The Other Side of Opioids

LAS VEGAS – Nightly newscasts across the country are filled with stories about the opioid epidemic — the opioid crisis. Tens of thousands of Americans who die each year are found with opioids in their systems, and so government at every level has stepped in to put limits on otherwise legal medications, including here in Nevada. For millions of chronic pain patients, the crackdown has been a nightmare. They are the forgotten victims in the opioid debate. Approximately 50,000 people a year die with opioids of one kind or another in their systems. The number you don’t hear is this one — there are as many as 25 million Americans who suffer with chronic pain. For many of them, opioid medication means the difference between leading somewhat normal lives, or surviving in constant agony. These are not the people who O.D. on heroin or mix drugs with booze. For the most part, they suffer and die in silence.

NO ONE can diagnose… and NO ONE wishes to help manage the pain ?

At 34-I have had chronic pain & migraines all my life- My mother used to tell me of all the times I Used to bang my head when I was a baby- I have suffered with migraines so bad it felt like my brain was going to squeeze thru my nose- I have pain all thru my body and have seen at least 100 doctors- most of them specialists- if there are others out there like me-I could use someone to talk to- someone to share ideas with or find out if there is a way to correct it- I am NOT A DRUG SEEKER- I am a pain relief seeker but NO ONE believes me- how do I get that across to any doctor or nurse? Does anyone know of a good patient advocate in Dover Delaware? would a Patient Advocate even help or do I have to continue with this miserable condition where I truly cannot lead a life- (I won’t say normal- I just want a life) Please contact me if there is any advice or referrals that I could access.

Almost 1 million Canadians give up food, heat to afford prescriptions: study

http://www.cbc.ca/news/canada/british-columbia/canadians-give-up-food-heat-to-afford-prescriptions-study-says-1.4533476

Nearly one million Canadians spent less on necessities like food and heat to afford their prescriptions in 2016, according to a new study.

The paper, published Tuesday, found that 730,000 people skimped on food and another 238,000 spent less on heating their home — a total of 968,000 people.

“We knew lots of Canadians were having trouble paying for medication,” said Michael Law, lead author on the paper and associate professor in UBC’s school of population and public health.

“Now we know they are trading off other everyday necessities in order to pay for prescription drugs.”

Vitamins and supplements

Canada is the only country in the world that has universal health care but no universal drug coverage. (David Gray/Reuters)

The study surveyed 28,091 people as part of the Statistics Canada Canadian Community Health Survey, asking questions about their finances and prescriptions.

People without insurance, people with lower incomes and younger people in general were more likely to say they struggle to afford medication.

Indigenous people were nearly twice as likely to report challenges, as were women comparatively to men.

The study also said more than 1.6 million Canadians — 8.2 per cent of people who were prescribed medication in 2016 — didn’t fill those prescriptions, skipped doses, or otherwise didn’t take the medicine because they couldn’t pay for it.

 

pharmacy

The study said more than 1.6 million Canadians prescribed medication in 2016 didn’t fill those scrips, skipped doses, or otherwise didn’t take the medicine because they couldn’t afford it. (iStock)

Not taking prescribed medication strains the health-care system, researchers said, as people who stay sick end up taking repeat visits to their doctor or the emergency room. 

The researchers — who are from UBC, Simon Fraser University, McMaster University, and The University of Toronto — said results show that Canada needs to take another look at how prescriptions are covered.

“Despite Canada’s reputation of having a universal healthcare system, the fact that so many people cannot afford their medicines is a sign that people are falling through the cracks,” Law said.

Universal care, no universal coverage

Canada is the only country in the world that has universal health care but no universal drug coverage.

Previous studies have said Canadians pay the second-highest drug prices in the world, after the United States.

On Friday, B.C. announced prescription-drug deductibles will be lowered or eliminated for those making less than $30,000 a year.

Health Minister Adrian Dix said families earning between $15,000 and $30,000 will no longer pay any deductibles for medication.

The cuts will come with changes to B.C.’s Fair PharmaCare plan on Jan. 1, 2019.

US drug companies accused of being ‘cheerleaders’ for opioids

https://www.theguardian.com/us-news/2018/feb/13/us-drug-companies-accused-cheerleaders-opioids

The five biggest companies making prescription opioids have been accused by a US Senate committee of spending $10m on patient advocacy and medical groups to encourage use of the addictive drugs, which are at the root of a public health crisis in America.

The committee reported on Monday that Purdue Pharma, manufacturer of leading narcotic painkiller OxyContin, made the largest donations to outside groups that present themselves as advocates for people suffering from chronic pain.

“In some instances they are merely fronting for these manufacturers, especially if you look at the lobbying they’ve done against restricting opioids,” said McCaskill, adding: “These financial relationships were insidious, lacked transparency, and are one of many factors that have resulted in arguably the most deadly drug epidemic in American history.”

The committee, which has been investigating Big Pharma practices from 2012 to 2017, said Purdue Pharma gave the most money, $4.15m to 12 groups. Purdue said in a statement that it supported organisations interested in helping patients receive appropriate care.

The report notes that organizations such as the American Academy of Pain Medicine play down the risks of addiction and abuse. The report names Purdue Pharma, Janssen Pharmaceuticals, Mylan, Depomed and Insys Therapeutics.

McCaskill launched the investigation last spring by saying: “We want to get to the bottom of why, all of a sudden, opioids have been handed out like candy in this country.”

Another congressional attorney that was in law school during the 70’s… as the DEA/war on drugs was ramping up… Criticizing that Purdue pharma gave about 1/3 million dollars to 12 different pro-patient chronic pain groups..  This is just one of the 535 members of Congress who the lobbyist industry spends 9+million/day to influence these members of Congress…

Congresswoman Mc Caskill won’t have to run for re-election until 2022… voters have short memories so she has plenty of time for voters to forget what Mc Caskill has investigated or voted for.

 

 

What has healthcare in this country SANK TO ?

I Am a 49 year old man with a rare syndrome called Klippel -Trenaunay- Webber -Syndrome..I been fighting this all my life without any doctors knowing what to do for me but rip me open time after time after time. Ever since they started the stop on opioids my pain doctor tells me he can’t do nothing but reduce me cause of the DEA. I’m about to put a bullet in my head to stop the extreme pain I get from him reducing me I am not a drug addict but yet cause of what is going on I get shuffled with them I am a chronic pain suffer NO MORE NO LESS. My doctor tells me I’m going to even get knocked down more when he does this I will not know if I can deal with it cause of what he’s doing I’m stuck in a wheel chair now I haven’t seen my blood doctor or my heart doctor. I get blood clots and bleed very bad get serious infections through out my body that needs to be monitored but can’t get to a hospital to be moved..please help or get my story out there. At my wits end why aren’t they going cause to case why is it that drug addicts get free clinics opened in New Jersey to go and soot up but I can’t get nothing to help with my pain…at this point in my life I don’t know if I should start going that way since that is the way the GOVERNMENT WANTS ME TOO. Or just end my pain. Can’t take it anymore please help…..

 

While I do not encourage anyone to commit suicide… there are some pts in this country are being left with a single choice to put a “end” to their pain – permanently…  Should these chronic pain pts make a final effort to share their pain… making a video… do a facetime live… make a post on FB… send a letter to many friends they can trust to follow thru with their wishes… and that would be to have their prescriber to be charged with assisting suicide or assisting manslaughter… what ever legal violation that they can be charged with…

IF they are so F-ing concerned about their license and their livelihood… shouldn’t a pt put in this position take that final swing at making sure that the prescriber gets what he/she is afraid of… losing their license and their livelihood…  The DEA has “taken out” untold number of prescribers because a small number of their pts have OD’d … maybe they committed suicide and the DEA is their zest to find a prescriber to “take to the cleaners” that they don’t look for the reason for the OD.

Those pts who have been pushed to this point should be “mad as hell and not going to take it anymore” and will spend their final hours/days in sharing their pain with those who have caused them to be in this position.

Personally, I am tried of trying to be politically correct and trying to offer pts some “guidance ” in dealing with their plight… when I know damn good and well that any reference that I give them… it will take 1-2 yrs for the bureaucrats that are suppose to protect these people from being abused to get their bureaucratic ass in gear.. .and we all know by then it will be too little too late.

I just made this post The “NO WIN GAME” … damn if you do… damn if you don’t  

where a prescriber is being sued by a spouse because her husband committed suicide while he was in the middle of a two month weaning down from being on opiates for chronic pain.  It is obvious that healthcare professionals have NO FEAR OF PTS… I feel sorry for this prescriber.. but.. this lawsuit could change the path that chronic pain treatment in this county could take…

Probably, the DEA doesn’t really care about public safety

opioid_supplement_fda_warning_25330089

Don’t ban kratom, end the War on Drugs instead

www.sbsun.com/2018/02/12/dont-ban-kratom-end-the-war-on-drugs-instead/

For hundreds of years, people have used kratom leaves or powders for pain relief.

Currently legal in the United States, millions of Americans have safely used kratom for therapeutic and recreational purposes.

In recent years, federal agencies which have no regard for individual liberty like the Drug Enforcement Administration and the Food and Drug Administration have set their sights on kratom.

In 2016, the DEA announced plans to “place the active materials in the kratom plant into Schedule I of the Controlled Substances Act in order to avoid an imminent hazard to public safety.”

Schedule I of the Controlled Substances Act is the most restrictive category of the drug scheduling system and includes drugs like heroin and marijuana. Practically, this would prohibit kratom for any use under federal law.

The DEA later backed off of this decision, an odd move if the DEA seriously believed the American people faced “an imminent hazard to public safety” because of kratom. Probably, the DEA doesn’t really care about public safety, it’s more interested in expanding its own powers and keeping the money flowing.

But now, the prospect of kratom prohibition is back. The FDA recently reiterated its own “concerns about kratom’s potential for abuse, addiction, and serious health consequences; including death.”

As evidence, the FDA pointed to 44 deaths involving the use of kratom. But as Reason pointed out, most of those deaths involved the presence of multiple drugs and many involved other health problems, and are hardly evidence of anything other than that bad things have happened to some people who have ingested kratom at some point prior to their deaths.

And as a group of nine scientists argued in a letter to the White House, “the existing science on kratom does not justify its placement into Schedule I of the CSA, nor for kratom to be added to any local or state Controlled Substances list that would effectively remove it from consumer access.”

Proponents of safe access to kratom and individual liberty alike should make clear their opposition to any attempt by the federal government to prohibit or overly restrict access to kratom. People should absolutely be aware of any risks or dangers of kratom use, but prohibition will only punish those with legitimate needs and create a whole new black market with all the risks and downsides black markets have.

Rather than exert the force of government to punish people for ingesting substances unapproved by some government bureaucrats, the federal government should respect the freedom of people to make their own choices and do with their own bodies what they wish.

Sal Rodriguez is an editorial writer and columnist for the Southern California News Group. He may be reached at salrodriguez@scng.com

 

Another example of DEA”S interpretation of CSA is UNCONSTITUTIONAL ?

Hemp Industrial Association’s Lawsuit Against DEA Lands in Court This Week

http://www.cannabisbusinesstimes.com/article/hia-dea-lawsuit-hemp-industrial/

This week, several federal lawsuits will push marijuana legalization into a judicial spotlight. On Wednesday, attorney Bob Hoban will offer oral arguments in support of his plaintiff clients in Hemp Industries Association v. Drug Enforcement Administration (DEA).

The crux of that lawsuit is the DEA’s stance toward industrial hemp and whether it conflicts with language in the 2014 U.S. Farm Bill. Within that landmark agricultural legislation, the U.S. Congress defined industrial hemp as “all parts of the plant cannabis sativa l., so long as the dried materials of the plant is less than 0.3 percent THC.”

But a January 2017 DEA “final rule” includes industrial hemp in its marijuana enforcement drug code, with the net result being no distinction between the non-psychoactive hemp compounds and the rest of the cannabis plant’s chemical makeup. According to the DEA, any amount of THC subjects the plant to the Controlled Substances Act. The HIA argues that cultivation of industrial hemp should be permitted legally, citing the Farm Bill language.

The current federal lawsuit has roots in a 2003 lawsuit, which bore much of the same argument. The Ninth Circuit Court of Appeals ruled in favor of the HIA in 2004.

In January of this year, 28 members of the U.S. Congress published a letter of support for the HIA. “The [DEA’s] Final Rule is inconsistent with the Farm Bill’s most fundamental purpose: to allow states that wish to experiment with commercial research and development of industrial hemp, including extracts and derivatives therefrom, to do so without interference from the DEA.”

In a public statement provided at the time the lawsuit was filed, Hoban’s associate, Garrett Graff, wrote, “We hope to accomplish a striking of the rule, permanent injunction of the rule and for the DEA to engage in the appropriate processes and procedures when making rules in the future. Alternatively, an amendment to the rule to make the definition of ‘marihuana extract’ consistent with existing law and reflect those portions and varieties of the plant which are in fact lawful could be considered.”

In our February 2018 issue of Cannabis Business Times, we took at close look at upcoming federal marijuana litigation, including HIA v. DEA. We also looked to Alexis Bortell v. Jess Sessions, for which oral arguments will take place on Feb. 14 in New York’s Southern District Court, and Colorado Alternative Health Care v. IRS.

Are cracks in the “war on drugs” facade… starting to form/show ?

See the source image

Could things in the war on drugs’ facade starting to show cracks ?  There has been a few things coming to the front that may suggest that may be the case…

I have made several posts over the past couple of weeks that I have not seen before

The “NO WIN GAME” … damn if you do… damn if you don’t

we know that it is normal for the DEA to come after a prescriber when a pt OD’s on opiates.. it is as if a prescriber never has a pt die… never has one that commits suicide… and that all opiate OD’s are “accidental “?  I have had untold number of chronic pain pts that have told me that they have contacted numerous law firms about suing for denial of care, ADA violations, pt abuse, medical battery and the like and have yet to find a law firm that is interested in their case.

The above article about a prescriber is being sued for a pt’s suicide – no doubt it was a suicide because the pt used a GUN… the prescriber had been weaning the pt off of his opiates for about one month and had promised to continue assistance in weaning for another month.. when the pt chose the ultimate solution to end his pain.

Yet a law firm is apparently ready, willing and able to sue this prescriber on behalf of the pt’s spouse because of the pt’s suicide.  Is this lawsuit just an anomaly or the first in many that may come to bear on prescribers for various reasons in failing to properly treat – or not treat at all – chronic pain pts.. especially those suffering from intractable moderate/severe chronic pain and have a medical necessity for 24/7 opiate therapy ?


if I approve too many expensive drugs, I won’t get my bonus at the end of the month.

This is story about a number of medical directors for various insurance companies who stated that they routinely deny coverage of care because they didn’t want to lose their monthly bonus. Who believes that a for-profit health insurance company really has the pt’s health/quality of life as a primary focus of the reason that they are in business ?


medical director insurer admitted he never looked at patients’ records when deciding whether to approve or deny care.

Does anyone believe that this one medical director from Aetna is a OUTLIER  or just the first one that was under oath in a court of law… and the doctor’s “reasoning” was that “he was following Aetna’s training, in which nurses reviewed records and made recommendations to him.”  So it would appear the Aetna is basically  granting nurses both diagnostic and prescriptive authority.  The term “nurse” can cover a whole range of educational background… from a 1 yr LPN, 2 yr RN, 4 yr BSRN, ARNP, PA, NP.  What if those nurses have the same monthly bonus incentive as those medical directors in the previous article ?  CVS Health is in the process of buying Aetna for some 60 + BILLION…  it would appear that the profitability of Aetna is quite sizeable…


Are we going from a covert GENOCIDE to CARPETING BOMBING the chronic pain community ?

We are seeing entities (PBM) Prescription benefit managers that are dictating how much or little opiate therapy a pt can have… the letter in this posts demonstrates that CVS is demanding that this particular pt reduce the pt’s Methadone from 70 mg/day to 24 mg/day and eliminate the 20 mg Oxycodone 4xd as needed for breakthru.  This is the therapy that this pt has been on for numerous years and according to the date on this letter the pt was being granted 60-90 days to wean down to what CVS considered a therapeutic level for this particular pt.  “to help ensure the pt’s use of opiates for pain management is SAFE “

now if this pt has been taking this amount of opiates for years… the pt is – without a question – opiate dependent and since the pt has not experienced any adverse reaction to this dosing level.. for this particular pt… it should be considered SAFE


how many more cracks in this war on drugs facade will we see over the near future and how much longer are law firms going to stand on the side lines and turn a blind eye to what is happening to not only chronic pain pts, but all too many pts with chronic diseases ?

#Kolodny suggesting that Purdue will continue to be blamed for the opiate crisis long after they stop promoting opiates ?

Opioid Maker To Stop Marketing Painkillers to Docs

https://www.webmd.com/mental-health/addiction/news/20180212/opioid-maker-to-stop-marketing-painkillers-to-docs

Faced with lawsuits and blame for contributing to the United States’ opioid epidemic, OxyContin maker Purdue Pharma announced that it will stop promoting its opioid painkiller drugs to doctors.

The company is slashing its sales force in half to 200, and the remaining representatives will no longer visit doctors to market Purdue’s opioid products, the Los Angeles Times reported.

“We have restructured and significantly reduced our commercial operation and will no longer be promoting opioids to prescribers,” according to a company statement. “Going forward, questions and requests for information about our opioid products will be handled through direct communications with our medical affairs department.”

The announcement was welcomed by Brandeis University researcher Dr. Andrew Kolodny, but, “It’s pretty late in the game to have a major impact,” he told the Times.

“The genie is already out of the bottle,” said Kolodny, executive director and co-founder of Physicians for Responsible Opioid Prescribing.

“Millions of Americans are now opioid-addicted because the campaign that Purdue and other opioid manufacturers used to increase prescribing worked well. And as the prescribing went up, it led to a severe epidemic of opioid addiction,” Kolodny told the Times.

Purdue faces dozens of lawsuits from U.S. cities that want to hold the company financially responsible for the opioid epidemic.

A Times investigation found that Purdue had significant evidence that its opioid pills were being illegally trafficked but often did not share it with local law enforcement agencies or halt supplies of the drugs.

It’s estimated that more than 7 million Americans have abused OxyContin since it became available in the U.S. in 1996, the Times reported.

It’s not clear if other opioid painkiller makers will also stop marketing the drugs to doctors, Kolodny noted.

 

“We would have more success in encouraging cautious prescribing if drug companies stopped promoting aggressive prescribing,” he told the Times.

Another questions is whether Purdue will continue marketing opioid painkillers to doctors outside the U.S. through its international arm.

 

medical director insurer admitted he never looked at patients’ records when deciding whether to approve or deny care.

CNN Exclusive: California launches investigation following stunning admission by Aetna medical director

http://www.cnn.com/2018/02/11/health/aetna-california-investigation/index.html

(CNN)California’s insurance commissioner has launched an investigation into Aetna after learning a former medical director for the insurer admitted under oath he never looked at patients’ records when deciding whether to approve or deny care.

California Insurance Commissioner Dave Jones expressed outrage after CNN showed him a transcript of the testimony and said his office is looking into how widespread the practice is within Aetna.
“If the health insurer is making decisions to deny coverage without a physician actually ever reviewing medical records, that’s of significant concern to me as insurance commissioner in California — and potentially a violation of law,” he said.
Aetna, the nation’s third-largest insurance provider with 23.1 million customers, told CNN it looked forward to “explaining our clinical review process” to the commissioner.

California insurance commissioner Dave Jones launched the investigation after being contacted by CNN.

The California probe centers on a deposition by Dr. Jay Ken Iinuma, who served as medical director for Aetna for Southern California from March 2012 to February 2015, according to the insurer.
During the deposition, the doctor said he was following Aetna’s training, in which nurses reviewed records and made recommendations to him.
Jones said his expectation would be “that physicians would be reviewing treatment authorization requests,” and that it’s troubling that “during the entire course of time he was employed at Aetna, he never once looked at patients’ medical records himself.”
“It’s hard to imagine that in that entire course in time, there weren’t any cases in which a decision about the denial of coverage ought to have been made by someone trained as a physician, as opposed to some other licensed professional,” Jones told CNN.
“That’s why we’ve contacted Aetna and asked that they provide us information about how they are making these claims decisions and why we’ve opened this investigation.”
The insurance commissioner said Californians who believe they may have been adversely affected by Aetna’s decisions should contact his office.
Members of the medical community expressed similar shock, saying Iinuma’s deposition leads to questions about Aetna’s practices across the country.
“Oh my God. Are you serious? That is incredible,” said Dr. Anne-Marie Irani when told of the medical director’s testimony. Irani is a professor of pediatrics and internal medicine at the Children’s Hospital of Richmond at VCU and a former member of the American Board of Allergy and Immunology’s board of directors.
“This is potentially a huge, huge story and quite frankly may reshape how insurance functions,” said Dr. Andrew Murphy, who, like Irani, is a renowned fellow of the American Academy of Allergy, Asthma and Immunology. He recently served on the academy’s board of directors.

The Gillen Washington case

Gillen Washington, 23, says he hopes to force change at Aetna.

The deposition by Aetna’s former medical director came as part of a lawsuit filed against Aetna by a college student who suffers from a rare immune disorder. The case is expected to go to trial later this week in California Superior Court.
Gillen Washington, 23, is suing Aetna for breach of contract and bad faith, saying he was denied coverage for an infusion of intravenous immunoglobulin (IVIG) when he was 19. His suit alleges Aetna’s “reckless withholding of benefits almost killed him.”
Aetna has rejected the allegations, saying Washington failed to comply with their requests for blood work. Washington, who was diagnosed with common variable immunodeficiency, or CVID, in high school, became a new Aetna patient in January 2014 after being insured by Kaiser.
Aetna initially paid for his treatments after each infusion, which can cost up to $20,000. But when Washington’s clinic asked Aetna to pre-authorize a November 2014 infusion, Aetna says it was obligated to review his medical record. That’s when it saw his last blood work had been done three years earlier for Kaiser.
Despite being told by his own doctor’s office that he needed to come in for new blood work, Washington failed to do so for several months until he got so sick he ended up in the hospital with a collapsed lung.
Once his blood was tested, Aetna resumed covering his infusions and pre-certified him for a year. Despite that, according to Aetna, Washington continued to miss infusions.
Washington’s suit counters that Aetna ignored his treating physician, who appealed on his behalf months before his hospitalization that the treatment was medically necessary “to prevent acute and long-term problems.”
“Aetna is blaming me for what happened,” Washington told CNN. “I’ll just be honest, it’s infuriating to me. I want Aetna to be made to change.”
During his videotaped deposition in October 2016, Iinuma — who signed the pre-authorization denial — said he never read Washington’s medical records and knew next to nothing about his disorder.

Intravenous immunoglobulin can cost as much as $20,000 per treatment. It helps patients like Gillen Washington stave off infection.

 
Questioned about Washington’s condition, Iinuma said he wasn’t sure what the drug of choice would be for people who suffer from his condition.
Iinuma further says he’s not sure what the symptoms are for the disorder or what might happen if treatment is suddenly stopped for a patient.
“Do I know what happens?” the doctor said. “Again, I’m not sure. … I don’t treat it.”
Iinuma said he never looked at a patient’s medical records while at Aetna. He says that was Aetna protocol and that he based his decision off “pertinent information” provided to him by a nurse.
“Did you ever look at medical records?” Scott Glovsky, Washington’s attorney, asked Iinuma in the deposition.
“No, I did not,” the doctor says, shaking his head.
“So as part of your custom and practice in making decisions, you would rely on what the nurse had prepared for you?” Glovsky asks.
“Correct.”
Iinuma said nearly all of his work was conducted online. Once in a while, he said, he might place a phone call to the nurse for more details.
How many times might he call a nurse over the course of a month?
“Zero to one,” he said.
Glovsky told CNN he had “never heard such explosive testimony in two decades of deposing insurance company review doctors.”

Aetna’s response

Aetna defended Iinuma, who is no longer with the company, saying in its legal brief that he relied on his “years of experience” as a trained physician in making his decision about Washington’s treatment and that he was following Aetna’s Clinical Policy Bulletin appropriately.
“Dr. Iinuma’s decision was correct,” Aetna said in court papers. “Plaintiff has asserted throughout this litigation that Dr. Iinuma had no medical basis for his decision that 2011 lab tests were outdated and that Dr. Iinuma’s decision was incorrect. Plaintiff is wrong on both counts.”

Gillen Washington receives an infusion of the medicine needed to boost his immune system. He calls it "the magic juice."

In its trial brief, Aetna said: “Given that Aetna does not directly provide medical care to its members, Aetna needs to obtain medical records from members and their doctors to evaluate whether services are ‘medically necessary.’ Aetna employs nurses to gather the medical records and coordinate with the offices of treating physicians, and Aetna employs doctors to make the actual coverage-related determinations.
“In addition to applying their clinical judgment, the Aetna doctors and nurses use Aetna’s Clinical Policy Bulletins (‘CPBs’) to determine what medical records to request, and whether those records satisfy medical necessity criteria to support coverage. These CPBs reflect the current standard of care in the medical community. They are frequently updated, and are publicly available for any treating physician to review.”
Jones, the California insurance commissioner, said he couldn’t comment specifically on Washington’s case, but what drew his interest was the medical director’s admission of not looking at patients’ medical records.
“What I’m responding to is the portion of his deposition transcript in which he said as the medical director, he wasn’t actually reviewing medical records,” Jones told CNN.
He said his investigation will review every individual denial of coverage or pre-authorization during the medical director’s tenure to determine “whether it was appropriate or not for that decision to be made by someone other than a physician.”
If the probe determines that violations occurred, he said, California insurance code sets monetary penalties for each individual violation.
CNN has made numerous phone calls to Iinuma’s office for comment but has not heard back. Heather Richardson, an attorney representing Aetna, declined to answer any questions.
Asked about the California investigation, Aetna gave this written statement to CNN:
“We have yet to hear from Commissioner Jones but look forward to explaining our clinical review process.
“Aetna medical directors are trained to review all available medical information — including medical records — to make an informed decision. As part of our review process, medical directors are provided all submitted medical records, and also receive a case synopsis and review performed by a nurse.
“Medical directors — and all of our clinicians — take their duties and responsibilities as medical professionals incredibly seriously. Similar to most other clinical environments, our medical directors work collaboratively with our nurses who are involved in these cases and factor in their input as part of the decision-making process.”

Gillen Washington became emaciated and gravely ill after four months without treatment.

‘A huge admission’

Dr. Arthur Caplan, founding director of the division of medical ethics at New York University Langone Medical Center, described Iinuma’s testimony as “a huge admission of fundamental immorality.”
“People desperate for care expect at least a fair review by the payer. This reeks of indifference to patients,” Caplan said, adding the testimony shows there “needs to be more transparency and accountability” from private, for-profit insurers in making these decisions.
Murphy, the former American Academy of Allergy Asthma and Immunology board member, said he was “shocked” and “flabbergasted” by the medical director’s admission.
“This is something that all of us have long suspected, but to actually have an Aetna medical director admit he hasn’t even looked at medical records, that’s not good,” said Murphy, who runs an allergy and immunology practice west of Philadelphia.
“If he has not looked at medical records or engaged the prescribing physician in a conversation — and decisions were made without that input — then yeah, you’d have to question every single case he reviewed.”
Murphy said when he and other doctors seek a much-needed treatment for a patient, they expect the medical director of an insurance company to have considered every possible factor when deciding on the best option for care.
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“We run into the prior authorization issues when we are renewing therapy, when the patient’s insurance changes or when an insurance company changes requirements,” he said.
“Dealing with these denials is very time consuming. A great deal of nursing time is spent filling and refilling out paperwork trying to get the patient treatment.
“If that does not work, then physicians need to get involved and demand medical director involvement, which may or may not occur in a timely fashion — or sometimes not at all,” he said. “It’s very frustrating.”