An Aetna medical director said he didn't review any cases, a bombshell admission even for one doctor, and damning if a normal practice.
CNN managed to get the attention of California’s insurance regulator Dave Jones over a bombshell admission in a suit against Aetna over the denial of care.1 From a videotaped deposition, as summarized in MedCity News Aetna’s former medical director Dr. Jay Ken Iinuma, whose job was to review whether to authorize payments:
He went on to admit he never looked at patients’ records at Aetna and instead relied on information provided by a nurse. Most of his work, he said, was found online. During any given month, Iinuma said he’d call a nurse “zero to one” times to gather more data.
Iinuma was a medical director at Aetna from 2012 to 2015. Commissioner Jones was so outraged over the testimony that he has not only opened up an investigation but is also soliciting information from other Aetna patients who believe they were treated improperly. The state insurance departmetn site urges “any Californians who are concerned that they might have been affected to contact the California Department of Insurance at 1-800-927-4357.” If you have trouble getting through, they also have a “File a Complaint” page.
Medical professionals were stunned by Iinuma’s admission. From the CNN story:
“Oh my God. Are you serious? That is incredible,” said Dr. Anne-Marie Irani when told of the medical director’s testimony. Irani is a professor of pediatrics and internal medicine at the Children’s Hospital of Richmond at VCU and a former member of the American Board of Allergy and Immunology’s board of directors.
“This is potentially a huge, huge story and quite frankly may reshape how insurance functions,” said Dr. Andrew Murphy, who, like Irani, is a renowned fellow of the American Academy of Allergy, Asthma and Immunology. He recently served on the academy’s board of directors..
Dr. Arthur Caplan, founding director of the division of medical ethics at New York University Langone Medical Center, described Iinuma’s testimony as “a huge admission of fundamental immorality.”
“People desperate for care expect at least a fair review by the payer. This reeks of indifference to patients,” Caplan said…
Murphy, the former American Academy of Allergy Asthma and Immunology board member, said he was “shocked” and “flabbergasted” by the medical director’s admission.
“This is something that all of us have long suspected, but to actually have an Aetna medical director admit he hasn’t even looked at medical records, that’s not good,” …
“If he has not looked at medical records or engaged the prescribing physician in a conversation — and decisions were made without that input — then yeah, you’d have to question every single case he reviewed.”
Murphy said when he and other doctors seek a much-needed treatment for a patient, they expect the medical director of an insurance company to have considered every possible factor when deciding on the best option for care.
Even though it is tempting to jump to worst-case conclusions, we’ve seen too often in corporate scandals that that is precisely how things pan out. As famed short seller David Einhorn says, “No matter how bad you think it is, it’s worse.”
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