Georgia Pathways to Coverage is not achieving two primary goals: enrolling people in healthcare and getting them to work.

This article was published on Wednesday, February 19, 2025 in ProPublica.

by Margaret Coker, The Current

In January, standing before a cluster of television cameras on the steps of the state Capitol, Georgia Gov. Brian Kemp promoted his experiment in Medicaid reform as a showcase for fellow conservatives seeking to overhaul safety net benefits around the country.

"What we are doing is working," Kemp boasted about Georgia Pathways to Coverage. The federally subsidized health insurance program is supposed to cover nearly a quarter-million low-income Georgians who can prove they are working, studying or volunteering.

What the governor did not disclose, however, was that his program is not achieving two primary goals: enrolling people in health care and getting them to work, according to an examination by The Current and ProPublica. The findings were confirmed recently by an independent evaluation commissioned by the state that has yet to be publicly released.

As of the end of 2024, the Pathways program has cost federal and state taxpayers more than $86.9 million, three-quarters of which has gone to consultants, The Current and ProPublica found. The state asserted that costs increased because of a two-year delay to the program's launch.

A mere 6,500 participants have enrolled 18 months into the program, approximately 75% fewer than the state had estimated for Pathways' first year. Thousands of others never finished applying, according to the state's data, as reports of technical glitches mounted. The state also never hired enough people to help residents sign up or to verify that participants are actually working, as Georgia required, federal officials and state workers said.

As a result, the Kemp administration has quietly rolled back a core tenet it heralded when it launched Pathways as an alternative to government entitlement programs for poor people that many conservatives deride as handouts and the nanny state. Rather than verifying that people are working every month, Georgia is confirming that participants meet these requirements only at the time of enrollment and upon their annual renewal, the state said in January.

Georgia's experience offers a warning for the nation as conservatives attempt to curtail federally subsidized health care for low-income Americans, as outlined by Project 2025, the playbook designed for a second Donald Trump presidency. Congressional Republicans are pushing for deep cuts to Medicaid along with requiring recipients to work. Right now, Georgia is the only state that imposes a work requirement for Medicaid coverage. But nearly a dozen largely Republican-led states are considering work requirements for Medicaid enrollees.

Federal and state officials who have worked on Pathways say a litany of bad decisions, some technical and some political, doomed the program from meeting Kemp's original goals. Even some lawmakers in Kemp's own party want to pull the plug on Pathways.

The quarter-million people eligible for Pathways would have had an easier road to coverage had the state simply chosen to expand Medicaid under the Affordable Care Act, the 2010 health reform law that extended insurance to tens of millions of Americans, said Joan Alker, executive director of the Center for Children and Families at Georgetown University McCourt School of Public Policy. Kemp is one of 10 Republican governors who refused federal government subsidies to expand Medicaid under the belief that entitlement programs encourage freeloaders and are a drag on federal and state budgets. Sixteen percent of working-age residents in Georgia lack health insurance, one of the highest uninsured rates in the nation.

In response to Pathways' low enrollment numbers, Kemp's spokesperson Garrison Douglas said the governor never thought it was realistic to enroll the entire pool of eligible Georgians in the program. Douglas said Kemp's health care strategy for low-income Georgians is superior to Medicaid expansion because it saves the state money and funnels participants into private health insurance, rather than what the Kemp administration has described as overregulated government-mandated plans that reimburse hospitals and doctors at lower rates.

"As the governor has said repeatedly, those who continue to promote full Medicaid expansion are selling Georgians a bill of goods," he said.

The Pathways program is slated to sunset this fall, but Georgia has filed a request with the Trump administration to extend the experiment for another five years with the less stringent verification rules, as independent evaluators recommended. The Trump administration did not respond to requests for comment about its support for Medicaid work requirements and its views on Georgia's Pathways experiment.

State officials did not explain why Georgia has not been able to meet its own verification standards.

"The governor's mandate for all state agencies is to continually seek ways to make government more efficient and accessible for hardworking Georgians," Fiona Roberts, a Department of Community Health spokesperson, said in a written statement.

The state requires Pathways participants to work at least 80 hours a month or be enrolled in school, job training or volunteering — activities the governor's office says it believes contribute to eventual "financial independence." Health policy research shows that requiring low-income people to work for health insurance does not increase coverage or boost their economic circumstances because most of them already have jobs.

"If the goal truly is to increase health insurance for low-income Georgians, they are doing it wrong," said Dr. Harry J. Heiman, a member of a state commission to study comprehensive health coverage and a professor at Georgia State University School of Public Health. "The one thing that Pathways seems to do well is waste taxpayer money on consultants and administrative costs."

Plagued by Tech Glitches

Pathways was supposed to help a group of Georgians whom the state had previously deemed ineligible for Medicaid: adults between 18 and 64 years old earning less than $15,650 a year if they are single, or $32,150 for a family of four.

The state told the federal government in its application to experiment with Pathways that it hoped to enroll 25,000 of the 246,000 Georgians eligible for Pathways during the program's first year.

But those seeking coverage faced technical hurdles right away, according to interviews with six applicants as well as federal officials and current and former state employees.

The enrollment portal crashed each of the three times Kelsey Williams tried to apply. The single mother had been kicked off Medicaid last spring, after her son turned 1, per state law allowing her to keep her coverage for a year after giving birth. She called the Pathways customer service hotline for help and was sent through a phone tree that ended in a voicemail asking callers to leave a message.

"You'd go from one robot voice to another," said Williams, who worked irregular hours as a convenience store clerk outside Macon.

No one called back. She gave up after nearly a month of trying. "I got the feeling that they really didn't want to help me," she said.

State officials have paid Deloitte Consulting more than $50 million so far for a software application that often froze and wiped out personal information, forcing applicants to start over. The technology also proved hard to navigate for many of Pathways' target clients who don't own smartphones or have access to reliable high-speed internet.

As of January, the state's own documents show that the program had a backlog of 16,000 applications awaiting processing, and in some months, upwards of 40% of people who started applications for Pathways gave up.

An independent evaluation from December, obtained by The Current and ProPublica, analyzed data gleaned from the first 13 months of the Pathways program and noted that applicants experienced administrative barriers to enrollment. People 50 and older had an especially difficult time proving they met the requirements, the evaluation said. The program requires applicants to provide paperwork that verifies their work status, including pay stubs and tax documents. That protocol contradicts Medicaid regulations that states should use available data to confirm most eligibility criteria, when possible, instead of making people provide documentation.

For Georgians who did manage to enroll, the technology problems persisted when they were required to verify each month that they had a job or were otherwise participating in a "qualifying activity."

Paul Mikell lives in an area outside Atlanta without reliable internet service — and he doesn't have the income for a phone plan with unlimited data. It takes him more than an hour each month to upload the employment documents necessary to reconfirm his eligibility, often using the free Wi-Fi at his public library.

Sometimes, Mikell said, the task has stretched days, even a whole week, because the Pathways verification portal freezes or crashes. One time, he said, he waited eight days for customer support to retrieve a password and restore his access.

The 49-year-old works part time for a hauling and trucking company in exchange for housing. He also picks up odd jobs to support his young son and elderly father. He does not receive traditional pay stubs that could be easily pulled by the state to verify his work status.

"It's really, really difficult," said Mikell, adding that stress over the possibility of losing coverage keeps him awake at night. "But it's the only health care for someone like me."

Mikell's informal employment situation is typical for many low-income Americans who exist outside mainstream financial networks, and illustrates why verification can be an arduous process for programs with work requirements, said Jennifer Wagner, an expert in Medicaid enrollment technology at the Center on Budget and Policy Priorities, a Washington think tank. In Georgia, 65% of people eligible for Pathways are employed at least part time, while many of the rest are tethered to unpaid work such as caregiving that Pathways does not recognize, state data shows.

To help automate the application and verification processes, Georgia uses digital tools to collect wage and work histories of employees at large companies as well as those who are self-employed. But these tools are not comprehensive, and the task of verifying applicants' eligibility for Pathways largely falls on a cadre of overburdened caseworkers.

In August 2023, a month after Pathways launched, the state was only able to verify that 39 of the 152 enrollees were indeed working or otherwise engaged in activities deemed acceptable by the state, according to state reports to the Centers for Medicare and Medicaid Services. Those reports attributed the low numbers to a lack of "functionality" and did not provide further explanation.

The state's contracts with Deloitte, which The Current and ProPublica obtained through a public records request, were heavily redacted and reveal no detail about the technical design of Pathways' digital platform or how it would be tested before launch.

Deloitte declined to comment and referred questions about the technical difficulties to Georgia officials. Roberts, the spokesperson for Georgia's Medicaid agency, referred to Pathways as "both a policy and technical success" but said it had to work through issues "consistent with the launch of a new program of similar scale and complexity."

"Based on feedback from customers and the community, the state continues to evolve the Pathways program and its processes," Roberts said in a written statement.

The state still requires Pathways recipients to upload paperwork every month, but Georgia is only verifying it annually, Roberts said. The state also says it is not kicking anyone off the rolls.

An Overwhelmed Workforce

Loosening Pathways' verification process does not change what federal and state officials say is another fundamental flaw in the program: Getting people enrolled would ultimately hinge on an understaffed department already struggling to keep up with processing applications for other safety net benefits.

About 30% of the staff at Georgia's Division of Family and Children Services that oversees benefits enrollment and employment verification had turned over between 2017 and 2022, according to state data. Former agency managers attribute the unusually high churn to a workforce fed up with low pay and high stress, exacerbated by the coronavirus pandemic.

In 2023, the year Pathways launched, the agency was already swamped.

Caseworkers had started the time-intensive task of reenrolling the 2 million Georgians who had traditional Medicaid benefits, a process that happens every five years to ensure that participants still meet the requirements.

Federal officials were simultaneously scrutinizing the department for its backlog of 157,000 food stamp applications and ordered it to develop a "corrective plan" to process those benefits more quickly. Georgia was also slipping behind the 45-day standard for processing Medicaid applications, according to federal data.

Meanwhile, for approximately six months before Pathways started, caseworkers needed extensive training for the new program, further delaying reviews of food stamps and Medicaid applications, former managers said.

That spring, Kemp approved a temporary fix to the department's workforce shortage: using federal grants to hire 300 additional caseworkers to handle the flood of Medicaid renewals. But state officials did not beef up staffing to handle Pathways applications, according to two federal employees and one former state manager, despite the fact that so much of Kemp's political capital was riding on the program's success.

The workload ballooned after Pathways' launch in July 2023, according to three former caseworkers. "I'd go into work every day with piles and piles of files, and each of those files represented a real human being with real suffering," said Deanna Matthews, who quit last year. "What people don't realize is that some of us were processing food stamp applications and our families were struggling and needing food assistance as well." (Starting salary for a caseworker who determines applicants' eligibility for federal benefits is approximately $32,000 — the same as the federal poverty line for a family of four.)

In December 2023, the state agency overseeing DFCS moved 200 caseworkers who had been processing applications for Medicaid to tackle the backlog of food stamp applications.

In Pathways' first six months, the department had enrolled just 2,300 people, according to state data.

In response to questions from The Current and ProPublica, Ellen Brown, a spokesperson for the Georgia Department of Human Services, said the state has committed enough people to administer Pathways but that it "can always use more caseworkers" and continues to hire.

At the state Capitol, Republican legislators representing rural counties, where large numbers of uninsured adults live, had begun questioning their governor's push for Pathways. They sought advice from other Republican-led states that were expanding Medicaid without work requirements.

Arkansas had removed its work requirements after a federal judge ruled that such policies resulted in a significant number of people losing health coverage, which goes against Medicaid's rules. The former head of North Carolina's Medicaid agency testified to Georgia lawmakers that Medicaid expansion would boost local economies, rather than drag down state budgets, as many conservatives fear.

Last spring, a bipartisan group of Georgia lawmakers introduced bills in both the House and Senate to allow Medicaid expansion and let Pathways sink into oblivion.

"What we're doing so far just hasn't seemed to work. And so, at some point, we've got to be open to more ideas," Georgia state Sen. Matt Brass, a Republican from Newnan and co-sponsor of the bill, said during a committee hearing at the time.

But the measure never made it to a full vote in either chamber.

Kemp quashed the rebellion after his allies in the Legislature argued that Pathways needed more time to prove itself. Georgia awarded Deloitte a $10.7 million advertising contract last summer to create television, radio and social media spots encouraging enrollment and to tout the program at community events around the state.

As a new legislative session is underway, no bill to abandon Pathways in favor of expanding Medicaid has emerged.

"We are focused on Pathways," said state Rep. Lee Hawkins, a Republican dentist who represents the rural constituency of Gainesville. "We are going to build on what we've got and focus on making it better."

Donald Trump's pick to lead the federal health agency has vowed to replace hundreds of staffers and shift research away from infectious diseases and vaccines. Such an overhaul could imperil the development of life-saving treatments, experts warn.

This article was published on Wednesday, January 15,2025 in ProPublica.

By Anna Maria Barry-Jester

Lifesaving HIV treatments. Cures for hepatitis C. New tuberculosis regimens and a vaccine for RSV.

These and other major medical breakthroughs exist in large part thanks to a major division of the National Institutes of Health, the largest funder of biomedical research on the planet.

For decades, researchers with funding from the NIH's National Institute of Allergy and Infectious Diseases have labored quietly in red and blue states across the country, conducting experiments, developing treatments and running clinical trials. With its $6.5 billion budget, NIAID has played a vital role in discoveries that have kept the nation at the forefront of infectious disease research and saved millions of lives.

Then came the COVID-19 pandemic.

NIAID helped lead the federal response, and its director, Dr. Anthony Fauci, drew fire amid school closures nationwide and recommendations to wear face masks. Lawmakers were outraged to learn that the agency had funded an institute in China that had engaged in controversial research bioengineering viruses, and questioned whether there was sufficient oversight. Republicans in Congress have led numerous hearings and investigations into NIAID's work, flattened NIH's budget and proposed a total overhaul of the agency.

More recently, Robert F. Kennedy Jr., Trump's nominee to run the Department of Health and Human Services, which oversees the NIH, has said he wants to fire and replace 600 of the agency's 20,000 employees and shift research away from infectious diseases and vaccines, which are at the core of NIAID's mission to understand, treat and prevent infectious, immunologic and allergic diseases. He has said that half of NIH's budget should focus on "preventive, alternative and holistic approaches to health." He has a particular interest in improving diets.

Even the most staunch defenders of NIH agree the agency could benefit from reforms. Some would like to see fewer institutes, while others believe there should be term limits for directors. There are important debates over whether to fund and how to oversee controversial research methods, and concerns about the way the agency has handled transparency. Scientists inside and outside of the institute agree that work needs to be done to restore public trust in the agency.

But experts and patient advocates worry that an overhaul or dismantling of NIAID without a clear understanding of the critical work performed there could imperil not only the development of future lifesaving treatments but also the nation's place at the helm of biomedical innovation.

"The importance of NIAID cannot be overstated," said Greg Millett, vice president and director of public policy at amfAR, a nonprofit dedicated to AIDS research and advocacy. "The amount of expertise, the research, the breakthroughs that have come out of NIAID — It's just incredible."

To understand how NIAID works and what's at stake with the new administration, ProPublica spoke with people who have worked for NIAID, received funding from it, or served on boards or panels that advise the institute.

Decisions, Decisions

The director of NIAID is appointed by the head of the NIH, who must be approved by the Senate. Directors have broad discretion to determine what research to fund and where to award grants, although traditionally those decisions are informed by recommendations from panels of outside experts.

Fauci led NIAID for nearly 40 years. He'd navigated controversy in the past, particularly in the early years of the HIV epidemic when community activists criticized him for initially excluding them from the research agenda. But in general until the pandemic, he enjoyed relatively solid bipartisan support for his work, which included a strong focus on vaccine research and development. After he retired in 2022, he was replaced by Dr. Jeanne Marrazzo, an HIV researcher who was formerly the director of the division of infectious diseases at the University of Alabama at Birmingham. She has spent much of her time in the halls of Congress working to restore bipartisan support for the institution.

NIH directors typically span presidential administrations. But Donald Trump has nominated Dr. Jay Bhattacharya to lead NIH, and current director Dr. Monica Bertagnolli told staff this week that she would resign on Jan. 17. A Stanford professor, Bhattacharya has spent his career studying health policy issues like the implementation of the Affordable Care Act and the efficacy of U.S. funding for HIV treatments internationally. He also researched the NIH, concluding that while the agency funds a lot of innovative or novel research, it should do even more.

In March 2020, Bhattacharya co-authored an opinion piece in The Wall Street Journal arguing that the death toll from the pandemic would likely be far lower than predicted and called for lockdown policies to be reevaluated. That October, he helped write a declaration that recommended lifting COVID-19 restrictions for those "at minimal risk of death" until herd immunity could be reached. In an interview with the libertarian magazine Reason in June, he said he believes the COVID-19 epidemic most likely originated from a lab accident in China and that he can't see Trump's Operation Warp Speed, which led to the development and distribution of COVID-19 vaccines at unprecedented speed, as a total success because it was part of the same research agenda.

Bhattacharya declined an interview request from ProPublica about his priorities for the agency. A recent Wall Street Journal article said he is considering how to link "academic freedom" on college campuses to NIH grants, though it's not clear how he would measure that or implement such a change. He's also raised the idea of term limits for directors and said the pandemic "was just a disaster for American science and public health policy," which is now in desperate need of reform.

Where the Money Goes

Grants from NIAID flow to nearly every state and more than half of the congressional districts across the country, supporting thousands of jobs nationwide. Last year, nearly $5 billion of NIAID's $6.5 billion budget went to U.S. organizations outside the institute, according to a ProPublica analysis of NIH's RePORT, an online database of its expenditures.

In 2024, Duke University in North Carolina and Washington University in Missouri were NIAID's largest grantees, receiving more than $190 and $173 million, respectively, to study, among other things, HIV, West Nile vaccines and biodefense.

Over the past five years, $10.6 billion, or about 40% of NIAID's budget to external U.S. institutions, went to states that voted for Trump in the 2024 presidential election, the analysis found. Research suggests that every dollar spent by NIH generates from $2.50 to $8 in economic activity.

That money is key to advancing medicine as well as careers in science. Most students and postdoctoral researchers rely on the funding and prestige of NIH grants to launch into the profession.

New Drugs and Global Influence

The NIH pays for most of the basic research globally into new drugs. The private sector relies on this public funding; researchers at Bentley University found that NIH money was behind every new pharmaceutical approved from 2010 through 2019.

That includes therapies for kids with RSV, COVID-19 vaccines and Ebola treatments, all of which have key patents based on NIAID-funded research.

Research from NIAID has also improved treatment for chronic diseases. New understandings of inflammation from NIAID-funded research has led to cutting-edge research into cures for Crohn's disease and ulcerative colitis, and a growing body of evidence shows how viruses can have long-term impacts, from multiple sclerosis to long COVID. When private companies turn that research into blockbuster drugs, the public benefits from new treatments, as well as jobs and economic growth.

The weight of NIAID's funding also allows it to play quieter roles that have been essential to advancing science and the United States' role in biomedicine, several people said.

The institute brings together scientists who are normally competitors to share findings and tackle big research questions. Having that neutral space is essential to pushing knowledge forward and ultimately spurring breakthroughs, said Matthew Rose of the Human Rights Campaign, who has served on multiple NIH advisory boards. "Academic bodies are very competitive with one another. Having NIH pull the grantees together is helpful to make sure they talk to one another and share research."

NIAID also funds researchers internationally, ensuring the U.S. continues to have an influential voice in global conversations about biosecurity.

NIH has also been working to improve representation in clinical trials. Straight, white men are still overrepresented in clinical research, which has led to missed diagnoses for women and all people of color, as well as those in the LGBTQ+ community. Rose pointed to a long history of missing signs of heart conditions in women as an example. "These are the type of things commercial companies don't care about," he said, noting that NIH helps to set the agenda on these issues.

Nancy Sullivan, a former senior investigator at NIAID, said that NIAID's power is its ability to invest in a broad understanding of human health. "It's the basic research that allows us to develop treatments," she said. "You never know which part of fundamental research is going to be the lynchpin for curing a disease or defining a disease so you know how to treat it," she said.

Sullivan should know: It was her work at NIAID that led four years ago to the first approved treatment for Ebola.

Anna Maria Barry-Jester is a reporter covering global health.

Officials acknowledged some errors after they stripped Medicaid coverage from more than 2 million people.

This article was published on Thursday, September 26, 2024 in ProPublica.

By Eleanor Klibanoff, The Texas Tribune, and Lomi Kriel, ProPublica and The Texas Tribune

For three years during the coronavirus pandemic, the federal government gave Texas and other states billions of dollars in exchange for their promise not to exacerbate the public health crisis by kicking people off Medicaid.

When that agreement ended last year, Texas moved swiftly, kicking off more people faster than any other state.

Officials acknowledged some errors after they stripped Medicaid coverage from more than 2 million people, most of them children. Some people who believe they were wrongly removed are desperately trying to get back on the state and federally funded health care program, adding to a backlog of more than 200,000 applicants. A ProPublica and Texas Tribune review of dozens of public and private records, including memos, emails and legislative hearings, clearly shows that those and other mistakes were preventable and foreshadowed in persistent warnings from the federal government, whistleblowers and advocates.

Texas' zealousness in removing people from Medicaid was a choice that contradicted federal guidelines from the start. That decision was devastating in Texas, which already insures a smaller percentage of its population through Medicaid than almost any other state and is one of 10 that never expanded eligibility after the passage of the Affordable Care Act.

"The difference in how Texas approached this compared to a lot of other states is and was very striking. It wanted everybody off, anybody extra off, even though we knew that meant that state systems would buckle under the pressure," said Erin O'Malley, a senior policy analyst with Every Texan, a left-leaning statewide advocacy group.

Medicaid rolls swelled nationally during the pandemic, with tens of millions of people added to the program and no one removed. In Texas, the number of people receiving Medicaid benefits grew by more than 50%, to 6 million. When the federal government stopped requiring continuous coverage in April 2023, states had to determine who was no longer eligible.

The question wasn't whether to remove people but instead how to do it in a way that caused the least disruption and ensured those who qualified stayed on.

To that end, the federal Centers for Medicare and Medicaid Services advised states to proceed slowly and rely heavily on existing government data to automatically renew eligible residents, steps the agency believed would prevent poor families from wrongly losing coverage. Congress gave states a year for the so-called "Medicaid unwinding."

But Texas opted for speed, launching reviews of about 4.6 million cases in the first six months. It also decided against the more vigorous use of automatic renewals urged by the federal government, forcing nearly everyone to resubmit documents proving they qualified. Nearly 1.4 million of those who lost coverage were disenrolled for bureaucratic reasons like failing to return a form or completing one incorrectly, not because they weren't eligible.

The decision to buck federal government guidelines was one of many that led to serious repercussions for Texas residents who rely on the program.

Among them were children forced to forgo or postpone lifesaving operations such as heart surgeries, said Dr. Kimberly Avila Edwards, an Austin pediatrician and Texas representative for the American Academy of Pediatrics. Children with severe diseases such as sickle cell anemia, as well as those with neurodevelopmental delays and autism, also unnecessarily lost critical care.

One of her colleagues treated a boy with a rare heart condition who lost Medicaid coverage in January after his parents failed to sign a form that even his caseworker was not aware the family needed to complete.

The boy's parents couldn't afford his $6,000 monthly pulmonary hypertension medication, nor could they pay for an ultrasound that would help determine whether he could survive without the drugs, said Avila Edwards, who declined to identify him because of medical privacy laws.

"If we have children who are less healthy, who are unable to get the preventative care they need for their chronic medical conditions, that fundamentally should raise concern for all of us," she said.

The boy was eventually reenrolled in Medicaid after Texas pediatricians persuaded the state health agency to restore his coverage, Avila Edwards said.

Thomas Vasquez, a spokesperson for the Texas Health and Human Services Commission, acknowledged that the agency "learned many lessons" and is working to improve eligibility processes. HHSC representatives defended the rollout, saying that the agency conducted community outreach and hired more than 2,200 employees.

Texas' approach to the Medicaid unwinding reflected the state's long-standing conservative ideology regarding the government-subsidized program, said Simon Haeder, an associate professor at Texas A&M University's School of Public Health.

As attorney general more than a decade ago, Gov. Greg Abbott helped lead a successful lawsuit against the federal government to ensure states didn't have to cover more residents under Medicaid as part of the Affordable Care Act. Since then, Abbott and state lawmakers have continued to severely limit the program to mostly children, pregnant women and disabled adults. Poor adults aren't typically eligible for Medicaid unless they have children. Parents of two kids must earn a combined income of less than $285 monthly to qualify for coverage.

A spokesperson for Abbott declined an interview on his behalf and did not respond to a request for comment on the state's handling of the unwinding.

Texas' stance during the unwinding, Haeder said, was, "We don't do anything illegal, but we want to get our program as fast as we can down to what it was before the pandemic."

Ignored Warnings

It was inevitable that the COVID-19 public health emergency would eventually end, as would the prohibition against pushing people off the rolls. Federal officials worried about the effects of the unwinding on vulnerable Americans almost from the start. In fact, the Biden administration repeatedly extended the emergency declaration, even after the peak of the crisis, to maintain safeguards that included keeping millions of low-income people on Medicaid.

Once the emergency officially ended in April 2023, states were free to cull their rolls. In preparation, federal officials advised states not to review more than 11% of their caseloads each month, cautioning that moving more quickly could overwhelm their systems and lead to the wrongful removal of eligible people.

But that was guidance, not a requirement, and Texas chose a far more aggressive plan.

In the first month of the unwinding, the state started the review process for about a million cases, or 17% of its caseload.

The federal government in May 2023 pressed Texas on why the state was moving so quickly. State officials downplayed the concerns, writing in an email obtained by the news organizations that they were frontloading people who most likely no longer qualified and were reviewing entire households at once.

Within the first four months of the unwinding, the state dropped more than 600,000 people from Medicaid. The vast majority were removed not because the state determined they were no longer eligible but for reasons such as failing to provide the proper documents in time.

That July, U.S. Health and Human Services Secretary Xavier Becerra called on Texas and other states to increase the number of eligible people they automatically renewed with existing government data. He warned in a letter that his agency would take action against states that were not complying.

In the same week, a group of employees anonymously emailed HHSC Executive Commissioner Cecile Young and media organizations, claiming senior management had alerted them that tens of thousands of people had improperly lost Medicaid due to the agency's poor handling of the unwinding. Young's chief of staff responded in an email that she couldn't address the allegations of unidentified whistleblowers.

Texas alerted the federal government days later that it had erroneously dropped nearly 100,000 people, according to records obtained by the news organizations.

In August 2023, CMS once again implored the state to stop requiring eligible people to resubmit paperwork proving they still qualified. The federal agency said it appeared that many people didn't know they needed to reenroll, didn't understand the forms or faced obstacles in submitting the required information.

Other states that had taken a similar approach, such as Pennsylvania and Maine, made significant changes. Not Texas.

The state agency flagged to CMS last September that more than 30,000 kids lost their coverage, even though most of them should have been moved from Medicaid to the Children's Health Insurance Program, according to emails the news organizations obtained through the state's Public Information Act.

State officials later told the news organizations that 95,000 people had been wrongly removed, instead of close to 130,000, as originally reported to CMS. Asked why the figures had decreased, a spokesperson said the agency "provided approximate numbers as we worked to resolve the issue." Agency representatives said the state quickly reinstated coverage and implemented changes to prevent further improper denials. They did not provide specifics.

Alarmed by the deluge of disenrollments, advocacy groups, health providers and newspaper editorial boards began calling on the state last summer to pause the unwinding and ensure people were not incorrectly losing coverage. It did not do so.

In October, after Texas had already disenrolled more than 1.2 million people, the state gave about 400,000 people who likely qualified for Medicaid an extra month to submit paperwork, according to an agency spokesperson.

Still, problems persisted.

In December, Becerra appealed directly to Abbott and eight other governors of states with the highest shares of children who had lost coverage. Texas accounted for nearly a quarter of all children in the U.S. who had lost Medicaid or CHIP during the unwinding, Becerra wrote. He again urged the state to employ a series of actions, including automatically renewing eligible people.

Without providing details, Becerra said the federal government would not hesitate to take action against states that did not comply with federal requirements.

'A One-Two Punch'

Three months later, Micaela Hoops' children lost the government-subsidized health insurance for which they had qualified their entire lives. After years of not having to renew their Medicaid coverage under the pandemic rules, the 37-year-old North Texas mother said she was confused about when she was required to reapply and missed the deadline to provide proof of the family's income.

In other states, the kids might have been automatically renewed using other government information, like quarterly payroll data reported by employers to the state or federal tax records. Instead, Hoops had to frantically reapply seven days after the coverage lapsed in March, submitting 24 pay statements for her husband's weekly wages as a marketing director for a real estate company. This put the family at the back of a monthslong waiting list.

During that time, Hoops, a stay-at-home mom who homeschools the children, had to take her eldest son to the emergency room for a debilitating migraine. The visit came with a $3,000 bill that she and her husband could not pay. A few months later, the 14-year-old broke his nose while playing with his brother on a trampoline. She paid a few hundred dollars out of pocket for the doctor but couldn't afford the CT scan required to reset his nose.

More than 100 days after Hoops reapplied, the state restored her children's coverage retroactively. She hopes Medicaid will cover the hospital visit, but her son's nose remains crooked.

"My children didn't deserve to go without insurance," Hoops said. "They're kids. They have medical emergencies, things happen, and they deserve to be taken care of."

While Hoops' children got their Medicaid back, some families that believe they wrongly lost Medicaid are still waiting after being forced to reapply. Texas' median processing time for Medicaid applications is almost three months, according to a recent agency briefing obtained by the news organizations. This exceeds the federal limit of 45 days for most cases.

The sudden suspension of health insurance for a population the size of New Mexico has had additional ramifications in Texas, including higher treatment costs for hospitals and clinics forced to take on more uninsured patients.

Texas Children's Hospital in Houston, the largest pediatric hospital in the country, laid off employees this year after significant budget shortfalls. A hospital spokesperson declined to comment, but, in a recent financial filing, the hospital attributed some of the challenges to losing Medicaid patients during the state's unwinding process.

Across the state, some safety net clinics reported a 30% decrease in Medicaid revenue due to the unwinding, said Jana Eubank, who heads the Texas Association of Community Health Centers. She said the extra costs added to challenges for the already financially strapped facilities.

"Some centers are having to lay off staff. Some centers are furloughing staff," Eubank said. "I've got a couple of CEOs that aren't taking a salary right now. I've had centers that are unfortunately having to cut back certain services or extended hours, like behavioral health services, dental services, just because they can't afford to continue to offer that care."

Separately, some families that were pushed off Medicaid are also waiting more than a month for food assistance because Texas uses the same eligibility system to process applications for both.

San Antonio Food Bank CEO Eric Cooper said the nonprofit was crushed by demand this summer when families faced sudden medical bills, kids were out of school and the state had a backlog of more than 277,000 food stamp applications. The situation worsened when Texas declined to participate in a federal nutrition program, turning down an estimated $450 million that could have helped feed nearly 3.8 million poor children during the summer. HHSC officials said they could not get the program running in time.

"It's felt like a one-two punch, the double whammy," Cooper said.

"We haven't really felt any relief since the Medicaid unwinding and the official end of the public health emergency," he added. "It's still an emergency. It's still a crisis."

Federal Investigation

In May, after Texas' unwinding ended, the federal government launched an investigation into long waits faced by people who had applied for Medicaid coverage. Addressing these persistent delays was especially important because they affected eligible people who lost coverage in the past year, Sarah deLone, director of CMS' Children and Adults Health Programs Group, wrote in a letter to the state.

Former federal officials and health policy experts called the probe a significant step by the agency, which typically works with states behind the scenes.

But CMS has few options to hold Texas accountable if it finds wrongdoing, said Joan Alker, executive director of the Center for Children and Families at Georgetown University in Washington, D.C. The Biden administration's major enforcement tool is yanking federal funding, but that could cause low-income people to lose health insurance and invite a lawsuit from Texas, Alker said. And the investigation likely won't go anywhere if Donald Trump wins in November, she said, since the former president previously encouraged states to restrict Medicaid access and promised to undo the Affordable Care Act entirely.

CMS spokesperson Stephanie Rossy declined to comment directly on its investigation or on Texas' handling of the unwinding. But in a statement she wrote that "states' choices have real consequences for eligible people's ability to stay covered."

Although the federal probe was welcomed by advocacy groups, as well as some health care providers and Texas families, it's unlikely to immediately help eligible people who lost Medicaid during the unwinding and are waiting to get back on.

While Hoops' children have regained coverage, she believes that what her family endured reflects state leaders' attitudes toward low-income people.

"Maybe they didn't realize they were making cruel decisions," she said. Still, she feels like the state's mentality is basically, "Well, you just shouldn't be dependent on us."

Cigna tracks every minute that its staff doctors spend deciding whether to pay for healthcare. Dr. Debby Day said her bosses cared more about being fast than being right.

This article was published on Monday, April 29, 2024 in ProPublica.

In late 2020, Dr. Debby Day said her bosses at Cigna gave her a stark warning. Work faster, or the company might fire her.

That was a problem for Day because she felt her work was too important to be rushed. She was a medical director for the health insurer, a physician with sweeping power to approve or reject requests to pay for critical care like life-saving drugs or complex surgeries.

She had been working at Cigna for nearly 15 years, reviewing cases that nurses had flagged for denial or were unsure about. At Cigna and other insurers, nurses can greenlight payments, but denials have such serious repercussions for patients that many states require that doctors make the final call. In more recent years, though, Day said that the Cigna nurses' work was getting sloppy. Patient files that nurses working in the Philippines sent to her, she said, increasingly had errors that could lead to wrongful denials if they were not corrected.

Day was, in her own words, persnickety. If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.

Some of her colleagues quickly denied requests to keep pace, she said. All a Cigna doctor had to do was cut and paste the denial language that the nurse had prepared and quickly move on to the next case, Day said. This was so common, she and another former medical director said, that people inside Cigna had a term for these kinds of speedy decisions: "click and close."

In late 2020, Dr. Debby Day said her bosses at Cigna gave her a stark warning. Work faster, or the company might fire her.

That was a problem for Day because she felt her work was too important to be rushed. She was a medical director for the health insurer, a physician with sweeping power to approve or reject requests to pay for critical care like life-saving drugs or complex surgeries.

She had been working at Cigna for nearly 15 years, reviewing cases that nurses had flagged for denial or were unsure about. At Cigna and other insurers, nurses can greenlight payments, but denials have such serious repercussions for patients that many states require that doctors make the final call. In more recent years, though, Day said that the Cigna nurses' work was getting sloppy. Patient files that nurses working in the Philippines sent to her, she said, increasingly had errors that could lead to wrongful denials if they were not corrected.

Day was, in her own words, persnickety. If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.

Some of her colleagues quickly denied requests to keep pace, she said. All a Cigna doctor had to do was cut and paste the denial language that the nurse had prepared and quickly move on to the next case, Day said. This was so common, she and another former medical director said, that people inside Cigna had a term for these kinds of speedy decisions: "click and close."

"Deny, deny, deny. That's how you hit your numbers," said Day, who worked for Cigna until the late spring of 2022. "If you take a breath or think about any of these cases, you're going to fall behind."

In a written response to questions, Cigna said its medical directors are not allowed to "rubber stamp" a nurse's recommendation for denial. In all cases, the company wrote, it expects its doctors to "perform thorough, objective, independent and accurate reviews in accordance with our coverage policies." The company said it was unaware of the use of the term "click and close" and that "such behavior would not be tolerated."

During Day's final years at Cigna, the company meticulously tracked the output of its medical directors on a monthly dashboard. Cigna shared this spreadsheet with more than 70 of its doctors, allowing them to compare their tally of cases with those of their peers. Day and two other former medical directors said the dashboard sent a message loud and clear: Cigna valued speed. (ProPublica and The Capitol Forum found these other former Cigna doctors independently; Day did not refer them.) One of Day's managers in a written performance evaluation called the spreadsheet the "productivity dashboard."

Measuring the speed and output of employees is common in many industries, from fast food to package delivery, but the use of these kinds of metrics in health care is controversial because the stakes are so high. It's one thing if a rushed server forgets the fries with your burger. It's another entirely if the pressure to act fast leads to wrongful denials of payment for vital care. Walgreens in 2022 dropped measurements of its pharmacists' speed from their performance reviews after some alleged that practice could lead to dangerous mistakes.

ProPublica and The Capitol Forum examined Cigna's productivity dashboards for medical directors from January and February 2022. These spreadsheets tallied the number of cases each medical director handled. Cigna gave each task a "handle time," which the company said was the average amount of time it took its medical directors to issue a decision.

Day and others said the number was something different: the maximum amount of time they should spend on a case. Insurers often require approval in advance for expensive procedures or medicines, a process known as prior authorization. The early 2022 dashboards listed a handle time of four minutes for a prior authorization. The bulk of drug requests were to be decided in two to five minutes. Hospital discharge decisions were supposed to take four and a half minutes.

"Medical directors would message me and say, 'We can't do these cases in four minutes. Not if you want to do a good job,'" Day recalled.

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

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

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

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

Day was afraid to look at the dashboards. Anyone could see that by Cigna's measures, she was a laggard. In January 2022, only a third of her peers had lower scores, and in February 2022, it was just a quarter.

In a recorded phone call and in emails with supervisors, Day complained that Cigna's metrics failed to account for the quality of decisions. She said she and others asked higher-ups how often medical director decisions were overturned on appeal but nobody would say.

Day gave Cigna written permission to discuss her employment with ProPublica and The Capitol Forum.

The company described Day as a "disgruntled former employee" and said her "personal view is not an accurate representation of the work of the many medical directors and clinicians we employ." Cigna added that prior authorization requests are often time-sensitive and the company's "mission is to ensure our patients receive the right care as quickly as possible."

Cigna rejected the assertions that denying cases was an effective way of working faster. "Even if medical directors were incentivized to review more claims — which they are not — it makes no sense to suggest that this incentivizes denials; it would be far quicker to approve all claims," the company spokesperson wrote. The insurer said that denials take more time because they require a deeper review of clinical data, potentially requesting additional reviews by senior clinical directors, drafting denial letters and possibly phoning the treating physicians.

But another doctor who had worked at Cigna also said that denying a request for payment was far quicker than approving one since the nurses served up language that could be used to justify the denial. That former Cigna medical director said, "Sometimes you just have to accept the nurse and click and close if you had too much work." (That doctor asked not to be named because they feared repercussions if they commented publicly.)

When Debby Day got her job at Cigna in November 2005, she thought it was a godsend.

She had been working for a health insurance startup in North Carolina. The charismatic founder of the company, Day said, had told her and a handful of principal executives to expect a windfall when the company went public. That never happened, and Day was eventually left with no job and no severance.

When a recruiter mentioned the medical director job at Cigna, it sounded like a perfect fit. The job was based in North Carolina, but Cigna didn't mind that she was licensed in California, where she did her residency at Harbor-UCLA Medical Center. She was ready to leave the executive track, and the position allowed her to put her medical training to good use without the daily grind of working in a clinic.

The daughter of an ophthalmologist, Day had watched her father perform eye surgery when she was a child, and she found medicine fascinating. When Day started practicing, she learned quickly that while she enjoyed the intellectual challenges of medicine, the hands-on work of seeing patients drained her. As a medical director, she said, "I could really take care of patients without having to talk to them all day long."

Cigna, like all health insurers, makes patients get approval in advance for certain treatments. Day became one of the people who reviewed these prior authorization requests, deciding what to cover and what to deny. Everyone Day worked with was under one roof in Raleigh, North Carolina. The office buzzed with conversations among colleagues, and she was able to consult with specialists on complex cases.

She never felt pressure to do anything but make the right decision for the patient. At the same time, she said, she didn't hesitate to reject treatment she thought was improper.

Day describes herself as persnickety but feels that the time she spent reviewing case files was essential to reaching the right decision. Credit:Andrea Bruce for ProPublica

A couple years into her time at Cigna, Day noticed some doctors prescribing a costly treatment called intravenous immunoglobulin, or IVIG, that helps patients with weakened immune systems fight off infections. Only she found they were prescribing it in cases where it didn't make any medical sense. That wasn't good for patients or for Cigna. "Some of these guys were pouring it into every patient they could get their hands on and then making hundreds of thousands of dollars billing for it," she recalled.

At the time, Cigna didn't have a policy for when IVIG should be used, so Day developed one based on the scientific evidence available at the time. Day said this saved millions of dollars and that Cigna rewarded her with bonuses and stock options.

"In my head I truly believed that you could marry good health care with business," she said.

As Day neared the end of her first decade at Cigna, the company closed regional offices in favor of a nationwide review system, she said. With medical directors working from home, Day could no longer pop down the hallway to consult with doctors in other specialities.

Cigna had used a productivity dashboard for years, but by 2019, these metrics began playing a more prominent role in the company's evaluations of medical directors, Day said. Now, making a fast decision seemed more important than making the right decision, she said. In February 2019 emails to her managers, Day openly questioned this system.

Her boss responded: "We all understand that many cases are involved and take more time," he wrote. "We have tried to account for that additional time in the allotment allowed for certain cases."

Still, he made it clear that transaction volume — the metric on the dashboard that was similar to a productivity score — was one of the factors "we use to determine merit raises, bonus" and stock awards. When asked about this, Cigna said that "any assertion that our Medical Directors' compensation (cash or stock) is tied to denials or their handle time for cases is false."

In that same 2019 email, Day's boss added, "We want to assist every medical director who wishes to improve his or her efficiency."

Day shot back, "Some of our newer MDs are quite terrified of the 'counting,'" she wrote. "All ask — 'how is quality measured?'"

Soon, Day realized that her boss wasn't talking in the abstract about improving efficiency; he was talking about her. She learned that managers were going to help her pick up the pace of her reviews.

When bosses reached out, they didn't discuss whether she was making the right call, only how long it took her to decide, she said.

By then, Day said, Cigna had shifted much of the nursing work to the Philippines. She found mistakes in the case files that these nurses sent. In an email to Day, a fellow medical director lamented the amount of time it took to untangle one case and said the reports by "the overseas nurses" were "messes."

Some of the more astonishing problems that Day spotted have stayed with her. In a case involving a newborn who needed an epilepsy evaluation, Day noticed that a Cigna nurse had listed the mother's name as the patient, rather than the baby's. Day fixed that mistake, avoiding what certainly would have been a denial. In another case, a nurse recommended denying payment for an ultrasound of the neck because the treatment wasn't medically necessary. But the nurse had gotten the body part wrong. It was a hip that was injured, and the imaging was needed. An appeal that landed on Day's desk involved Cigna's decision to reject payment for a test because it wasn't medically necessary for a patient with a sexually transmitted disease. But Day figured out that the patient had toenail fungus, not an STD.

Day said her bosses didn't want to hear that she was catching errors. By October 2020, Cigna had placed Day on a performance improvement plan that required her to raise her "productivity level" — referring to the score on the dashboard — to at least 70%, which would be a significant jump for her but was slightly below the median for medical directors. The company made the consequences crystal clear: If she failed to successfully complete the plan, she could be terminated.

ProPublica and The Capitol Forum asked Cigna how it calculated that score, but the company wouldn't say. "Transaction volume helps gauge productivity and efficiency — the amount of work done, not the speed at which it is done," a Cigna spokesperson wrote. The company said this metric measured the time a medical director spent on tasks involving medical judgment versus other work, such as internal meetings or training.

On the early 2022 productivity dashboard, though, a different calculation could explain Day's score, and this math reflects how fast medical directors reviewed cases. ProPublica and The Capitol Forum multiplied the number of cases Day handled by the time Cigna allotted for each type of case, then divided that total by the hours she worked that month. The resulting percentage equaled her score. Medical directors who spent every available minute of their workdays clearing cases within the time constraints Cigna set would score at least 100%. Indeed, some medical directors had scores greater than 100%, meaning they cleared cases in even less than the allotted time. The newsrooms' formula accurately reproduced the scores of 87% of the Cigna doctors listed; the scores of all but one of the rest fell within 1 to 2 percentage points of the number generated by this formula. When asked about this formula, Cigna said it may be inaccurate but didn't elaborate.

Day said her bosses told her that the way to boost her score was to review more cases during her normal work hours.

Responding to questions, Cigna said the productivity dashboard was "primarily used to ensure that we have enough medical directors to perform the amount and type of work that needs to be done." It is not used, the company said, to evaluate the performance of medical directors or track the speed at which individual doctors do their work.

Cigna, however, later said of the dashboard that "in the unusual situation that a medical director is a significant outlier to peers performing similar types of reviews, managers might use this metric as one data point to understand and discuss the variance with the medical director." It also said Day was placed on a performance improvement plan "to help her meet the most basic standards to support patient care."

During the time Day spent on the performance improvement plan, she refused to change her approach, which she felt was necessary to make the right call.

In December 2020, she appealed to the human resources department, figuring that colleagues there would see that it was wrong to fire a medical director for taking care to decide critical medical questions.

She was wrong.

"You feel that the time constraints/metrics, which are in place to review these cases are unreasonable, for some cases are very complex consisting of multiple pages to review," a Cigna human resources employee wrote, summing up Day's feelings as the matter escalated.

And while Day's supervisor "appreciates your attention to detail," the human resources employee wrote, he "also realizes that there are metrics in place that he must hold everyone to."

When asked about this, Cigna said, "Dr. Day raised questions about her performance improvement plan through appropriate internal ethics channels available to all employees, and there was no wrongdoing found."

Eventually, the daily stress of being pushed to work faster coupled with the threat of being fired took a toll on Day. Sleepless and fighting depression, Day was at the breaking point.

"I actually sort of had a mental breakdown," she recalled.

On a recorded call with her boss about her lagging productivity score, Day brought the subject back to the quality of the decisions she was making. Her boss made it sound like Day was a broken record.

"We have the same discussion every time we talk," he said. While saying "nobody's asking you not to do quality work," her boss said, "you must know I just have to redirect our discussion."

But Day continued: "When there is no measurement of quality, then the discussion will continue to have that element to it."

The supervisor said he heard Day's concerns "loud and clear" but warned that "at the end of the day, we need to get your productivity up and we don't have a lot of time to do that."

The focus on metrics was proof Cigna was losing its way, Day told her boss. When she started working at Cigna 15 years earlier, there was a "commitment to quality and taking care of our customers." Day said that it was still important to her and other medical directors that "we go home at the end of the day and think we've done a good job for Cigna."

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

In a response to questions, Cigna said the supervisor, who works in California, was unaware that he was being recorded and that under that state's laws, it is illegal to record a private phone call without all parties' consent. Day said that she was in North Carolina during the call and that North Carolina law allows a person on a call to record without getting the consent of others.

Day took a monthslong leave from the job in mid-2021 that allowed her to work part time, and she found a therapist who helped her manage the depression. When she returned, Day said, it was more of the same.

In the late spring of 2022 she decided to retire from Cigna.

In a written response to questions, Cigna said its medical directors are not allowed to "rubber stamp" a nurse's recommendation for denial. In all cases, the company wrote, it expects its doctors to "perform thorough, objective, independent and accurate reviews in accordance with our coverage policies." The company said it was unaware of the use of the term "click and close" and that "such behavior would not be tolerated."

During Day's final years at Cigna, the company meticulously tracked the output of its medical directors on a monthly dashboard. Cigna shared this spreadsheet with more than 70 of its doctors, allowing them to compare their tally of cases with those of their peers. Day and two other former medical directors said the dashboard sent a message loud and clear: Cigna valued speed. (ProPublica and The Capitol Forum found these other former Cigna doctors independently; Day did not refer them.) One of Day's managers in a written performance evaluation called the spreadsheet the "productivity dashboard."

Measuring the speed and output of employees is common in many industries, from fast food to package delivery, but the use of these kinds of metrics in health care is controversial because the stakes are so high. It's one thing if a rushed server forgets the fries with your burger. It's another entirely if the pressure to act fast leads to wrongful denials of payment for vital care. Walgreens in 2022 dropped measurements of its pharmacists' speed from their performance reviews after some alleged that practice could lead to dangerous mistakes.

ProPublica and The Capitol Forum examined Cigna's productivity dashboards for medical directors from January and February 2022. These spreadsheets tallied the number of cases each medical director handled. Cigna gave each task a "handle time," which the company said was the average amount of time it took its medical directors to issue a decision.

Day and others said the number was something different: the maximum amount of time they should spend on a case. Insurers often require approval in advance for expensive procedures or medicines, a process known as prior authorization. The early 2022 dashboards listed a handle time of four minutes for a prior authorization. The bulk of drug requests were to be decided in two to five minutes. Hospital discharge decisions were supposed to take four and a half minutes.

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

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

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

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

Day was afraid to look at the dashboards. Anyone could see that by Cigna's measures, she was a laggard. In January 2022, only a third of her peers had lower scores, and in February 2022, it was just a quarter.

In a recorded phone call and in emails with supervisors, Day complained that Cigna's metrics failed to account for the quality of decisions. She said she and others asked higher-ups how often medical director decisions were overturned on appeal but nobody would say.

Day gave Cigna written permission to discuss her employment with ProPublica and The Capitol Forum.

The company described Day as a "disgruntled former employee" and said her "personal view is not an accurate representation of the work of the many medical directors and clinicians we employ." Cigna added that prior authorization requests are often time-sensitive and the company's "mission is to ensure our patients receive the right care as quickly as possible."

Cigna rejected the assertions that denying cases was an effective way of working faster. "Even if medical directors were incentivized to review more claims — which they are not — it makes no sense to suggest that this incentivizes denials; it would be far quicker to approve all claims," the company spokesperson wrote. The insurer said that denials take more time because they require a deeper review of clinical data, potentially requesting additional reviews by senior clinical directors, drafting denial letters and possibly phoning the treating physicians.

But another doctor who had worked at Cigna also said that denying a request for payment was far quicker than approving one since the nurses served up language that could be used to justify the denial. That former Cigna medical director said, "Sometimes you just have to accept the nurse and click and close if you had too much work." (That doctor asked not to be named because they feared repercussions if they commented publicly.)

When Debby Day got her job at Cigna in November 2005, she thought it was a godsend.

She had been working for a health insurance startup in North Carolina. The charismatic founder of the company, Day said, had told her and a handful of principal executives to expect a windfall when the company went public. That never happened, and Day was eventually left with no job and no severance.

When a recruiter mentioned the medical director job at Cigna, it sounded like a perfect fit. The job was based in North Carolina, but Cigna didn't mind that she was licensed in California, where she did her residency at Harbor-UCLA Medical Center. She was ready to leave the executive track, and the position allowed her to put her medical training to good use without the daily grind of working in a clinic.

The daughter of an ophthalmologist, Day had watched her father perform eye surgery when she was a child, and she found medicine fascinating. When Day started practicing, she learned quickly that while she enjoyed the intellectual challenges of medicine, the hands-on work of seeing patients drained her. As a medical director, she said, "I could really take care of patients without having to talk to them all day long."

Cigna, like all health insurers, makes patients get approval in advance for certain treatments. Day became one of the people who reviewed these prior authorization requests, deciding what to cover and what to deny. Everyone Day worked with was under one roof in Raleigh, North Carolina. The office buzzed with conversations among colleagues, and she was able to consult with specialists on complex cases.

She never felt pressure to do anything but make the right decision for the patient. At the same time, she said, she didn't hesitate to reject treatment she thought was improper.

A couple years into her time at Cigna, Day noticed some doctors prescribing a costly treatment called intravenous immunoglobulin, or IVIG, that helps patients with weakened immune systems fight off infections. Only she found they were prescribing it in cases where it didn't make any medical sense. That wasn't good for patients or for Cigna. "Some of these guys were pouring it into every patient they could get their hands on and then making hundreds of thousands of dollars billing for it," she recalled.

At the time, Cigna didn't have a policy for when IVIG should be used, so Day developed one based on the scientific evidence available at the time. Day said this saved millions of dollars and that Cigna rewarded her with bonuses and stock options.

"In my head I truly believed that you could marry good health care with business," she said.

As Day neared the end of her first decade at Cigna, the company closed regional offices in favor of a nationwide review system, she said. With medical directors working from home, Day could no longer pop down the hallway to consult with doctors in other specialities.

Cigna had used a productivity dashboard for years, but by 2019, these metrics began playing a more prominent role in the company's evaluations of medical directors, Day said. Now, making a fast decision seemed more important than making the right decision, she said. In February 2019 emails to her managers, Day openly questioned this system.

Her boss responded: "We all understand that many cases are involved and take more time," he wrote. "We have tried to account for that additional time in the allotment allowed for certain cases."

Still, he made it clear that transaction volume — the metric on the dashboard that was similar to a productivity score — was one of the factors "we use to determine merit raises, bonus" and stock awards. When asked about this, Cigna said that "any assertion that our Medical Directors' compensation (cash or stock) is tied to denials or their handle time for cases is false."

In that same 2019 email, Day's boss added, "We want to assist every medical director who wishes to improve his or her efficiency."

Day shot back, "Some of our newer MDs are quite terrified of the 'counting,'" she wrote. "All ask — 'how is quality measured?'"

Soon, Day realized that her boss wasn't talking in the abstract about improving efficiency; he was talking about her. She learned that managers were going to help her pick up the pace of her reviews.

When bosses reached out, they didn't discuss whether she was making the right call, only how long it took her to decide, she said.

By then, Day said, Cigna had shifted much of the nursing work to the Philippines. She found mistakes in the case files that these nurses sent. In an email to Day, a fellow medical director lamented the amount of time it took to untangle one case and said the reports by "the overseas nurses" were "messes."

Some of the more astonishing problems that Day spotted have stayed with her. In a case involving a newborn who needed an epilepsy evaluation, Day noticed that a Cigna nurse had listed the mother's name as the patient, rather than the baby's. Day fixed that mistake, avoiding what certainly would have been a denial. In another case, a nurse recommended denying payment for an ultrasound of the neck because the treatment wasn't medically necessary. But the nurse had gotten the body part wrong. It was a hip that was injured, and the imaging was needed. An appeal that landed on Day's desk involved Cigna's decision to reject payment for a test because it wasn't medically necessary for a patient with a sexually transmitted disease. But Day figured out that the patient had toenail fungus, not an STD.

Day said her bosses didn't want to hear that she was catching errors. By October 2020, Cigna had placed Day on a performance improvement plan that required her to raise her "productivity level" — referring to the score on the dashboard — to at least 70%, which would be a significant jump for her but was slightly below the median for medical directors. The company made the consequences crystal clear: If she failed to successfully complete the plan, she could be terminated.

ProPublica and The Capitol Forum asked Cigna how it calculated that score, but the company wouldn't say. "Transaction volume helps gauge productivity and efficiency — the amount of work done, not the speed at which it is done," a Cigna spokesperson wrote. The company said this metric measured the time a medical director spent on tasks involving medical judgment versus other work, such as internal meetings or training.

On the early 2022 productivity dashboard, though, a different calculation could explain Day's score, and this math reflects how fast medical directors reviewed cases. ProPublica and The Capitol Forum multiplied the number of cases Day handled by the time Cigna allotted for each type of case, then divided that total by the hours she worked that month. The resulting percentage equaled her score. Medical directors who spent every available minute of their workdays clearing cases within the time constraints Cigna set would score at least 100%. Indeed, some medical directors had scores greater than 100%, meaning they cleared cases in even less than the allotted time. The newsrooms' formula accurately reproduced the scores of 87% of the Cigna doctors listed; the scores of all but one of the rest fell within 1 to 2 percentage points of the number generated by this formula. When asked about this formula, Cigna said it may be inaccurate but didn't elaborate.

Day said her bosses told her that the way to boost her score was to review more cases during her normal work hours.

Responding to questions, Cigna said the productivity dashboard was "primarily used to ensure that we have enough medical directors to perform the amount and type of work that needs to be done." It is not used, the company said, to evaluate the performance of medical directors or track the speed at which individual doctors do their work.

Cigna, however, later said of the dashboard that "in the unusual situation that a medical director is a significant outlier to peers performing similar types of reviews, managers might use this metric as one data point to understand and discuss the variance with the medical director." It also said Day was placed on a performance improvement plan "to help her meet the most basic standards to support patient care."

During the time Day spent on the performance improvement plan, she refused to change her approach, which she felt was necessary to make the right call.

In December 2020, she appealed to the human resources department, figuring that colleagues there would see that it was wrong to fire a medical director for taking care to decide critical medical questions.

She was wrong.

"You feel that the time constraints/metrics, which are in place to review these cases are unreasonable, for some cases are very complex consisting of multiple pages to review," a Cigna human resources employee wrote, summing up Day's feelings as the matter escalated.

And while Day's supervisor "appreciates your attention to detail," the human resources employee wrote, he "also realizes that there are metrics in place that he must hold everyone to."

When asked about this, Cigna said, "Dr. Day raised questions about her performance improvement plan through appropriate internal ethics channels available to all employees, and there was no wrongdoing found."

Eventually, the daily stress of being pushed to work faster coupled with the threat of being fired took a toll on Day. Sleepless and fighting depression, Day was at the breaking point.

"I actually sort of had a mental breakdown," she recalled.

On a recorded call with her boss about her lagging productivity score, Day brought the subject back to the quality of the decisions she was making. Her boss made it sound like Day was a broken record.

"We have the same discussion every time we talk," he said. While saying "nobody's asking you not to do quality work," her boss said, "you must know I just have to redirect our discussion."

But Day continued: "When there is no measurement of quality, then the discussion will continue to have that element to it."

The supervisor said he heard Day's concerns "loud and clear" but warned that "at the end of the day, we need to get your productivity up and we don't have a lot of time to do that."

The focus on metrics was proof Cigna was losing its way, Day told her boss. When she started working at Cigna 15 years earlier, there was a "commitment to quality and taking care of our customers." Day said that it was still important to her and other medical directors that "we go home at the end of the day and think we've done a good job for Cigna."

In a response to questions, Cigna said the supervisor, who works in California, was unaware that he was being recorded and that under that state's laws, it is illegal to record a private phone call without all parties' consent. Day said that she was in North Carolina during the call and that North Carolina law allows a person on a call to record without getting the consent of others.

Day took a monthslong leave from the job in mid-2021 that allowed her to work part time, and she found a therapist who helped her manage the depression. When she returned, Day said, it was more of the same.

In the late spring of 2022 she decided to retire from Cigna.