And the Hits keep on rolling in: Sickness scores surged for UnitedHealth Medicare Advantage patients: WSJ

[Duaine]

UnitedHealth Group has optimized its ability to increase Medicare Advantage members' sickness scores and corresponding government payments by directly employing thousands of physicians at Optum and integrating sophisticated software tools into clinical workflows, according to a Dec. 29 investigation from The Wall Street Journal.

CMS bases Medicare Advantage payments on patient risk scores derived from medical diagnoses. According to the report, UnitedHealth uses software to suggest potential diagnoses for patients, which physicians must address before completing patient visits. These diagnoses are often obscure or minimally substantiated, physicians formerly employed by the company told the WSJ. The report found that sickness scores for UnitedHealth patients transitioning from traditional Medicare increased by 55% during their first year in a Medicare Advantage plan, outpacing the 30% industry average and leading to higher payments.

UnitedHealth also incentivizes physicians to confirm diagnoses through performance-based compensation plans, according to the report.

In a statement to the WSJ, a spokesperson for UnitedHealth said the company's practices lead to "more accurate diagnoses, greater availability of care and better health outcomes and prevention, including less hospitalization, more cancer screenings and better chronic disease management."

In February, the newspaper reported that the DOJ has launched an antitrust investigation into UnitedHealth, probing the company's relationship between its insurance unit, UnitedHealthcare, and Optum.

Nearly every major Medicare Advantage carrier has been accused of or settled allegations of upcoding in recent years. An investigation published in the WSJ in July found MA plans received $50 billion in payments between 2018 and 2021 for "questionable diagnoses" insurers added to medical records. An audit by HHS' Office of Inspector General published in October found MA companies brought in $7.5 billion in "questionable" payments found during in-home visits and chart reviews.

In the most recent example, MA insurer Independent Health will pay up to $98 million to settle allegations that a now-defunct subsidiary knowingly submitted invalid diagnoses to boost Medicare Advantage payments, according to the Justice Department.
[EXTERNAL LINK] - Sickness scores surged for UnitedHealth Medicare Advantage patients: WSJ

 

[Duaine]

UnitedHealth's Army of Doctors Helped It Collect Billions More From Medicare​

The biggest Medicare Advantage insurer presented physicians with checklists of potential diagnoses; 'I didn't think I was obese'​

Another Link if you have a subscription: https://www.wsj.com/health/healthcare/unitedhealth-medicare-payments-doctors-c2a343db

 

[Duaine]

UHC's Response: [EXTERNAL LINK] - UnitedHealth Group's Response to the Wall Street Journal's Recent Reporting on Medicare Advantage

 

[somarco]

I find the UHC response interesting and a bit one-sided. They waste a lot of ink talking about fewer hospitalizations but nary a word about health outcomes. Denying care should not be a metric a carrier strives for.


Medicare Advantage delivers higher-quality care than Medicare fee-for-service.

Medicare Advantage beneficiaries have a 43% lower rate of avoidable hospitalizations for any condition.
Medicare Advantage dual-eligible beneficiaries experience fewer hospitalizations and are more likely to receive preventive services like breast cancer screenings.
33% fewer total hospitalizations.
49% fewer potentially avoidable hospitalizations for acute conditions.
A higher frequency of testing and preventive services, including a 46% higher rate of breast cancer screening.
In an accepted study that will be published in JAMA Network Open in January, a retrospective cross-sectional regression analysis of CMS enrollment and encounter data from 2016-2019, merged with a contemporaneous APG provider dataset, found at-risk Medicare Advantage had higher quality and better health resource utilization outcomes when compared to FFS Medicare Advantage.

 

[sshafran]

Maybe ---- just maybe, if we can have a system where people literally pay, out of their own pockets, for anything and everything under $5,000 (i.e. surgery +) - all the games will go away.
Or at least the game will get harder to play.

But - give them a 2 yr warning. It starts in January 2027. So.... You might want to start saving a little money because insurance (i.e. taxpayers) won't cover it.

 

[annon123]

Maybe ---- just maybe, if we can have a system where people literally pay, out of their own pockets, for anything and everything under $5,000 (i.e. surgery +) - all the games will go away.
Or at least the game will get harder to play.

But - give them a 2 yr warning. It starts in January 2027. So.... You might want to start saving a little money because insurance (i.e. taxpayers) won't cover it.

And for many that would include the game of getting any health care at all...

 

[somarco]

High deductible plans (without copay) have never been popular.

A significant number of folks believe they can't afford to go to the doctor unless there is a copay. I battled that mindset for years when my focus was under 65 major med (BO). And that was working with mostly middle income, college educated people.

If you are suggesting a cash only system without repricing that won't work. Par providers offering a cash discount price that is lower than the managed care negotiated fee structure is a violation of the managed care contract.

Lately I have noticed some specialty providers showing a bundled cash price for common procedures. The posted pricing is for folks without insurance but if the patient has insurance they can opt to pay the cash price that may be adjusted after the claim is filed and adjudicated.

I really can't envision the MAPD crowd accepting a plan that did not have a copay.

 

[sshafran]

High deductible plans (without copay) have never been popular.

A significant number of folks believe they can't afford to go to the doctor unless there is a copay. I battled that mindset for years when my focus was under 65 major med (BO). And that was working with mostly middle income, college educated people.

If you are suggesting a cash only system without repricing that won't work. Par providers offering a cash discount price that is lower than the managed care negotiated fee structure is a violation of the managed care contract.

Lately I have noticed some specialty providers showing a bundled cash price for common procedures. The posted pricing is for folks without insurance but if the patient has insurance they can opt to pay the cash price that may be adjusted after the claim is filed and adjudicated.

I really can't envision the MAPD crowd accepting a plan that did not have a copay.

I do wonder - if building the "system" from scratch today - how should it be built?

It doesn't really matter since it won't happen.

 

[annon123]

High deductible plans (without copay) have never been popular.

I really can't envision the MAPD crowd accepting a plan that did not have a copay.

That is too weird... I believe you as you have had far more experience than I have, but that just doesn't make logical sense to me.

 

[somarco]

Before managed care all I had to offer (group and individual) were high deductible plans and no copays. There was no repricing. Providers billed what they wanted and the only write offs were folks who did not pay their bills.

The high deductible was usually $100 that eventually became $250 and later $500. Above the deductible it was 80/20 up to a cap of $50,000 - $250,000. Some group plans had a $500,000 or $1,000,000 cap.

Original Medicare is the closest thing to how health insurance worked in the 70's.