Political Climate, Public Health & Problematic
New Insurance Legislation
by Kathleen Liporace
A critical aspect in the battle on Lyme disease is that of informing people, physicians and politicians about the seriousness of this illness. It is often misdiagnosed or undiagnosed for extensive periods of time, leaving devastation in its wake.
Here in South Carolina, we have a compassionate governor whom we have provided educational medical material to. In reviewing the scientific evidence presented, he has made informed decisions to declare May as Lyme Disease Awareness Month for both 2007 & 2008.
Each year, a citizen of South Carolina must make a request for the proclamation to be declared. Various individuals have made these efforts over many years and addressed two governors who very much care about their citizens. The governor does not advertise or promote Lyme Disease Awareness Month, other than by making the proclamation, since there are many proclamations for the month of May. This, however, provides the opportunity to the people of South Carolina to bring attention to the disease by their own efforts.
Many ask the mayors of their respective towns and cities to make a similar proclamation. This can bring exposure to the public through press and news coverage. It is a further opportunity to write articles and Op-Eds and to do educational activities that promote Lyme disease awareness among individuals. So, in South Carolina, efforts are at a "grass-roots" level.
As far as the Department of Health and Environmental Control in South Carolina is concerned, they are not. Very little is done on their part to inform the public of the risk of Lyme and tick- borne diseases at all. Most unusually, they do make much ado of nothing in that DHEC does have monthly press releases for updating the public on West Nile Virus. The reported incidence rate for this rare virus is improperly noted to be 0.1 for 2005, yet there were zero cases reported on page 11 of the 2005 Annual Report on Reportable Conditions. Page 19 tells another story, since the county-by-county report shows that there were four cases of West Nile Virus in 2005 for all of South Carolina. In all of this, the focus is off of Lyme and onto a very rare virus. There is no true "position" paper on Lyme disease, but what is available was easily found by using the search feature on the DHEC website. As well, the South Carolina Department of Health and Environmental Control does little to educate the people of this state on the seriousness or true prevalence of Lyme. In comparing the 2004 DHEC reported cases with a 2004 survey of physicians, there is a serious disconnect with the statistics in this state. 253 cases of Lyme were reported by physicians responding to this latest survey, while DHEC only had 8 confirmed, five probable, and thirteen total cases reported for 2004. Yet somehow there were 22 cases of Lyme reported to the CDC in the same year from South Carolina. The upstate region totaled 42.5% of all Lyme cases reported for 2004, according to the physician survey. In North Carolina, where the population is roughly double that of South Carolina, their reported cases of Lyme to the North Carolina Department of Health in 2004 totaled 122 people infected. This shows the level of utter confusion at the state level.
In the aftermath of the medical board's unjust persecution of Dr. Jemsek in North Carolina, a chill ran throughout the Carolinas' physician communities. Patients now find it very difficult to obtain a diagnosis, let alone adequate treatment, for a disease that is both highly debilitating and can be fatal. There is no follow-up in this state (or any other that I know of) for chronic Lyme. So, hundreds of patients remain ill from Lyme and are left unchecked at the state level and at minimum, tens of thousands at the federal level.
Somehow this serious oversight needs to be addressed.
In the South Carolina 2005 Annual Report on Reportable Conditions, 11 total cases of Lyme were reported by DHEC on page 10 for 2005, with precious little information on Lyme contained in this volume of 176 pages. However, a shocking truth is revealed if one examines the numbers carefully on a county-by-county basis: these numbers add up to a total of 63 for the state in 2005, as enumerated on page 16. As well, the incidence rate of Lyme is falsely reported as 0.0 in 2005. For Ehrlichia, the incidence rate for 2005 is inaccurately reported as being 0.26, yet the total number of cases reported is also 11. Again, when looking at the county-by-county statistics, the number of Ehrlichia cases actually totals 8 cases on page 15. Someone can't add here (maybe a product of our fine educational system…). We know that Lyme is underreported between 6-12 fold, so sadly, these figures aren't reliable anyway. It would do you well to examine your own state's statistical information for such errors and bring the information to the state's attention.
For 2006, 55 cases were reported as confirmed and probable. Interestingly, a mere 22 cases were reported by December of 2007 in the SC CHESS system (Carolina's Health Electronic Surveillance System). However, DHEC Epi Notes Winter 2008 reports that there were 27 cases of Lyme reported from January 1, 2007 to November 30th 2007. The South Carolina DHEC can't really seem to land on a solid number and the totals are suspect, especially when compared to the overall high figure of reported cases of Rocky Mountain spotted fever.
In searching the DHEC database, there is no proper listing of any county being "endemic" for Lyme at all (though many should be classified as such). As well, most curiously, the only year that specifies a death specifically by Lyme is in 2000. Since the year 2001, Lyme mortality by ICD 10 code (A69.2) is lumped into a category spanning ICD 10 codes from A65-A79 and titled as, "OTH. INFECTIONS BY SPIROCHETES CHLAMYDIA OR RICKETTSIA". However, most interestingly, tick-borne spotted fever (A77) is listed separately and not included in the above-noted range in which death by Lyme is hidden.
Many physicians in South Carolina miss the diagnosis of Lyme disease, as they are generally not looking for it. DHEC does not provide anything remotely near adequate information to physicians in this state! Often people are left with misdiagnosis or a lack of diagnosis altogether. People here are not currently well-educated on the signs and symptoms of Lyme, therefore it is up to those who are knowledgeable about the disease to inform those who are not. There are groups in South Carolina that are informing others, but still much headway needs to be made. However, now it is an increasingly uphill battle due to some interesting legislation.
Recently, a very dangerous piece of health insurer legislation was passed in this state which allows a medical director of an insurance company the latitude of determining what is medically necessary for a patient (bill H 3192). This is the statement that Governor Sanford ordered to be printed in the journal when the bill was vetoed by him (but later overturned):
"This bill revises several provisions of the Physician Practice Act. Although the majority of the bill serves as a clean up to the statute, I have concerns about sections six and seven. These two sections, which were added the last day of session, state "determination of medical necessity of a decision affecting the diagnosis and/or treatment of a patient is not the practice of medicine."
"First, our administration has always respected the relationship between a physician and patient and believes that the act of determining medical necessity falls within the practice of medicine. No one can professionally determine what treatment a patient needs without having a license to practice medicine. The physician must establish a medical record, examine the patient, make a diagnosis and document the rationale for treatment."
"However, this bill steps between the physician and patient relationship. By stating that the determination of medical necessity is not the practice of medicine, this bill allows insurance company medical directors to tell a physician what treatments patients should have - even with no direct connection to or responsibility for the care of the patient. Additionally, this bill offers no public protection by not requiring a medical director to be licensed to practice medicine in our state and subject to our laws."
"Secondly, while patients continue to be faced with ever increasing health insurance costs, a health insurer has a direct financial conflict of interest with regard to the review process - especially in favor of denial of payment. By continuing to deny an ordered medical procedure as "not deemed medically necessary," or "experimental," the insurance company rations health care and undermines the trust placed in physicians by the public."
"For these reasons, I am returning H. 3912, R. 417, without my signature."
Now, we in South Carolina are treading on dangerous ground. The amendments to the state law reads as such:
40-47-20, AS AMENDED, RELATING TO THE DEFINITION OF TERMS IN THE LICENSURE AND REGULATION OF PHYSICIANS, INCLUDING THE DEFINITION OF “THE PRACTICE OF MEDICINE,” SO AS TO PROVIDE THAT RENDERING A DETERMINATION OF MEDICAL NECESSITY OR A DECISION AFFECTING THE DIAGNOSIS OR TREATMENT OF A PATIENT IS NOT, UNDER CERTAIN CIRCUMSTANCES, THE PRACTICE OF MEDICINE WHEN SUCH DETERMINATION OR DECISION IS A COVERAGE DECISION DENYING HEALTH CARE SERVICES OR COVERAGE FOR A COVERED BENEFIT OR APPROVING A COVERED BENEFIT; AND BY ADDING SECTION 38-59-25 SO AS TO FURTHER SPECIFY THOSE CIRCUMSTANCES UNDER WHICH RENDERING A DETERMINATION OR MAKING A DECISION DENYING OR APPROVING HEALTH CARE SERVICES OR BENEFITS IS NOT THE PRACTICE OF MEDICINE.
Well, isn't that a classic case of the fox guarding the hen-house? Governor Sanford originally vetoed this bill, but it was incredulously overturned in a vote by 2/3 of the state house of representatives and 96 renegade state senators! What were those who we voted into office thinking? Are they under some illusion that they're holding up their oath of office to be for the people? If so, I'm missing something. No doubt insurers will take full advantage of this biased piece of legislation. Suppose it is carried into other states, then look out, because we're all in trouble!
