Three additional states have joined California in an investigation of the third largest insurer in the United States – Aetna – alleging their medical director denied a $20,000-per-dose infusion, admitting in a deposition that he never looked at [the] patient’s medical records. The media and public have cried out that the insurer has put profits over patient health. Much of the media attention was focused on the statement made during a sworn deposition. Now Aetna has countered with another sworn statement from the doctor stating that while he did not look at the entire medical record he did evaluate relevant sections and that the doctor followed claim protocols.
It is very popular to go after the health insurance companies. They are an easy target which play well in our soundbite-driven society – but a balanced report by CNN shows there is a lot more to this case. Aetna has countered that the denial is due to the fact the patient refused requested medical tests. Apparently, although the condition was ongoing, there had been no blood work to evaluate effectiveness of the drug in three years. To me, it’s unclear why the tests were refused. Having been intimately involved in medical appeals during my 25+ years in this business, insurance companies are always receptive to peer to peer discussions with physicians if there is some special circumstance that mitigated the need to perform follow-up tests.
But that’s not my point; this case highlights the divisiveness in our system. It is important to note that the alternative to insurance carrier oversight is government oversight and this denial has played into the hands of the single-payer movement – and I am not sure that’s the answer. Would you rather argue with an insurance carrier or the government? How do you feel about the DMV or the IRS? I am on vacation right now in a single-payer country and my taxi driver spent much of the ride complaining about care rationing, which is incredible in her country. To me what comes to mind first is “why does this drug cost $20,000 per dose?” Let’s do something about the cost of healthcare and stop putting politics into it. The politicians should be spending their time on more important things – like keeping our schools safe.