Former Aetna Medical Director Never Looked at Patients' Records Before Approving or Denying Care

Arthur L. Caplan, PhD


February 28, 2018

Hi. I'm Art Caplan. I'm at NYU School of Medicine. I head the Division of Medical Ethics.

A shocking report came out from CNN. It said that they had found a deposition in a legal case involving a former chief medical officer at Aetna Insurance who had said that he, in reviewing appeals for coverage from doctors for their patients, had not paid any attention to the information supplied, the dossiers given, the standard-of-care information. He had just rubber-stamped what his underlings, almost exclusively nurses, had recommended about saying yes or no [in regard to whether] a patient could get something or be denied something.

This is terrifying because it reeks of indifference to patients' interests. I know that many physicians watching this are going to say, "I'm not surprised, I'm not shocked; I deal with this indifference all the time—people delay and they don't want to cover, and they're trying to save money by turning down things." It isn't a surprise that maybe they were quicker to rubber-stamp a no than to try to look carefully at the information supplied by the physician advocating for coverage for a patient.

I think we heard a lot about death panels back in the days when Obamacare was first being proposed. People were saying that we can't do this because we're going to have government panels determining who will live and who will die. What this case in California reminds us about is that there are panels making these life-and-death decisions all the time, whether it's the formulary committee at the hospital that makes decisions about what you can prescribe or not have available, all the way up to insurance companies that have benefits committees—which hopefully behave better than this one apparently did but are making decisions about whether you can get something or not get something.

I think there are a couple of lessons to be learned going forward so that, whether it's government decision-making, for-profit private decision-making, or health system decision-making, all of us—every American citizen—understands what's taking place. First, we need transparency. How do the decisions get made? What evidence is submitted? What are the reviewers supposed to be looking at? Who's doing the reviewing? Can you appeal or not appeal the decision? How does all of that work? We're getting a lot of decision-making about resource limits behind closed doors in what I would generously describe as star chambers with no one watching. That's not acceptable.

I think the other reform that ought to happen is, we need more patient and community voices sitting on some of these committees. I understand that the average citizen is not an expert on pharmacology to be placed on the formulary committee, but they bring values and perspectives that I think ought to be reflected in some of that decision-making. Certainly, when you have Aetna or other insurance companies—health systems making decisions on coverage appeals—the voice of the patient, the voice of someone who speaks from the patient's point of view, ought to be present and ought to be heard. To some extent, the committee ought to be accountable to saying that that member was present and knew what the rest of us were talking about as doctors, as experts in medicine.

I think more transparency, more understanding of the procedures that are used to make these decisions, and more input from lay people and patients are needed. That's the future we should head toward if we're going to do something about decision-making where life and death hang in the balance, but it isn't always clear that the decision maker is doing what they're supposed to be doing.

I'm Art Caplan at the NYU School of Medicine. Thanks for watching.


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