Monday, April 17, 2023

What’s Behind the GOP’s War Against Democracy? -The Hartman Report

 And are rightwing billionaires who want more, more, more money willing to make common cause with bigots, fascists, and wannabee killers to get it?

Apr 17, 2023

 

https://open.substack.com/pub/thomhartmann/p/whats-behind-the-gops-war-against?r=3qu3t&utm_campaign=post&utm_medium=email

Louise and I just finished watching the Netflix short series Transatlantic, and it prompted us to consider what happens when a rightwing social movement takes over a country, as we’re currently experiencing in the US with more than a third of our states openly embracing fascism.

Transatlantic is a gripping drama about a group of Jewish refugees — including Hannah Arendt and Marc Chagall — who are trapped in Marseilles trying to flee the Nazis as they sweep across France in late 1940. Complicating their flight, the American envoy and the head of the local French police are both in agreement with the Nazis that the Jewish refugees are “degenerates” and “animals” who should appropriately end up in the Nazi camps.

The parallels to today’s America are startling. The Republican rhetoric about the queer and Black communities — and, often, about Jews (usually coded as “George Soros”) — is startlingly similar to that of the Nazis and the Vichy French about Jews. Donald Trump, for example, is openly calling Alvin Bragg an “animal.”

But how do things get this far? How and why did it happen in Germany, and how and why is it happening here today?

After Hitler’s failed beer hall putsch, he was legally banned from public speaking and mass rallies. In 1930, however, German media mogul Alfred Hugenberg — a rightwinger who owned two of the largest national newspapers and had considerable influence over radio — joined forces with Hitler and relentlessly promoted him, much like the Murdoch media empire and billionaire-owned rightwing radio helped bring Trump to power in 2016.

While politically independent, German President Paul von Hindenburg’s sympathies lay with the conservatives and monarchists. Like Reagan’s GOP, Hindenburg’s coalition favored Germany’s morbidly rich (Hindenburg’s father was an aristocrat) and industry, but was always just short of achieving total power over the German state.

Hitler, on the other hand, didn’t seem to care much at first about Germany’s aristocrats; he led a populist evangelical movement dedicated to “purifying” Germany of the “filth” of Jews, homosexuals, Gypsies, and socialists. While Hindenburg and the German conservative movement looked down on Hitler and his followers as ignoble rabble rousers, they were more than enthusiastic about getting their votes.

As German industrialist Fritz Thyssen writes in his apologetic book I Paid Hitler, he pressured German President von Hindenburg to appoint Hitler as chancellor, and then lobbied the Association of German Industrialists, that country’s and era’s version of the US Chamber of Commerce, to donate 3 million Reichsmarks to the Nazi Party for the 1932 election.

While Thyssen did it primarily because he wanted tax cuts for morbidly rich people like himself and government contracts for his company, his efforts combined with Hugenberg’s media empire brought Hitler and his bigots to power.

Hitler’s sales pitch to the German people was grounded in the idea that average German working people were victims and Hitler was their champion.

He claimed Jews, homosexuals, and socialists had “stabbed Germany in the back” by participating in negotiations for the Treaty of Versailles that imposed punitive conditions on the country, producing widespread poverty and an economic crisis.

If the German people were victims, Hitler told them, the villains were German minorities, promoting degeneracy like jazz and swing music, tolerance of homosexuality and transgender people, and the “international Jewish conspiracy.”

Once the Nazis took power they banned books, outlawed drag shows and homosexuality, changed school curricula to remove mention of their atrocities in WWI, and rewrote election laws so they’d never again lose an election.

The transformation of Germany was swift. Former German Nazis I knew well in the 1980s when I lived in that country often commented to me on how “a party of bullies” threatened violence and intimidated people to the point that the average person gave up resisting or even joined along for fear of ending up a victim themselves.

Thus, a minority party that never took more than a third of the national vote before seizing power began a process that inevitably led to the death of 73 million human beings.

Once you build your party’s political base on hate and fear it’s pretty much impossible to one day say, “You know, those Jews and Blacks and queer people we were vilifying aren’t really such bad people after all.”

This is all echoed in the crisis today facing both the GOP and the Democratic Party’s opposition to it.

As former Labor Secretary Robert Reich recently wrote:

“My friends, the Republican Party is no longer committed to democracy. It is rapidly becoming the American fascist party.”

Rightwing American billionaires, parroting Fritz Thyssen, have spent the past decade pouring money into Republican-aligned groups working to change school textbooks, ban library books, outlaw healthcare for queer people, criminalize trans participation in civil society, and make it harder for college students and Black people to vote.

Like Thyssen, most probably aren’t all that bigoted themselves: their primary motivation is lowering their own taxes and increasing their companies’ government purchases and subsidies.

But to get there they must have Republicans in power, and the GOP’s base — while they don’t much care about billionaire’s taxes or corporate deregulation — are fervent bigots.

Democrats, meanwhile, face the same crisis the Social Democrats did in Germany in the 1930s.

They believe in the free speech and free flow of political ideas associated with democracy, so are wary of using government power to squelch the rise of the current fascist movement within the GOP. Yet they see the direction things are moving and are frequently — but impotently — calling it out.

Holding bullies to account for their crimes and their intimidation tactics is really and truly difficult, as the German Social Democrats discovered in 1933 and Manhattan DA Alvin Bragg is realizing today. Typically the only thing that stops bullies is to punch them in the face, which can reduce one to their level.

There are signs that a few of the billionaires funding the modern neofascist wing of the GOP’s rise to power are having second thoughts, much as Fritz Thyssen ultimately did in Germany.

Billionaire DeSantis backer Thomas Peterffy (the second richest man in Florida at $26 billion) told The Financial Times last week:

“I have put myself on hold.  Because of (DeSantis’) stance on abortion and book banning ... myself, and a bunch of friends, are holding our powder dry.”

So far, Peterffy is the outlier. The billionaire-funded movement to pass anti-voting, anti-trans, anti-Black history, anti-gay marriage, anti-abortion, and anti-public school legislation and policy is roaring down the track, as is the billionaire-owned media campaign to promote fascism.

And since five corrupt Republicans on the Supreme Court legalized political bribery with Citizens United, the deck remains stacked in their favor.

There is no Democratic equivalent to Fox “News,” 1500 rightwing radio stations, hundreds of subsidized rightwing podcasts and media sites, The Wall Street Journal, ALEC, Heritage Foundation, Musk’s rightwing reinvention of Twitter, Facebook’s GOP-leaning algorithms, or the hundreds of other state and national policy operations and think tanks.

The American people, however, seem to be waking up even in the face of this onslaught of billionaire-owned and -funded media and political infrastructure.

The velocity with which Republican governors are leaving ERIC so they can quietly purge people from their voting rolls (now that five corrupt Republicans on the Supreme Court legalized that in 2018) and passing over 400 new make-it-harder-to-vote laws shows how concerned they are about this trend.

So, to the question about what’s really behind the war Republicans are waging against American democracy, the answer is simple: rightwing billionaires who want more, more, more money and are willing to make common cause with bigots, fascists, and wannabee killers to get it.

Given how far we are down this road to fascism — and how the GOP’s fascist faction is being supported by both American billionaires and outsiders like Orb├ín, Putin, and Xi — the 2024 election may well be the equivalent of the November, 1932 German elections: a make-or-break moment for American democracy.

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B4’ It’s Too Late: The Socialist Left’s Role in Fighting Autocracy - Convergence/Portside

 B4—the Broad Front Opposing the Right—can’t be about the status quo. While it must be aimed at defeating all attacks on our democratic rights, its thrust must be to expand democracy and shift US domestic and foreign policy.

https://portside.org/2023-01-07/b4-its-too-late-socialist-lefts-role-fighting-autocracy?utm_source=portside-general&utm_medium=email

Breach of the US Capitol, January 6, 2021, photo by Brett Davis, licensed CC BY-NC 2.0

I found myself watching the Netflix series Babylon Berlin over the last several weeks.  Netflix has three seasons of this German-made look at 1929 Weimar Germany.  Though technically a mystery revolving around a German police detective, this is a story of the collapse of the Weimar Republic and the growing strength of the Communists as well as various right-wing currents within the republic, including but not limited to Nazism.  As such, it is chilling and cannot but force a US viewer to reflect upon the growth of right-wing populism and right-wing authoritarianism in the US.

It was within this broader political and media context of the growth of right-wing authoritarianism that I read Pro-Democracy Organizing against Autocracy in the United States (PDOA for short).  This is an amazing, comprehensive, and sobering look at what needs to be considered and undertaken in the face of virulent right-wing authoritarian mass movement.

By way of preface, it is important to be clear that the right-wing populist/authoritarian movement that has become energized since 2009 did not appear out of nowhere.  The history of the US as a racial settler-colonial project laid very firm foundations for the periodic rise of nefarious movements of the political Right, movements that are regularly racist, sexist, xenophobic and irrationalist.  The current incarnation of right-wing populism aims to create a future for the US based on a reconfigured US, something akin to the pre-1912 country, if not being a 21st century version of the Confederate States of America. A neoliberal right-wing combined with a far-right semi-fascist tendency has resulted in the development of what can be understood as a “neo-Confederate” political bloc.  This is a complicated and contradictory alliance that shares the objective of establishing a semi-apartheid system in the US along with the suppression of basic democratic rights up to and including the possibility of gutting and redoing the Constitution.

Pro-Democracy Organizing Against Autocracy in the United States takes, as its starting point, the possibility of the successful capture of government by right-wing authoritarian forces.  It does not treat this as inevitable, nor does it suggest that all is hopeless should such a scenario come into existence.  But it does argue that in order to prevent the success of right-wing authoritarians and undermine a right-wing authoritarian hegemony, there must be a new practice introduced by progressive forces.  In sum this includes:

  • Building and maintaining a large-scale, multi-racial, cross-class pro-democratic united front
  • Protecting, holding and building local community power through alternative institutions
  • Building pressure to create splits and defections within the Right
  • Preventing, deterring, and strengthening resistance to state security force and/or paramilitary violence.

The paper also suggests specific steps in this direction that include information networks, education and training efforts, international outreach and, interestingly, development of conflict resolution mechanisms for handling contradictions within the broad front.

Rather than reiterate the excellent points raised in the paper, points with which I am largely in agreement, I believe it necessary to focus on the particular role and vision that a socialist Left can advance in our current situation and in building resistance to right-wing authoritarianism.

Clarity on the nature of the enemy

PDOA is unapologetic in identifying the principal enemy at this juncture being what I described earlier as the “neo-Confederate bloc.”  To say that it is the principal enemy does not mean that it is the only enemy.  It means, however, that strategy must focus, first and foremost, on taking down the principal enemy and that all else is secondary.

There should be nothing surprising in this assertion.  Whether in war or politics, one must first ascertain who or what is the main enemy and then figure out the steps—and alliances—necessary in order to bring them down.  A failure to attain that clarity can mean a dispersal of resources and, ultimately, failure. 

Starting here is critical since there are many forces on the US Left that refuse to identify the neo-Confederate bloc as the principal enemy.  They remain obsessed with taking down centrist Democrats or believing that these two opponents are equally dangerous, as if the centrist Democrats are trying to destroy abortion, voting rights and the recognition that the Earth is round.  If one cannot identify the principal opponent, the approach elaborated in PDOA is futile.

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The need for “B4”—before it is too late

As PDOA suggests as its first point, there is a need for what I would term a “Broad Front Opposing the Right,” i.e., “B4.”  The authors suggest that efforts towards such a front need to be started immediately through a series of summits.  Let’s step back for a moment, however.

Using the term “broad front” aims to convey both the scale and scope of this project, but also to avoid unnecessary discussions that disarm the Left over whether one is building a “united front” or a “popular front.”  In the context of 21st century US, what is being proposed is a “broad” front that has a focus on overcoming and smashing the far-Right, i.e., demolishing the neo-Confederate bloc.  PDOA is correct in saying that this must be multi-racial/multi-national and cross-class.  It cannot be an alignment of the Left alone nor can it be limited to those who are in total agreement with a left/progressive agenda.

B4 must first of all be defensive in that it is actively opposing the thrust from the far-Right.  It is aiming to put the breaks on the neo-Confederate offensive.  Thus, the question that must be asked by those trying to bring such a front into existence—which is hopefully the socialist Left and our immediate allies—revolves around identifying who that should include.  To answer that, there must be a broad mapping of liberal, progressive and left forces across the US.

There is a prior step, however.  The socialist Left and left/progressive forces need to have a convening to ensure that there exists a critical mass of organizations and individuals committed to this path.  Building B4 will involve considerable political, organizational and diplomatic work.  This core will need to take responsibility for moving the B4 process, though a broader left/progressive configuration will be necessary in order to actually convene a full-blown B4 process.

A socialist Left core that has an analysis of the larger national picture, will need to undertake the diplomatic work involved in initiating the sorts of convenings that PDOA suggests.

B4 needs to be convened by organizations and individuals with a real base

There are too many left and progressive convenings that have involved noted individuals and interested people who have no base.  Even a large gathering of people is next to irrelevant if they lack a base.  Thus, there is a need for groups such as the Working Families Party, Progressive Democrats of America, as well as a host of state-based and locally based left/progressive groups that have a real mass base to play the leading role in a convening.  The socialist Left, through its work in such groups, must fight for a united front orientation and against sectarianism and small-group mentality.

Principles that unite and the need to reject purity

The Right is far better at united fronts/broad fronts than the Left.  They make it easy for people to join their mass movements and set very few preconditions.  Their assumption, proven over and again, is that they will win people to their overall framework through the course of their work in one of their fronts.

The Left, on the other hand, insists on raising the bar for entry into our various projects.  We tend to set purity tests of various sorts and identify why we cannot unite, rather than determining what steps are necessary in order to unite.

B4 necessitates principles of unity that distinguish it from both the neo-Confederate bloc and the Democratic National Committee.  This does not mean that it should take a sectarian stand towards the Democratic National Committee.  Rather, it must be far broader in content but also in its strategic and tactical approaches.  More about that below.

Establish clear strategic objectives

It is one thing to convene a gathering (no matter how difficult); it is another to establish clarity on strategic direction.  B4 needs to have a set of strategic objectives in terms of what it seeks to accomplish at the national, state and local levels over the next 10 years.  Those objectives, we should note, should not be restricted to electoral cycles.  They should aim at winning broad left/progressive power at the national, state and local levels through defeating the Right and presenting a program that breaks with the status quo.

This last point cannot be overemphasized.  B4 cannot be about the status quo.  While it must be aimed at defeating all attacks on our democratic rights, its thrust must be to expand democracy; a program of consistent democracy.  As such B4 must aim to shift US domestic and foreign policies, combatting the Right domestically and globally.

Encourage splits within the Right

One of the most insightful and courageous points raised in PDOA is the need to encourage defections from the neo-Confederate bloc.  For many leftists, such an idea is an anathema to our general approach.  Yet, in order to defeat our opponents, we must ascertain means of provoking splits within their ranks and demoralizing component parts of their blocs.

To use a strange analogy, I was once engaged in protecting a meeting from the intrusion of provocateurs.  The provocateurs showed up and said—openly—that if they had to bust into the meeting, they needed to attack my colleague first and not me.  That was a brilliant move aimed at destabilizing the alliance with my colleague and trying to get me to fight less.

B4 must employ a similar approach.  That means that there will be Republicans, independents, etc., with whom we have no strategic unity, but with whom we may have tactical unity in opposing the far-Right.  Under those circumstances, we must find means for united action or, at a minimum, aim to neutralize them.

And B4 does what?

Left and progressive forces regularly form coalitions and then nothing happens!  Usually this is connected with lack of strategy and, specifically, the inability to prioritize.  B4 will need to coordinate activities among its constituents; provide on-going information as well as counter the propaganda of the Right; and engage in various campaigns (electoral and non-electoral).  This work includes:

  • Building up electoral fronts on a state-wide basis
  • Mounting electoral assaults or counterassaults against the Right
  • Overturning efforts being undertaken by the Right to convene a Constitutional Convention
  • Utilizing ballot initiatives in order to destabilize the Right, consolidate progressive opinion, and build base areas in Republican-dominated states
  • Constructing social media strategy focused on mobilization and information provision
  • Organizing mass mobilizations that go beyond ‘Saturday in the park’ rallies.  Specifically, countering mass mobilizations carried out by the Right; building defensive mass actions when the far-Right makes is appearance
  • Building legal assistance networks when progressive and liberal forces come under attack, e.g., when rightwing elected leaders move against so-called Antifa elements and BLM elements
  • Building various levels of self-defense.

Conflict-resolution within B4 and resolving “contradictions among the people”

So many progressive coalition efforts are undermined by rumor-mongering, miscommunications, and the heightening of contradictions until differences result in splits.  We have little successful experience in internal mediation with an aim of resolving differences.

While some differences are actually splitting differences, a new approach can be introduced in order to sustain and build B4. Among the understandings and practices in this approach:

  • Allegations do not equal the truth.  When allegations are offered, whether regarding personal behavior or a political stance, B4 needs to have a conflict-resolution policy and mechanism to surface  issues and address them directly.  Allegations must be accompanied by facts rather than remain as feelings and opinions.
  • Presume good will.  Despite what will inevitably be major differences, B4 participants should start from an assumption of positive intent.  Internal differences should not be treated as equivalent to differences with our opponents.
  • There should be protocols or agreements on acceptable and unacceptable behavior within B4.
  • Organizations within B4 should not act unilaterally on any matters that the broader front is attempting to resolve—or act upon—except and insofar as B4 is incapable of making a decision.
  • B4 should anticipate that contradictions and problems will emerge along racial, ethnic, gender and religious lines.  These should be handled according to the prior approach.  Individuals and organizations should be encouraged to hold back on jumping to conclusions.  And, where errors have been committed, a process of rectification should be put into place in order to correct the underlying problem.

Is the socialist Left up to the challenge?

Therein lies the question.  The socialist Left vacillates between grandiosity and myopia.  We often cannot conceive of winning because winning necessitates broad alliances with forces with whom we are frequently at odds.  Additionally, we quickly elevate every difference to one of principle rather than deciding what issues/matters can and must be resolved at any given moment and what can be placed on hold.

If we can agree that B4 is essential, and if we can agree on the overall approach offered by PDOA, then we can proceed with all deliberate speed, in organizing to weather the coming storm and build a countercurrent advancing consistent democracy.

Bill Fletcher Jr. is a longtime trade unionist, writer and speaker. He was also a president of TransAfrica Forum, chairperson of the board of directors of Advocates for Minor Leaguers, and co-coordinator of the Campaign to End the Moroccan Occupation of Western Sahara. He is a member of the International Work Team of Liberation Road. He has written and edited several books, including Solidarity Divided: The Crisis in Organized Labor and A New Path Toward Social Justice (with Fernando Gapasin, University of California Press, 2009) and the murder mystery novel The Man Who Fell From the Sky (Hardball Press, 2018) and its forthcoming sequel.

 Convergence is a magazine for radical insights. We work with organizers and activists on the frontlines of today’s most pressing struggles to produce articles, videos and podcasts that sharpen our collective practice, lift up stories from the grassroots, and promote strategic debate. Our goal is to create the shared strategy needed to change our society and the world. Our community of readers, viewers, and content producers are united in our purpose: winning multi-racial democracy and a radically democratic economy.

 

Thursday, April 13, 2023

Illustration by Lisa Larson-Walker/ProPublica Health Care How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them

  by Patrick Rucker, Maya Miller and David Armstrong March 25, 5 a.m. EDT

https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims

Internal documents and former company executives reveal how Cigna doctors reject patients’ claims without opening their files. “We literally click and submit,” one former company doctor said.

Series: Uncovered

How the Insurance Industry Denies Coverage to Patients

Do you have experiences with health insurance denials? Please get in touch.

When a stubborn pain in Nick van Terheyden’s bones would not subside, his doctor had a hunch what was wrong.

Without enough vitamin D in the blood, the body will pull that vital nutrient from the bones. Left untreated, a vitamin D deficiency can lead to osteoporosis.

A blood test in the fall of 2021 confirmed the doctor’s diagnosis, and van Terheyden expected his company’s insurance plan, managed by Cigna, to cover the cost of the bloodwork. Instead, Cigna sent van Terheyden a letter explaining that it would not pay for the $350 test because it was not “medically necessary.”


The letter was signed by one of Cigna’s medical directors, a doctor employed by the company to review insurance claims.

Something about the denial letter did not sit well with van Terheyden, a 58-year-old Maryland resident. “This was a clinical decision being second-guessed by someone with no knowledge of me,” said van Terheyden, a physician himself and a specialist who had worked in emergency care in the United Kingdom.

 
Nick van Terheyden Credit: Jared Soares for ProPublica

The vague wording made van Terheyden suspect that Dr. Cheryl Dopke, the medical director who signed it, had not taken much care with his case.

Van Terheyden was right to be suspicious. His claim was just one of roughly 60,000 that Dopke denied in a single month last year, according to internal Cigna records reviewed by ProPublica and The Capitol Forum.

The rejection of van Terheyden’s claim was typical for Cigna, one of the country’s largest insurers. 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.

In the 17 hours and 20 minutes and 30 seconds you’ve been on this page, Cigna’s doctors could have denied 74916 claims, according to company documents.

Before health insurers reject claims for medical reasons, company doctors must review them, according to insurance laws and regulations in many states. Medical directors are expected to examine patient records, review coverage policies and use their expertise to decide whether to approve or deny claims, regulators said. This process helps avoid unfair denials.

But the Cigna review system that blocked van Terheyden’s claim bypasses those steps. 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.”

Not all claims are processed through this review system. For those that are, it is unclear how many are approved and how many are funneled to doctors for automatic denial.

Insurance experts questioned Cigna’s review system.

Patients expect insurers to treat them fairly and meaningfully review each claim, said Dave Jones, California’s former insurance commissioner. Under California regulations, insurers must consider patient claims using a “thorough, fair and objective investigation.”

“It’s hard to imagine that spending only seconds to review medical records complies with the California law,” said Jones. “At a minimum, I believe it warrants an investigation.”

Do You Have Insights Into Health Insurance Denials? Help Us Report on the System.

Insurers deny tens of millions of claims every year. ProPublica is investigating why claims are denied, what the consequences are for patients and how the appeal process really works.

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Within Cigna, some executives questioned whether rendering such speedy denials satisfied the law, according to one former executive who spoke on condition of anonymity because he still works with insurers.

“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.”

Cigna adopted its review system more than a decade ago, but insurance executives say similar systems have existed in various forms throughout the industry.

In a written response, Cigna said the reporting by ProPublica and The Capitol Forum was “biased and incomplete.”

Cigna said its review system was created to “accelerate payment of claims for certain routine screenings,” Cigna wrote. “This allows us to automatically approve claims when they are submitted with correct diagnosis codes.”

When asked if its review process, known as PXDX, lets Cigna doctors reject claims without examining them, the company said that description was “incorrect.” It repeatedly declined to answer further questions or provide additional details. (ProPublica employees’ health insurance is provided by Cigna.)

Former Cigna doctors confirmed that the review system was used to quickly reject claims. An internal corporate spreadsheet, viewed by the news organizations, lists names of Cigna’s medical directors and the number of cases each handled in a column headlined “PxDx.” The former doctors said the figures represent total denials. Cigna did not respond to detailed questions about the numbers.

Cigna's explanation that its review system was designed to approve claims didn’t make sense to one former company executive. “They were paying all these claims before. Then they weren’t,” said Ron Howrigon, who now runs a company that helps private doctors in disputes with insurance companies. “You’re talking about a system built to deny claims.”

Cigna emphasized that its system does not prevent a patient from receiving care — it only decides when the insurer won’t pay. “Reviews occur after the service has been provided to the patient and does not result in any denials of care,” the statement said.

"Our company is committed to improving health outcomes, driving value for our clients and customers, and supporting our team of highly-skilled Medical Directors,” the company said.

PXDX

Cigna’s review system was developed more than a decade ago by a former pediatrician.

After leaving his practice, Dr. Alan Muney spent the next several decades advising insurers and private equity firms on how to wring savings out of health plans.

In 2010, Muney was managing health insurance for companies owned by Blackstone, the private equity firm, when Cigna tapped him to help spot savings in its operation, he said.

Insurers have wide authority to reject claims for care, but processing those denials can cost a few hundred dollars each, former executives said. Typically, claims are entered into the insurance system, screened by a nurse and reviewed by a medical director.

For lower-dollar claims, it was cheaper for Cigna to simply pay the bill, Muney said.

“They don’t want to spend money to review a whole bunch of stuff that costs more to review than it does to just pay for it,” Muney said.

Muney and his team had solved the problem once before. At UnitedHealthcare, where Muney was an executive, he said his group built a similar system to let its doctors quickly deny claims in bulk.

In response to questions, UnitedHealthcare said it uses technology that allows it to make “fast, efficient and streamlined coverage decisions based on members benefit plans and clinical criteria in compliance with state and federal laws.” The company did not directly address whether it uses a system similar to Cigna.

At Cigna, Muney and his team created a list of tests and procedures approved for use with certain illnesses. The system would automatically turn down payment for a treatment that didn’t match one of the conditions on the list. Denials were then sent to medical directors, who would reject these claims with no review of the patient file.

Cigna eventually designated the list “PXDX” — corporate shorthand for procedure-to-diagnosis. The list saved money in two ways. It allowed Cigna to begin turning down claims that it had once paid. And it made it cheaper to turn down claims, because the company’s doctors never had to open a file or conduct any in-depth review. They simply denied the claims in bulk with an electronic signature.

“The PXDX stuff is not reviewed by a doc or nurse or anything like that,” Muney said.

The review system was designed to prevent claims for care that Cigna considered unneeded or even harmful to the patient, Muney said. The policy simply allowed Cigna to cheaply identify claims that it had a right to deny.

Muney said that it would be an “administrative hassle” to require company doctors to manually review each claim rejection. And it would mean hiring many more medical directors.

“That adds administrative expense to medicine,” he said. “It’s not efficient.”

But two former Cigna doctors, who did not want to be identified by name for fear of breaking confidentiality agreements with Cigna, said the system was unfair to patients. They said the claims automatically routed for denial lacked such basic information as race and gender.

“It was very frustrating,” one doctor said.

Some state regulators questioned Cigna’s PXDX system.

In Maryland, where van Terheyden lives, state insurance officials said the PXDX system as described by a reporter raises “some red flags.”

The state’s law regulating group health plans purchased by employers requires that insurance company doctors be objective and flexible when they sit down to evaluate each case.

If medical directors are “truly rubber-stamping the output of the matching software without any additional review, it would be difficult for the medical director to comply with these requirements,” the Maryland Insurance Administration wrote in response to questions.

Medicare and Medicaid have a system that automatically prevents improper payment of claims that are wrongly coded. It does not reject payment on medical grounds.

Within the world of private insurance, Muney is certain that the PXDX formula has boosted the corporate bottom line. “It has undoubtedly saved billions of dollars,” he said.

Insurers benefit from the savings, but everyone stands to gain when health care costs are lowered and unneeded care is denied, he said.

Speedy Reviews

Cigna carefully tracks how many patient claims its medical directors handle each month. Twelve times a year, medical directors receive a scorecard in the form of a spreadsheet that shows just how fast they have cleared PXDX cases.

Dopke, the doctor who turned down van Terheyden, rejected 121,000 claims in the first two months of 2022, according to the scorecard.

 
Van Terheyden’s denial letter from Cigna Credit: highlights and redactions added by ProPublica

Dr. Richard Capek, another Cigna medical director, handled more than 80,000 instant denials in the same time span, the spreadsheet showed.

Dr. Paul Rossi has been a medical director at Cigna for over 30 years. Early last year, the physician denied more than 63,000 PXDX claims in two months.

Rossi, Dopke and Capek did not respond to attempts to contact them.

Howrigon, the former Cigna executive, said that although he was not involved in developing PXDX, he can understand the economics behind it.

“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.”

Cigna knows that many patients will pay such bills rather than deal with the hassle of appealing a rejection, according to Howrigon and other former employees of the company. The PXDX list is focused on tests and treatments that typically cost a few hundred dollars each, said former Cigna employees.

“Insurers are very good at knowing when they can deny a claim and patients will grumble but still write a check,” Howrigon said.

Muney and other former Cigna executives emphasized that the PXDX system does leave room for the patient and their doctor to appeal a medical director’s decision to deny a claim.

But Cigna does not expect many appeals. In one corporate document, Cigna estimated that only 5% of people would appeal a denial resulting from a PXDX review.

“A Negative Customer Experience”

In 2014, Cigna considered adding a new procedure to the PXDX list to be flagged for automatic denials.

Autonomic nervous system testing can help tell if an ailing patient is suffering from nerve damage caused by diabetes or a variety of autoimmune diseases. It’s not a very involved procedure — taking about an hour — and it costs a few hundred dollars per test.

The test is versatile and noninvasive, requiring no needles. The patient goes through a handful of checks of heart rate, sweat response, equilibrium and other basic body functions.

At the time, Cigna was paying for every claim for the nerve test without bothering to look at the patient file, according to a corporate presentation. Cigna officials were weighing the cost and benefits of adding the procedure to the list. “What is happening now?” the presentation asked. “Pay for all conditions without review.”

By adding the nerve test to the PXDX list, Cigna officials estimated, the insurer would turn down more than 17,800 claims a year that it had once covered. It would pay for the test for certain conditions, but deny payment for others.

These denials would “create a negative customer experience” and a “potential for increased out of pocket costs," the company presentation acknowledged.

But they would save roughly $2.4 million a year in medical costs, the presentation said.

Cigna added the test to the list.

“It’s Not Good Medicine”

By the time van Terheyden received his first denial notice from Cigna early last year, he had some answers about his diagnosis. The blood test that Cigna had deemed “not medically necessary” had confirmed a vitamin D deficiency. His doctor had been right, and recommended supplements to boost van Terheyden’s vitamin level.

 
Van Terheyden Credit: Jared Soares for ProPublica

Still, van Terheyden kept pushing his appeal with Cigna in a process that grew more baffling. First, a different Cigna doctor reviewed the case and stood by the original denial. The blood test was unnecessary, Cigna insisted, because van Terheyden had never before been found to lack sufficient vitamin D.

“Records did not show you had a previously documented Vitamin D deficiency,” stated a denial letter issued by Cigna in April. How was van Terheyden supposed to document a vitamin D deficiency without a test? The letter was signed by a Cigna medical director named Barry Brenner.

Brenner did not respond to requests for comment.

Then, as allowed by his plan, van Terheyden took Cigna’s rejection to an external review by an independent reviewer.

In late June — seven months after the blood test — an outside doctor not working for Cigna reviewed van Terheyden’s medical record and determined the test was justified.

The blood test in question “confirms the diagnosis of Vit-D deficiency,” read the report from MCMC, a company that provides independent medical reviews. Cigna eventually paid van Terheyden’s bill. “This patient is at risk of bone fracture without proper supplementations,” MCMC’s reviewer wrote. “Testing was medically necessary and appropriate.”

Van Terheyden had known nothing about the vagaries of the PXDX denial system before he received the $350 bill. But he did sense that very few patients pushed as hard as he had done in his appeals.

As a physician, van Terheyden said, he’s dumbfounded by the company’s policies.

“It’s not good medicine. It’s not caring for patients. You end up asking yourself: Why would they do this if their ultimate goal is to care for the patient?” he said.

“Intellectually, I can understand it. As a physician, I can’t. To me, it feels wrong.”

In the 17 hours and 20 minutes and 30 seconds you’ve been on this page, Cigna’s doctors could have denied 74916 claims, according to company documents.

Doris Burke contributed research.

Clarification, March 27, 2023: This article was updated to clarify that a response from the Maryland Insurance Administration referred to medical directors in general.

 

Hey, New York City Council Progressives - You Can Fix This Medicare Advantage Mess! - Work-Bites

 

https://www.work-bites.com/view-all/3d3nxazh7ue99bbmy50at8o4v3i6j7

Hey, New York City Council Progressives - You Can Fix This Medicare Advantage Mess!

By Joe Maniscalco

The supposedly most progressive New York City Council to date could choose to advance proposed legislation protecting traditional Medicare benefits for municipal retirees — instead it’s watching ailing senior citizens fighting for what they’ve earned collapse on the streets in protest, and being out-lefted by Republican colleagues.

Roughly 1,000 New York City municipal retirees and their supporters rallied outside the gates of City Hall on Tuesday, April 11, calling on Speaker Adrienne Adams and the rest her Democratic colleagues in the City Council to support retiree legislation introduced back in December that could save traditional Medicare health insurance from being replaced by a profit-driven Aetna Medicare Advantage program.

Work-Bites observed at least three elderly people needing medical attention during the course of the large and boisterous afternoon rally.

The Speaker of the City Council Adrienne Adams is following the directions of the mayor, and being told not to give our bill a number,” New York City Organization of Public Service Retirees President Marianne Pizzitola told protesters on Broadway. “They’re refusing to release our bill…have it introduced…won’t give it a number. So, it’s just sitting there.”

A number of senior citizens fighting to save their traditional Medicare benefits at this week’s City Hall rally required medical attention after collapsing in the heat.

The rationale given for the inaction stems from New York’s Public Employees’ Fair Employment Act — the Taylor Law, which stipulates the terms of collective bargaining for municipal employees. But the public sector unions subject to the Taylor Law only bargain on behalf of active workers — not retirees.

“They told us our bill was preempted by Taylor — and we called bulls—t on that because we’re not subject to Taylor,” Pizzitola added.

DC37 Retirees Organization President Robert Gervasi denounced “pulling the rug out” from underneath municipal retirees who, once they’re forced into Aetna’s profit-driven Medicare Advantage health insurance plan, face well-documented delays, denials and limited choice of doctors.

“We need the unions to understand, we need choice,” Gervasi said. “We don’t need one option to be available when so many of the people here are used to seeing their doctors for what…twenty…twenty-five…thirty years? It’s not the time to change things on retirees.”

Protesters blasted the heads of New York City’s most powerful public sector unions — United Federation of Teachers President Michael Mulgrew, District Council 37 Executive Director Henry Garrido and Municipal Labor Committee [MLC] President Harry Nespoli as “scabs” for driving the ongoing campaign to strip retirees of their traditional Medicare benefits and push them into a profit-driven, sandal-plagued Medicare Advantage program.

DC37 Retirees Organization President Robert Gervasi denounces “pulling the rug out” from underneath municipal retirees.

“We know that in this country healthcare is broken,” Neal Frumkin, District Council 37 Retirees Association vice-president for Inter-Union Relations said. “It goes up faster than inflation. And it’s been going up like that for years. In response to that, unfortunately, our union leaders didn’t take on big Pharma; they didn’t take on the medical establishment; they didn’t take on the hospital establishment — they went after us. What we’ve seen is a massive distribution of costs from the insurance companies to us.”

Retired FDNY Deputy Chief Richard Alles jeered Mayor Eric Adams as a “hypocrite” for calling Medicare Advantage a “bait and switch” on the campaign trail — but is now its biggest proponent.

“I made a simple and moral contract with the City of New York that if I were to protect the citizens of New York, they guaranteed me just two simple things: my pension and my health benefit,” Alles said. “Now, they want to take that away — No Effing Way!”

NEVER FORGET - EXCEPT WHEN IT COMES TO MONEY

Like Alles, the municipal retirees fighting the privatization of their traditional Medicare benefits at this week’s rally are responsible for seeing New York City through some of the worst calamities in this town’s history — including the September 11 attacks on the World Trade Center.

But, as Pizzitola pointed out, being stripped of their traditional Medicare benefits means civilian survivors of 9/11 are now subject to “prior authorizations” and a “narrowed network.”

Marianne Pizzitola hands off the mic to Oren Barzilay, head of Local 2507, Uniformed EMTs, Paramedics and Fire Inspectors.

“And rather than having the ease of just going to any doctor in America that takes Medicare, you are only allowed to go to whatever doctors that are in their network,” Pizzitola said. “And if you choose to go out of the network, you are then going to have to go through ‘pre-visit confirmations’ — which is another fancy word for prior-authorization — which delay and deny your care.”

John Feal, 9/11 first-responder and fierce advocate for the 9/11 Victim’s Compensation Fund, was as blunt as you can be.

F—-k the MLC,” he said. “You people are retirees for a reason — you survived twenty, thirty, forty years working for this city. F—-k you to anybody that tries to take away your healthcare.”

The fiery 9/11 activist said the rally should be “down the street in Mike Mulgrew’s face.”

“Who here is in the World Trade Center Health Program?” Feal asked. “You’re f——d. The City of New York will f—k you now if you are in the World Trade Center Health Program. If you’re in the program and the doctor sends you to see a specialist — you’re gonna have to wait for your new insurance to approve it? Get the f—k outta here! Never underestimate small numbers. We went to Washington, D.C. and handed Congress their f—-ing balls. Now, we’re gonna give New York City its balls.”

Former Democratic Party-turned Republican Party City Council Member Ari Kagan of Brooklyn, said saving municipal retirees’ traditional Medicare benefits isn’t a “Democratic or Republican issue.”

Nearly 90-year-old Evelyn Jones Rich helps electrify this week’s rally against Medicare Advantage in New York City.

“This is a human issue,” he said. “I don’t buy any explanation that we don’t have money to provide healthcare to municipal retirees.”

The Adams administration says pushing municipal retirees into a profit-driven Medicare Advantage program will save the city $600 million a year.

Work-Bites reached out to the Mayor’s Office for comment on this story, but has been unsuccessful.

When asked what he and his Republican colleagues in the Common Sense Caucus will do to help advance proposed legislation in the City Council to protect traditional Medicare for municipal retirees, Kagan told Work-Bites, “Public pressure — that’s the only way to do it.”

Democratic Council Member Charles Barron, also of Brooklyn, told protesters New York has plenty of money to fulfill its obligations to municipal retirees, and said any City Council member who voices support for traditional Medicare, but then “goes inside and votes for a budget that doesn’t have your six million dollars in it — they are betraying our cause.”

The organizers of this week’s rally for traditional Medicare benefits plan on being back out on the streets shortly, and “going into the districts” of City Council members to “remind them of the promise that this city made to us.” 

“What is happening is manipulative — it contradicts everything that unions have stood for, which shocks me,” 82-year-old Brooklynite Arnie Rothstein told Work-Bites. “It’s a sellout. I think Adams is really an extension of [former Mayor Bill] de Blasio.”

Rothstein, who’s wife Barbara is a retired school teacher, said Medicare benefits are the same as pensions.

“They were negotiated, they are grandfathered in,” he said. “They have no right to do this.”

Pizzitola later criticized MLC members who voted for Aetna’s Medicare Advantage contract, saying in a YouTube video posted after the rally, “Not only did you screw retirees — you just screwed yourselves. But don’t feel bad, Pat Lynch from the PBA [Police Benevolent Association] just did the same thing — and he stepped down today.”

 

NYC municipal retirees fighting to save their traditional Medicare benefits line up outside City Hall waiting for a chance to attend this week’s stated City Council meeting. Photos by Joe Maniscalco