Health Care Matters | January 10, 2025
UnitedHealth’s Army of Doctors Helped It Collect Billions More From Medicare
The Wall Street Journal published an article examining practices UnitedHealth Group (UHG) has employed to increase Medicare Advantage payments, including making questionable diagnoses. Physicians employed by UnitedHealth often receive lists of potential diagnoses for patients, many of which are irrelevant or questionable. These diagnoses are important because Medicare Advantage plans are reimbursed based on patient acuity, which increases with more diagnoses. UnitedHealth's doctors have seen an average 55% increase in risk scores for new patients in the first year, leading to significantly higher Medicare payments.
This is not the first time UnitedHealth has been put on blast for these actions. STAT news published an explosive series investigating how UnitedHealth uses its vast physician network to boost profits and expand its influence. Physicians employed by UHG continue to raise alarms but are no match for the insurance giant, often facing the difficult choice of continuing to practice with ongoing pressure to prioritize financial incentives over patient care or leaving UHG (and their patients) to find employment elsewhere. Read more here and here.
Why It Matters
The issues raised in these articles are not limited to UnitedHealth Group alone, but point to systemic issues across the health care industry. While UnitedHealth, as one of the largest employers of physicians, is a significant player, other private insurers also engage in similar practices that have serious implications for both patient care and the health care system as a whole. From 2018 to 2021, private insurers—including UnitedHealth—made hundreds of thousands of diagnoses that triggered extra taxpayer-funded payments. Many of these diagnoses were for conditions patients did not have or for which they received no treatment, adding tens of billions of dollars to the Medicare Advantage program and undermining its goal of saving taxpayer money.
In response to these practices, the Biden Administration has implemented stricter regulations to curb such abuses. For instance, CMS finalized CY 2024 technical and clinical updates to the Medicare Advantage (MA) risk adjustment model to keep it up-to-date and improve payment accuracy. While these changes are being phased in, they ultimately result in reduced payments to health plans, thereby cracking down on bad behavior by ensuring that payments are more accurately aligned with patients’ risk status. However, it remains to be seen how the Trump Administration will address these issues, given its historically more favorable stance towards Medicare Advantage insurers.
American’s View of Health Care Quality Declines to 20 Year Low Despite Positive View of Their Own Care
Despite widespread negativity about the health care system as a whole, many Americans still rate their own personal health care experiences positively. Recent data published by Gallup highlights that approximately 70% of Americans think their own healthcare experience is "good" or "excellent." Specifically, 65% rate their healthcare coverage positively, and 71% rate the quality of care they receive as "excellent" or "good." Although these numbers have slightly declined over the past 24 years, they remain relatively high.
However, these data also show Americans' perception of the quality of U.S. health care has hit a 24-year low, with only 31% rating it as "excellent" or "good." This decline in positive ratings is accompanied by broadly negative views on health care coverage across the nation. These sentiments contribute to a growing belief that the U.S. health care system is in a deep state of crisis, with the most pressing issue identified by Americans as the cost of health care. Read here.
Why It Matters
The insights from Gallup data reveals a complex and often contradictory view of the U.S. health care system. While many Americans report positive experiences with their personal care, they hold far more negative views about the system as a whole. This disconnect suggests that public discourse, often focused on systemic flaws, may not fully reflect the diversity of individual experiences.
The recent murder of UnitedHealthcare CEO Brian Thompson has intensified public debate, amplifying the deep frustrations surrounding U.S. health care. The incident has fueled a surge of online resentment toward health insurers, underscoring widespread dissatisfaction with how health care is managed and delivered. It highlights the urgent need for reform to address the cost and coverage issues that plague the system.
The fact that cost is identified as the most pressing issue further emphasizes the financial burden health care places on many Americans. Even if individuals are satisfied with their own care, the broader concerns about the system’s effectiveness and affordability remain unaddressed. This gap between personal experiences and general perceptions calls for a more nuanced conversation in policymaking. Only by understanding this divide can stakeholders craft reforms that improve both the quality and accessibility of care for all Americans. The tragic event involving Brian Thompson serves as a stark reminder of the real-world consequences of the ongoing health care debate and the need for meaningful change.
Where We Are Going
The Fourth Virtual Value-Based Payment Summit Special Edition
The Fourth Virtual Value-based Payment Summit is offering its complimentary virtual session on February 24 - 28, 2025 during Health Care Value Week, including a session featuring Adam Boehler, Liz Fowler, JD, PhD & Mark McClellan, MD, PhD. To learn more and register, click here.
What We Are Reading
TMaH States Announced
CMS announced the 15 states selected to participate in the Transforming Maternal Health (TMaH) model. TMaH aims to improve health outcomes and foster a safe and supportive environment for mothers and infants enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). To learn more about the model, click here.
Chevron’s Fall and Its Impact On Medical AI
The recent Supreme Court decision Loper Bright Enterprises v. Raimondo (2024), which overruled a longstanding legal doctrine that required courts to defer to reasonable agency interpretations of ambiguous statutes, is likely to have indirect effects on how the FDA regulates medical artificial intelligence and machine learning. This article examines this landmark decision and analyzes how it could influence the FDA’s approach to regulating medical AI/ML. Read here.
Hospital Participation in the Acute Hospital Care at Home Waiver Program
This study explores whether hospital participation in the Acute Hospital Care at Home program continued to increase following the extension of the program and the characteristics of participating hospitals. Read here.
