The peer-review appeal was contentious. Aetna had denied my mother-in law’s request for transfer from the hospital where she was recovering to a rehabilitative care facility. In a last ditch effort, her primary care doctor was on the phone with the health insurance giant’s representative appealing the denial in what is called a “Peer to Peer Appeal”. She was still ill. She could not get out of bed unassisted. She needed 24/7 care. The Aetna “peer” doctor was unmoved. No further treatment would be approved. Her primary care doctor persisted: would he at least speak with the patient? No further treatment would be approved. Would he speak to her daughter acting as her Power of Attorney. No further treatment would be approved.
Finally in frustration, her primary care doctor asked what was an 84-year old woman who could not care for herself was supposed to do? Denying care would most likely kill her. The Aetna doctor said there would be no further treatment approved, so she should just “go home to die.”
Seriously. Just “go home and die.”
My mother-in-law worked for a twenty-five years as a machine operator for Kraft Foods. She was a single mother who cared for five kids, working extra shifts to pay for two of them to go to college. Her retirement wasn’t luxurious, but the small pension she earned through Kraft helped to augment her Social Security benefit, allowing her to own her own two-bedroom condo and maintain her lower-middle class life into her senior years.
As was common with many in her generation, she had been a smoker. Years of factory work and first and second-hand smoke had left her at 84-years old with COPD and declining health. But she was still self-sufficient, living alone, driving, and going to her weekly bingo sessions with her local senior group.
Thinking it was a Medicare plan with reduced premiums and out of pocket expenses, she elected Aetna Health insurance to administer her managed health plan. She thought she had Medicare. She had what she thought was a Medicare card. Her insurance card looked like a Medicare card. That’s because Aetna markets the plan as a "Medicare" plan, but in reality it was a private managed health insurance plan with little overlap with Medicare benefits. As a managed plan, every course of treatment had to be approved by Aetna.
Early this year it became apparent that Aetna’s objective was more about profit than her care.
Shortly after the first of the year, she became ill with a nasty virus that lingered almost a month for even healthy people. Living with COPD, her illness quickly deepened, landing her in the emergency room with difficulty breathing. She was admitted to Palos Hospital that night where she recovered for over two weeks. She was then was transferred to ManorCare Health Services — Palos Heights West rehab facility to regain her strength.
The care at ManorCare was abysmal. She was left repeatedly in soiled diapers for 2-11 hours. She was ignored by the staff. Even though it was the reason she was there, she had physical therapy only once a day Monday - Friday. They repeatedly did not feed her on the weekends, and during the week her meals were more often than not delivered cold. During the last 24 hours she was there, she received nothing but 4 slices of bacon and a muffin for breakfast and a piece of pie after complaining of not getting her meals.
My wife and her brother visited daily to run down the care that was supposed to be provided, communicated with the ManorCare Administrator repeatedly via phone or email, and met with the Administrator and Director of Nursing (DON) multiple times. The Administrator’s and DON’s claims of "call me anytime" quickly became "only call during business hours M-F" and sarcasm. Despite the repeated conversations with ManorCare’s management, her care did not improve and she became sicker and sicker.
Finally after the third weekend of being ignored with no response from those at ManorCare, my wife’s brother attempted to right the situation again in person. They found their mother covered in vomit, sitting in a soiled diaper, unable to sit up, in pain, shaking, feverish, dehydrated, and severely depressed wanting to kill herself. In fear for their mother’s life, they called an ambulance and had her taken back to the hospital.
She was immediately admitted and placed in the Telemetry Unit. She was severely dehydrated, diagnosed with MRSA, the flu, pneumonia and near death. Her primary care doctor said another 24 hours and she might have died.
With proper care, after ten days her condition had improved, but she was still very weak and unable to get out of bed unassisted. The family with the help of hospital’s social worker found another rehab facility for her to regain her strength, and had a bed waiting for her. She was ready for discharge from the hospital when Aetna denied her transfer. But not only did it deny this particular rehab facility, Aetna refused to approve treatment at ANY rehab facility.
The only recourse for such a blatantly dangerous decision was to appeal through Aetna’s “peer to peer” appeal process. In this process, my mother-in law’s primary doctor would review her case with one of Aetna’s doctors. The idea is that medical professionals, not bean counters, would decide the best course of treatment. But when only one doctor in this equation represents the patient’s care, and the other represents the interests of the for-profit insurer and has the final say, the appeal process is stacked against the patient.
Aetna’s position during the appeal process was simultaneously that her condition had improved significantly while at the same time was not responding to care. ManorCare embellished her physical therapy records to indicate that she was able to walk 15-feet TWO TIMES down a hallway and back with assistance and a wheelchair — something that is ludicrous given her condition when she was returned to the hospital near death. So due to this one-time note in her file, Aetna claimed no further care was required. But at the same time, Aetna’s representative doctor argued that her condition had not improved in over a month ignoring the lack of treatment at ManorCare and her leaving there near death with MRSA, the flu, and pneumonia. Therefore, no continued treatment would be approved as she was just not responding treatment.
She should just go home and die. No further treatment would be approved by Aetna.
At this point, life for my mother-in law and her family because a nightmare. Aetna would no longer approve any more time in the hospital either. She had to be discharged that day. But she was not able to care for herself, nor was the family able to provide 24-7 around the clock nursing care. As all of her children have full time jobs and had by this point exhausted their sick leave, none of them was able nor skilled enough to provide the care needed. The cost of 24-7 care was out of the question.
So to get her the care she needed at a rehabilitation facility, the hospital social worker was able to negotiate a short term cash rate for three weeks care. The family liquidated what few cash assets her mother had and paid a substantial sum by cash and credit card.
Due to this, my 84-year old mother-in law is finally receiving the care she needs by paying thousands of dollars for it out of pocket even though she has health insurance.
We’ve contacted the State of Illinois Department of Human Services for assistance, and they have begun to see where help may be available for my mother-in law. Without it, the family will have to sell her what limited assets she has left — her condo and car.
Every time Biden talks about how people like their private health insurance or Buttigieg says Medicare for All would take away people’s health insurance it just makes me hate candidates like them even more. It shows they are at best clueless and at worst carrying water for the an insurance industry that puts profits ahead of health care. Don’t get me started on “democratic” candidate Michael Bloomberg. His views historically have been in line with Aetna’s denial of care.
The care my mother-in law has received from Aetna should be criminal and is certainly amoral. In the USA no one should have to endure such treatment just because they get sick. Aetna executives should be put in jail and rot in hell for what they are doing. For profit-health “care” has nothing to do with health or care, but everything to do with profit.
Please warn your loved ones, especially your older relatives, to avoid Aetna's "Medicare" plan - it's not a Medicare plan. It’s a managed-care private health insurance plan. Aetna will take your premiums and then deny coverage every chance they can.