Media headlines have run amok over the so-called “stunning admission” obtained during a deposition of a former Aetna medical director whose job was to authorize (or deny) patient pre-certifications of insurance coverage. As a result of his sworn statements, uncovered during a lawsuit against the insurer, he in part suggested that during his tenure he never personally reviewed medical records to inform his opinion and mostly made his decisions based on relevant information collected and presented to him by nurses.
Despite the fact he recently clarified his understanding of the attorney’s questions with more detailed and informative answers, he opened Pandora’s box at the mere prospect of even a morsel of truth being behind his prior version. The result has been an enraged public (See Notes Section). Initially affirming this as standard and customary protocol of the company drew such a firestorm that state officials from California along with Colorado, Washington and Connecticut are now investigating the behemoth health insurers’ protocols and practices for denials of coverage.
But, is it even ethical for a doctor to be in this role at an insurance company?
The ex-medical director says
“In addition to reviewing the relevant portions of submitted medical records, it was also generally my practice to review Aetna nurses' summaries, notes, and the applicable Aetna Clinical Policy Bulletins...After reviewing the relevant, submitted portions of the medical record, the nurse's notes, and the Clinical Policy Bulletin(s), I would apply my medical training, experience, and judgment to reach an appropriate coverage determination."
But, is there not an innate conflict of interest for a doctor who has taken an oath to first do no harm to be in a position to deny a patient what their treating physician recommends in the first place? What happens when Aetna (or any of the insurers) Clinical Policy Bulletins are incongruous with standard of care or what is in the best interest of the patient?
The lines only get more malleable with increasing complexities in cases. Defining the moment someone is not our patient when we are still a doctor and tasked to uphold the sanctity of the doctor-patient relationship calls into question the ability to fulfill our duty to maintain a certain ethical standard and guarantee that relationship remains on solid ground.
Could being a medical director at an Aetna represent the ultimate in conflict of interest?
Just because a job exists does not make it one that’s worthwhile. That said, one might argue that having some doctors at insurance carriers is essential to keeping them in check. But, the constant tug-of-war between the goals of a physician and that of a health insurance provider are routinely not aligned. Constant tension might be an occupational hazard and when you are reliant on your income to sustain your family your power to change things is likely very limited while employed.
Your voice is probably only greater once no longer there. And, if a non-disclosure agreement had been signed, then your hands are tied.
Part of such a job requirement is to determine outliers in hospital lengths of stay and to be the ultimate arbiter in appeals. I imagine on occasion this can be a positive thing given you might pick up bad practices that could potentially harm the patient. But, all too often, the background of the medical director might not even be the most informed to make a decision within that specialty.
Why is the testimony in this instance so stunning an “admission” at all?
Doctors forever have been shouting from the rooftops to anyone who would listen about the frustrations over coverage for their patients. But, crickets. For years, we have lamented the rampant delay, delay, deny, deny tactics employed to alter physician behavior. Some offices have the resources to battle insurance carriers all day, many do not and this becomes an additional burden for the health care professional which manages to serve no purpose other than to distract from patient care - while also unnecessarily intensifying a usually stressful situation for the patient.
As I have long maintained, health coverage has got to stop being conflated with health care. They are not the same. The former often antagonizes the latter.
What’s the solution?
Creating false narratives that blame doctors for supposed “burnout” or claim they reflect the lion’s share of healthcare costs is a dishonest start. Until doctors and patients are no longer marginalized players in the health care discussion, endless competing profit centers like insurance carriers will only continue to erode and further fragment the system. Leaving them to their own devices has not been a successful path. (Check out The Big Ideas in Medicine Often Come From The Front Lines, Not The Ivory Tower here).
Note(s):
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As per CNN, Aetna -the nation’s third-largest provider covering 23.1 million Americans -is fighting back maintaining the physician’s words were "taken out of context” and insisting “medical records were in fact an integral part of the clinical review process."
The ex-medical director has also clarified his testimony:
“When I stated at the deposition that I never looked at a 'medical record' while at Aetna, I understood the term 'medical record' to refer to the entirety of a patient historical file containing all charts, doctors' notes, laboratory tests, and any other report generated by a treating provider for that patient...In my mind, and based on my experience, this is the definition of a patient's 'medical record' -- a record of their treatment and medical history. Not only is a patient's medical record generally a very large file or files, in my experience neither patients nor providers submit the entirety of a patient's medical record to Aetna. Patients and providers submit only portions of a patient's medical record for Aetna's review...
