Cigna Accused of Using AI, Not Doctors, to Deny Claims: Lawsuit

Steph Weber

Medscape.com

Originally posted 4 August 23

A new lawsuit alleges that Cigna uses artificial intelligence (AI) algorithms to inappropriately deny "hundreds or thousands" of claims at a time, bypassing legal requirements to complete individual claim reviews and forcing providers to bill patients in full.

In a complaint filed last week in California's eastern district court, plaintiffs and Cigna health plan members Suzanne Kisting-Leung and Ayesha Smiley and their attorneys say that Cigna violates state insurance regulations by failing to conduct a "thorough, fair, and objective" review of their and other members' claims.

The lawsuit says that instead, Cigna relies on an algorithm, PxDx, to review and frequently deny medically necessary claims. According to court records, the system allows Cigna's doctors to "instantly reject claims on medical grounds without ever opening patient files." With use of the system, the average claims processing time is 1.2 seconds.

Cigna says it uses technology to verify coding on standard, low-cost procedures and to expedite physician reimbursement. In a statement to CBS News, the company called the lawsuit "highly questionable."

The case highlights growing concerns about AI and its ability to replace humans for tasks and interactions in healthcare, business, and beyond. Public advocacy law firm Clarkson, which is representing the plaintiffs, has previously sued tech giants Google and ChatGPT creator OpenAI for harvesting internet users' personal and professional data to train their AI systems.

According to the complaint, Cigna denied the plaintiffs medically necessary tests, including bloodwork to screen for vitamin D deficiency and ultrasounds for patients suspected of having ovarian cancer. The plaintiffs' attempts to appeal were unfruitful, and they were forced to pay out of pocket.

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Last year, the American Medical Association and two state physician groups joined another class action against Cigna stemming from allegations that the insurer's intermediary, Multiplan, intentionally underpaid medical claims. And in March, Cigna's pharmacy benefit manager (PBM), Express Scripts, was accused of conspiring with other PBMs to drive up prescription drug prices for Ohio consumers, violating state antitrust laws.

Cohen says he expects Cigna to push back in court about the California class size, which the plaintiff's attorneys hope will encompass all Cigna health plan members in the state.

The info is here.

Abortion Access Tied to Suicide Rates Among Young Women

Michael DePeau-Wilson

MedPage Today

Originally posted 28 DEC 22

Restrictions on access to reproductive care were associated with suicide rates among women of reproductive age, researchers found.

In a longitudinal ecologic study using state-based data from 1974 to 2016, enforcement of Targeted Regulation of Abortion Providers (TRAP) laws was associated with higher suicide rates among reproductive-age women (β=0.17, 95% CI 0.03-0.32, P=0.02) but not among women of post-reproductive age, according to Ran Barzilay, MD, PhD, of the University of Pennsylvania in Philadelphia, and colleagues.

Nor was enforcement of TRAP laws associated with deaths due to motor vehicle crashes, they reported in JAMA Psychiatry in a new tab or window.

Additionally, enforcement of a TRAP law was associated with a 5.81% higher annual rate of suicide than in pre-enforcement years, the researchers found.

"Taken together, the results suggest that the association between restricting access to abortion and suicide rates is specific to the women who are most affected by this restriction, which are young women," Barzilay told MedPage Today.

Barzilay said their study "can inform, number one, clinicians working with young women to be aware that this is a macro-level suicide risk factor in this population. And number two, that it informs policymakers as they allocate resources for suicide prevention. And number three, that it informs the ethical, divisive debate regarding access to abortion."

In an accompanying editorial, Tyler VanderWeele, PhD, of Harvard T.H. Chan School of Public Health in Boston, wrote that while analyses of this type are always subject to the possibility of changes in trends being attributable to some third factor, Barzilay and colleagues did "control for a number of reasonable candidates and conducted sensitivity analyses indicating that these associations were observed for reproductive-aged women but not for a control group of older women of post-reproductive age."

VanderWeele wrote the findings do suggest that a "not inconsiderable" number of women might be dying by suicide in part because of a lack of access to abortion services, and that "the increase is cause for clinical concern."

But while more research "might contribute more to our understanding," VanderWeele wrote, its role in the legal debates around abortion "seems less clear. Regardless of whether one is looking at potential adverse effects of access restrictions or of abortion, the abortion and mental health research literature will not resolve the more fundamental and disputed moral questions."

"Debates over abortion access are likely to remain contentious in this country and others," he wrote. "However, further steps can nevertheless be taken in finding common ground to promote women's mental health and healthcare."

For their "difference-in-differences" analysis, Barzilay and co-authors relied on data from the TRAP laws index to measure abortion access, and assessed suicide data from CDC's WONDER database in a new tab or window database.

The info is here.

Tackling Implicit Bias in Health Care

J. A. Sabin

N Engl J Med 2022; 387:105-107

DOI: 10.1056/NEJMp2201180

Implicit and explicit biases are among many factors that contribute to disparities in health and health care. Explicit biases, the attitudes and assumptions that we acknowledge as part of our personal belief systems, can be assessed directly by means of self-report. Explicit, overtly racist, sexist, and homophobic attitudes often underpin discriminatory actions. Implicit biases, by contrast, are attitudes and beliefs about race, ethnicity, age, ability, gender, or other characteristics that operate outside our conscious awareness and can be measured only indirectly. Implicit biases surreptitiously influence judgment and can, without intent, contribute to discriminatory behavior. A person can hold explicit egalitarian beliefs while harboring implicit attitudes and stereotypes that contradict their conscious beliefs.

Moreover, our individual biases operate within larger social, cultural, and economic structures whose biased policies and practices perpetuate systemic racism, sexism, and other forms of discrimination. In medicine, bias-driven discriminatory practices and policies not only negatively affect patient care and the medical training environment, but also limit the diversity of the health care workforce, lead to inequitable distribution of research funding, and can hinder career advancement.

A review of studies involving physicians, nurses, and other medical professionals found that health care providers’ implicit racial bias is associated with diagnostic uncertainty and, for Black patients, negative ratings of their clinical interactions, less patient-centeredness, poor provider communication, undertreatment of pain, views of Black patients as less medically adherent than White patients, and other ill effects.1 These biases are learned from cultural exposure and internalized over time: in one study, 48.7% of U.S. medical students surveyed reported having been exposed to negative comments about Black patients by attending or resident physicians, and those students demonstrated significantly greater implicit racial bias in year 4 than they had in year 1.

A review of the literature on reducing implicit bias, which examined evidence on many approaches and strategies, revealed that methods such as exposure to counterstereotypical exemplars, recognizing and understanding others’ perspectives, and appeals to egalitarian values have not resulted in reduction of implicit biases.2 Indeed, no interventions for reducing implicit biases have been shown to have enduring effects. Therefore, it makes sense for health care organizations to forgo bias-reduction interventions and focus instead on eliminating discriminatory behavior and other harms caused by implicit bias.

Though pervasive, implicit bias is hidden and difficult to recognize, especially in oneself. It can be assumed that we all hold implicit biases, but both individual and organizational actions can combat the harms caused by these attitudes and beliefs. Awareness of bias is one step toward behavior change. There are various ways to increase our awareness of personal biases, including taking the Harvard Implicit Association Tests, paying close attention to our own mistaken assumptions, and critically reflecting on biased behavior that we engage in or experience. Gonzalez and colleagues offer 12 tips for teaching recognition and management of implicit bias; these include creating a safe environment, presenting the science of implicit bias and evidence of its influence on clinical care, using critical reflection exercises, and engaging learners in skill-building exercises and activities in which they must embrace their discomfort.

The info is here.

‘Pastorally dangerous’: U.S. bishops risk causing confusion about vaccines, ethicists say

Michael J. O’Loughlin

America Magazine

Originally published March 02, 2021

Here is an excerpt:

Anthony Egan, S.J., a Jesuit priest and lecturer in theology in South Africa, said church leaders publishing messages about hypothetical situations during a crisis is “unhelpful” as Catholics navigate life in a pandemic.

“I think it’s pastorally dangerous because people are dealing with all kinds of crises—people are faced with unemployment, people are faced with disease, people are faced with death—and to make this kind of statement just adds to the general feeling of unease, a general feeling of crisis,” Father Egan said, noting that in South Africa, which has been hard hit by a more aggressive variant, the Johnson & Johnson vaccine is the only available option. “I don’t think that’s pastorally helpful.”

The choice about taking a vaccine like Johnson & Johnson’s must come down to individual conscience, he said. “I think it’s irresponsible to make a claim that you must absolutely not or absolutely must take the drug,” he said.

Ms. Fullam agreed, saying modern life is filled with difficult dilemmas stemming from previous injustices and “one of the great things about the Catholic moral tradition is that we recognize the world is a messy place, but we don’t insist Catholics stay away from that messiness.” Catholics, she said, are called “to think about how to make the situation better” rather than retreat in the face of complexity and given the ongoing pandemic, receiving a vaccine with a remote connection to abortion could be the right decision—especially in communities where access to vaccines might be difficult.

The info is here.

Examining clinician burnout in health industries

Cynda Hylton Rushton

Danielle Kress
Johns Hopkins Magazine
Originally posted 26 Dec 19


Here is an excerpt from the interview with Cynda Hylton Rushton:

How much is burnout really affecting clinicians?

Among nurses, 35-45% experience some form of burnout, with comparable rates among other providers and higher rates among physicians. It's important to note that burnout has been viewed as an occupational hazard rather than a mental health diagnosis. It is not a few days or even weeks of depletion or exhaustion. It is the cumulative, long-term distress and suffering that is slowly eroding the workforce and leading to significant job dissatisfaction and many leaving their professions. In some instances, serious health concerns and suicide can result.

What about the impact on patients?

Patient care can suffer when clinicians withdraw or are not fully engaged in their work. Moral distress, long hours, negative work environments, or organizational inefficiencies can all impact a clinician's ability to provide what they feel is quality, safe patient care. Likewise, patients are impacted when health care organizations are unable to attract and retain competent and compassionate clinicians.

What does this mean for nurses?

As the largest sector of the health care professions, nurses have the most patient interaction and are at the center of the health care team. Nurses are integral to helping patients to holistically respond to their health conditions, illness, or injury. If nurses are suffering from burnout and moral distress, the whole care team and the patient will experience serious consequences when nurses' capacities to adapt to the organizational and external pressures are eventually exceeded.

The info is here.

Patients don't think payers, providers can protect their data, survey finds

Paige Minemyer
Fierce Healthcare
Originally published on August 26, 2019

Patients are skeptical of healthcare industry players’ ability to protect their data—and believe health insurers to be the worst at doing so, a new survey shows.

Harvard T.H. Chan School of Public Health and Politico surveyed 1,009 adults in mid-July and found that just 17% have a “great deal” of faith that their health plan will protect their data.

By contrast, 24% said they had a “great deal” of trust in their hospital to protect their data, and 34% said the same about their physician’s office. In addition, 22% of respondents said they had “not very much” trust in their insurer to protect their data, and 17% said they had no trust at all.

The firms that fared the worst on the survey, however, were online search engines and social media sites. Only 7% said they have a “great deal” of trust in search engines such as Google to protect their data, and only 3% said the same about social media platforms.

The info is here.

How Could Commercial Terms of Use and Privacy Policies Undermine Informed Consent in the Age of Mobile Health?

Cynthia E. Schairer, Caryn Kseniya Rubanovich, and Cinnamon S. Bloss
AMA J Ethics. 2018;20(9):E864-872.

Abstract

Granular personal data generated by mobile health (mHealth) technologies coupled with the complexity of mHealth systems creates risks to privacy that are difficult to foresee, understand, and communicate, especially for purposes of informed consent. Moreover, commercial terms of use, to which users are almost always required to agree, depart significantly from standards of informed consent. As data use scandals increasingly surface in the news, the field of mHealth must advocate for user-centered privacy and informed consent practices that motivate patients’ and research participants’ trust. We review the challenges and relevance of informed consent and discuss opportunities for creating new standards for user-centered informed consent processes in the age of mHealth.

The info is here.

Increasing patient engagement in healthcare decision-making

Jennifer Blumenthal-Barby
Baylor College of Medicine Blogs
Originally posted March 10, 2017

Making decisions is hard. Anyone who has ever struggled to pick a restaurant for dinner knows well – choosing between options is difficult even when the stakes are low and you have full access to information.

But what happens when the information is incomplete or difficult to comprehend? How does navigating a health crisis impact our ability to choose between different treatment options?

The Wall Street Journal published an article about something I have spent considerable time studying: the importance of decision aids in helping patients make difficult medical decisions. They note correctly that simplifying medical jargon and complicated statistics helps patients take more control over their care.

But that is only part of the equation.

The blog post is here.

How Doctors Deal With Racist Patients

Sumathi Reddy
The Wall Street Journal
Originally published January 22, 2018

Her is an excerpt:

Patient discrimination against physicians and other health-care providers is an oft-ignored topic in a high-stress job where care always comes first. Experts say patients request another physician based on race, religion, gender, age and sexual orientation.

No government entity keeps track of such incidents. Neither do most hospitals. But more trainees and physicians are coming forward with stories and more hospitals and academic institutions are trying to address the issue with new guidelines and policies.

The examples span race and religion. A Korean-American doctor’s tweet about white nationalists refusing treatment in the emergency room went viral in August.

A trauma surgeon at a hospital in Charlotte, N.C., published a piece on KevinMD, a website for physicians, last year detailing his own experiences with discrimination given his Middle Eastern heritage.

Penn State College of Medicine adopted language into its patient rights policy in May that says patient requests for providers based on gender, race, ethnicity or sexual orientation won’t be honored. It adds that some requests based on gender will be evaluated on a case-by-case basis.

The article is here.

Failing better

Erik Angner
BPP Blog, the companion blog to the new journal Behavioural Public Policy
Originally posted June 2, 2017

Cass R. Sunstein’s ‘Nudges That Fail’ explores why some nudges work, why some fail, and what should be done in the face of failure. It’s a useful contribution in part because it reminds us that nudging – roughly speaking, the effort to improve people’s welfare by helping them make better choices without interfering with their liberty or autonomy – is harder than it might seem. When people differ in beliefs, values, and preferences, or when they differ in their responses to behavioral interventions, for example, it may be difficult to design a nudge that benefits at least some without violating anyone’s liberty or autonomy. But the paper is a useful contribution also because it suggests concrete, positive steps that may be taken to help us get better simultaneously at enhancing welfare and at respecting liberty and autonomy.

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Moreover, even if a nudge is on the net welfare enhancing and doesn’t violate any other values, it does not follow that it should be implemented. As economists are fond of telling you, everything has an opportunity cost, and so do nudges. If whatever resources would be used in the implementation of the nudge could be put to better use elsewhere, we would have reason not to implement it. If we did anyway, we would be guilty of the Econ 101 fallacy of ignoring opportunity costs, which would be embarrassing.

The blog post is here.

Informed Patient? Don’t bet on it

Mikkael Sekeres and Timothy Gilligan
The New York Times
Originally posted March 1, 2017

Here is an excerpt:

The secret is that informed consent in health care is commonly not-so-well informed. It might be a document we ask you to sign, at the behest of our lawyers, in case we end up in court if a bad outcome happens. Unfortunately, it’s often not really about informing you. In schools, teachers determine what students know through tests and homework. The standard is not whether the teacher has explained how to add, but instead whether the student can add. If we were truly invested in whether you were informed, we’d give you a quiz, or at least ask you to repeat back to us what you heard so we could assess its accuracy.

The article is here.

Clinicians’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests

Tammy C. Hoffmann & Chris Del Mar
JAMA Intern Med. 
Published online January 9, 2017.
doi:10.1001/jamainternmed.2016.8254

Question

Do clinicians have accurate expectations of the benefits and harms of treatments, tests, and screening tests?

Findings

In this systematic review of 48 studies (13 011 clinicians), most participants correctly estimated 13% of the 69 harm expectation outcomes and 11% of the 28 benefit expectations. The majority of participants overestimated benefit for 32% of outcomes, underestimated benefit for 9%, underestimated harm for 34%, and overestimated harm for 5% of outcomes.

Meaning

Clinicians rarely had accurate expectations of benefits or harms, with inaccuracies in both directions, but more often underestimated harms and overestimated benefits.

The research is here.

Is Knowing Your Genetic Information Helpful?

By Laura Landro
The Wall Street Journal
Originally published June 26, 2016

Here is an excerpt:

How different people handle uncertainty is also a concern. The surveys include questions such as whether unforeseen events are highly upsetting and whether participants can function well in a climate of uncertainty.

The survey results aren’t final yet. But Dr. Leonard says one concern people have is “learning about something they just don’t want to know about.”

Among the ethical issues she is exploring is “whether someone should be given the choice not to know about a disease risk for which there are preventive or monitoring strategies that would reduce the severity of the disease and therefore the cost of care.”

The article is here.

A Unified Code of Ethics for Health Professionals: Insights From an IOM Workshop.

Matthew K. Wynia, Sandeep P. Kishore, & Cynthia D. Belar
JAMA, 2014;311(8):799-800.

Here is an excerpt:

Professional obligations under these social contracts are often expressed in codes of ethics; although, unlike laws and regulations, the level of public engagement in developing professional codes has traditionally been limited. Still, when professional codes have failed to meet societal expectations, they have been publicly criticized and eventually changed, such as when the American Medical Association's code initially failed to fully obligate physicians to care for patients with human immunodeficiency virus infection.

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First, a new social contract should be articulated in a code of ethics that does not focus on the roles and obligations of just 1 subset of health professionals. The traditional approach to professionalism in health care has separated health professionals according to education and credentialing, with each group seeking to establish its own social contract. In negotiating their social roles, this separation has allowed groups at times to ignore, show little regard for, or even be overtly hostile toward the roles of other groups (for example, in debates over scope of practice and payment issues). This approach is counterproductive in today's health care environment, which demands teamwork.

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Second, transdisciplinary professionalism demands more than a 1-time listing of shared values by a multidisciplinary group. A meaningful transdisciplinary professionalism will entail the creation of new institutional frameworks, which are required for 'defining, debating, declaring, distributing and enforcing" the expectations and standards that health care professionals and the public agree should govern work in the health care arena'.

The article is here.

Things are looking app

The Economist
Originally posted March 12, 2016

Here is an excerpt:

Constant, wireless-linked monitoring may spare patients much suffering, by spotting incipient signs of their condition deteriorating. It may also spare health providers and insurers many expensive hospital admissions. When Britain’s National Health Service tested the cost-effectiveness of remote support for patients with chronic obstructive pulmonary disease, it found that an electronic tablet paired with sensors measuring vital signs could result in better care and enormous savings, by enabling early intervention. Some m-health products may prove so effective that doctors begin to provide them on prescription.

So far, big drugmakers have been slow to join the m-health revolution, though there are some exceptions. HemMobile by Pfizer, and Beat Bleeds by Baxter, help patients to manage haemophilia. Bayer, the maker of Clarityn, an antihistamine drug, has a popular pollen-forecasting app. GSK, a drug firm with various asthma treatments, offers sufferers the MyAsthma app, to help them manage their condition.

The article is here.

Bias, Black Lives, and Academic Medicine

By David A. Ansell and Edwin K. McDonald
The New England Journal of Medicine
Originally published February 18, 2015

Here is an excerpt:

First, there is evidence that doctors hold stereotypes based on patients' race that can influence their clinical decisions.  Implicit bias refers to unconscious racial stereotypes that grow from our personal and cultural experiences. These implicit beliefs may also stem from a lack of day-to-day interracial and intercultural interactions. Although explicit race bias is rare among physicians, an unconscious preference for whites as compared with blacks is commonly revealed on tests of implicit bias.

Second, despite physicians' and medical centers' best intentions of being equitable, black–white disparities persist in patient outcomes, medical education, and faculty recruitment.

The entire article is here.

Laws that Conflict with the Ethics of Medicine: What Should Doctors Do?

By Dena S. Davis and Eric Kodish
Hastings Center Report 44, no. 6 (2014): 11-14.
DOI: 10.1002/hast.382

Here is an excerpt:

Medical ethics has always asked doctors to put their patients first, even at some risk to themselves. “Medicine is, at its center, a moral enterprise grounded in a covenant of trust,” writes Christine Cassell. “This covenant obliges physicians to be competent and to use their competence in the patient's best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times.”[19] Physicians are expected to care for patients with infectious diseases, even at risk of their own health. Physicians are expected to do some pro bono work, to take on some patients who are not financial assets, and so on. Physicians should be advocates for the health of all people, above and beyond even their own patients. The AAP is “dedicated to the health of all children.”[20] The imperative to act on this ethical norm clearly suggests that physicians should challenge these types of laws. On rare occasions, individual doctors may be ethically justified in disobeying or breaking the law.

The entire article is here.

When Doctors Treat Patients Like Themselves

By Abigail Zuger
The New York Times
Originally posted May 19, 2014

Here is an excerpt:

Professional training may not remove the interpersonal chemistry that binds us to some and estranges us from others, but it can neutralize these forces somewhat, enough to enable civilized and productive dialogue among all comers. Yet until the day when we deal only in cells, organs and genes and not their human containers, we will, for better or worse, always see ourselves in some patients, our friends and relatives in others, and our patients will likewise instinctively experience doctor as mother or father, buddy or virtual stranger.

Are the ties that bind us for better, medically, or are they for worse? Is health care more effective when patient and doctor are the same — the same sex, class, race, tax bracket, sore feet and cholesterol level? Or does essential objectivity require some differences? When your doctor looks at you and sees a mirrored reflection, is that good for you, or bad?

The entire article is here.

So much for Hippocrates: Why docs won’t reveal each other’s mistakes

Research suggests physicians are concerned about becoming known as a tattler and losing referrals

By Marshall Allen
Propublica
Originally published November 12, 2013

Patients don’t always know when their doctor has made a medical error. But other doctors do.

A few years ago I called a Las Vegas surgeon because I had hospital data showing which of his peers had high rates of surgical injuries – things like removing a healthy kidney, accidentally puncturing a young girl’s aorta during an appendectomy and mistakenly removing part of a woman’s pancreas.

I wanted to see if he could help me investigate what happened. But the surgeon surprised me.

Before I could get a question out, he started rattling off the names of surgeons he considered the worst in town. He and his partners often had to correct their mistakes — “cleanup” surgeries, he said. He didn’t need a database to tell him which surgeons made the most mistakes.

The entire story is here.

Thanks to Gary Schoener for this article.