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

[renee15]

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

this should be a violation of one of the many ethics laws we test for each year- "UnitedHealth also incentivizes physicians to confirm diagnoses through performance-based compensation plans"

 

[renee15]

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.

doubtful "Medicare Advantage delivers higher-quality care than Medicare fee-for-service."
Original Medicare does not incentivize Seniors to get vaccines or a mammo, but since they pay little to none OOP with a MedSup, they have no reason not to receive care.

 

[renee15]

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.

5K annual medical cost for Seniors who get 2K/month is SS benefits?

 

[sshafran]

5K annual medical cost for Seniors who get 2K/month is SS benefits?

Did I stutter?

 

[sshafran]

Did I stutter?

When cost-sharing increases - if it's quite literally across the board, regardless of age or income - i.e. everywhere, insurance is banned from paying for anything under $5,000 - then (a) providers would be forced to charge reasonable and transparent fees, (b) people (you and me and grandma) would start saving and putting money aside (this behavior change would take time - and yes, this is the hard part), and (c) prices would go down for medical care (it would have to).

UHC / Aetna / Humana / etc would tank in profits but where would that money go.... back to us. Insurance would no longer be $1,750/mo for a family of 5.

The government subsidies would greatly decrease. Who benefits there?

'Merica.

Tax Payers.

Sounds good to me.

 

[sshafran]

When cost-sharing increases - if it's quite literally across the board, regardless of age or income - i.e. everywhere, insurance is banned from paying for anything under $5,000 - then (a) providers would be forced to charge reasonable and transparent fees, (b) people (you and me and grandma) would start saving and putting money aside (this behavior change would take time - and yes, this is the hard part), and (c) prices would go down for medical care (it would have to).

UHC / Aetna / Humana / etc would tank in profits but where would that money go.... back to us. Insurance would no longer be $1,750/mo for a family of 5.

The government subsidies would greatly decrease. Who benefits there?

'Merica.

Tax Payers.

Sounds good to me.

The problem here, of course, is now providers are going to figure out a way to get the bill over that magic $5,000 threshold.

I'll let someone else figure that one out.... I'm sure there is a solution, and the amount of claims under $5,000 vs over $5,000 might make it where there is some sort of oversight on providers billing over 5k.

 

[sshafran]

The problem here, of course, is now providers are going to figure out a way to get the bill over that magic $5,000 threshold.

I'll let someone else figure that one out.... I'm sure there is a solution, and the amount of claims under $5,000 vs over $5,000 might make it where there is some sort of oversight on providers billing over 5k.

But I'm all about skin in the game.

I have a friend who works for a big corp and they quite literally could care less whether they go to the ER or Urgent Care of a PCP because their cost is the same. THE cost is not the same -- their cost is the same. That's not good.

Similar to grandma when she hits $2,000 TrOOP on Part D in 2025 - this is all free? Great! Load up the meds.

 

[somarco]

insurance is banned from paying for anything under $5,000

Eliminating repricing . . . but it also means those "claims" do not accumulate towards the deductible.

The HDG reprices but does not pay claims under ~$2600 . . . and the claims count towards the high deductible.

The other problem is, folks won't buy the plan because there are no copays and they "can't afford to go to the doctor".

And . . . agents can't make a living selling HDG plans.

 

[somarco]

doubtful "Medicare Advantage delivers higher-quality care than Medicare fee-for-service."
Original Medicare does not incentivize Seniors to get vaccines or a mammo, but since they pay little to none OOP with a MedSup, they have no reason not to receive care.

For some reason I expected folks reading this thread to follow and READ the linked information . . . including the UHC extremely weak "rebuttal".

UnitedHealth Group’s Response to the Wall Street Journal’s Recent Reporting on Medicare Advantage

www.unitedhealthgroup.com

 

[sshafran]

Eliminating repricing . . . but it also means those "claims" do not accumulate towards the deductible.

The HDG reprices but does not pay claims under ~$2600 . . . and the claims count towards the high deductible.

The other problem is, folks won't buy the plan because there are no copays and they "can't afford to go to the doctor".

And . . . agents can't make a living selling HDG plans.

I mean, I'm good with just being your VP - I'm sure we can hash a plan out.

I actually was not even thinking of the 5k as a deductible.

I was thinking - insurance does not pay on any line item under 5k.