Wellpoint has been slammed (justifiably) for its rescission practices (retroactively canceling insureds’ policies when they have the temerity to actually get care) and sued for allegedly inflating earnings expectations (although some of the slamming is, in my view, unjustified).
United Healthcare has also crossed the stupid line a time or four, inflating the CEO’s compensation package by back-dating stock options and fumbling the acquisition and integration of Pacificare, publicly fighting with providers (although occasionally I have to come down on UHC’s side) and mishandling customer complaints.
HealthNet has not escaped unscathed either. The company went way way past the stupid line when it actually paid bonuses based on executives’ success in canceling individual policies (but only for individuals with high claims).
Aetna has been able to avoid embarrassing itself, while making some significant strides in areas that matter. Whether its chronic disease management, sharing data re provider quality and price, or publishing data on outcomes, the huge insurer is moving in the right direction.
Aetna has also been able to build a substantial presence in the work comp network business, essentially forcing its largest competitor to replace its networks with Aetna’s (while sticking with WC despite doubts among industry experts (that would include me) that Aetna had the patience required to survive and prosper).
Their latest move also makes sense – Aetna is investigating a P4P model for pharma, potentially basing payment on efficacy for the wildly expensive specialty drugs.
Perhaps this is partially due to lessons learned after the company’s well-publicized stumbles after merging with USHealthcare a decade ago. For a while, the staid, customer-oriented culture at the old mother Aetna looked to be overwhelmed by the aggressive, no-holds-barred, occasionally-downright-nasty USHC approach. Management righted the ship just in time, and Aetna has enjoyed better relations with providers, solid financial returns, and growing membership for several years now.
As one reader pointed out some months ago, mother Aetna is certainly capable of doing much more – pushing disease management further and faster, becoming more aggressive on P4P, and building out its member services applications.
But compared to its competitors, Aetna is doing well. Sure, the stock is down by 25% so far this year, but that’s a result UHC, Wellpoint, HealthNet, Humana, and Coventry owners would take in a heartbeat.
Mar
20
Unfortunately when it comes to Aetna’s chronic disease management, they are also often crossing the stupid line. For example, they would rather deny (claiming it’s experimental) a fully FDA approved continuous glucose monitor (CGMS) for a diabetic with hypoglycemia unawareness (about $999 plus intermittent supplies costing about about $125/month) in favor of paying routine ambulance and emergency room visits during severe hypoglycemia (e.g. eleven ambulance calls, [some with ER also] in one calendar quarter.) If each ambulance call is about $600 and the ER is another $1500, which is a smarter financial expenditure for the company? But they prefer the ambulance/ER combo.
Anonymity, if Aetna has denied your claim, it’s most likely that you do not fit the clinical criteria and also possible that your physician has failed to make your case, if he thinks you do fit the clinical criteria. I have a suggestion:
Go to Aetna’s PUBLIC site for coverage policy,
http://www.aetna.com/cpb/cpb_menu.html
select “Medical” (you may also have to click on “I accept”) then under Search CPB’s type in Continuous Glucose Monitoring. Open the most recent statement, dated 2/8/08. Read what you find.
· Continuous Glucose Monitoring Devices:
Aetna considers continuous glucose monitoring devices (e.g., MiniMed Continuous Glucose Monitoring System, Guardian Real-Time Continuous Glucose Monitoring System, and the DexCom STS), which are used to continuously monitor diabetic persons’ blood glucose levels over a three-day (72-hour) period, medically necessary for persons with type 1 diabetes who have either of the following problems in controlling blood glucose level, unresponsive to conventional insulin dose adjustment:
· repeated hypo- and hyperglycemia at the same time each day; or
· hypoglycemia unawareness.
No more than two CGMS monitoring periods are considered medically necessary within a 12-month period. Aetna considers the long-term use of continuous glucose monitoring devices for home self-monitoring of blood glucose experimental and investigational.
[Excerpts from Discussion] Continuous Glucose Monitors
Guidelines from the National Institute for Health and Clinical Excellence (2004) recommend the use of continuous glucose monitoring devices for the evaluation of persons with type 1 diabetes on insulin therapy who have “repeated hypo- and hyperglycaemia at the same time each day, and hypoglycaemia unawareness, unresponsive to conventional insulin dose adjustment.”
There is insufficient evidence to support the prolonged use of continuous glucose monitoring devices as an adjunct to home blood glucose monitoring. The potential advantages of adjunctive use of continuous glucose monitoring devices in managing persons with poorly controlled diabetes are theoretical. There are no adequate prospective clinical studies in the peer-reviewed published medical literature demonstrating that the use of continuous glucose monitoring devices results in durable improvements in outcomes of individuals with diabetes.
The American Diabetes Association Position Statement “Tests of Glycemia in Diabetes” (2004) recommends that the frequency and timing of glucose monitoring be dictated by the needs and goals of the individual patient. For most persons with type 1 diabetes, self-monitoring of blood glucose three or four times daily by the standard finger-stick method is sufficient. The ADA guidelines conclude that the “role [of CGMS] in improving diabetes outcomes remains to be established.”
A major limitation of CGMS is the durability and stability of the glucose sensors. Interstitial glucose concentrations, obtained with subcutaneous sensors, correlate with blood glucose concentrations. However, the sensors become progressively less accurate over time, so they cannot be used on a maintenance basis, and must be changed every three days. Another potential concern is the six to ten minute delay in interstitial glucose sensor response to changes in serum glucose levels. This delay appears to be most important when glucose levels are falling rapidly, since it might result in development of clinically significant hypoglycemia before it was reflected in the sensor reading
Are you kidding me. Aetna was just one of 16 insurance companies New York Attorney General Andrew Cuomo issued subpoenas for just last month. “In a scheme by health insurers to defraud consumers by manipulating reimbursement rates.”
Anonymity – no, I’m not “kidding” you, I’m providing you good information.
If you want your claim paid, you ought to be paying attention.
Do you want Aetna to change its mind about paying you – or not?
Joe… I have to disagree with you. I do not like the direction Aetna is going with their WC network product. In lieu of sending actual WC PPO contracts to secure legitimate WC PPO discounts with providers, AWCA recently sent out letters to providers in our state indicating “you’re in our network unless you opt out”, and we will start applying discounts effective May. The providers are in an uproar and have alerted the Bureau of WC to this practice.
I was hoping AWCA would be a good alternative to Coventry and hoping their reputation would improve with the provider community, but in my opinion, this is a major set back.
Please note, there were two posts from Anonymity preferred (i.e.different people.)
TO: John Fembup:
I am very well aware of Aetna’s CPBs, inaccurate as they may be by citing the use of Continuous Glucose Monitoring as “experimental” (as a clinical rationale for denial.)
Your citation )and theirs) of outdated information clearly shows their lack of currency and use of evidence based medicine. CGMS devices were approved for “Continuous use” by the FDA in 2005, not just for three days of monitoring.
Would you also advocate continuous ambulance and emergency room visits for recurring unconscius hypoglycemia over CGMS which could provide warnings to a TYPE 1 diabetic with hypoglycemia unawareness before the blood sugar drops too much and reduce the risk of an episode of unconscious hypoglycemia, ambulance and ER which are substantially more costly than a CGMS device and supplies.
For an industry that continuously thinks about financial impacts, just the math shown in the original post clearly demonstrates this. Perhaps the financial impact of automatically denying medically necessary services has a positive impact on the CEO and CMO’s pockets, but jeopardizes the healthcare of their consumers resulting in much higher healthcare expenditures. How can they feel good about that?
“Please note, there were two posts from Anonymity preferred (i.e.different people.)”
Swell. I read somewhere that historians are not entirely agreed whether the Iliad was written by Homer, or by someone else using the same name. I guess it’s reasonable to conclude it doesn’t matter, either in Homer’s case, or in yours.
May we return to your original comment. You complained that Aetna would not recognize the expense of a particular medical device under certain conditions. The CPB I posted appears to state that Aetna DOES consider use of the device medically necessary – and therefore covered – under the very conditions you described. Not knowing about your familiarity with Aetna’s CPB’s, or your low opinion of them, I thought pointing this one out would be helpful to you. Time to think again.
If Aetna won’t cover the device it seems to me the most likely reason is that, based on research disclosed in the CPB, Aetna considers the device appropriate for limited use, while you want Aetna to buy the devices for you on demand without limit. Aetna’s position may be “stupid” – or it may reflect a willingness to spend more when it’s necessary to ensure that patients actually receive effective treatment. From the information in your comments, it’s not apparent which is true although you do not hide your own opinion on the matter.
Aetna’s CPB is dated 2008. You say you know of research from 2005 that contradicts their position. Medical research can be contradictory or equivocal, as you must be aware. Still, if you know of more compelling research than Aetna is using, that is something you should be discussing with Aetna. Or maybe Aetna made a mistake and failed to follow their own guidelines. Wouldn’t be the first time. That is also something you should be discussing with Aetna. Or maybe you have not sufficiently demonstrated that Aetna’s clinical criteria have been met in this case. In each situation, you need to be discussing the matter with Aetna like the rational person you are.
I am concerned that I need 1 more day of home health care to remove the huber needle sticking out of my chest, and my mediport flushed with heparin which I do not have, and you will not approve the 1 day of Oct. 2 2008. I called the 800 number spoke with a repersenative and was told there was nothing they could do. This is my 1 and only submission. Deborah