CBS 5 Investigates With Anna Werner

SAN FRANCISCO (CBS 5) ― He's a former insider from the health insurance industry who said he quit because those companies are concerned too much with profit and not about care.

And he said if you think your health insurer is focused on the money, you're probably right.

Wendell Potter worked as the top public relations executive for CIGNA and was the consummate insider.

Now, as health care reform proposals are debated in Congress, he's speaking out against insurance companies, who he said aren't interested in real health care reform.

"The insurance companies want if not the status quo, at least health care reform that will enable them to continue to operate very profitably," said Potter.

Potter said the industry is dominated by roughly seven for-profit insurance companies that he calls a "cartel." He said that cartel focuses on controlling costs, or claims, what the industry calls a company's "medical loss ratio."

"It is a measure of the percentage of every premium dollar that is paid in premiums. In other words, they consider that a loss," Potter explained. And he said any claim the company pays is considered a loss.

Potter describes an industry driven by Wall Street to reduce medical loss ratios and reduce the amount and number of valid medical claims paid. And as profits rise, he said, executives and shareholders benefit.

The case the Potter said became "the final straw" for him at CIGNA was that of California patient Nataline Sarkisyan, whose doctors advocated for a liver transplant. Her claim was denied twice by CIGNA.

Her case became the subject of protests from the community and the California Nurses' Association and the company subsequently reversed course and approved the transplant. The approval came too late, however; Nataline died that same day.

"I just didn't want to be the spokesperson for an industry that I felt often was not doing the right thing for the American public," said Potter.

Potter believes the push to reform health care in the U.S. faces an uphill battle and warns the public not to believe a common insurance industry argument that setting up a public health care plan will put a government bureaucrat between patients and their doctors.

"Right now we have a corporate bureaucrat who's calling the shots, who's very much between you and your doctor," Potter said.

Potter now works as Senior Fellow on Health Care for the Center for Media and Democracy.

CIGNA sent the following statements in response to Wendell Potter's comments:

 

America is engaged in an important debate about how to improve our health care system. Although we respect that there are different opinions on the solutions, we strongly disagree with the suggestion that, motivated by profits, the insurance industry has deliberately attempted to confuse or unfairly treat covered individuals.

We are an advocate for, and believe in, the importance of information transparency and simplicity. Our goal is to help make useful information easy to obtain and at CIGNA we have a team dedicated to eliminating confusion and helping the people we serve understand and fully leverage their benefits. Our success at serving our customers has been validated by many organizations, for example:

· CIGNA call centers have been recognized as providing "An Outstanding Customer Service Experience" for three consecutive years under the J.D. Power and Associates Certified Call Center Program.SM

· CIGNA's commitment to clinical quality is evidenced in the company's competitive HEDIS scores, which have shown continuous improvement for the past five years. HEDIS scores are reported by the National Committee for Quality Assurance (NCQA),

· CIGNA was selected by the readers of Business Insurance magazine as the best health plan in 2008 and the best employee assistance program for four years in a row,

· We have been consistently ranked for the past three years as a leader in timely and accurate claims payment and low denial rates by athenahealth.

At CIGNA we are committed to improving the current system and that is why, from the beginning, we have consistently supported: a requirement for all to participate; guaranteed coverage at the same rates regardless of whether or not the person has a pre-existing illness; and the creation of a minimum benefits design.

Regarding Nataline Sarkisyan:

The Nataline Sarkisyan case was a tragic one for all involved and raised many issues about coverage of experimental treatments and scarcity of organs needed for transplants.

In this particular case, Mr. Sarkisyan self-insured employer was responsible for all costs. As in more than 80% of CIGNA's business, we were acting as administrators for a self-insured employer. Had the procedure been covered under the plan, the employer would have paid the cost. CIGNA, as the administrator, had no financial stake in the decision. Notwithstanding the type of health plan, CIGNA makes all coverage determinations on the basis of the best available medical evidence, regardless of cost.

The role of the insurer is to make determinations as to whether or not a particular procedure is covered under the member's health benefit plan. It is always the physician who makes treatment decisions.

Coverage determinations are based on the best available medical evidence. In this instance, the determination that the Sarkisyan's health benefit plan did not cover the procedure was due to the fact that the procedure was unproven and ineffective in these circumstances. That judgment relied on the opinions of two independent experts as well as the guidelines established by the medical community - particularly those of the American Association for the Study of Liver Diseases and the American Society of Transplantation.

As you may know, the family challenged our decision-making related to this situation through the courts. On April 16, 2009, the United States District Court for the Central District of California dismissed all of the claims against CIGNA related to the coverage determination. The Sarkisyan's have not challenged the Court's decision.

Finally, in the context of health care reform it is important to point out that no health plan - public or private; US or International - provides coverage for procedures that are unproven and ineffective. Neither Medicare or Medicaid nor government-run single payer systems in other countries provide coverage for treatments deemed to be unproven and ineffective - this is particularly true given the scarcity of organs.

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