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mostlysignssomeportents · 1 year ago

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The real AI fight

Tonight (November 27), I'm appearing at the Toronto Metro Reference Library with Facebook whistleblower Frances Haugen.

On November 29, I'm at NYC's Strand Books with my novel The Lost Cause, a solarpunk tale of hope and danger that Rebecca Solnit called "completely delightful."

Last week's spectacular OpenAI soap-opera hijacked the attention of millions of normal, productive people and nonsensually crammed them full of the fine details of the debate between "Effective Altruism" (doomers) and "Effective Accelerationism" (AKA e/acc), a genuinely absurd debate that was allegedly at the center of the drama.

Very broadly speaking: the Effective Altruists are doomers, who believe that Large Language Models (AKA "spicy autocomplete") will someday become so advanced that it could wake up and annihilate or enslave the human race. To prevent this, we need to employ "AI Safety" – measures that will turn superintelligence into a servant or a partner, nor an adversary.

Contrast this with the Effective Accelerationists, who also believe that LLMs will someday become superintelligences with the potential to annihilate or enslave humanity – but they nevertheless advocate for faster AI development, with fewer "safety" measures, in order to produce an "upward spiral" in the "techno-capital machine."

Once-and-future OpenAI CEO Altman is said to be an accelerationists who was forced out of the company by the Altruists, who were subsequently bested, ousted, and replaced by Larry fucking Summers. This, we're told, is the ideological battle over AI: should cautiously progress our LLMs into superintelligences with safety in mind, or go full speed ahead and trust to market forces to tame and harness the superintelligences to come?

This "AI debate" is pretty stupid, proceeding as it does from the foregone conclusion that adding compute power and data to the next-word-predictor program will eventually create a conscious being, which will then inevitably become a superbeing. This is a proposition akin to the idea that if we keep breeding faster and faster horses, we'll get a locomotive:

https://locusmag.com/2020/07/cory-doctorow-full-employment/

As Molly White writes, this isn't much of a debate. The "two sides" of this debate are as similar as Tweedledee and Tweedledum. Yes, they're arrayed against each other in battle, so furious with each other that they're tearing their hair out. But for people who don't take any of this mystical nonsense about spontaneous consciousness arising from applied statistics seriously, these two sides are nearly indistinguishable, sharing as they do this extremely weird belief. The fact that they've split into warring factions on its particulars is less important than their unified belief in the certain coming of the paperclip-maximizing apocalypse:

https://newsletter.mollywhite.net/p/effective-obfuscation

White points out that there's another, much more distinct side in this AI debate – as different and distant from Dee and Dum as a Beamish Boy and a Jabberwork. This is the side of AI Ethics – the side that worries about "today’s issues of ghost labor, algorithmic bias, and erosion of the rights of artists and others." As White says, shifting the debate to existential risk from a future, hypothetical superintelligence "is incredibly convenient for the powerful individuals and companies who stand to profit from AI."

After all, both sides plan to make money selling AI tools to corporations, whose track record in deploying algorithmic "decision support" systems and other AI-based automation is pretty poor – like the claims-evaluation engine that Cigna uses to deny insurance claims:

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

On a graph that plots the various positions on AI, the two groups of weirdos who disagree about how to create the inevitable superintelligence are effectively standing on the same spot, and the people who worry about the actual way that AI harms actual people right now are about a million miles away from that spot.

There's that old programmer joke, "There are 10 kinds of people, those who understand binary and those who don't." But of course, that joke could just as well be, "There are 10 kinds of people, those who understand ternary, those who understand binary, and those who don't understand either":

https://pluralistic.net/2021/12/11/the-ten-types-of-people/

What's more, the joke could be, "there are 10 kinds of people, those who understand hexadecenary, those who understand pentadecenary, those who understand tetradecenary [und so weiter] those who understand ternary, those who understand binary, and those who don't." That is to say, a "polarized" debate often has people who hold positions so far from the ones everyone is talking about that those belligerents' concerns are basically indistinguishable from one another.

The act of identifying these distant positions is a radical opening up of possibilities. Take the indigenous philosopher chief Red Jacket's response to the Christian missionaries who sought permission to proselytize to Red Jacket's people:

https://historymatters.gmu.edu/d/5790/

Red Jacket's whole rebuttal is a superb dunk, but it gets especially interesting where he points to the sectarian differences among Christians as evidence against the missionary's claim to having a single true faith, and in favor of the idea that his own people's traditional faith could be co-equal among Christian doctrines.

The split that White identifies isn't a split about whether AI tools can be useful. Plenty of us AI skeptics are happy to stipulate that there are good uses for AI. For example, I'm 100% in favor of the Human Rights Data Analysis Group using an LLM to classify and extract information from the Innocence Project New Orleans' wrongful conviction case files:

https://hrdag.org/tech-notes/large-language-models-IPNO.html

Automating "extracting officer information from documents – specifically, the officer's name and the role the officer played in the wrongful conviction" was a key step to freeing innocent people from prison, and an LLM allowed HRDAG – a tiny, cash-strapped, excellent nonprofit – to make a giant leap forward in a vital project. I'm a donor to HRDAG and you should donate to them too:

https://hrdag.networkforgood.com/

Good data-analysis is key to addressing many of our thorniest, most pressing problems. As Ben Goldacre recounts in his inaugural Oxford lecture, it is both possible and desirable to build ethical, privacy-preserving systems for analyzing the most sensitive personal data (NHS patient records) that yield scores of solid, ground-breaking medical and scientific insights:

https://www.youtube.com/watch?v=_-eaV8SWdjQ

The difference between this kind of work – HRDAG's exoneration work and Goldacre's medical research – and the approach that OpenAI and its competitors take boils down to how they treat humans. The former treats all humans as worthy of respect and consideration. The latter treats humans as instruments – for profit in the short term, and for creating a hypothetical superintelligence in the (very) long term.

As Terry Pratchett's Granny Weatherwax reminds us, this is the root of all sin: "sin is when you treat people like things":

https://brer-powerofbabel.blogspot.com/2009/02/granny-weatherwax-on-sin-favorite.html

So much of the criticism of AI misses this distinction – instead, this criticism starts by accepting the self-serving marketing claim of the "AI safety" crowd – that their software is on the verge of becoming self-aware, and is thus valuable, a good investment, and a good product to purchase. This is Lee Vinsel's "Criti-Hype": "taking press releases from startups and covering them with hellscapes":

https://sts-news.medium.com/youre-doing-it-wrong-notes-on-criticism-and-technology-hype-18b08b4307e5

Criti-hype and AI were made for each other. Emily M Bender is a tireless cataloger of criti-hypeists, like the newspaper reporters who breathlessly repeat " completely unsubstantiated claims (marketing)…sourced to Altman":

https://dair-community.social/@emilymbender/111464030855880383

Bender, like White, is at pains to point out that the real debate isn't doomers vs accelerationists. That's just "billionaires throwing money at the hope of bringing about the speculative fiction stories they grew up reading – and philosophers and others feeling important by dressing these same silly ideas up in fancy words":

https://dair-community.social/@emilymbender/111464024432217299

All of this is just a distraction from real and important scientific questions about how (and whether) to make automation tools that steer clear of Granny Weatherwax's sin of "treating people like things." Bender – a computational linguist – isn't a reactionary who hates automation for its own sake. On Mystery AI Hype Theater 3000 – the excellent podcast she co-hosts with Alex Hanna – there is a machine-generated transcript:

https://www.buzzsprout.com/2126417

There is a serious, meaty debate to be had about the costs and possibilities of different forms of automation. But the superintelligence true-believers and their criti-hyping critics keep dragging us away from these important questions and into fanciful and pointless discussions of whether and how to appease the godlike computers we will create when we disassemble the solar system and turn it into computronium.

The question of machine intelligence isn't intrinsically unserious. As a materialist, I believe that whatever makes me "me" is the result of the physics and chemistry of processes inside and around my body. My disbelief in the existence of a soul means that I'm prepared to think that it might be possible for something made by humans to replicate something like whatever process makes me "me."

Ironically, the AI doomers and accelerationists claim that they, too, are materialists – and that's why they're so consumed with the idea of machine superintelligence. But it's precisely because I'm a materialist that I understand these hypotheticals about self-aware software are less important and less urgent than the material lives of people today.

It's because I'm a materialist that my primary concerns about AI are things like the climate impact of AI data-centers and the human impact of biased, opaque, incompetent and unfit algorithmic systems – not science fiction-inspired, self-induced panics over the human race being enslaved by our robot overlords.

If you'd like an essay-formatted version of this post to read or share, here's a link to it on pluralistic.net, my surveillance-free, ad-free, tracker-free blog:

https://pluralistic.net/2023/11/27/10-types-of-people/#taking-up-a-lot-of-space

Image: Cryteria (modified) https://commons.wikimedia.org/wiki/File:HAL9000.svg

CC BY 3.0 https://creativecommons.org/licenses/by/3.0/deed.en

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mariacallous · 2 months ago

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Abortion is a top issue in the 2024 election, with a “growing share of voters in swing states now say[ing] abortion is central to their decision this fall,” according to Times/Siena College polls published in August. It is the “single most important issue” for women under 45.

On September 3, Vice President Kamala Harris began a “Fighting for Reproductive Freedom” bus tour in Florida, a state the Democratic Party has lost in the last two presidential elections, but which has abortion on the ballot this year. On November 5, citizens of Florida will be able to vote on an amendment that would restore legal access to abortion “before viability or when necessary to protect a patient’s health, as determined by the patient’s healthcare provider.” Florida currently has a six-week abortion ban, a law signed by Gov. Ron DeSantis in the wake of Dobbs.

The Harris bus tour began about a twenty-minute drive from Mar-a-Lago, the home of the former president who has declared responsibility for the fall of Roe under the Dobbs decision. The decision spawned multiple state abortion bans with severe repercussions upon a woman’s ability in ban states to receive critical or life-saving health care that may necessarily involve an abortion. At the September 10 presidential debate, Harris directly spoke to the post-Roe experiences of women suffering miscarriages and bleeding out in hospital parking lots because they couldn’t get treatment from doctors who were afraid of being prosecuted.

The other presidential candidate, former president Donald Trump, has bragged about overturning Roe v. Wade as a personal achievement of consummate importance. Public opinion polling shows, however, that the majority of Americans support legalized abortion. Moreover, the pro-reproductive rights position has won on abortion-related ballot measures following the Dobbs decision in conservative states like Ohio, Kansas, and Kentucky, and abortion measures are on the ballot this November in key states like Florida, Nevada, Colorado, and Arizona. Trump is now trying to downplay his involvement because the issue of abortion has become an albatross around the neck of the Trump campaign and the Republican Party itself. No wonder, then, in recent comments Trump has stated that abortion policy should be left to the states, and he has been publicly unwilling to endorse a nationwide abortion ban. At the debate, however, he repeatedly refused to answer whether he would veto legislation containing such a ban if it were presented to him as president, rejecting the question as an unlikely hypothetical while claiming he did the country “a great service” by helping overturn Roe.

In the wake of threats to in vitro fertilization (IVF) spurred by the Alabama Supreme Court decision that frozen embryos are children and the corresponding religious view held by some in the anti-abortion movement that a fertilized egg is a full-fledged person, Trump said both that he would mandate insurance companies cover IVF and the federal government would cover it for all Americans in need.

Attempting to persuade women who want their reproductive rights back, he suggested that Florida’s six-week abortion ban is “too short,” stating that he will be “voting that we need more than six weeks.” Later, however, his campaign walked this statement back, indicating that he “has not yet said how he will vote on the ballot initiative in Florida.” Trump attempted to rehabilitate his position on abortion further for his far right, evangelical base by spreading the disinformation that some states allow the legal execution of babies after birth. At the debate, he repeated this false statement, and one of the debate moderators fact-checked him on that. These are just a few examples of the ducking, bobbing, and weaving on abortion that Trump has been doing over the past few weeks.

But Trump’s attempts to obfuscate the abortion policy of his party and his future administration are laid bare by what is stated in the 2024 Republican Party platform and in the 2025 Presidential Transition Project (also known as Project 2025), a detailed blueprint for overhauling the executive branch, published by the Heritage Foundation, which involves at least 140 people who worked in the last Trump administration.

The word “abortion” only appears once in the 28-page Republican Party platform with the statement “[w]e will oppose Late Term Abortion, while supporting mothers and policies that advance Prenatal Care, access to Birth Control, and IVF.” But that statement must be understood in the context of the sentence that immediately precedes it: “We believe that the 14th Amendment to the Constitution of the United States guarantees that no person can be denied Life or Liberty without Due Process, and that the States are, therefore, free to pass Laws protecting those Rights.” By invoking the 14th Amendment to the Constitution in the context of abortion, the platform projects consistency with a religious belief that fertilized eggs, or so-called “unborn children” are full-fledged people deserving all of the rights and protections afforded by the U.S. Constitution. Neither abortion nor IVF, where some embryos may be discarded, is consistent with this “personhood” view. The limited and coded treatment of abortion in the platform is, however, consistent with Trump’s stated belief that the issue is harming the Republican Party and his candidacy with women.

But the Republican Party platform’s concise treatment of abortion should not be separated from Project 2025—a 922-page document replete with instances of the word abortion, along with detailed plans for how a Republican administration should promote “pro-life” policies and, in doing so, further curtail reproductive rights and access to reproductive healthcare.

Project 2025’s explicit anti-abortion positions and goals are summarized in the forward section of the document, which proclaims that “conservatives should gratefully celebrate the greatest pro-family win in a generation: overturning Roe v. Wade, a decision that for five decades made a mockery of our Constitution and facilitated the deaths of tens of millions of unborn children. But the Dobbs decision is just the beginning.”

A national abortion ban emerges as a prominent goal, as the document instructs that “[c]onservatives in the states and in Washington, including in the next conservative Administration, should push as hard as possible to protect the unborn in every jurisdiction in America. In particular, the next conservative President should work with Congress to enact the most robust protections for the unborn that Congress will support . . . .”

Some of the most noteworthy ideas and policies construed to achieve these outcomes presented in the rest of the document include:

A series of actions focused on preventing access to medication abortion nationwide. It is important to recognize that medication abortion accounted for 63% of all abortions in 2023—and that number does not account for pills that were mailed to people in states with an abortion ban, so the overall percentage is likely higher. It can be a particularly useful way to circumvent abortion bans. From the perspective of Project 2025, “[a]bortion pills pose the single greatest threat to unborn children in a post-Roe world.” Accordingly, Project 2025 recommends, among other things, that the FDA “reverse its approval of chemical abortion drugs,” and “stop promoting or approving mail-order abortions.” It also recommends that the DOJ “enforce the Comstock Act,” a law passed in 1873 that would, if read literally, make the mailing of any kind of abortifacient unlawful, effectively resulting in a nationwide ban on medication abortion.

Preventing both HHS and the CDC from treating or promoting abortion as health care. Consistent with this goal, and in furtherance of a “Life Agenda,” Project 2025 states that HHS should be known as the “Department of Life” through “explicitly rejecting the notion that abortion is health care.” Accordingly, Project 2025 recommends that the next Secretary of HHS eliminate the current HHS Reproductive Access Task Force and replace it with “a pro-life task force to ensure that all of the department’s divisions seek to use their authority to promote the life and health of women and their unborn children.” With respect to the CDC, Project 2025 recommends that it “should eliminate programs and projects that do not respect human life and conscious rights and that undermine family formation.” This would include the types of research it chooses to fund.

Preventing any kind of federal funding from supporting abortion care, including helping women travel out of state to receive an abortion. Project 2025 would also prohibit Planned Parenthood or any other abortion provider from receiving Medicaid funds. Two steps recommended in furtherance of this goal are having HHS “[i]ssue guidance reemphasizing that states are free to defund Planned Parenthood in their state Medicaid plans” and “[p]ropose rulemaking to interpret the Medicaid statute to disqualify providers of elective abortion from the Medicaid program.”

In stark contrast, the Democratic Party platform, written when President Biden was still the Democratic candidate for president, has its own section on “Reproductive Freedom” that embraces the idea that abortion is health care. It begins by acknowledging that since the fall of Roe, “more than 20 states have imposed extreme and dangerous abortion bans—many of which include no exception even for rape or incest—that put the health and lives of women in jeopardy, force women to travel hundreds of miles for care, and threaten to criminalize doctors for providing the health care that their patients need and that they are trained to provide.”

The platform looks to the range of actions taken during the Biden-Harris administration as a foundation for continuing efforts to protect reproductive rights and health care. Some of the most notable actions mentioned, which are opposite of the policies promoted by Project 2025, include enabling pharmacies to dispense medication abortion and defending FDA approval of medication abortion in court, expanding reproductive health care for service members and veterans, defending access to emergency abortion care, challenging threats by a Republican attorney general to prosecute those who assist women traveling out of state for abortion care, and assisting states in expanding access under Medicaid for people who travel from states where they are denied access to abortion care.

Going forward, the platform states that Democrats will, among other things, work to restore abortion rights through legislation (assuming a Congress with sufficient Democratic control), protect the right to access IVF, strengthen access to contraception, and continue to support access to medication abortion. The platform also indicates that Democrats will work to repeal the Hyde amendment, which “restricts federally funded abortions under major federal health care programs.”

The contrast between the parties’ platforms and policies is clear. Simply put, the Democratic Party platform explicitly states that “President Biden, Vice President Harris, and Democrats are committed to restoring the reproductive rights Trump ripped away.” As the presidential candidate who has proudly claimed responsibility for the fall of Roe, Trump’s rhetoric resembles the defensive moves of a boxer ducking, bobbing, and weaving to slip an opponent’s punches: he has tried to disavow Project 2025, tried to obfuscate Republican Party positions and plans, and backtracked on some of his positions in an attempt to portray his future administration as “great for women and their reproductive rights.”

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greelin · 2 years ago

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there are literally people whose entire job is to see insurance claims and find any way possible to reject them. And well legally i cannot say what should happen to them but i’m thinking real hard. in my mind. manifesting. but hey. Health insurance being privatized works!

#like this is documented. People have gone on record and said they intentionally rejected shit without even reading it. LMAO

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haberdashing · 3 months ago

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It's been a while since I've posted any of my dreams on here, but I feel like tumblr would like this one.

I had a dream about a group of teenagers, or perhaps college kids in their early 20s, getting trapped in an upper-middle-class, three-story suburban house. The house was haunted and slowly drove several of the teenagers insane, to the point where only the ground floor could be used because the second and third floors were now occupied by fellow young adults turned into violent murderers who would now kill anyone who intruded on "their space".

You couldn't see the outside world out the windows, just pure darkness, and the first group to leave through the front door never returned from their scouting mission, left to an unknown but presumably horrible fate.

Fairly typical horror stuff, really.

But somewhere around where dreams meet half-awake thoughts, I realized that there wasn't one Final Girl to this story, there were three. (Although for one, Final Girl's a bit of a misnomer.)

The first was Luna, long-haired and pretty, who started out as the token group mystic pointing out that it was the night of the full moon. Turns out she knows a lot about nature and spiritualism in general. Also she was a trans woman; there was a throwaway line about how she was such a jerk back when she was (deadname). But she's a sweetheart now, if in need of some grounding now and then.

The second... I don't think ever got a name, but I have her mental image clear in my head. Scruffy short brown hair, glasses, fairly nondescript clothes. Started off as the quiet one. Then as things played out, she revealed that she had a history of depression and suicidal thoughts, which as it turns out is quite helpful for dealing with the whole haunted house thing. This wasn't her first time dealing with part of her mind turning against her and trying to cause her harm, after all. She dealt with that on an everyday basis.

The third was Piper, nonbinary, the one who actually lives in the house in question and invited everybody else over. Started off kind of keeping in the background, playing the good host while also trying not to answer too many questions. We learned that Piper grew up in a rich family, in keeping with the big fancy house... but was largely neglected by their parents, pawned off on various nannies and babysitters before having to make their peace with spending time alone more often than not.

Piper realized that the source of the haunting was their parents' jobs--the exact jobs weren't clear, but they were things like "engineer at Lockheed Martin" and "CEO of a health insurance company pushing claim rejections". Unethical jobs, albeit commonplace and lucrative ones. The house was bought with blood money, that's what the problem was.

And Piper figured that the house needed their blood, blood from the family that purchased the home with those dirty funds, their blood used to atone for the blood spilled in the name of owning the home... but after some discussion the three determined that it didn't need to be all of Piper's blood sacrificed to fix the curse. And hey, depressed girl has some experience here too, she can provide guidance on how to make a cut that will bleed plenty but won't cause any permanent damage...

It ended with the three hand in hand, leaving out the front door and walking down the seemingly-endless sidewalk with nothing but pristine lawn on both sides, unsure of what lay ahead of them but ready to find out together.

(And yes, they're all dating.)

#personal #self-harm #i don't think i actually knew/decided luna's deadname here #but i DO know it was something very bro-esque in nature #kyle or kevin or cody or hunter #jock frat boy type name

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life-and-health-insurance · 1 month ago

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#health insurance #Claim rejection

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religion-is-a-mental-illness · 1 year ago

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By: Eliza Mondegreen

Published: Sept 12, 2023

First comes the pushback, then the pullback.

Yesterday, the Washington University Transgender Center at St. Louis Children’s Hospital announced that doctors there will no longer prescribe puberty blockers or cross-sex hormones to children and adolescents. This decision follows months of controversy and comes in the wake of a new law that just went into effect in Missouri, which limits hormonal and surgical interventions for gender transition to patients over the age of 18.

Under a “grandfather clause” in the new law, the Transgender Center could have continued to prescribe puberty blockers and cross-sex hormones to current patients. However, it decided to back away from these interventions altogether:

We are disheartened to have to take this step. However, Missouri’s newly enacted law regarding transgender care has created a new legal claim for patients who received these medications as minors. This legal claim creates unsustainable liability for health-care professionals and makes it untenable for us to continue to provide comprehensive transgender care for minor patients without subjecting the university and our providers to an unacceptable level of liability. - WASHINGTON UNIVERSITY TRANSGENDER CENTER

The Center first came under intense scrutiny earlier this year, when former case manager Jamie Reed blew the whistle on what she had come to see as dangerous practices within the clinic. In an article for The Free Press, Reed reported that:

“During the four years I worked at the clinic as a case manager—I was responsible for patient intake and oversight—around a thousand distressed young people came through our doors. The majority of them received hormone prescriptions that can have life-altering consequences—including sterility. I left the clinic in November of last year because I could no longer participate in what was happening there. By the time I departed, I was certain that the way the American medical system is treating these patients is the opposite of the promise we make to ‘do no harm.’ Instead, we are permanently harming the vulnerable patients in our care.” - JAMIE REED

Reed catalogued “red flag” cases to keep track of “the kind of patients that kept my colleague and me up at night” and documented cases of youth with serious mental health struggles rushed onto life-altering drugs and even undergoing surgeries they soon regretted. The Transgender Center rejected Reed’s assessment and conducted their own internal investigation — an investigation in which they never bothered to speak to Reed — before declaring her allegations “unsubstantiated”.

But the case for youth gender transition has been unravelling this year, under pressure from state officials and legislators and increased scrutiny from the media. At the end of August, St. Louis Circuit Court Judge Steven Ohmer allowed Missouri’s ban on hormonal and surgical interventions for youth to go into effect, writing that the evidence for youth transition “raises more questions than answers”.

Hence the “unsustainable liability” Washington University cited in its decision to pull back from this area of healthcare. That’s because Missouri’s new law also extended the period of time former patients have to sue for damages to 15 years. Perhaps, when the Washington University investigated themselves, they found more merit to Reed’s allegations than they were willing to acknowledge publicly. They fear being made to pay for it.

Medical scandals tend to end quietly: the “chemical lobotomy” phased out the lobotomy-lobotomy. The Satanic Panic choked not on its own absurdities but in courtrooms and insurance offices. Public reckonings are few and far between. “Unsustainable liability” may be the beginning of the end for youth gender transition.

How could there be an "unacceptable level of liability" when all of this "gender affirming care" is based on evidence, of which there is definitely plenty, and "the science," which is definitely reliable and high quality? Isn't it "life-saving"? We were told it was "life-saving," right? Wasn't it "life-saving"? How can anything be an "unacceptable liability" when people aRe LiTeRaLLy dYiNg!!1!

If all of these drugs and cosmetic surgeries and amputations and other sex trait modifications were so well evidenced, so ethical and so necessary, it should be an absolute doddle in the insurance office and the courtroom. It all just needs to be explained clearly and people will agree. Right? Because detransition is rare, regret is rare, complications are rare, "kids know who they are," all the medical experts agree, and there's no legitimate concern, just "far-right" bigots conducting their "genocide." Right?

I said some time ago that only the lawsuits would stop it in the US and Canada. It looks like that's begun. Hospitals aren't willing to put their bottom line ahead of, or their necks on the chopping block for, adherence to this religion.

#Eliza Mondegreen #Jamie Reed #Washington University Transgender Center #Washington University #sex trait modification #queer theory #gender ideology #gender lobotomy #lobotomy #gender transition #medical transition #medical malpractice #medical scandal

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feminist-space · 2 years ago

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How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them

by Patrick Rucker, Maya Miller and David Armstrong for ProPublica

March 25, 5 a.m. EDT

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.

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.

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.

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.”

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 Cigna 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.

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.

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.”

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morlock-holmes · 12 days ago

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More true stories of American health care:

Insurance: "Here's the primary care physician we've assigned to you, Dr. X"

Calls Dr. X's office

Receptionist: "Let me see if the scheduling department is taking phone calls right now"

The scheduling department is not taking phone calls, but they do have a voice message saying that there are no openings and no wait list.

Me: calls a bunch of other numbers

Me: gets an appointment to see a PCP on Christmas Eve morning, the earliest they have.

Me: Realizes that I don't have enough medicine refills to last until then, so I call insurance.

Me: "Hey, the PCP I am supposed to see doesn't have any openings to see me until six months from now, how do I get refills until then?

Insurance Company: "Oh, don't worry, if your PCP can't see you we can give you a telehealth appointment with a registered nurse, we have a program specifically designed to do that."

Me: "Great"

At which point I am billed $700 for that telehealth appointment, with a note saying that the claim was rejected, because I am supposed to go to my PCP for prescription services.

The PCP I have never met. The one I can't get an appointment with.

The one I specifically told them I couldn't get an appointment with, leading them to explain to me that this is what Bridges is for.

As usual, once I find the right person to talk to (Not in the billing department) they basically act like this is my fault.

"Well, when you called our number and told the customer service rep that you weren't able to see your PCP, you informed the wrong part of the company about it. It's your responsibility to make sure that the right part of the company knows about this, you obviously can't just call customer service, duh."

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mostlysignssomeportents · 2 years ago

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Private equity finally delivered Sarah Palin's death panels

Tonight (Apr 26), I’ll be in Burbank, signing Red Team Blues at Dark Delicacies at 6PM.

Remember “death panels”? Sarah Palin promised us that universal healthcare was a prelude to a Stalinist nightmare in which unaccountable bureaucrats decided who lived or died based on a cost-benefit analysis of what it would cost to keep you alive versus how much your life was worth.

If you’d like an essay-formatted version of this post to read or share, here’s a link to it on pluralistic.net, my surveillance-free, ad-free, tracker-free blog:

https://pluralistic.net/2023/04/26/death-panels/#what-the-heck-is-going-on-with-CMS

Palin was right that any kind of healthcare rationing runs the risk of this kind of calculus, where we weight spending $10,000 to extend a young, healthy person’s life by 40 years against $1,000 to extend an elderly, disabled person’s life by a mere two years.

It’s a ghastly, nightmarish prospect — as anyone who uses the private healthcare system knows very well. More than 27m Americans have no health insurance, and millions more have been tricked into buying scam “cost-sharing” systems run by evangelical grifters:

https://www.nytimes.com/2020/01/02/health/christian-health-care-insurance.html

But for the millions of Americans with insurance, death panels are an everyday occurrence, or at least a lurking concern. Anyone who pays attention knows that insurers have entire departments designed to mass-reject legitimate claims and stall patients who demand that the insurer lives up to its claim:

https://kffhealthnews.org/news/article/khn-podcast-an-arm-and-a-leg-how-to-shop-for-health-insurance-november-24-2021/

The private healthcare sector is designed to deny care. Its first duty is to its shareholders, not its patients, and every dollar spent on care is a dollar not available for dividends. The ideal insurance customer pays their premiums without complaint, and then pays cash for all their care on top of it.

All that was true even before private equity started buying up and merging whole swathes of the US healthcare system (or “healthcare” “system”). The PE playbook — slash wages, sell off physical plant, slash wages, reduce quality and raise prices — works in part because of its scale. These aren’t the usual economies of scale. Rather the PE strategy is to buy and merge all the similar businesses in a region, so customers, suppliers and workers have nowhere else to turn.

That’s bad enough when it’s aimed at funeral homes, pet groomers or any of the other sectors that have been bigfooted by PE:

https://pluralistic.net/2022/12/16/schumpeterian-terrorism/#deliberately-broken

But it’s especially grave when applied to hospitals:

https://pluralistic.net/2020/05/21/profitable-butchers/#looted

Or emergency room physicians:

https://pluralistic.net/2022/03/14/unhealthy-finances/#steins-law

And if you think that’s a capitalist hellscape nightmare, just imagine how PE deals with dying, elderly people. Yes, PE has transformed the hospice industry, and it’s even worse than you imagine.

Yesterday, the Center for Economic and Policy Research published “Preying on the Dying: Private Equity Gets Rich in Hospice Care,” written by some of the nation’s most valiant PE slayers: Eileen Appelbaum, Rosemary Batt and Emma Curchin:

https://cepr.net/report/preying-on-the-dying-private-equity-gets-rich-in-hospice-care/

Medicare pays private hospices $203-$1,462 per day to take care of dying old people — seniors that a doctor has certified to have less than six months left. That comes to $22.4b/year in public transfers to private hospices. If hospices that $1,462 day-rate, they have lots of duties, like providing eight hours’ worth of home care. But if the hospice is content to take the $203/day rate, they are not required to do anything. Literally. It’s just free money for whatever the operator feels like doing for a dying elderly person, including doing nothing at all.

As Appelbaum told Maureen Tkacik for her excellent writeup in The American Prospect: “Why anybody commits fraud is a mystery to me, because you can make so much money playing within the guidelines the way the payment scheme operates.”

https://prospect.org/health/2023-04-26-born-to-die-hospice-care/

In California, it’s very, very easy to set up a hospice. Pay $3,000, fill in some paperwork (or don’t — no one checks it, ever), and you’re ready to start caring for beloved parents, grandparents, sisters, brothers, aunts and uncles as they depart this world. You do get a site inspection, but don’t worry — you aren’t required to bring your site up to code until after you’re licensed, and again, they never check — not even if there are multiple complaints. After all, no one at the Centers for Medicare & Medicaid Services (CMS) has the job of tracking complaints.

This is absolute catnip for private equity — free government money, no obligations, no enforcement, and the people you harm are literally dying and can’t complain. What’s not to like? No wonder PE companies have spent billions “rolling up” hospices across the country. There are 591 hospices in Van Nuys, CA alone — but at least 30 of them share a single medical director:

https://auditor.ca.gov/reports/2021-123/index.html#pg34A

Medicare caps per-patient dispersals at $32,000, which presents an interesting commercial question for remorseless, paperclip-maximizing, grandparent-devouring private equity ghouls: do you take in sick patients (who cost more, but die sooner) or healthy patients (cost less, potentially live longer)?

In Van Nuys, the strategy is to bring in healthy patients and do nothing. 51% of Van Nuys hospice patients are “live discharged” — that is, they don’t die. This figure — triple the national average — is “a reliable sign of fraud.”

There are so many hospice scams and most of them are so stupid that it takes a monumental failure of oversight not to catch and prevent them. Here’s a goodun: hospices bribe doctors to “admit” patients to a hospice without their knowledge. The hospice bills for the patient, but otherwise has no contact with them. This can go on for a long time, until the patient tries to visit the doctor and discovers that their Medicare has been canceled (you lose your Medicare once you go into hospice).

Another scam: offer patients the loosest narcotics policy in town, promising all the opioids they want. Then, once their benefits expire, let them die of an overdose (don’t worry, people who die in hospice don’t get autopsies):

https://www.newyorker.com/magazine/2022/12/05/how-hospice-became-a-for-profit-hustle

You can hire con artists to serve as your sales-force, and have them talk vulnerable, elderly people into enrolling in hospice care by convincing them they have nothing to live for and should just die already and not burden their loved ones any longer.

Hospitals and hospices also collude: hospitals can revive dying patients, ignoring their Do Not Resuscitate orders, so they can be transfered to a hospice and die there, saving the hospital from adding another dead patient to their stats.CMS’s solution is perverse: they’re working with Humana to expand Medicare Advantage (a scam that convinces patients to give up Medicare and enrol in a private insurance program, whose private-sector death panel rejects 13% of claims that Medicare would have paid for). The program will pay private companies $32,000 for every patient who agrees to cease care and die. As our friends on the right like to say, “incentives matter.”

Appelbaum and co have a better idea:

Do more enforcement: increase inspections and audits.

Block mergers and rollups of hospices that make them too big to fail and too big to jail.

Close existing loopholes.

They should know. Appelbaum and her co-authors write the best, most incisive analysis of private equity around. For more of their work, check out their proposal for ending pension-plan ripoffs by Wall Street firms:

https://pluralistic.net/2022/05/05/mego/#A09948

Catch me on tour with Red Team Blues in Burbank, Mountain View, Berkeley, San Francisco, Portland, Vancouver, Calgary, Toronto, DC, Gaithersburg, Oxford, Hay, Manchester, Nottingham, London, and Berlin!

[Image ID: An industrial meat grinder, fed by a conveyor belt. A dead, elderly man is traveling up the conveyor, headed for the grinder's intake. The grinder is labelled 'HOSPICE' in drippy Hallowe'en lettering. It sits in a spreading pool of blood.]

Image: Seydelmann (modified) https://commons.wikimedia.org/wiki/File:GW300_1.jpghttps://commons.wikimedia.org/wiki/File:GW300_1.jpg

CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0/deed.en

#pluralistic #cepr #medicare advantage #medicare #hospice #aca #aging #death panels #fraud #california #preying on the dying

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anarkittyuwuuniverse · 1 year ago

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"Although DSM III considerably expanded the range of behaviors defined as markers of mental disorder, the manual never actually defined what exactly qualified these behaviors as mental disorders. The creation of a classification system in which symptoms signified and thus qualified as markers of a mental or emotional disorder now pathologized a wide range of behaviors. For example, “oppositional disorder” (coded 313.81) is defined “as a pattern of disobedient, negativistic, and provocative opposition to authority figures,” “histrionic personality disorder” (coded 301.50) occurs when individuals are “lively and dramatic and always drawing attention to themselves,” and “avoidant and personality disorder” (coded 301.82) is characterized by “hypersensitivity to potential rejection, humiliation, or shame and unwillingness to enter into relationships unless given unusually strong guarantees of uncritical accep-tance.” With the attempt to carefully codify and classify pathologies, the category of mental disorder became very loose and very wide, including behaviors or personality traits that merely fell outside the range of what psychologists postulated was “average.” Behaviors or personality features that might have been previously categorized as “having a bad temper” were now in need of care and management and were henceforth pathologized. Herb Kutchins and Stuart Kirksuggest that the codification of pathologies is related to the close connection between mental health treatment and insurance coverage. DSM III grew out of the need to make the relationship between diagnosis and treatment tighter so that insurance companies (or other payers) could process claims more efficiently. As Kutchins and Kirk put it, “DSM is the psychotherapist’s password for insurance reimbursement.” DSM—which provides the code numbers to be listed on the claims for insurance reimbursement—is the bridge connecting mental health professionals and such large money-giving institutions as Medicaid, Social Security Disability Income, benefit programs for veterans, and Medicare. Not only is it used by the majority of mental health clinicians, but it is increasingly used by third parties such as “state legislatures, regulatory agencies, courts, licensing boards, insurance companies, child welfare authorities, police, etc.” In addition, pharmaceutical industries have an interest in the expansion of mental pathologies that can then be treated with psychiatric medications. As Kutchin and Kirk eloquently put it, “For drug companies, . . . unlabeled masses are a vast untapped market, the virgin Alaskan oil fields of mental disorder.” Thus the DSM, willfully or not, helps label and chart new mental health consumer territories, which in turn help expand pharmaceutical companies. Hence the expansion of the category of mental illness, dysfunction, or emotional pathology is related to the professional and financial interests of mental health professionals and drug companies. It is also related to the increasing use of psychological categories to claim benefits, compensations, or extenuating circumstances in courts. In this process, the DSM has clearly considerably enlarged the scope of psychologists’ authority, who now legislate over such questions as how much anger may be appropriately expressed, how much sexual desire one should have, how much anxiety one should feel, and which emotional behaviors should be given the label of “mental disease.”" -Saving the modern soul: Therapy, emotions and the culture of self-help by Eva Illouz

#saving the modern soul #eva illouz #sociology #mental illness #dsm #anti psychiatry

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