Bob Herman
Appearances
Today, Explained
The UnitedHealth CEO shooting
But people don't recognize all the other components that it owns. It owns a ton of medical practices. It either employs or is affiliated with one out of every 10 doctors in the country. And I don't think everybody fully recognizes just how large and involved this company is outside of health insurance. It is not just a health insurance company. That's what it's most known for.
Today, Explained
The UnitedHealth CEO shooting
That's why it's often reviled. But it is everywhere else. And I think people need to recognize, especially on the medical group side, the physician side, they play a major role there.
Today, Explained
The UnitedHealth CEO shooting
Yeah, the reactions were pretty morbid, pretty grim. You know, the dancing on the death of somebody was just pretty vile. But anyone who covers healthcare knows that people are fed up with the system. This is not new. This has been going on for decades. Even when the Affordable Care Act or Obamacare came into play 15 years ago, people still hated the system. And it's just persisted since then.
Today, Explained
The UnitedHealth CEO shooting
So people's frustrations have been bubbling under the surface for so long. So to say you were surprised by all of the reactions, then I think maybe you had your head buried in the sand a little bit.
Today, Explained
The UnitedHealth CEO shooting
So UnitedHealthcare is the largest health insurance company in America. They cover more people than anyone. That includes Medicare Advantage, Medicaid, Obamacare. and all the different types of employer plans out there, and there's a lot.
Today, Explained
The UnitedHealth CEO shooting
Yeah. Now, a lot of healthcare dynamics are local. You know, the fights that often occur between health insurers and providers like hospitals and doctors, it's all about who has market share in a specific area. So United might not always have the biggest market share in a given area, but nationally... They are very powerful. They are very profitable.
Today, Explained
The UnitedHealth CEO shooting
There's no way getting around them in pretty much any market. They exist almost everywhere in some capacity.
Today, Explained
The UnitedHealth CEO shooting
If you have a UnitedHealthcare plan, you want them to negotiate better rates for you. That's their primary function. And so they use some of that heft to try and drive better deals with hospitals and doctors and other types of facilities. They're also an insurance company and they happen to deny or delay claims as well.
Today, Explained
The UnitedHealth CEO shooting
As an insurance company, the easiest way to make money is to make sure you're paying out fewer dollars. Now, there are... laws in place, especially a federal law that says you have to spend a certain amount of your premium dollars on care for people. You just have to do it. But insurers have an incentive to stay as close to those thresholds as possible.
Today, Explained
The UnitedHealth CEO shooting
They don't want to have to pay out more than they absolutely have to.
Today, Explained
The UnitedHealth CEO shooting
I think every health insurance company out there is known for their denials to some degree. Specific rates of denials are tough to come by, but insurers, especially the for-profit ones that sell on the stock market, they have an incentive to deny care.
Today, Explained
The UnitedHealth CEO shooting
You know, there have been so many issues with denials over the years, and my colleague Casey Ross and I reported on a big one within Medicare Advantage, and that's the program for older adults.
Today, Explained
The UnitedHealth CEO shooting
And UnitedHealthcare is the biggest in Medicare Advantage, and they, over the past several years, they've been using algorithmic prediction, predictive tools, and artificial intelligence to basically ramp up denials specifically in post-acute care, and that's the care that somebody gets when they leave the hospital.
Today, Explained
The UnitedHealth CEO shooting
So especially on that side of the coin, post-acute care denials have been a very big issue for United.
Today, Explained
The UnitedHealth CEO shooting
Yeah, so let's say someone goes to the hospital and then the hospital says, okay, you're ready for physical therapy, occupational therapy, speech therapy. Let's send you to a rehab facility, a nursing home. So a person will go there and they'll start their physical therapy. And behind the scenes, United Healthcare has used a tool called NaviHealth.
Today, Explained
The UnitedHealth CEO shooting
And there's an algorithm within the company that basically looks at the patient's demographics, how sick they are, their history. And tries to come up with some kind of prediction of how much time they'll need in that nursing home. Let's say it's 16 days. That's what the algorithm says. After 16 days, you should be good. Now, if it's used as a guide, that's fine.
Today, Explained
The UnitedHealth CEO shooting
But in many cases, I mean, we found documents that said... that United told their case managers, you have to stick to the algorithm.
Today, Explained
The UnitedHealth CEO shooting
And that's where it becomes a problem because if you're saying this algorithm spits out 16 days for somebody and they're not ready to go home on the 16th day, if they can't even go to the bathroom themselves, if they still can't walk around, but the algorithm says time to ship them out, that's where it's a problem. And that's what's happened. And then families are left with a decision of,
Today, Explained
The UnitedHealth CEO shooting
Do I pay out of pocket to stay at this nursing home to get the care that my mom or dad or grandparent needs? Or do I take them home with me and then risk having them fall or get hurt again and have to go back to the hospital or worse? So that's how the algorithms play in those types of situations. And people know this is happening and they're mad about it. On the Medicare Advantage side,
Today, Explained
The UnitedHealth CEO shooting
Most people actually don't. They're not aware as much on this because the algorithm happens behind the scenes. It's not like families are getting a sheet of paper saying, hey, our algorithm says you have this much time here. They really don't find out about this until the nursing home says, hey, your insurance is up and we have to kick you out. Now,
Today, Explained
The UnitedHealth CEO shooting
The denials are very front and center in other insurance plans where they say like, oh, you know, I need this back surgery or I need this prescription. And then United will come along with maybe a prior authorization, which just says, hey, doctor, fill out more paperwork to make sure that this person needs this procedure and needs this drug.
Today, Explained
The UnitedHealth CEO shooting
And then maybe they'll come back with a denial then that says, we're not going to cover this procedure or this prescription drug. That's where it's most front and center for people. That's where I think a lot of the outrage comes from. It's just those widespread kind of delays and denials there. And anyone can appeal any denial, but it is such an arduous process that
Today, Explained
The UnitedHealth CEO shooting
If you're sick or injured, that's not something you want to be doing. And you might not have family to help you out either. So it is very clearly a problem.
Today, Explained
The UnitedHealth CEO shooting
Yeah, I think that's right. This is systemic. This is not isolated to just UnitedHealthcare. UnitedHealthcare gets the most... criticism and heat for this because they are the largest, I mean, they're just a very common provider for any workplace plan. But, I mean, there are other large insurers. This is a very common thing. Cigna, Aetna, all the Blue Cross Blue Shield plans, Humana.
Today, Explained
The UnitedHealth CEO shooting
This is just how U.S. health insurance works. This is a systemic issue. This is, especially for the insurance companies that are on the stock market, they have a duty to make money for shareholders. And one of the ways that they do that is by making sure that they pay out fewer claims. That's just part of it.
Today, Explained
The UnitedHealth CEO shooting
The most watched number in every earnings call for an insurer is called the medical loss ratio. That's a number that says this is how much money of our premiums that we spend on medical care. And lower is better. If it's higher than expected, Wall Street freaks out. So I think that kind of tells you a lot.
Today, Explained
The UnitedHealth CEO shooting
My name is Bob Herman. I'm a reporter at Stat News. I cover the business of healthcare, so hospitals, health insurance, all types of providers, anything where the money flows in healthcare.
Today, Explained
The UnitedHealth CEO shooting
UnitedHealthcare is just one part of this massive company called UnitedHealth Group. And we've had a whole series this year called Healthcare's Colossus that's looked at healthcare this massive company, kind of how it has its tentacles everywhere. A lot of people recognize it for United Healthcare, this insurance company. It's just, you know, everyone hates an insurance company.