The ugly truth behind Aetna doctor's testimony

A company doctor who spent three years reviewing medical claims for the insurance giant Aetna has confessed that he n...

Posted: Feb. 16, 2018 9:12 AM
Updated: Feb. 16, 2018 9:12 AM

A company doctor who spent three years reviewing medical claims for the insurance giant Aetna has confessed that he never once looked at any patient's medical records before making his decisions. The doctor, Jay Ken Iinuma, said during a deposition in a lawsuit that he followed Aetna's procedures and relied only on nurse's summaries.

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Iinuma's sworn testimony, first reported by CNN, left a lot of people shaking their heads, but physicians like me also nodding knowingly. This sure explains a lot. Sure, brief medical snapshots help doctors handle heavy caseloads, but anyone doing the job responsibly must also stop and look into the actual chart. Frequently.

Iinuma said he never did.

There's reason to believe Iinuma's confession is an accurate peek into the inner workings of the nation's third-largest health insurer. We've been here before.

A congressional whistleblower named Dr. Linda Peeno told a House subcommittee in 1996 about what she called "the dirty work of managed care." "In the spring of 1987, as a physician, I caused the death of a man," she said -- by denying him coverage for a heart transplant. "I was 'rewarded' for this. It bought me an improved reputation in my job, and contributed to my advancement afterwards. Not only did I demonstrate I could indeed do what was expected of me, I exemplified the 'good' company doctor: I saved a half million dollars!"

Peeno is now a medical ethicist, and has engaged in a long campaign against the abuses she saw in her former line of work. Michael Moore featured her in his 2007 documentary "Sicko."

After reading the CNN story, Peeno told me via email that it makes her "disheartened," but she's been disheartened for years now. While Obamacare improved access and affordability, it isn't doing enough to regulate a system that's designed to limit coverage, she says. "The fact that the medical director didn't look at the charts didn't surprise me" she wrote. "It would surprise me if he did." She says medical directors are "superfluous" and there to give a "veil of legitimacy" to a system where the clinical information is strained by much lower level staff through tight criteria designed to weed out claims.

As for Iinuma, who oversaw Aetna's Southern California claims, that state's insurance commissioner is vowing to scrutinize every case where he denied treatments. No wonder: Over three pages of his transcribed testimony, Iinuma responds quite clearly to a variety of questions trying to get at whether he ever laid eyes on actual medical records like doctor's notes, imaging reports, pathology and so on, as they appear in a patient's chart. Repeatedly, his answer is "No."

We can credit this discovery to a lawsuit by Gillen Washington, a 23-year-old who takes an expensive treatment called intravenous immunoglobulin for his common variable immune deficiency, or CVID. In CVID some of the body's immune cells are defective, and don't produce enough immunoglobulins, key proteins that help the immune system fight off infections. Washington claims that Iinuma's decision to deny the treatment for a period of time (while insisting on updated lab results) led to his suffering an acute bout of his illness during which he almost died. Iinuma also testified he knew next to nothing about the condition.

These tales of "utilization review" (the industry's suitably anodyne term for questioning your health care choices) ring true when I reflect on the time I've logged on the other side of the phone and fax machine, advocating for my patients. I treat people who are often catastrophically injured in accidents of all sorts. These injuries upend lives, and while we do our best to put them back together again, the process is so long and expensive we confront the limits of insurance coverage on a regular basis.

When I go to bat for one of my patients, I'll sometimes prep like I'm about to appear on a cable news shouting match. The medical director on the other end of the line doesn't want to give me the time of day, so he or she immediately starts reciting whatever internal insurance criteria my patient doesn't meet. It's my job to try to get a word in edgewise, explaining in sometimes pressured speech why a particular barrier to coverage shouldn't apply to my patient.

My team and I have fantasized about sending in videos of our patients. It's funny how progress that's obvious in a video often doesn't show up in the industry's preferred scales. We know video would help humanize our patients, too. We want to make the insurance company denials as real as possible for the people with beating hearts sitting behind company keyboards. But the companies won't allow it. So we try to make our patients' stories jump out of the medical records, and we hope the right person on the other end is at least paying attention.

But as Iinuma's testimony lays bare, our records are picked over and plugged into the insurance company's forms and fields. It's a system we no longer need only suspect is designed to make denials come more efficiently.

I don't dispute that there's plenty of wasteful and bogus so-called medical care that insurance companies shouldn't pay for, and sometimes it calls for a doctor to spot another doctor's shoddy recommendations. Such work might even call for dusting off the chart. I'm not trying to order those kind of "treatments," nor are my similarly frustrated colleagues.

The uncomfortable subtext in every conversation I've had with an insurance medical director -- and I've had hundreds -- is cost control. In some cases I've made the assertion explicitly: Isn't this really about what the treatment costs? The reply is usually black and white: The policy as written doesn't allow any of this, or any more of that.

Wherever physicians work, whether in hospitals or in biotech companies or even in the insurance industry, we have a higher oath than even the one we take in a court of law. We first pledge to do no harm. Whenever we find ourselves in a system that violates that foundational oath, we must try our best to change it, as Peeno has done. We cannot allow ourselves to become cogs in a dangerous machine, or we'll take the whole of medicine down with us.

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