Gillen Washington was a student at Northern Arizona University in 2014 when his health insurer, Aetna, denied authorization for the costly drug infusion he’d been receiving each month to treat his rare immunodeficiency disease. He appealed, but while he was waiting for a decision he wound up hospitalized with pneumonia and a collapsed lung.
These ugly facts were enough to prompt a lawsuit, but Washington’s claim against Aetna surfaced an even uglier revelation: that Aetna’s medical director at the time, Dr. Jay Ken Iinuma, granted or denied coverage for treatments without ever bothering to look at the patients’ medical records. According to CNN, Iinuma said in his sworn deposition that he relied on what he was told by the nurses working for Aetna, who checked to see whether the requested treatments complied with the insurer’s guidelines.
Aetna’s lawyers have defended Iinuma’s handling of the case, and the company issued a statement asserting that its guidelines are “based on health outcomes and not financial considerations.” In other words, the company contends, it second-guesses the doctors who treat its customers not to keep costs down so much as to improve the quality of their care.
Others aren’t buying that explanation. CNN’s report triggered investigations by two California agencies and an explosion of outrage, particularly among doctors. "If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records, that is a significant concern and could be a violation of the law," California Insurance Commissioner Dave Jones said in a statement about his investigation.
Jones’ comment, though, glides right past the bigger question. Although CNN’s story focused on alleged deficiencies in how Aetna handles claim reviews, it’s worth remembering that virtually every insurer interposes itself into the doctor-patient relationship to review and potentially deny payment for treatments, drugs, devices and therapies. And make no mistake — denying authorization amounts to vetoing a treatment for all but the very few people who can afford to cover the cost out of pocket (although California law does give consumers the right to an independent medical review whenever an insurer declines to pay).
Why do we put up with insurers telling doctors how to treat their patients? Because one of the flaws in the current healthcare system is the way it encourages many doctors, hospitals, drug companies and other care providers to find the most intensive, expensive way to treat patients. With some notable exceptions, providers are rewarded for volume, not value. Keeping patients healthy is a lousy way for doctors to make money when they’re paid by the procedure. Having corridors of unused beds is a symptom of a sick hospital.
So insurers are often the only brake on runaway spending in a system notorious for duplicative testing, defensive medicine, fraud and other forms of waste. If they maintain up-to-date guidelines on the most effective treatments, they can also serve as a check on providers who don’t. They can push back against doctors and hospitals unduly swayed by drug and device representatives peddling costly new therapies. And they can prod doctors to do a better job discussing treatment options with their patients, who typically have so little medical knowledge that they depend on their doctors to make these choices for them.
That’s the theory, at least. But in practice, it’s impossible to tell whether an insurer is denying a treatment because it’s not the right one or because it’s costly. In Gillen Washington’s case, Aetna reportedly balked at paying for a new infusion until he had another blood test showing he still needed treatment. Advocates for people with immunodeficiency diseases say that they often encounter this sort of roadblock from insurers — prove you still need the treatment — even if their conditions are incurable.
So, as healthcare is practiced in much of America, patients’ interests don’t line up well with either their providers’ or their insurers’. But rising costs and climbing premiums have prompted employers, governments and the healthcare industry to explore alternative ways to deliver and pay for care that do a better job aligning everyone’s interests. The most promising ones encourage doctors and hospitals to take over the job of reviewing treatment decisions and promoting best practices, while rewarding them for delivering the most efficient and effective care.
Washington’s story would still be unnerving if it turns out that a physician at Aetna had personally reviewed his medical records. The bottom line is that the insurer withheld approval for months for the infusion his doctor had ordered, a treatment that could have spared him weeks of misery. But in the current system, that sort of tension between insurers, doctors and patients is hard to escape. That’s why we need to keep moving toward a better one.