Medically Unnecessary
Health Insurance
Anyone who reads this newsletter is well aware that the American health care system excels at providing extremely expensive, sub-standard care via a byzantine system of private, often for-profit insurance companies. That is not to say every doctor or nurse or hospital system sets out to provide lousy care, but they are often at odds with insurers, who are quick to dispute or deny procedures. Sometimes this culminates in patients not receiving critical treatment because a faceless bureaucrat at an insurer decides it is not ‘medically necessary’.
Who are the people deciding whether or not someone gets treatment? At Cigna, one of America’s largest insurers, they are part of a rocket docket the company has set up to decline as many claims as possible as quickly as possible, spending effectively zero time reviewing any pertinent data:
The company has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials. Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. The company has reported it covers or administers health care plans for 18 million people.
Oh, yeah, cool. In order to deny claims, insurers submit them for review by in-house doctors. ‘Medical directors’ are supposed to review a patient’s file, medical records, and compare that with coverage policies and make an informed decision on whether a claim is valid. Not at Cigna!
Medical directors do not see any patient records or put their medical judgment to use, said former company employees familiar with the system. Instead, a computer does the work. A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity.
“We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”
It’s our old friend, the algorithm. Cigna doesn’t send every claim through its click and ship pipeline, only the ones that a computer system written by Cigna decides might not be valid. Is this legal? The company’s lawyers seem to think so:
“We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.”
How nice to be able to build a system to deny hundreds of thousands of claims a month, saving your company millions, and have your legal department and executives sign off on it. It’s only illegal if you get caught, right?
Shouldn’t denying claims in violation of standard practices be illegal? Insurers are overseen by state regulators wherever they write policies, so while California might decide it’s illegal and sue Cigna, other states with AGs who don’t read ProPublica might not be aware of what’s going on, or care.
A Google search for ‘lawsuit Cigna denied claims’ brings up a couple of law firms trawling for class action participants, right above an AMA article about another class action lawsuit from 2022 against the company for underpaying claims. Below that is a 2022 DoJ lawsuit against Cigna for defrauding Medicare.
For companies Cigna’s size, who are essentially ‘too big to jail’ because the government relies on private companies to administer both it’s ACA and Medicare health plans, getting caught doing illegal stuff to make more money is a cost of doing business. They’ll pay the fine and move on, because that’s what they literally do every year when a new batch of lawsuits crops up.
Assisted Living
It’s one thing to have a medical claim denied and be forced to forego a procedure or pay for a medication out of pocket. What if your insurance literally evicted you from your home?
Residents of assisted-living facilities — promoted as a homier, more appealing alternative to nursing homes — face an especially precarious situation. While federal law protects Medicaid beneficiaries in nursing homes from eviction, the law does not protect residents of assisted-living facilities, leaving them with few options when turned out.
Around 4.4 million Americans rely on long-term care options covered by Medicaid. Because Medicaid is administered at the state level and federal oversight is often light, needy patients can be at the whims of an assisted living home management company, who may decide they want to boot out poor patients in favor of more affluent ones, or really for pretty much any reason at all:
The U.S. government does not monitor or regulate assisted-living facilities, and no federal data is available on the frequency of evictions.
[…]
But evictions have become so common that some states, including New Jersey, have enacted policies to curb them. Nationally, state ombudsman programs for long-term care received 3,265 complaints related to evictions from assisted-living facilities in 2020, the latest data available.
There is scant data available, because the government doesn’t track it, and newspapers reserve little page space for the poor. The facility in Wisconsin featured in the WaPo piece made a business decision to stop accepting Medicaid, putting many of its residents out on the street. As the country’s population gets older, and assisted living costs rise - remember, we’ve got shortages of every sort of medical professional in this country - more facilities will avoid Medicaid patients, leaving them few options for housing.
The government could step in and provide more funding for elderly housing, or it could regulate assisted living facilities the same way it does nursing homes - not that it does a great job there, either - but like most things in the American health care system, those who can’t afford to pay our inflated market rates often fall through the cracks, ending up with substandard care if they can find care at all.
Dianne Feinstein
For those of you blissfully unaware, much ink has been spilled by the political press over the fate of California’s senior senator. She was out with ‘shingles’ for a couple months, which held up work on the Judiciary Committee and elsewhere in the Senate.
It’s been an open secret for awhile now that Feinstein suffers from cognitive decline, but it was on full display last week when she interacted with reporters:
When the fellow reporter asked her what the response from her colleagues had been like since her return, though, the conversation took an odd turn.
“No, I haven’t been gone,” she said.
OK.
“You should follow the—I haven’t been gone. I’ve been working.”
When asked whether she meant that she’d been working from home, she turned feisty.
“No, I’ve been here. I’ve been voting,” she said. “Please. You either know or don’t know.”
Not great. There are stories of ancient Senators being wheeled in to cast votes in various states of physical decay, but they were presumably not suffering advanced dementia.
The Feinstein situation raises political and ethical concerns. She has a large staff whose jobs literally depend on her staying in office, and these people insist she’s fit to do the job while the political press regurgitates the fiction, despite anonymous sources and former staffers openly admitting the Senator’s mental acuity has been an issue for years:
Multiple sources tell Rolling Stone that in recent years Feinstein’s office had an on-call system — unbeknownst to Feinstein herself — to prevent the senator from ever walking around the Capitol on her own. At any given moment there was a staff member ready to jump up and stroll alongside the senator if she left her office, worried about what she’d say to reporters if left unsupervised. The system has been in place for years.
“They will not let her leave by herself, but she doesn’t even know it,” says Jamarcus Purley, a former staffer.
The people caring for Feinstein aren’t doing it out of any sense of duty to the country - were Feinstein to resign, the governor of California would appoint another Democrat in her place. Instead they’re engaging in elder abuse to keep their jobs, forcing a woman not mentally capable of doing hers to keep casting votes in the country’s highest legislative seat.
Lest we place blame solely on a bunch of nameless staffers, there’s another wrinkle - Nancy Pelosi’s daughter is a ‘close personal confidant’ and caretaker? What?!
Not only did [Nancy] Prowda escort Feinstein around Capitol Hill last week, she was again at her side yesterday, helping aides surround the senator in a Capitol hallway as a reporter tried to speak to her. Multiple people familiar with the arrangement say it’s only the most visible part of a quiet but critical role the Pelosi family has played in helping to take care of the ailing senator, both in Washington and San Francisco.
Oh, yeah, completely normal stuff. If I were the daughter of an unbelievably rich San Francisco power broker, I’d spend my days wandering the halls of DC with my pet dotard in tow. Prowda may very well be doing her mother’s bidding for political reasons:
The intrigue surrounds the future of Feinstein’s seat. Pelosi has endorsed Rep. Adam Schiff, her longtime protégé and former hand-picked House Intelligence Committee chair, to succeed Feinstein after her sixth and final term ends next year. Schiff (D-Calif.) is a household name in California and already has a $15 million campaign cash advantage over his nearest competitor.
But if Feinstein were to bow to pressure and retire early, Schiff’s advantage could disappear. Gov. Gavin Newsom (D-Calif.) has pledged to appoint a Black woman to serve out her term, and one of Schiff’s declared opponents, Rep. Barbara Lee (D-Calif.), would fit the bill.
Extremely cool that we’re being subjected to the whims of one political relic because another wants to ensure her hand-picked successor takes her place instead of a Black woman. Politics is an ugly business, but it doesn’t often veer into abusing a frail, demented senior to help a political ally.
Psychiatric Detention
Last year, the government rebranded the National Suicide Prevention Lifeline the “988 Suicide and Crisis Lifeline” with a new hotline number and better, more centralized control of its operation.
By some metrics - number of calls and chats made and answered - the new hotline has ben a smashing success. People who need help during difficult times can find it thanks to the 988 line, which is important in a country that devalues and barely funds mental health care.
People calling the Lifeline might reasonably expect their conversations would be confidential and private, but in some cases the org is getting the cops involved:
…according to its own policy, if a call-attendant believed a person might be at “imminent risk” of taking their own life in the next few hours, days, or week, the call-attendant was required to contact 911 or a Public Safety Answering Point to send out police and/or an ambulance to forcibly take the person to a psychiatric hospital.
Lifeline spokespeople insist only around two percent of callers are referred to emergency services, but that’s a lot of people, with the burgeoning popularity of the system:
However, continuing at 2% means that detentions are climbing on pace with the rising number of contacts to 988. This means that, over the past ten months, a staggering 81,000 Americans who’ve reached out to 988 for confidential conversations have ended up being coercively taken to psychiatric hospitals. In 988’s first full year of operation, its call centers are on pace to incarcerate nearly 100,000 people.
There is a delicate balance between taking appropriate action when a caller is at risk of harming themselves and providing necessary mental health services while protecting patient privacy. The non-profits operating the Lifeline have their work cut out establishing clear guidelines to ensure they aren’t needlessly admitting people to mental health facilities, an option that should be saved for the most dire of emergencies.
The country’s mental health system has been allowed to crumble to the point millions of people a year need to call a crisis line to talk through their problems. We need to improve mental health services more broadly, so those people can seek help before their problems reach a crisis point. And, we need to ensure the Lifeline isn’t involving law enforcement or emergency services unless absolutely necessary.
Short Cons
WIRED - “In fact, the Justice Department and Volexity had stumbled onto one of the most sophisticated cyberespionage campaigns of the decade. The perpetrators had indeed hacked SolarWinds’ software.”
FT - “In all three cases, KPMG gave the banks’ financial statements a clean bill of health as recently as the end of February.”
Insider - “A proposed class-action suit claims that the delivery service tacks on extra fees to orders placed through iPhones compared to otherwise identical orders from users with Android smartphones.”
AP - “A dozen poor countries are facing economic instability and even collapse under the weight of hundreds of billions of dollars in foreign loans, much of them from the world’s biggest and most unforgiving government lender, China.”
ProPublica - “Scholar Launch, which started in 2019, connects high school students with mentors who work with them on research papers that can be published and enhance their college applications.”
RestofWorld - “In 2021, Urban Company faced two protests in three months, after female workers raised issues around safety and working conditions. It made headlines for responding to the second protest by suing some of the workers involved.”
Atlantic - “The children of the Facebook era—which truly began in 2006, when the platform opened to everyone—are growing up, preparing to enter the workforce, and facing the consequences of their parents’ social-media use. Many are filling the shoes of a digital persona that’s already been created, and that they have no power to erase.”
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