The trouble is that Dr. Iinuma denied Mr. Washington’s appeal without having reviewed it. Mr. Washington sued Aetna for “reckless withholding of benefits,” and as part of the lawsuit, Dr. Iinuma was deposed. During the deposition, Dr. Iinuma admitted that he had never reviewed Mr. Washington’s records. He knew this because during his time as the medical director for Aetna, he had not reviewed any patient’s medical records. We apparently should not find this concerning, because he also admitted that he did not know anything about common variable immunodeficiency and did not know the consequences of stopping therapy.
With the system we have now, … [w]e learn to overdocument & undertreat, using regimens that we know are doomed to failure, because we must demonstrate that failure to gain access to the drugs that might actually help our patients.
The mind reels. We have all complained—privately and not so—about implacable insurance companies making arbitrary or ill-reasoned decisions, but I wonder how many of us suspected that these decisions were not reasoned at all. And yet, this seems like a natural extension of what we already knew to be true. Of all the times I have received a rejection of preapproval from an insurance company, I wonder how many times the undersigned recognized (or could even spell) granulomatosis with polyangiitis. Treating rheumatic diseases is challenging even for rheumatologists; it is difficult to imagine that every medical director of every insurance company is actually a peer.
Even if Dr. Iinuma had reviewed every page of Mr. Washington’s medical record, it seems doubtful that it would have changed his decision. That possibility was precluded by Dr. Iinuma’s lack of understanding of the patient’s illness and lack of interest in learning about the condition before rejecting a therapy that, by his own admission, he knew nothing about. Dr. Iinuma cannot be the first medical director to sign off on a decision that he was not qualified to make; he was just the first to be caught.