HEALTHCARE DENIALS AND THE 800 LB GORILLA

[somarco]

United Healthcare, AKA the 800 pound gorilla, flexed its' muscles in the continuing battle to deny health care in the Medicare Advantage market.


Frustration was boiling into open conflict within #NaviHealth, a company that uses computer predictions to help control the cost of caring for millions of older and disabled Americans on privatized Medicare plans.

The source of the outrage was not a customer or a salesperson, but an algorithm — specifically one that was being used to predict the amount of care needed by seriously ill patients. In 2021, employees raised alarms that efforts to bypass the algorithm — and pay for longer rehab stays — were getting slapped down at higher levels of the organization. Multiple cases involved patients who were still so sick they needed daily infusions to treat infections.

“It’s still happening,” one employee complained in internal communications obtained by STAT. Another added: “I had one that I had to communicate two times that was an IV and very clear on the continued stay — and it was still [denied].”

But a new investigation shows the denials weren’t just roiling patients and physicians — even clinical staffers within NaviHealth became increasingly distressed by the way their bosses were letting an algorithm override their discretion.

The tensions emerged after NaviHealth was acquired by Optum, a division of #UnitedHealth Group, which also owns the nation’s largest Medicare Advantage insurer, according to three former NaviHealth employees. Attempts to extend care past a predicted discharge date, or authorize treatment in a more expensive facility, resulted in pushback from managers. If employees did it repeatedly, managers questioned whether they needed to be retrained.

[EXTERNAL LINK] - How UnitedHealth's acquisition of a popular Medicare Advantage algorithm sparked internal dissent over denied care

Resistance is futile. You will be assimilated.

 

[ValeRosso]

• To be fair, this is literally a selling point on their website, so this algorithm is doing exactly what it’s made to do, at the expense of patients.
  
  “Cost Reduction: impact on post-acute site of care, length of stay, duration of therapy and functional outcome”
  
  Yes, AI will kill you. Even if it’s just an algorithm.

 

[somarco]

There is nothing fair about overriding the recommendations of attending medical personnel in the name of saving dollars . . . for the carrier. Bean counter medicine is the bain of health care and has been a problem for years.



ONS’s latest winter survey, published on 27 February, found 70% of adults in Great Britain who were waiting for NHS treatment reported last month that it had negatively affected their life.1 Among these people, 57% said the wait affected their wellbeing, for example through boredom, loneliness, anxiety, or stress, while around 38% said it had made their condition worse. Around 18% reported having had an appointment cancelled or delayed in the past month.
[EXTERNAL LINK] - Long NHS waits and rising living costs are harming people’s health, show ONS data


The UK is not the only place where bean counter medicine has a negative impact. Canada has similar problems as do several European countries. Most deliver adequate primary care services but get lower grades when it comes to acute and chronic care.

 

[yorkriver1]

1. UK has "modern" capitalist as PM. Profit for shareholders is #1 Must reduce all government "freebies". Note: corporations tax breaks and favorable rulings for profits are also "freebies", but are never considered that way by modern capitalism. UK keeps lowering the funding for NHS. In the USA this is not the capitalism of the post war II era where there was a strong blue collar middle class. Employees could unionize, most had pensions. Enter transfer of retirement risk from the corporation (fixed benefit pensions) to the employee (self managed 401K). Buy and sell companies gut employees, benefits, pensions, send jobs overseas. Destroy Glass Steagall, banks can take big risks with depositors money, under the white wash "Modernization" this has not been a strictly partisan enterprise, now that corporations can donate to politicians most are reluctant to avoid that funding. A notable few don't take PAC money, only individual donations.
2. "modern" capitalism (shareholders and CEO's top priority) is in charge
Bob, I signed up for at least a month of STAT so I could read the full article. It's pretty pricey for a year, will see.
The description of the situations where extra days in SNF were denied were pretty grim.
Original Medicare will be under pressure eventually to "modernize".