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Just watched an interesting documentary about lyme disease called "Under Our Skin" (Available on Hulu http://www.hulu.com/watch/268761/under-our-skin)

Essentially, it argues that Lyme disease is underdiagnosed and current treatment and testing is inadequate. The primary reasons it gives for this seem to be that the guidelines for treatment are written by doctors who have a conflicts of interest, insurance companies don't want to pay for expensive courses of treatment. It paints a favorable picture of non-mainstream doctors who proscribe extremely long-term courses of antibiotics as treatment.

My initial reaction is that rogue doctors who don't practice evidence-based medicine, and doctors who misuse antibiotics are a not to be trusted, and represent a significant problem. I'm also quite skeptical of people who feel like they "just know" what's wrong with them. The other tell-tale sign of a medical myth is that it hints at a panacea, in this case, there is an implication that a wide variety of disease including alzheimers, als, mls and parkinsons may all be due to lyme disease, or misdiagnoses of what actually is lyme disease. That's a bit suspicious, though not entirely implausible.

That said, I'm torn between thinking that it's entirely conspiracy theory nonsense, and wondering if there is anything to their point. I do think there are problems related to conflicts of interests, particularly involving patents and insurance company influence. The pressure that insurance companies exert can be beneficial in keeping doctors to treatments that really work and don't just waste money, but it can also lead to effective treatment being suppressed because of high costs. And I also think that there is a tendency for the medical system to prefer labeling ailments as psychosomatic or depression-induced when the alternative is admitting that they just don't know the cause. That of course doesn't mean that lyme disease must be the culprit, as there could certainly be another unknown factor at play, but it does open up the possibility that lyme disease is involved.

What do you guys, especially those in the medical field think?

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- Justin Powell

I'm not a doctor, but just curious. . . In this mornings' Orlando Sentinel, there was a very interesting article regarding: "Big Pharma has paid $56M since 209 to state's doctors."

Now I know that my insurance pays my doctors lots of money for checkups, etc., but why would "Big Pharma" have my doctor on their payroll????

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GEM
"Do or do not. there is no try!"

Justin

That was a very balanced and nicely written expose on the issue. Kudos!

The Institute of Medicine defines poor quality as the overuse, underuse, and misuse of health care services. And there you have "the problem" of poor quality defined very nicely.

Going back to The RAND Health Insurance Experiment in the 1980s, we know that money influences the health care system. For example, the higher the deductible in a health insurance policy, the lower the overall utilization (as measured by dollars spent per member per month of eligibility). Basically if you have no deductible and no copay, you'll go to your doc-in-the-box for any little ache and pain, demanding a prescription be written before you leave. If you have a $500 yearly deductible and you're basically a healthy person (no chronic conditions like diabetes or severe asthma), then you'll elect to ride your aches and drippy nose out at home with a painkiller, chicken soup, and sleep. But high deductibles can cause the cost-sensitive asthmatic not to take his/her steroid inhaler or leucotriene inhibitor meds, leading later on to unnecessary ER admits for asthma. This is why so many different benefit designs have been created and experimented with. The classic fee-for-service design "incents" doctors to treat more, as they don't get money unless they actually do something. The more they do and the more complex the thing they do, the more the reimbursement. The higher their training (to super sub specialty), the higher their reimbursement because of the kinds of things they can do, which drives our current shortage of primary care MDs and oversupply of specialists. The latter creates a problem called supply-induced demand, where it's shown that there are more equivocal services in an area where there is an oversupply of the specialists who can do it - with no evidence of better health in said area. The staff-model HMO where MDs get a salary has its issues, where doctors can sometimes under-treat.

Insurance companies? They are in business to keep costs down (unit price, number of services), assure their large group customers that they play a role in the coordination and continuity of care, demand that their network doctors practice evidence-based care (when there actually is a medical standard for said care) and to make money. Nothing wrong with any of those roles, but sometimes problems happen.

For what it's worth... I benefit from a fee-for-service system because MDs have to bill for said services and I mine their data to track health care utilization and health outcomes. If there's no money tied to submitting the data, then the quality of the data drop precipitously. It is what it is.

So...

Yes sometimes consumer activists get it wrong. One rogue MD publishes a bogus (falsified data) article in Lancet about the dangers of the MMR vaccine and next thing you know we have activist groups who are SURE that their kid has autism because of the thimerisol in his measles vaccine. The rogue MD is exposed and his article retracted, but not before we have hoards of parents not getting their kids vaccinated which now is causing very dangerous measles epidemics. Oops!

This is what I know about Lyme's disease.

• It is a relatively new (decades) condition.
  ...
• It's usually but not always easy to detect.
  ...
• Sometimes the symptoms look like other conditions such as rheumatoid arthritis.
  ...
• Sometimes it's difficult to treat.

So all those factors come into play when the rubber meets the medical road. Most people are diagnosed and treated just fine, but not all. And most (but not all) people who think they have some rare manifestation of the condition don't.

- Bill

So they'll prescribe THEIR new (on patent) meds rather than older generics and/or their competitor's meds.

Beware of hot-looking drug reps bearing lunch and free samples.

- Bill

One of the early Mystery Diagnosis shows told the story of a woman with undiagnosed lyme disease. Seemed pretty devastating to her life. I think the false-negative rate of testing for lyme disease is a great concern. Over-use of antibiotics is likewise a great concern. This results in a collision of legitimate interests. If I were a patient with a tick bite with the classic presentation, of duration greater than 24 hours (or even close to it), I would want the antibiotics. If I had a shorter-term tick bite, I would take a wait-and-see attitude. Actually, I would probably still want the antibiotics, to be honest, but I don't think that is the right answer from my comfortable chair right here and now.

The mention of drug companies paying doctors reminds me that currently Express Scripts and Walgreens have apparently reached an impasse in their negotiations. Walgreens is asking their customers to try to influence Express Scripts (via our employers or whatever path might be available). I couldn't help but think that, insofar as my employer shares profits reliably through a quarterly program, that Express Scripts was bargaining on my behalf and that they were thus barking up the wrong tree.

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Mike

Why did we never get any hot-looking drug reps? That's just not fair. Lunch on the other hand, was usually very good.

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Life begins & ends cold, naked & covered in crap.

There was an extremely interesting article in the September, 2009 [i]Atlantic[i] Monthly magazine that really took a different approach to affordable health care. It didn't just talk about insurance reform, but really deconstructed the entire process of health care and brought in several different mechanisms used in other sectors of the economy to address cost control and payment. It was also unique in that it didn't present itself as the panacea for compelte health care access, and identified some of the shortcomings of its own ideas. I will look to see if I still have the hard copy of the issue, but will also look for an electronic copy and pass it on.

I'd love to read that.

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Life begins & ends cold, naked & covered in crap.

Here is the link to the September 2009 article. The title is misleading, though his father's death did lead him to this journey.

http://www.theatlantic.com/magazine/arc ... ther/7617/

Mary

This is an interesting article, but the person just can't get their arms around "the problem." Here's a good example.

Oh wouldn't that world of unicorns be lovely!

The truth of the matter is much different. For every bag of groceries, the grocery store gets a whole quarter of profit. For every similar bag of health care services, the insurer gets pennies.

Meanwhile... Go ahead and go it alone in the health care world. Want to pay hospital charges? They're often OVER double what an insurer or the government (CMS) - the 800-pound gorillas - negotiate with the hospital. There's a joke in insurance about pharmaceutical AWP or Average Wholesale Price. In the insurance world, AWP is known as Ain't What's Paid.

Everyone gets hot under the collar about the money going through the hands of insurance companies and the small percentage they take for profit. But the fact of the matter is society can't get enough health care, and has hired the insurance company to be the bad cop. "They" are asked to get us the best possible unit price, monitor the activity of doctors and hospitals, and to say "No!" when things truly get out of control.

The problem is to some extent the insurer, but not in the way people think of it. The insurer is the problem only to the extent that they prevent people from making decisions they don't want to make. By shielding the public from much of the cost and hassle and by using state and federal governments to beat up on them, the individual thus has absolved responsibility for runaway utilization and excessive demand.

The other gross distortion comes from giving large employers the tax break for health care benefits, but not giving that tax break to the individual. Obummer had a chance to fix that, but he didn't. The liberals wanted to turn things over to the government, but they (Medicare, Medicaid) are so bad that insurers are running circles around them (via Medicare Advantage and other alternatives). Once again, the consumer of services is taken out of the supply/demand equation. Once again, the consumer has absolved him/herself of responsibility and accountability. We want it all, and we want it now. We cannot understand why we can't live forever, and we bitch and moan when we eat until we're morbidly obese and then heath CARE fails us. We would never expect our auto insurance policy to cover oil changes, and yet we want our insurer to cover immunizations, well-care visits, and our daily meds. If our auto mechanic screws up on our cars, he loses business. If a doctor screws up, Dewey Chetham and Howe take a ride on the gravy train and the doctor is protected because we've invested too much money in his/her training.

By the way, I walk the talk. I'm (chronologically) an old fart, and yet I need no daily medicine except to manage my allergies. My weight, blood pressure, and cholesterol are perfect, and I have no Type II diabetes. When I get banged up, I do most of my own physical therapy. I OWN my health and well being, and I'm at peace with my mortality. I live an older paradigm, and I try to teach it in the dojo. Most folks haven't a clue.

- Bill

I haven't read the article in a while, but a few points that I recall and found interesting are: 1) looking at the role of insurance in a way similar to other insurance industries, to cover the unexpected or outrageously unaffordable for most incomes, and look at other paying options, such as health savings accounts or loans to cover small to mid size (my terms, not the article), say up to $10,000 in expenses. This would facilitate Bill's point of enhanced personal responsibility (my term, not his). He did include a subsidy suggestion for the lower income.

2) Also interesting to me was the author's discussion of market triggers in other industries driving prices down once items go to "market scale (again, my term)," computers, for example, but that this does not happen in the health care market in the same way, perhaps due to requirements for insurance coverage. He discussed the high costs of several items covered by insurance and contrasted them with lasik (sp?) surgery, which is not covererd, and had steadily decreased in price since its introduction (at the time of the article).

I really appreciated his deconstruction of the health care paradigm, and that his health care reform construct was larger than the, "Mandated coverage? Public Option? Employer Pay?" loop that the talks started and stopped at two years ago. I would have loved these and other ideas put out in the health care reform debate, which, in my opinion, sadly fell short of offering the public or well-intentioned, but overwhelmed policy-makers the opportunity to really understand all of the "feeders" into a health care system, which are too many for me to mention here.

I will just have to go back and read that article again. If any of you have other material on this topic, I would appreciate a reading list. And, I am large part policy and novice research geek, so academic publications are welcome, too.

Mary

Point of Clarification: When I wrote, "He did include a subsidy suggestion for the lower income.," I was referring to the author, not Bill Glasheen. Pardon the sloppy writing.

Mary