Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Finances. Show all posts
Showing posts with label Finances. Show all posts

Saturday, June 8, 2024

A Doctor at Cigna Said Her Bosses Pressured Her to Review Patients’ Cases Too Quickly

P. Rucker and D. Armstrong
Originally posted 29 APR 24

Here is an excerpt:

As ProPublica and The Capitol Forum reported last year, Cigna built a computer program that allowed its medical directors to deny certain claims in bulk. The insurer’s doctors spent an average of just 1.2 seconds on each of those cases. Cigna at the time said the review system was created to speed up approval of claims for certain routine screenings; the company later posted a rebuttal to the story. A congressional committee and the Department of Labor launched inquiries into this Cigna program. A spokesperson for Rep. Cathy McMorris Rodgers, the chair of the congressional committee, said Rodgers continues to monitor the situation after Cigna shared some details about its process. The Labor Department is still examining such practices.

One figure on Cigna’s January and February 2022 dashboards was like a productivity score; the news organizations found that this number reflects the pace at which a medical director clears cases.

Cigna said it was incorrect to call that figure on its dashboard a productivity score and said its “view on productivity is defined by a range of factors beyond elements included in a single spreadsheet.” In addition, the company told the news organizations, “The copy of the dashboard that you have is inaccurate and secondary calculations made using its contents may also be inaccurate.” The news organizations asked what was inaccurate, but the company wouldn’t elaborate.

Nevertheless, Cigna said that because the dashboard created “inadvertent confusion” the company was “reassessing its use.”

Here is my summary:

The article reports on Dr. Debby Day, who alleges that Cigna, her employer, pressured her to prioritize speed over thoroughness when reviewing patients' requests for healthcare coverage.

According to Day, managers emphasized meeting quotas and processing claims quickly, even if it meant superficially reviewing cases. Dr. Day said Cigna expected medical directors to review cases in as little as 4 minutes, which she felt was too rushed to properly evaluate them.  The pressure to deny claims quickly was nicknamed "click and close" by some employees.

Day felt this practice compromised patient care and refused to expedite reviews at the expense of quality. The article suggests this may have led to threats of termination from Cigna.

Monday, April 22, 2024

Union accuses Kaiser of violations months after state fine on mental health care

Emily Alpert Reyes
Los Angeles Times
Originally posted 9 April 24

Months after Kaiser Permanente reached a sweeping agreement with state regulators to improve its mental health services, the healthcare giant is facing union allegations that patients could be improperly losing such care.

The National Union of Healthcare Workers, which represents thousands of Kaiser mental health professionals, complained earlier this year to state regulators that Kaiser appeared to be inappropriately handing off decisions about whether therapy is still medically necessary.

The union alleged that Rula Health, a contracted network of therapists that Kaiser uses to provide virtual care to its members, had been directed by Kaiser to use “illegal criteria” to make those decisions during regular reviews.

Here is my thoughts:

Kaiser Permanente is facing accusations from the National Union of Healthcare Workers (NUHW) that it is still violating mental health care laws, even after a recent $200 million settlement with the California Department of Managed Health Care (DMHC) over its mismanagement of behavioral health benefits.

The union alleges that Kaiser is inappropriately delegating decisions about the medical necessity of therapy during regular reviews to a contracted network of therapists, Rula Health, who are using "illegal criteria" to make these decisions instead of professional group criteria as required by California law.

The union claims this is resulting in patients with psychological disorders being unfairly denied continued access to necessary treatment.  Furthermore, the union argues that the frequent clinical care reviews Kaiser is subjecting mental health patients to violate laws prohibiting insurers from erecting more barriers to mental healthcare than for other health conditions.  Importantly, Kaiser does not subject other outpatient care to such reviews.

The DMHC has confirmed it is examining the issues raised by the union under the recent $200 million settlement agreement, which required Kaiser to pay a $50 million fine and invest $150 million over five years to improve its mental healthcare.  The settlement came after the DMHC's investigation found several deficiencies in Kaiser's provision of behavioral health services, including long delays for patients trying to schedule appointments and a failure to contract enough high-level behavioral care facilities.

Kaiser has stated that it does not limit the number of therapy sessions and that decisions on the level and frequency of therapy are made by providers in consultation with patients based on clinical needs.  However, the union maintains that Kaiser's actions are still violating mental health parity laws.

Monday, March 18, 2024

Mega Malpractice Verdicts Against Physicians on the Rise

Alicia Gallegos
Originally posted 2 Feb 24

Here is an excerpt:

Why Are Juries Awarding Higher Verdicts?

There's no single reason for the rise in nuclear verdicts, Henderson said.

One theory is that plaintiffs' attorneys held back on resolving high-dollar cases during the COVID pandemic and let loose with high-demand claims when courts returned to normal, he said.

Another theory is that people emerged from the pandemic angrier.

"Whether it was political dynamics, masking [mandates], or differences in opinions, people came out of it angry, and generally speaking, you don't want an angry jury," Henderson said. "For a while, there was the halo effect, where health professionals were seen as heroes. That went away, and all of a sudden [they] became 'the bad guys'."

"People are angry at the healthcare system, and this anger manifests itself in [liability] suits," added Bill Burns, vice president of research for the Medical Professional Liability Association, an industry group for medical liability insurers.

Hospital and medical group consolidation also reduces the personal connection juries may have with healthcare providers, Burns said.

"Healthcare has become a big business, and the corporatization of medicine now puts companies on the stand and not your local community hospital or your family doctor that you have known since birth," he said.

Plaintiffs' attorneys also deploy tactics that can prompt higher verdicts, White said. They may tell a jury that the provider or hospital is a threat to the community and that awarding a large verdict will deter others in the healthcare community from repeating the same actions.

Juries may then want to punish the defendant in addition to assessing damages for economic harm or pain and suffering, White said.

Sunday, March 17, 2024

The Argument Over a Long-Standing Autism Intervention

Jessica Winter
The New Yorker
Originally posted 12 Feb 24

Here are excerpts:

A.B.A. is the only autism intervention that is approved by insurers and Medicaid in all fifty states. The practice is widely recommended for autistic kids who exhibit dangerous behaviors, such as self-injury or aggression toward others, or who need to acquire basic skills, such as dressing themselves or going to the bathroom. The mother of a boy with severe autism in New York City told me that her son’s current goals in A.B.A. include tolerating the shower for incrementally longer intervals, redirecting the urge to pull on other people’s hair, and using a speech tablet to say no. Another kid might be working on more complex language skills by drilling with flash cards or honing his ability to focus on academic work. Often, A.B.A. targets autistic traits that may be socially stigmatizing but are harmless unto themselves, such as fidgeting, avoiding eye contact, or stereotypic behaviors commonly known as stimming—rocking, hand-flapping, and so forth.


In recent years, A.B.A. has come under increasingly vehement criticism from members of the neurodiversity movement, who believe that it cruelly pathologizes autistic behavior. They say that its rewards for compliance are dehumanizing; some compare A.B.A. to conversion therapy. Social-media posts condemning the practice often carry the hashtag #ABAIsAbuse. The message that A.B.A. sends is that “your instinctual way of being is incorrect,” Zoe Gross, the director of advocacy at the nonprofit Autistic Self Advocacy Network, told me. “The goals of A.B.A. therapy—from its inception, but still through today—tend to focus on teaching autistic people to behave like non-autistic people.” But others say this criticism obscures the good work that A.B.A. can do. Alicia Allgood, a board-certified behavior analyst who co-runs an A.B.A. agency in New York City, and who is herself autistic, told me, “The autistic community is up in arms. There is a very vocal part of the autistic population that is saying that A.B.A. is harmful or aversive or has potentially caused trauma.”


In recent years, private equity has taken a voracious interest in A.B.A. services, partly because they are perceived as inexpensive. Private-equity firms have consolidated many small clinics into larger chains, where providers are often saddled with unrealistic billing quotas and cut-and-paste treatment plans. Last year, the Center for Economic and Policy Research published a startling report on the subject, which included an account of how Blackstone effectively bankrupted a successful A.B.A. provider and shut down more than a hundred of its treatment sites. Private-equity-owned A.B.A. chains have been accused of fraudulent billing and wage theft; message boards for A.B.A. providers overflow with horror stories about low pay, churn, and burnout. High rates of turnover are acutely damaging to a specialty that relies on familiarity between provider and client. “The idea that we could just franchise A.B.A. providers and anyone could do the work—that was misinformed,” Singer, of the Autism Science Foundation, said.

Sunday, January 21, 2024

Doctors With Histories of Big Malpractice Settlements Now Work for Insurers

P. Rucker, D. Armstrong, & D. Burke
Originally published 15 Dec 23

Here is an excerpt:

Patients and the doctors who treat them don’t get to pick which medical director reviews their case. An anesthesiologist working for an insurer can overrule a patient’s oncologist. In other cases, the medical director might be a doctor like Kasemsap who has left clinical practice after multiple accusations of negligence.

As part of a yearlong series about how health plans refuse to pay for care, ProPublica and The Capitol Forum set out to examine who insurers picked for such important jobs.

Reporters could not find any comprehensive database of doctors working for insurance companies or any public listings by the insurers who employ them. Many health plans also farm out medical reviews to other companies that employ their own doctors. ProPublica and The Capitol Forum identified medical directors through regulatory filings, LinkedIn profiles, lawsuits and interviews with insurance industry insiders. Reporters then checked those names against malpractice databases, state licensing board actions and court filings in 17 states.

Among the findings: The Capitol Forum and ProPublica identified 12 insurance company doctors with either a history of multiple malpractice payments, a single payment in excess of $1 million or a disciplinary action by a state medical board.

One medical director settled malpractice cases with 11 patients, some of whom alleged he bungled their urology surgeries and left them incontinent. Another was reprimanded by a state medical board for behavior that it found to be deceptive and dishonest. A third settled a malpractice case for $1.8 million after failing to identify cancerous cells on a pathology slide, which delayed a diagnosis for a 27-year-old mother of two, who died less than a year after her cancer was finally discovered.

None of this would have been easily visible to patients seeking approvals for care or payment from insurers who relied on these medical directors.

The ethical implications in this article are staggering.  Here are some quick points:

Conflicted Care: In a concerning trend, some US insurers are employing doctors with past malpractice settlements to assess whether patients deserve coverage for recommended treatments.  So, do these still licensed reviewers actually understand best practices?

Financial Bias: Critics fear these doctors, having faced financial repercussions for past care decisions, might prioritize minimizing payouts over patient needs, potentially leading to denied claims and delayed care.  In other words, do the reviewers have an inherent bias against patients, given that former patients complained against them?

Transparency Concerns: The lack of clear disclosure about these doctors' backgrounds raises concerns about transparency and potential conflicts of interest within the healthcare system.

In essence, this is a horrible system to provide high quality medical review.

Saturday, January 20, 2024

Private equity is buying up health care, but the real problem is why doctors are selling

Yashaswini Singh & Christopher Whaley
The Hill
Originally published 21 Dec 23

Here is an excerpt:

But amid warnings that private equity is taking over health care and portrayals of financiers as greedy villains, we’re ignoring the reality that no one is coercing individual physicians to sell. Many doctors are eager to hand off their practices, and for not just for the payday. Running a private practice has become increasingly unsustainable, and alternative employment options, such as working for hospitals, are often unappealing. That leaves private equity as an attractive third path.

There are plenty of short-term steps that regulators should take to keep private equity firms in check. But the bigger problem we must address is why so many doctors feel the need to sell. The real solution to private equity in health care is to boost competition and address the pressures physicians are facing.

Consolidation in health care isn’t new. For decades, physician practices have been swallowed up by hospital systems. According to a study by the Physicians Advocacy Institute, nearly 75 percent of physicians now work for a hospital or corporate owner. While hospitals continue to drive consolidation, private equity is ramping up its spending and market share. One recent report found that private equity now owns more than 30 percent of practices in nearly one-third of metropolitan areas.

Years of study suggest that consolidation drives up health care costs without improving quality of care, and our research shows that private equity is no different. To deliver a high return to investors, private equity firms inflate charges and cut costs. One of our studies found that a few years after private equity invested in a practice, charges per patient were 50% higher than before. Practices also experience high turnover of physicians and increased hiring of non-physician staff.

How we got here has more to do with broader problems in health care than with private equity itself.

Here is my summary, which is really a warning:

The article dives into the concerning trend of private equity firms acquiring healthcare practices. It argues that while this might seem concerning, the bigger issue lies in understanding why doctors are willing to sell their practices in the first place.

The author highlights the immense financial burden doctors shoulder while running their own practices. Between rising costs and stagnant insurance reimbursements, it's becoming increasingly difficult for them to stay afloat. This, the article argues, is what's pushing them towards private equity firms, who offer immediate financial relief but often come with their own set of downsides for patients, like higher costs and reduced quality of care.

Therefore, instead of solely focusing on restricting private equity involvement, the article suggests we address the root cause: the financial woes of independent doctors. This could involve solutions like increased Medicare payments, tax breaks for independent practices, and alleviating the administrative burden doctors face. Only then can we ensure a sustainable healthcare system that prioritizes patient well-being.

Friday, November 24, 2023

UnitedHealth faces class action lawsuit over algorithmic care denials in Medicare Advantage plans

Casey Ross and Bob Herman
Originally posted 14 Nov 23

A class action lawsuit was filed Tuesday against UnitedHealth Group and a subsidiary alleging that they are illegally using an algorithm to deny rehabilitation care to seriously ill patients, even though the companies know the algorithm has a high error rate.

The class action suit, filed on behalf of deceased patients who had a UnitedHealthcare Medicare Advantage plan and their families by the California-based Clarkson Law Firm, follows the publication of a STAT investigation Tuesday. The investigation, cited by the lawsuit, found UnitedHealth pressured medical employees to follow an algorithm, which predicts a patient’s length of stay, to issue payment denials to people with Medicare Advantage plans. Internal documents revealed that managers within the company set a goal for clinical employees to keep patients rehab stays within 1% of the days projected by the algorithm.

The lawsuit, filed in the U.S. District Court of Minnesota, accuses UnitedHealth and its subsidiary, NaviHealth, of using the computer algorithm to “systematically deny claims” of Medicare beneficiaries struggling to recover from debilitating illnesses in nursing homes. The suit also cites STAT’s previous reporting on the issue.

“The fraudulent scheme affords defendants a clear financial windfall in the form of policy premiums without having to pay for promised care,” the complaint alleges. “The elderly are prematurely kicked out of care facilities nationwide or forced to deplete family savings to continue receiving necessary care, all because an [artificial intelligence] model ‘disagrees’ with their real live doctors’ recommendations.”

Here are some of my concerns:

The use of algorithms in healthcare decision-making has raised a number of ethical concerns. Some critics argue that algorithms can be biased and discriminatory, and that they can lead to decisions that are not in the best interests of patients. Others argue that algorithms can lack transparency, and that they can make it difficult for patients to understand how decisions are being made.

The lawsuit against UnitedHealth raises a number of specific ethical concerns. First, the plaintiffs allege that UnitedHealth's algorithm is based on inaccurate and incomplete data. This raises the concern that the algorithm may be making decisions that are not based on sound medical evidence. Second, the plaintiffs allege that UnitedHealth has failed to adequately train its employees on how to use the algorithm. This raises the concern that employees may be making decisions that are not in the best interests of patients, either because they do not understand how the algorithm works or because they are pressured to deny claims.

The lawsuit also raises the general question of whether algorithms should be used to make healthcare decisions. Some argue that algorithms can be used to make more efficient and objective decisions than humans can. Others argue that algorithms are not capable of making complex medical decisions that require an understanding of the individual patient's circumstances.

The use of algorithms in healthcare is a complex issue with no easy answers. It is important to carefully consider the potential benefits and risks of using algorithms before implementing them in healthcare settings.

Saturday, September 9, 2023

Academics Raise More Than $315,000 for Data Bloggers Sued by Harvard Business School Professor Gino

Neil H. Shah & Claire Yuan
The Crimson
Originally published 1 Sept 23

A group of academics has raised more than $315,000 through a crowdfunding campaign to support the legal expenses of the professors behind data investigation blog Data Colada — who are being sued for defamation by Harvard Business School professor Francesca Gino.

Supporters of the three professors — Uri Simonsohn, Leif D. Nelson, and Joseph P. Simmons — launched the GoFundMe campaign to raise funds for their legal fees after they were named in a $25 million defamation lawsuit filed by Gino last month.

In a series of four blog posts in June, Data Colada gave a detailed account of alleged research misconduct by Gino across four academic papers. Two of the papers were retracted following the allegations by Data Colada, while another had previously been retracted in September 2021 and a fourth is set to be retracted in September 2023.

Organizers wrote on GoFundMe that the fundraiser “hit 2,000 donors and $250K in less than 2 days” and that Simonsohn, Nelson, and Simmons “are deeply moved and grateful for this incredible show of support.”

Simine Vazire, one of the fundraiser’s organizers, said she was “pleasantly surprised” by the reaction throughout academia in support of Data Colada.

“It’s been really nice to see the consensus among the academic community, which is strikingly different than what I see on LinkedIn and the non-academic community,” she said.

Elisabeth M. Bik — a data manipulation expert who also helped organize the fundraiser — credited the outpouring of financial support to solidarity and concern among scientists.

“People are very concerned about this lawsuit and about the potential silencing effect this could have on people who criticize other people’s papers,” Bik said. “I think a lot of people want to support Data Colada for their legal defenses.”

Andrew T. Miltenberg — one of Gino’s attorneys — wrote in an emailed statement that the lawsuit is “not an indictment on Data Colada’s mission.”

Monday, August 21, 2023

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

Steph Weber
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.


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.

Sunday, March 26, 2023

State medical board chair Dr. Brian Hyatt resigns, faces Medicaid fraud allegations

Ashley Savage
Arkansas Democrat Gazette
Originally published 3 MAR 23

Dr. Brian Hyatt stepped down as chairman of the Arkansas State Medical Board Thursday in a special meeting following "credible allegations of fraud," noted in a letter from the state's office of Medicaid inspector general.

Members of the board met remotely Thursday with only one item on the agenda: "Discussion of Arkansas State Board's leadership."

The motion to approve Hyatt's request to step down as chairman and out of an executive role on the board was approved unanimously.

Board members also decided that Dr. Rhys Branman will take over as the interim chairman until an election to fill the seat is held in April.

According to the board Thursday, the vacant seats for vice chair and chair of the board will be voted on separate ballots in the April elections.

The Medicaid letter states "red flags" were discovered in Hyatt's use of Medicaid claims and process of billing for medical services. In Arkansas, Medicaid fraud resulting in an overpayment over $2,500 is a felony.

"Dr. Hyatt is a clear outlier, and his claims are so high they skew the averages on certain codes for the entire Medicaid program in Arkansas," the affidavit states.

"The suspension is temporary and there's a right to appeal. I see only allegations and I don't see any actual charges and I haven't dealt with this a lot," said Branman.

Hyatt has 30 days to appeal his suspension from the Medicaid program.

Other information from the letter shows that Hyatt is alleged to have billed more Medicaid patients at the 99233 code than any other doctor billed for all of their Medicaid patients between January of 2019 and June 30, 2022.

Thursday, December 8, 2022

‘A lottery ticket, not a guarantee’: fertility experts on the rise of egg freezing

Hannah Devlin
The Guardian
Originally posted 11 NOV 22

Here is an excerpt:

This means that a woman who freezes eggs at the age of 30 boosts her chances of successful IVF at 40 years. But, according to Dr Zeynep Gurtin, a lecturer in women’s health at UCL, this concept has led to a false narrative that if you freeze your eggs “you’ll be fine”. “A lot of people who freeze their eggs don’t get pregnant,” Gurtin said.

First, only a fraction opt to use the eggs down the line – some get pregnant without IVF, others decide not to for a range of reasons. For those who go ahead, HFEA figures show that, as an average across all age groups, just 2% of all thawed eggs ended up as pregnancies and 0.7% resulted in live births in 2018. For each IVF cycle, this gives a 27% chance on average of a birth for those who froze their eggs before the age of 35 and a 13% for those who froze their eggs after this age. The most common age for egg freezing in the UK is 38 years old.

A recent analysis by the Nuffield Council on Bioethics found women often felt frustrated at having received insufficient information on success rates, but also reported feeling relief and a sense of empowerment.

Egg freezing, Gurtin suggested, should be viewed as “having a lottery ticket rather than having an insurance policy”.

“An insurance policy suggests you’ll definitely get a payout,” she said. “You’re just increasing your chances.”

As lottery tickets go, it is an expensive one. The average cost of having eggs collected and frozen is £3,350, with additional £500-£1,500 costs for medication and an ongoing expense of £125-£350 a year for storage. And clinics are not always upfront about the full extent of costs.

“In many cases, you’re going to spend a third more than the advertised price – and you’re spending that money for something that’s not an immediate benefit to you,” said Gurtin. “It’s a big gamble.”

“When people talk about egg freezing revolutionising women’s lives, you have to ask: how many can afford it?” she added.

Travelling abroad, where treatments may be cheaper, is an option but can be logistically problematic. “When it comes to repatriating eggs, sperm and embryos, it is possible, but it’s not always that straightforward,” said Sarris. “You need to follow a process, you don’t just send them with DHL.”

Sunday, July 3, 2022

Mental Illness Is Not in Your Head

Marco Ramos
Boston Review
Originally posted 17 MAY 22

Here are two excerpts:

In Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, Anne Harrington argues that the current crisis is just the latest in a long line of failures to discover the biology of mental illness over the last two centuries. In this sweeping study, the history of psychiatry undulates like the boom and bust of a speculative market. First a wave builds with enthusiastic promises of revolutionary breakthroughs that will change psychiatry as we know it. Then the wave collapses, as psychiatrists fail to deliver on those bold promises. Crisis ensues, and after the requisite finger-pointing, the next wave of psychiatric revolution begins to build. Rinse and repeat.

The first “revolution” in American psychiatry that Harrington tracks arrived in the nineteenth century. At the time, large lunatic asylums dominated the psychiatric landscape, such as the Blackwell’s Island hospital on what today is called Roosevelt Island in New York City. These institutions were designed to cure patients with mental disorders by placing them in the hospitable environment of the asylum architectural space. However, a series of journalistic exposés revealed that these asylums were overcrowded and underfunded with patients living in deplorable, instead of therapeutic, conditions. For example, in 1887, journalist Elizabeth Seaman, who wrote under the pen name Nellie Bly, went undercover as a patient in Blackwell’s Island Hospital and exposed horrible acts of brutality in her best-seller Ten Days in a Mad-House. Asylum psychiatry faced a crisis of public trust.

As Harrington explains, European neuroanatomists came to the rescue. Unlike asylum physicians, anatomists were pessimistic about the potential for a cure. Building on eugenic theories, they believed that asylum patients were “degenerates” who were biologically unfit to cope with the stresses of modern life. But they also believed that the mentally ill could provide a service to society after their deaths by offering their brains to science. The dissection of their pathological brains, the anatomists hoped, could reveal the biological causes of mental suffering.


But if the pharmaceutical industry has invested so heavily in psychiatry, why have there been no breakthroughs in drug treatment? A major reason is that the industry has spent billions of dollars more on advertising psychiatric medications than on research and development of novel drugs. As psychiatrist David Healy has shown, money earmarked for R&D is often not intended to produce genuine innovation. Almost all of the psychopharmaceuticals produced since 1990 have been “copycats” that mimic older, generic pharmaceuticals, with only minor chemical modifications. These (unfortunately named) “me-too” drugs work no better clinically than the drugs that came before them, but their slight biochemical novelty means that they can be patented, so that pharma can charge insurance companies’ top dollar.

Perhaps the worst news is that Big Pharma, having created and capitalized on psychiatric markets, is now jumping ship. Anthropologist Joe Dumit has shown that most psychiatric drugs will soon go off patent, so companies will be forced to charge less for them. With the market already saturated with pharmaceutical copycats and no significant scientific biological breakthroughs in sight, there is suddenly little room for growth. Almost all of the major pharmaceutical companies have decided to divest from psychiatric drug research and turn to more promising sectors, especially the development of “biologics” and other cancer drugs.

Thursday, December 16, 2021

The hidden ‘replication crisis’ of finance

Robin Wigglesworth 
Financial Times
Originally published 15 NOV 2021

Here is an excerpt:

Is investing suffering from something similar?

That is the incendiary argument of Campbell Harvey, professor of finance at Duke university. He reckons that at least half of the 400 supposedly market-beating strategies identified in top financial journals over the years are bogus. Worse, he worries that many fellow academics are in denial about this.

“It’s a huge issue,” he says. “Step one in dealing with the replication crisis in finance is to accept that there is a crisis. And right now, many of my colleagues are not there yet.”

Harvey is not some obscure outsider or performative contrarian attempting to gain attention through needless controversy. He is the former editor of the Journal of Finance, a former president of the American Finance Association, and an adviser to investment firms like Research Affiliates and Man Group.


Obviously, the stakes of the replication crisis are much higher in medicine, where lives can be in play. But it is not something that remains confined to the ivory towers of business schools, as investment groups often smell an opportunity to sell products based on apparently market-beating factors, Harvey argues. “It filters into the real world,” he says. “It definitely makes it into people’s portfolios.”

Tuesday, November 9, 2021

Louisiana woman learns WWII vet husband’s cadaver dissected at pay-per-view event

Peter Aitken
Originally published 7 NOV 21

The family of a deceased Louisiana man found out that his body ended up in a ticketed live human dissection as part of a traveling expo.

David Saunders, a World War II and Korean War veteran who lived in Baker, died at the age of 98 from COVID-19 complications in August. His family donated his remains to science – or so they thought: Instead, his wife, Elsie Saunders, discovered that his body had ended up in an "Oddities and Curiosities Expo" in Oregon.

The expo, organized by DeathScience.org, was set up at the Portland Marriot Downtown Waterfront. People could watch a live human dissection on Oct. 17 for the cost of up to $500 a seat, KING-TV reported.

"From the external body exam to the removal of vital organs including the brain, we will find new perspectives on how the human body can tell a story," an online event description says. "There will be several opportunities for attendees to get an up-close and personal look at the cadaver."

The Seattle-based station sent an undercover reporter to the expo and noted David Saunders’ name on a bracelet he was wearing. The reporter was able to contact Elsie Saunders and let her know what had happened.

She was, understandably, horrified.

"It’s horrible what has happened to my husband," Elsie Saunders told NBC News. "I didn’t know he was going to be … put on display like a performing bear or something. I only consented to body donation or scientific purposes."

"That’s the way my husband wanted it," she explained. "To say the least, I’m upset."

Monday, October 25, 2021

Federal Reserve tightens ethics rules to ban active trading by senior officials

Brian Cheung
Yahoo Business News
Originally posted 21 OCT 21

The Federal Reserve on Thursday said it will tighten its ethics rules concerning personal finances among its most senior officials, the latest development in a trading scandal that has led to the resignation of two policymakers.

The central bank said it has introduced a “broad set of new rules” that restricts any active trading and prohibits the purchase of any individual securities (i.e. stocks, bonds, or derivatives). The new restrictions effectively only allow purchases of diversified investment vehicles like mutual funds.

If policymakers want to make any purchases or sales, they will be required to provide 45 days of advance notice and obtain prior approval for any purchases and sales. Those officials will also be required to hold onto those investments for at least one year, with no purchases or sales allowed during periods of “heightened financial market stress.”

Fed officials are still working on the details of what would define that level of stress, but said the market conditions of spring 2020 would have qualified.

The new rules will also increase the frequency of public disclosures from the reserve bank presidents, requiring monthly filings instead of the status quo of annual filings. Those at the Federal Reserve Board in Washington already were required to make monthly disclosures.

The restrictions apply to policymakers and senior staff at the Fed’s headquarters in Washington, as well as its 12 Federal Reserve Bank regional outposts. The new rules will be implemented “over the coming months.”

Fed officials said changes will likely require divestments from any existing holdings that do not meet the updated standards.

Sunday, September 19, 2021

How Does Cost-Effectiveness Analysis Inform Health Care Decisions?

David D. Kim & Anirban Basu
AMA J Ethics. 2021;23(8):E639-647. 
doi: 10.1001/amajethics.2021.639.


Cost-effectiveness analysis (CEA) provides a formal assessment of trade-offs involving benefits, harms, and costs inherent in alternative options. CEA has been increasingly used to inform public and private organizations’ reimbursement decisions, benefit designs, and price negotiations worldwide. Despite the lack of centralized efforts to promote CEA in the United States, the demand for CEA is growing. This article briefly reviews the history of CEA in the United States, highlights advances in practice guidelines, and discusses CEA’s ethical challenges. It also offers a way forward to inform health care decisions.


Ethical Considerations

There have been a few criticisms on ethical grounds of CEA’s use for decision making. These include (1) controversies associated with the use of QALYs, (2) distributive justice, and (3) incomplete valuation. We discuss each of them in detail here. However, it is worth pointing out that cost-effectiveness evidence is only one of many factors considered in resource allocation decisions. We have found that none of the international HTA bodies bases its decisions solely on cost-effectiveness evidence. Therefore, much of CEA’s criticisms, fair or not, can be addressed through deliberative processes.

QALYs. The lower health utility, or health-related quality of life, assigned to patients with worse health (because of more severe disease, disability, age, and so on) raises distributional issues in using QALYs for resource allocation decisions. For example, because patients with disabilities have a lower overall health utility weight, any extension of their lives by reducing the health burden from one disease “would not generate as many QALYs as a similar extension of life for otherwise healthy people.” This distributional limitation arises because of the multiplicative nature of QALYs, which are a product of life-years and health utility weight. Consequently, the National Council on Disability has strongly denounced the use of QALYs.

Alternatives to QALYs have been proposed. The Institute for Clinical and Economic Review has started using the equal value of life-years gained metric, a modified version of the equal value of life (EVL) metric, to supplement QALYs. In EVL calculations, any life-year gained is valued at a weight of 1 QALY, irrespective of individuals’ health status during the extra year. EVL, however, “has had limited traction among academics and decision-making bodies” because it undervalues interventions that extend life-years by the same amount as other interventions but that substantially improve quality of life. More recently, a health-years-in-total metric was proposed to overcome the limitations of both QALYs and EVL, but more work is needed to fully understand its theoretical foundations.

Monday, March 29, 2021

The problem with prediction

Joseph Fridman
Originally published 25 Jan 21

Here is an excerpt:

Today, many neuroscientists exploring the predictive brain deploy contemporary economics as a similar sort of explanatory heuristic. Scientists have come a long way in understanding how ‘spending metabolic money to build complex brains pays dividends in the search for adaptive success’, remarks the philosopher Andy Clark, in a notable review of the predictive brain. The idea of the predictive brain makes sense because it is profitable, metabolically speaking. Similarly, the psychologist Lisa Feldman Barrett describes the primary role of the predictive brain as managing a ‘body budget’. In this view, she says, ‘your brain is kind of like the financial sector of a company’, predictively allocating resources, spending energy, speculating, and seeking returns on its investments. For Barrett and her colleagues, stress is like a ‘deficit’ or ‘withdrawal’ from the body budget, while depression is bankruptcy. In Blackmore’s day, the brain was made up of sentries and soldiers, whose collective melancholy became the sadness of the human being they inhabited. Today, instead of soldiers, we imagine the brain as composed of predictive statisticians, whose errors become our neuroses. As the neuroscientist Karl Friston said: ‘[I]f the brain is an inference machine, an organ of statistics, then when it goes wrong, it’ll make the same sorts of mistakes a statistician will make.’

The strength of this association between predictive economics and brain sciences matters, because – if we aren’t careful – it can encourage us to reduce our fellow humans to mere pieces of machinery. Our brains were never computer processors, as useful as it might have been to imagine them that way every now and then. Nor are they literally prediction engines now and, should it come to pass, they will not be quantum computers. Our bodies aren’t empires that shuttle around sentrymen, nor are they corporations that need to make good on their investments. We aren’t fundamentally consumers to be tricked, enemies to be tracked, or subjects to be predicted and controlled. Whether the arena be scientific research or corporate intelligence, it becomes all too easy for us to slip into adversarial and exploitative framings of the human; as Galison wrote, ‘the associations of cybernetics (and the cyborg) with weapons, oppositional tactics, and the black-box conception of human nature do not so simply melt away.’

Monday, January 25, 2021

Late Payments, Credit Scores May Predict Dementia

Judy George
MedPage Today
Originally posted 30 Nov 20

Problems paying bills and managing personal finances were evident years before a dementia diagnosis, retrospective data showed.

As early as 6 years before they were diagnosed with dementia, people with Alzheimer's disease and related dementias were more likely to miss credit account payments than their peers without dementia (7.7% vs 7.3%; absolute difference 0.4 percentage points, 95% CI 0.07-0.70), reported Lauren Hersch Nicholas, PhD, MPP, of Johns Hopkins University in Baltimore, and co-authors.

They also were more likely to develop subprime credit scores 2.5 years before their dementia diagnosis (8.5% vs 8.1%; absolute difference 0.38 percentage points, 95% CI 0.04-0.72), the researchers wrote in JAMA Internal Medicine.

Higher payment delinquency and subprime credit rates persisted for at least 3.5 years after a dementia diagnosis.

"Our study provides the first large-scale evidence of the financial symptoms of Alzheimer's disease and related dementias using administrative financial records," Nicholas said.

"These results are important because they highlight a new source of data -- consumer credit reports -- that can help detect early signs of Alzheimer's disease," she told MedPage Today. "While doctors have long believed that dementia presents in the checkbook, our study helps show that these financial symptoms are common and span years before and after diagnosis, suggesting unmet need for assistance managing money."

Thursday, January 14, 2021

Memorial Sloan Kettering Gave Top Doctor $1.5 Million After He Was Forced to Resign Over Conflicts of Interest

Katie Thomas & Charles Ornstein
Originally published 22 Dec 20

Here is an excerpt:

After months of review, Memorial Sloan Kettering overhauled its conflict-of-interest policy, barring its top executives from serving on corporate boards of drug and health care companies and placing limits on how executives and top researchers could profit from work developed at the institution.

Like other major hospitals, Memorial Sloan Kettering’s finances have taken a hit during the coronavirus pandemic. For the first three quarters of 2020, the hospital reported an operating loss of $453 million compared with an operating profit of nearly $77 million in the first nine months of 2019. The hospital saw a decline in surgical procedures and clinic visits, as well as clinical trials and other research. The hospital did receive $100 million in relief funds as part of the Coronavirus Aid, Relief and Economic Security (CARES) Act.

Baselga wasn’t the only former official to receive severance from Memorial Sloan Kettering in 2019. It also paid more than $250,000 in severance to Avice Meehan, the hospital’s former chief communications officer, according to its IRS filing. Meehan declined to comment.

Laurie Styron, the executive director of CharityWatch, an independent watchdog group, said that hospitals often compensate their staff generously because they must attract highly trained and educated doctors who would be well-paid elsewhere. Still, she said, the multimillion-dollar sums can surprise donors, who typically give money to support research or patient care.

Saturday, January 2, 2021

Involuntary Commitments: Billing Patients for Forced Psychiatric Care.

Nathaniel P. Morris & Robert A. Kleinman
The American Journal of Psychiatry
Vol 177, 12, 1115-1116.

Surprise medical billing, in which patients face unexpected out-of-pocket medical costs, has attracted widespread attention. As of March 2020, members of the U.S. House of Representatives and Senate were working on legislation to limit these billing practices. Surprise medical bills have various consequences for patients and families, including loss of income or savings, worsened credit scores, use of resources for legal counsel or litigation, and psychological stress. Patients can receive surprise medical bills for care they did not authorize, including treatment for loss of consciousness, cardiac arrest, traumatic injuries, and other emergencies where informed consent cannot be obtained before care. A related set of medical bills has not garnered much attention yet may rank among the most surprising for patients and families—bills for involuntary psychiatric care.

Billing patients for involuntary psychiatric care deserves more attention for several reasons. First, these patients may be held financially liable for care they did not authorize and even actively refused. Compared with most medical care, involuntary psychiatric care is different in that patients can be detained for evaluation and treatment against their expressed wishes. All U.S. states have statutes that authorize emergency and inpatient civil commitment, such as involuntary hospitalization on grounds of dangerousness to self or others due to a mental disorder, and a majority of states have provisions for outpatient civil commitment. These statutes are based on principles that under specific circumstances, individual and/or public benefits of managing someone’s mental health needs supersede that person’s rights to refuse psychiatric care. However, forcing someone to assume financial liability for involuntary psychiatric care may infringe upon additional liberties, including individuals’ abilities to consent to contracts and to allocate money. By shifting the balance of autonomy, justice, beneficence, and nonmaleficence associated with involuntary psychiatric care, these billing practices raise ethical concerns.