John Sharp’s Post

💭 Time for a Reality Check 💭 We all love a good healthcare villain, don’t we? The big, bad payer denying claims and raking in profits. This week, UnitedHealthcare seems to have drawn the short straw once again. The recent The Wall Street Journal article has everyone grabbing their torches and pitchforks. Imperfect risk adjustment rules based on the documentation and coding of suspected diagnosis is now on Version 28... not exactly hot-off-the-press newsworthy. Before we storm the gates, let’s pause for a moment to look in the mirror. Insurance is, at its core, just a mechanism for pooling and distributing funds. It’s not inherently good or evil—it’s the rules we set and the incentives we align (or misalign) that shape its impact. On one hand, we bemoan high premiums and taxes. On the other, we frown upon population health initiatives that aim to curb utilization. We complain about socialized medicine and corporate medicine in the same breath. Let’s get real: Fee-for-service oncologists have, at times, prescribed $millions in chemotherapy for patients with no realistic chance of recovery. These efforts are celebrated by families as "heroic" rather than questioned as potentially wasteful or harmful. Government sets the quality and risk adjustment programs, directly influencing what insurers chase. Is it any surprise that corporations—built to maximize profits—play the game accordingly? Sure, some actions deserve scrutiny. But let’s not pretend that the system is one-sided. It’s a complex web where everyone—patients, providers, hospitals, drug companies, payers, and policymakers—has a role to play. Instead of just pointing fingers at insurers, maybe it’s time we ask: 1) Are we ready to support tough policies that actually reduce overutilization? 2) Can we accept the trade-offs of value-based care models, even if they feel restrictive? 3) Do we want profit-driven innovation, or are we ready to embrace a more socialized model? It’s easy to bash "the system" until we realize... we are the system. If we want change, maybe we need to stop cheering for unsustainable heroics and start building better incentives for everyone. So next time you’re yelling at UnitedHealthcare, remember: the system’s a mess, but at least your misplaced outrage is free of charge. #Healthcare #ValueBasedCare #Insurance #PopulationHealth #Perspective Optum

Last week, the Senate Permanent Subcommittee on Investigations, led by Sen. Richard Blumenthal (D-Connecticut), released a Majority Staff Reporton rampant prior authorization (PA) abuses in Medicare Advantage (MA). The report offers unique insight into recent trends in the use of prior authorization by Medicare Advantage plans and the strategy and motives behind insurance corporations’ use of it. While the findings won’t surprise those who’ve been following health policy trends, it is immensely concerning that between 2019 and 2022, the prior authorization denial rate for post-acute care in UnitedHealth’s Medicare Advantage plans doubled. The denial rate for long-term acute care hospitals in Humana’s Medicare Advantage plans increased by 54% from 2020 to 2022. During this time, UnitedHealth, CVS/Aetna, and Humana increased their use of artificial intelligence (AI) for prior authorization reviews, often resulting in increasing denial numbers and decreasing (or absent) review time by human beings. https://lnkd.in/grJ8MrEw

We should all be concerned with a system that rewards insurers and clinicians financially for exaggerating and misstating our health risks and illnesses. The magnitude of the #fraud and #abuse committed by UnitedHealth Group and Optum in Medicare Advantage, as documented by reporters at STAT and The Wall Street Journal demands immediate attention of policymakers. United is killing the goose that lays its golden eggs and driving Medicare to insolvency. Its behaving with the arrogance of a company whose lawyers are confident they can beat back RADV audits and delay whistleblower suits. #MedicareAdvantage had great potential to align incentives across insurers, clinicians, and patients, but its risk adjustment system--also used for #ACOs--must be rethought and overhauled. In one small #Medicare demonstration, Million Hearts, clinicians were rewarded (modestly) for lowering the heart disease risk/progression among their patients--not for exaggerating or inventing illness. They reduced deaths from heart disease. Could such an approach be scaled across most major health conditions? UHC and Optum undermined the value and trust built by exceptional medical groups and clinicians over many years in its unbridled race to build shareholder value and big executive pay days. It's hard to overstate the damage "upcoding" is doing well beyond ripping off and endangering Medicare. It's damaging the credibility of clinicians and #EHRs, and exploiting major weaknesses in FDA's approval process for medical devices in the case documented here by STAT. It's undermining trust in #medicine. #riskadjustment Casey Ross Lizzy Lawrence Bob Herman Tara Bannow https://lnkd.in/e5RDHA9D

Primary care physicians for adults and children 💛taking care of your family. We don’t love the massive amount of paperwork that insurance companies, government, and even our employers mandate every day. Did you know that many of us spend MORE time on this administrative work than caring for you? Follow Massachusetts Medical Society for more understanding of what barriers are coming between you and your primary care team and why so many physicians are either leaving direct care practices or never starting in the first place. #primarycare #physicianworkforce

The new hospital price transparency rules put in place for January 2025 now include requirements to publish “average insurer reimbursements."Averages can obscure the real financial burden on patients and fail to provide actionable clarity. Patients deserve straightforward, upfront pricing—not complex data that hides true costs. Transparency should empower patients, not protect hospital profits.

As of November 2023, UnitedHealth Group, the parent company of UnitedHealthcare, employs or has affiliations with about 90,000 doctors, which is around 10% of all physicians in the United States. This is more than any other hospital system or clinic chain. UnitedHealth's Optum Health division is the largest employer of physicians, with 70,000 employed or affiliated physicians across the country Is this totally correct factual information with evidence of the following matter of https://lnkd.in/gt35qABy How UnitedHealth harnesses its physician empire to squeeze profits out of patientsBy Bob Herman , Tara Bannow , Casey Ross ,  and Lizzy Lawrence July 25, 2024This is the first in a periodic series about how UnitedHealth Group wields its unrivaled physician empire to boost its profits and expand its influence.UnitedHealth Group started out as a small, Minnesota health insurance company and has since morphed into a modern-day Standard Oil, exerting unmatched dominance over health care in the United States.It’s no secret that UnitedHealth is a colossus: It’s the country’s largest health insurer and the fourth-largest company of any type by revenue, just behind Apple. And thanks to a series of stealthy deals, almost 1 in 10 U.S. doctors — some 90,000 clinicians — now either work for UnitedHealth or are under its influence, more than any major clinic chain or hospital system.ADVERTISEMENTBut behind those statistics, there’s a lot UnitedHealth doesn’t want you to know. A STAT investigation reveals the untold story of how the company has gobbled up multiple pieces of the health care industry and exploited its growing power to milk the system for profit. UnitedHealth’s tactics have https://lnkd.in/gnCTMZ6B

This is the battlefield front for employers and patients, not to get euthanized with discussions around physician referrals. A colleague faces a year delay due to an insurance provider sending him to a service-lacking provider. Time to wake up – this is American Healthcare: sick people fighting for care denial in a "sick care" system. #denialofcare #healthplans #healthequity #healthcarefinance #cms #AI #lackofregulatoryenforcement Medicare Advantage insurers are leveraging technology to deny claims, as revealed in a Senate investigation: [Link to article] #MedicareAdvantage #healthcare #technology #claimsdenials

As a primary care physician, I left the traditional healthcare model because insurance companies had too much control over my patients' healthcare decisions and my time ⏳. Now, as a direct primary care doctor, I work directly for you, the patient! This gives me more time with you and allows you to have more control over your healthcare decisions and overall well-being. 🌿💙 At Fort Wayne DPC, my patients don’t have to wait days or weeks to see me. I offer same-day or next-day appointments with little to no wait time when you arrive.  Plus, you’ll enjoy extended appointments, so I can get to know you better and ensure you have plenty of time to ask questions and share your concerns. ⏰ Whether you’re visiting for annual labs or any of the many services included in your membership (depending on the package you choose), you’ll have access to: 👇 
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REFLEFTIONS ON US HEALTHCARE: The recent death of the UnitedHealthcare CEO is a tragic event, and it is important to recognize that violence is never a solution to societal grievances. However, the widespread outrage expressed on social media reflects deeply rooted frustrations with the United States’ healthcare and insurance systems, which are undeniably flawed and in need of reform. Medicare Advantage Plans exemplify some of these systemic issues. These plans often employ misleading advertising tactics, a practice that is tacitly enabled by federal policies. The government’s preference for enrolling patients in private Medicare Advantage Plans—because it is less costly than traditional Medicare—has contributed to the perpetuation of these deceptive practices. Moreover, the increasing reliance on artificial intelligence in claim denials has exacerbated the problem. In the case of UnitedHealthcare, AI systems have reportedly been used to deny claims en masse, with alarmingly high error rates. Such practices can have devastating consequences, particularly for patients with severe conditions. For instance, individuals with amyotrophic lateral sclerosis (ALS) are often denied ventilators until their lung function has deteriorated to 60%, despite substantial evidence that early ventilation improves both lifespan and quality of life. As someone who has spent their career in the healthcare industry, committed to prioritizing patient care and contributing to advancements in drug development, I have witnessed both the strengths and weaknesses of the system. However, my experience as a patient with a chronic illness and a high user of healthcare services has illuminated the system’s alarming decline. The emphasis on administrative barriers—denials of necessary care, convoluted appeals processes, and the burdens placed on already vulnerable patients—creates the impression that the system is designed to wear patients down rather than support them. At every stage, it seems as though the system’s intent is to deny care and hope patients abandon their pursuit of necessary treatment. This moment calls for profound reflection and systemic reform. The healthcare industry must seize this opportunity to reevaluate its policies and practices, removing unnecessary obstacles to care and prioritizing the well-being of patients. Without meaningful change, the system risks further alienating the very individuals it exists to serve. #healthinsurance #healthcare

What value does prior authorization serve? According to recent insights, very little value is created by this process. Members express frustration at the health plan coming between them and their doctors, while physicians find the additional paperwork burdensome. In a strategic shift in the 90s, UHG recognized that educating members just in time for their interventions could lead to informed decision-making. This approach proved successful for many reviewed procedures like hysterectomies. Former UHG CEO, Dr. Bill McGuire, took a bold step by halting prior authorization, resulting in a better experience for physicians and members, along with substantial cost savings by eliminating the related jobs roles. For plans considering the future of prior authorization, embracing AI may be the key, as a few aggressive physicians often trigger authorization requests for all. Notably, the low percentage of upheld prior authorization denials highlights the need for a more efficient approach. Payers in 2022 were ranked by their prior authorization request denial overturn rates as follows: - Centene: 95.3% - Aetna: 90.8% - Anthem BCBS: 89.2% - UnitedHealthcare: 86.1% - Cigna: 85.3% - BCBS: 80.3% - Anthem: 75.1% - Kaiser: 69.5% - Humana: 68.4% Explore more on this insightful ranking here: [Link to the article](https://lnkd.in/dh5EUGns)