So they just sacked CVS/Aetna prez Brian Kane

CEO Karen Lynch thought he really had to go when CVS’s income fell 9% in the 2nd quarter compared to last year at the same time. 

Mulgrew should be thrilled, then, that Marianne and the courts forced him out of the Aetna plan he built for retirees a couple of years ago. 

Whew. Dodged a bullet.


Hardly. 

Mulgrew couldn’t have cared less what would have happened to the retirees after a year or two when Aetna’s promises would no longer be viable. Prior authorizations won’t get in your way, he told us. Almost everything is free, you can see any doctor you want, go to all the hospitals you want.  What don’t people understand? The plan is the cat’s whiskers and all that.

According to Forbes, parent company CVS was having problems with its insurance businesses (Aetna) – particularly with Medicare Advantage, which had seen “higher costs from increased utilization of services from seniors.”

Wendell Potter puts it much more simply. The company was paying out too many claims in its Advantage plans. Brian Kane wasn’t doing his job.

Potter reports that CVS is planning to get rid of about 10% of Advantage enrollment, leaving these unfortunate rejectees to look around for the best personal health care solution in a swamp of underwhelming options. And looking to turn things around, CVS is apparently planning some operational changes described in this bit of corpo-speak:

It will initiate a “a multi-year expense management opportunity to deliver $2 billion in savings” that will include “streamlining and optimizing operations and processes.” Executives also plan to accelerate the use of artificial intelligence and automation across the company’s businesses.

We better start getting used to the health insurance strategies du jour,  which none of us learned about in high school. What’s become standard procedures in this for-profit industry is mind-bending obfuscation in how they work, coupled with our deep belief that a serious health catastrophe might leave us stranded physically and financially. 

In a guest column I wrote for the Examiner a couple of months ago called “Navigating the Medical Maze” (here) I tried to highlight how thick the industry has become with insider strategies meant to help Them, not Us. 

We no longer know what to expect from our coverage when even simple terms like “hospital,” “out-of-pocket medications,” or “skilled nursing” don’t actually guarantee the cost or extent of services, the medications or the equipment we’re being prescribed.

Here’s the handful of terms I included in that article:

Upcoding.  When providers are encouraged to assign inaccurate or additional codes for procedures in order to trigger a higher reimbursement from public agencies such as Medicare.

Overutilization.  Decisions on medical necessity are often subjective. Overutilization is when doctors are incentivized to prescribe or charge more for services and equipment because they know public or private insurance is picking up the tab.

Defensive medicine:  When doctors recommend tests or treatments not so much for their patient’s benefit but to protect themselves from potential lawsuits. 

Click-and-close: a term (used at Cigna) to describe how the company encourages staff physicians to review first-stage or questionable denials as quickly as possible, neglecting time-consuming research into guidelines, medical studies, and medical records. More money stays with the insurance company and often keeps patients from getting the vital but more complicated services they might need.

Direct-to-consumer advertising:  When patients are encouraged to ask their doctors for specific drugs, tests or equipment, a practice that frequently puts the doctor in the position of having to explain why these may not be in the patient’s best interest.

Pharmacy benefit managers:   These middlemen between insurance companies and the pharmacies run every aspect of the delivery of prescription drugs, from formularies, to prior authorizations and co-pays, to rebates. They profit at almost every stage in the supply chain.

Kickbacks: Rewards to medical professionals for prescribing specific procedures, equipment or drugs. Free vacations, cash, speaking positions, and research grants are some of the many kinds of gifts that can call into question the value of what you’re being prescribed.

That was a short list. We could easily add AI and automation to it, both of which just slipped off the tongue in the Forbes article.

I KNOW that Mulgrew is out of his depth with this stuff, just like the rest of us. 

How on earth do we get the union to put people in charge of these decisions not only to get us the best deal with this corrupt industry, but to stop pretending they know what they’re doing and stop lying to us to make us believe they’re on our side.