changes in Public charge rule- See updates on the Public Charge rule here, blocked by federal court injunctions in October 2019. Read more about this change in public charge rules here.

What is lasix cost per pill Temporary Protected Status?. TPS is a temporary immigration status granted to eligible individuals of a certain country designated by the Department of Homeland Security because serious temporary conditions in that country, such as armed conflict or environmental disaster, prevents people from that country to return safely. On January 21, 2010 the United States determined that individuals from Haiti warranted TPS because of the devastating earthquake that occurred there on January 12.

TPS gives undocumented Haitian residents, who lasix cost per pill were living in the U.S. On January 12, 2010, protection from forcible deportation and allows them to work legally. It is important to note that the U.S.

Grants TPS to individuals from other countries, as well, including individuals from El Salvador, Honduras, Nicaragua, Somalia and Sudan lasix cost per pill. TPS and Public Health Insurance TPS applicants residing in New York are eligible for Medicaid and Family Health Plus as long as they also meet the income requirements for these programs. In New York, applicants for TPS are considered PRUCOL immigrants (Permanently Residing Under Color of Law) for purposes of medical assistance eligibility and thus meet the immigration status requirements for Medicaid, Family Health Plus, and the Family Planning Benefit Program.

Nearly all children in New York lasix cost per pill remain eligible for Child Health Plus including TPS applicants and children who lack immigration status. For more information on immigrant eligibility for public health insurance in New York see 08 GIS MA/009 and the attached chart. Where to Apply What to BringIndividuals who have applied for TPS will need to bring several documents to prove their eligibility for public health insurance.

Individuals will need to lasix cost per pill bring. 1) Proof of identity. 2) Proof of residence in New York.

3) Proof of lasix cost per pill income. 4) Proof of application for TPS. 5) Proof that U.S.

Citizenship and Immigration Services (USCIS) has received the application lasix cost per pill for TPS. Free Communication Assistance All applicants for public health insurance, including Haitian Creole speakers, have a right to get help in a language they can understand. All Medicaid offices and enrollers are required to offer free translation and interpretation services to anyone who cannot communicate effectively in English.

A bilingual worker or an interpreter, whether in-person or over the telephone, must be provided in all interactions with the office. Important documents, such as Medicaid applications, should be translated either orally or in writing. Interpreter services must be offered free of charge, and applicants requiring interpreter services must not be made to wait unreasonably longer than English speaking applicants.

An applicant must never be asked to bring their own interpreter. Related Resources on TPS and Public Health Insurance o The New York Immigration Coalition (NYIC) has compiled a list of agencies, law firms, and law schools responding to the tragedy in Haiti and the designation of Haiti for Temporary Protected Status. A copy of the list is posted at the NYIC’s website at http://www.thenyic.org.

o USCIS TPS website with links to status in all countries, including HAITI. O For information on eligibility for public health insurance programs call The Legal Aid Society’s Benefits Hotline 1-888-663-6880 Tuesdays, Wednesdays and Thursdays. 9:30 am - 12:30 pm FOR IMMIGRATION HELP.

CONTACT THE New York State New Americans Hotline for a referral to an organization to advise you. 212-419-3737 Monday-Friday, from 9:00 a.m. To 8:00 p.m.Saturday-Sunday, from 9:00 a.m.