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.”
As the doctors’ comments above indicate, at a bare minimum, every decision made by Iinuma could be subject to sanctions by the State of California, and every denial of care made by him could be challenged by patients. But even as Aetna is taking the standard big company line of “We had procedures in place, nothing to see here,” at a bare minimum, there was a breakdown in controls, and a real possibility that Iinuma was merely an extreme version of a widely accepted practice of what amounted to doctor robosigning of nurse-at-best reviews.
Aetna’s Handwave Defense
Amusingly, Aetna’s initial response is to point to its policies. Its written comment to CNN:
We have yet to hear from Commissioner Jones but look forward to explaining our clinical review process.
Aetna medical directors are trained to review all available medical information — including medical records — to make an informed decision. As part of our review process, medical directors are provided all submitted medical records, and also receive a case synopsis and review performed by a nurse.
Medical directors — and all of our clinicians — take their duties and responsibilities as medical professionals incredibly seriously. Similar to most other clinical environments, our medical directors work collaboratively with our nurses who are involved in these cases and factor in their input as part of the decision-making process.
This is insulting to the intelligence, and does not speak well for Aetna either. They can’t deny what Iinuma said in his deposition. Yet it looks like they think they can even beat back what is sure to be their bare minimum level of exposure: that of facing a penalty for his decisions plus having all of his denials opened up to patient challenges. The much better posture from a PR perspective would be to throw Iinuma under the bus, for Aetna to say it was appalled at his statement and would investigate.
As anyone who has been in a large organization knows, formal policies often exist solely as a liability shield for senior management and mean bupiks in practice. The real rules of the road are codified in what behaviors are rewarded (what is paid and who gets promoted). Another signal is goals and metrics.
It’s not hard to see that Aetna’s passive “We give medical directors the patient records and the nurse-provided summary and recommendation” is a grotesque effort to pretend it has no institutional responsibility. It’s as if its medical directors just needed to sit through the training and then they were independent operators using Aetna-provided information.
Go back to Iinuma. At a bare minimum, he had to be processing a ton of cases as a result of his lack of review. Given how Corporate America is obsessed with costs, you can be sure it was tracking how many cases medical directors completed over some time frame, say daily or weekly.
So there are only two possibilities here, neither of them pretty:
1. There was no supervision of Iinuma, no higher-level check whatsoever on his volume and quality of review
2. Iinuma’s high volume output was exactly what Aetna wanted
Do you seriously believe 1, which appears to be what Aetna is trying to portray? Even if true, they can’t pretend that they are not ultimately responsible for what their employees do. This approach might limit the damage to Iinuma provided there aren’t other cases of medical directors not reviewing patient records. Aetna may hope the California insurance director doesn’t go on a wide-ranging investigation, and that other insurance directors don’t jump in. That seems pretty unlikely. At a minimum, New York State has a tough insurance bureau, and it’s not hard to imagine them opening an inquiry based on what unfolds in California.
It seems far more probable that Aetna had targets or incentives to reward medical directors for keeping approvals down as well as total output targets. Just like the mortgage servicing robosigners, medical directors like Iinuma may have been given so many cases to get done that there was no way to get through them without rubber stamping most of them. He may have been engaging in normal behavior, or not very far outside common practice.
The first step for Commissioner Jones is to demand Iinuma’s personnel reviews and those of his immediate boss. That will tell pretty clearly what behavior they really wanted from their medical directors.
Given Aetna’s ham-handed initial response, we might be in for a replay of a Wells-Fargo-esque effort to shift blame for top management setting goals that could be achieved only by fraud onto lower level “bad apples”. Stay tuned.
1 I’ve skipped over the underlying lawsuit because it winds up being ancillary to the deposition admission, plus the CNN summary has me wondering if more facts are needed to make sense of what happened.
The short version is plaintiff Gillen Washington is suing Aetna for breach of contract and bad faith. He was diagnosed with common variable immunodeficiency (CVID). Based on some web searches, it appears that the protocol for people diagnosed with CVID includes regular, from what I can infer, typically monthly intravenous immunoglobulin (IVIG) infusions, which are pricey. CNN says they cost up to $20,000 a treatment. The literature also makes clear, in a not-very-coded fashion, that life expectancy with CVID depends to a significant degree on how well the condition is managed.
Washington had been with Kaiser and then had his policy transferred to Aetna. After approving some IVIG treatments, Aetna then denied them. This is the part that is squirrel-y, from CNN:
But when Washington’s clinic asked Aetna to pre-authorize a November 2014 infusion, Aetna says it was obligated to review his medical record. That’s when it saw his last blood work had been done three years earlier for Kaiser.
Despite being told by his own doctor’s office that he needed to come in for new blood work, Washington failed to do so for several months until he got so sick he ended up in the hospital with a collapsed lung.
Once his blood was tested, Aetna resumed covering his infusions and pre-certified him for a year. Despite that, according to Aetna, Washington continued to miss infusions.
Washington’s suit counters that Aetna ignored his treating physician, who appealed on his behalf months before his hospitalization that the treatment was medically necessary “to prevent acute and long-term problems.”
“Aetna is blaming me for what happened,” Washington told CNN. “I’ll just be honest, it’s infuriating to me. I want Aetna to be made to change.”
Since I don’t have access to the filings, it may be that Washington filed his case and the material above comes from Aetna’s response, and Washington’s side has yet to reply to it (or that may come only in the trial phase). It would seem to make no sense for Washington not to have gotten a blood test, unless his doctor was arguing with Cigna that the annual blood tests weren’t medically necessary (as in CVID one of those conditions you never get over). This isn’t as crazy as it sounds in light of this admission by Iinuma:
During his videotaped deposition in October 2016, Iinuma — who signed the pre-authorization denial — said he never read Washington’s medical records and knew next to nothing about his disorder.
Questioned about Washington’s condition, Iinuma said he wasn’t sure what the drug of choice would be for people who suffer from his condition.
Iinuma further says he’s not sure what the symptoms are for the disorder or what might happen if treatment is suddenly stopped for a patient.
“Do I know what happens?” the doctor said. “Again, I’m not sure. … I don’t treat it.”
While it may be that Washington was a non-complaint patient, the tenor of his response suggests that he believes Aetna misrepresented what happened. He may be posturing for the press, but he presents himself as more interested in getting Aetna to shape up than getting monetary damages. He’s making a lot of progress on that front already. And if that is his aim, he would be more likely than most plaintiffs to go to court to expose Aetna’s conduct. So there are decent odds of getting a more detailed account of what went on with his case.