Aetna Debacle Deepens Skepticism about Coverage Decisions

Think an informed medical expert is making the coverage decisions at your health insurance company?  You might think again.

In a story that’s sending ripples of outrage across the country, CNN reports that a former California medical director for insurance giant Aetna didn’t consider patients’ medical records when deciding to approve or deny care.  Ever.

CNN calls the admission “stunning.”  But patient advocates might call it just plain predictable.

“For years, doctors have taken precious time away from patient care, even hired additional staff, to manage health insurers’ over-the-top prior authorization demands,” explained pulmonologist Samuel Louie, MD, of the University of California Davis Health.  “And what are their medical directors and experts doing with all this paperwork?  Not even giving it a glance before they deny our patients care.”

“If it is happening at one insurance company,” added Dr. Louie, who is a member of the Alliance for Patient Access, “think what is happening at all the others.”

California neonatologist and National Coalition for Infant Health Medical Director Mitchell Goldstein, MD, echoed these concerns.  “This story confirms one of physicians’ nagging fears: Coverage decisions aren’t really about patient need; they’re about insurers’ profit margins.”



What Happened in California

The medical director in question, Jay Ken Iinuma, MD, worked for Aetna from 2012 to 2015.  His admission of ignoring patients’ medical records emerged during a lawsuit filed by an Aetna beneficiary who was denied life-saving medication during Dr. Iinuma’s tenure.

California Insurance Commissioner Dave Jones is worried.

“If the health insurer is making decisions to deny coverage without a physician actually ever reviewing medical records, that’s of significant concern to me as insurance commissioner in California,” Commissioner Jones explained, “and potentially a violation of law.”

Dr. Iinuma relied upon nurses’ recommendations for his decisions.  He says he was just following Aetna’s protocol.

The insurance company should soon have a chance to explain that protocol.  Commissioner Jones launched an investigation of Aetna that will include reviewing every denial of coverage from the medical director’s tenure, explains CNN.

Patients, Not Profits

For patients and physicians who are weary of jumping through health plan hoops, the investigation offers a glimmer of justice.

But real change demands that policymakers in California and beyond take a closer look at health plan approval processes – and consider how the system can be reformed to once again put patients’ interests above health plans’ profits.


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