Last August I posted a story on how home nursing visits were being used by insurance companies to bilk Medicare for billions. (Home Nursing Visits Bilking Medicare for Billions)

The story was reported in The Wall Street Journal by Anna Wilde Mathews, Christopher Weaver, Tom McGinty, and Mark Maremont. They discovered that insurance companies were instructing their home nurses who visited Medicare Advantage patients to add diagnoses to the patient record whenever possible to increase payments from the federal government.

Now these same investigative reporters have uncovered similar activity by doctors working for the UnitedHealth Group. Their report in The Wall Street Journal reveals how the insurer prepared a checklist of potential diagnoses even before the patients were examined. Here’s how they described the situation:

“Like most doctors, Nicholas Jones prefers to diagnose patients after examining them. When he worked for UnitedHealth Group, though, the company frequently prepared him a checklist of potential diagnoses before he ever laid eyes on them.

UnitedHealth only did that with the Eugene, Ore., family physician’s Medicare Advantage recipients, he said, and its software wouldn’t let him move on to his next patient until he weighed in on each diagnosis. The diagnoses were often irrelevant or wrong, Jones said. UnitedHealth sometimes suggested a hormonal condition, secondary hyperaldosteronism, that was so obscure Jones had to turn to Google for help. “I needed to look it up,” he said.”

The government’s Medicare Advantage system, which uses private insurers to provide health benefits to seniors and disabled people, pays the companies based on how sick patients are, to cover the higher costs of sicker patients. Medicare calculates sickness scores from information supplied by doctors and submitted by the insurers. In the case of UnitedHealth, many of those doctors work directly for UnitedHealth.

More diagnoses make for higher scores—and larger payments. A Wall Street Journal analysis found sickness scores increased when patients moved from traditional Medicare to Medicare Advantage, leading to billions of dollars in extra government payments to insurers.

The authors say, “Patients examined by doctors working for UnitedHealth, an industry pioneer in directly employing large numbers of physicians, had some of the biggest increases in sickness scores after moving from traditional Medicare to the company’s plans, according to the Journal’s analysis of Medicare data between 2019 and 2022. Sickness scores for those UnitedHealth patients increased 55%, on average, in their first year in the plans, the analysis showed. That increase was roughly equivalent to every patient getting newly diagnosed with HIV, the virus that causes AIDS, and breast cancer, the analysis showed.”

That far outpaced the 7% year-over-year rise in the sickness scores of patients who stayed in traditional Medicare, according to the analysis. Across Medicare Advantage plans run by all insurers, including UnitedHealth, scores for all newly enrolled patients rose by 30% in the first year.

A spokesman for UnitedHealth said in a written statement that 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.” The company’s approach, he said, helped to avert more serious health problems later, and to achieve Medicare Advantage’s goals of improving quality and reducing costs.

It is revealing that Dr. Jones, the Oregon doctor mentioned above, said UnitedHealth didn’t suggest diagnoses for patients he treated outside Medicare Advantage, where it doesn’t pay. Traditional Medicare patients treated by UnitedHealth doctors had much lower sickness scores, the Journal’s analysis showed.

UnitedHealth has acquired dozens of medical groups over the past decade-and-a half. Its Optum unit now employs about 10,000 physicians, its top executive has said, making it one of the nation’s largest employers of doctors. It contracts with tens of thousands more. No other national insurer has acquired and hired doctors on that scale.

In my opinion, the company is rationalizing their policies to justify the additional diagnoses that lead to much higher payments from the government. This is exactly why I abhor the recent trend of doctors leaving private practice to work for insurance companies, hospitals, and other large corporations. This inevitably leads to doctors compromising their judgements about diagnosis and treatment due to pressure from their employers. Doctors need to make decisions based on what’s best for the patient, not their employer.

Regular readers of this blog know I love to read. In 1998 I made the only New Year’s resolution I’ve ever kept by reading at least two books per month or 24 books for the year. I’ve kept that resolution for 27 years and have read over 1000 books in that time. (1085) That discipline has immeasurably brightened my life and increased my knowledge of this world we live in; much more than watching television ever could.

It’s become a tradition in recent years for me to publish my list of favorite books I read in the last year. These books are listed in the order I read them, not necessarily in any ranking.

1. Blood Lines – Nelson and Alex DeMille – Nelson DeMille has been one of my favorite fiction writers for decades and has been a regular on the New York Times Bestseller Lists. This book is the debut of his son as co-author and together they have done a great job. I’m usually skeptical of these father-son co-authorships but this duo works well together, delivering the same quality we’ve come to expect from Nelson DeMille alone.
2. The Edge – David Baldacci – Another high-quality fiction work from another staple on the bestseller lists for fiction. Baldacci always delivers!
3. 700 Sundays – Billy Crystal – This book is a memoir of the 700 Sundays Billy Cristal spent with his father, Jack Crystal, who died when Billy was 15. He tells the many stories of growing up in Brooklyn, New York and the relationships he had with his father and many celebrities his father knew.
4. Saying It Well – Chuck Swindoll – A great book on how to prepare and deliver meaningful sermons or lessons for all those teachers and preachers who want to learn from one of the best ever. I read it this year for the second time.
5. The Endurance – Caroline Alexander – This book chronicles the expedition to the South Pole by Sir Ernest Shackleton, a British explorer of the early 20^th It is an amazing story of human determination in the face of seemingly insurmountable obstacles. The book is filled with fascinating photographs of this voyage to Antarctica taken by one of the crew.
6. D-Day – Stephen Ambrose – This year marked the 80^th anniversary of the D-Day Invasion that was the turning point in the war to defeat the Nazi’s Third Reich. Since my father was a paratrooper in the 101^st Airborne who jumped into Normandy on that historic day, I was impressed to re-read this great historical account of that day.
7. Pagan America – John Daniel Davidson – This book gives an historical account of the world before the birth of Christ when evil was rampant and human sacrifices to the gods was a common practice in several different parts of the world. The author makes the case that such evil was temporarily checked by Christ’s appearance on earth, but may someday soon be unleashed as the world turns its back on Christianity in the last days.
8. The War on Warriors – Pete Hegseth – The author is currently the nominee to be our next Secretary of Defense under the Trump Administration. His book documents his time in the military and his deep disdain for the “woke” policies that have permeated our military under the Biden Administration. His determination to resurrect our military to its primary role of protecting America is evident throughout the book.
9. The Watchmaker’s Hand- Jeffery Deaver – Another great work of fiction from the writer who first gave us the character of Lincoln Rhyme in the book The Bone Collector. Deaver delivers another great story using the same characters.
10. The Road to Armageddon – Chuck Swindoll/ DTS professors – This book, first published in 1999, gives us a great understanding of the last days as recorded in the Bible in the books of Daniel and Revelation in particular. There are six chapters written by six theology professors at Dallas Theological Seminary in a book written for understanding by non-seminary students. Great reading for everyone!

That’s my list for this year. I hope you will pick them up at your library or book store soon and enjoy them as much as I did. Keep reading!

In Part I of this series, we discussed the shocking response some Americans had to the cold-blooded murder of United Healthcare executive Brian Thompson on the streets of New York. While most were outraged that this could happen to anyone, some actually cheered the brutal murder of a health insurance executive as if “he had it coming to him.” This raises the question why some Americans are so angered by the health insurance industry.

We learned in Part I that most Americans like their health insurance and a substantial majority give positive ratings to their health plans. But there are some problems that need to be addressed. John C. Goodman tells us in Forbes that “With one exception described below, no insurer in our health care system wants a sick person. No employer. No commercial insurer in the marketplace. No Medicaid managed care plan. And no safety net institution. Every time someone with an expensive medical problem enters one of these plans, the organization loses money. If the patient leaves the plan (for whatever reason) the plan makes money. If the plan develops a reputation for being really good at handling serious medical problems, it will attract more sick people and incur more losses. Given the horrible economic incentives that government regulation has created, the surprise is not that some patients experience mistreatment. The surprise is how few there are.”

The exception is Medicare Advantage plans. More than half of Medicare enrollees are now in private health insurance plans, called Medicare Advantage, or Part C. Like everyone else in the country they pay community-rated premiums that are independent of their health status. But unlike every one else, their premiums are topped up by Medicare, based on individual risk assessments. As a result, the total premium that the plans receive makes the healthy and the sick equally attractive from a financial point of view.

There are other advantages. The Medicare Advantage Program is the only place in our healthcare system where a doctor who discovers a change in a patient’s health status can send that information to an insurer (in this case Medicare) and receive a higher premium payment—reflecting the new expected costs of care. Accordingly, MA plans have financial incentives to discover patient problems early and solve them. These plans make money by getting patients the care they need and keeping them away from the emergency room and out of the hospital.

And, unique in our health care system are MA plans that specialize in such chronic conditions as diabetes, heart disease, cancer, etc. These MA plans actually seek to enroll patients that conventional health insurance would like to avoid. Medicare Advantage costs less than traditional Medicare and is of higher quality. Moreover, as MA presence expands in an area, medical practices begin to change – resulting in lower cost, higher-quality care for other patients.

Could the system be better? Sure. For example, United Healthcare is said to deny about one-third of its claims. But there are MA plans in Houston that have denial rates as low as 3 percent.

Goodman responds: “There are often good reasons to deny a claim. But how many are successfully appealed and how long does it take to adjudicate them? Insurance companies should be free to advertise these facts and compete on how well they take care of their enrollees after they get sick. Then, we should explore ways of making individualized risk adjustment available to the rest of the healthcare system. Economist John Cochrane believes that would happen naturally in a free market for health insurance. Maybe it’s time to give that idea a try.”

Medicare Advantage is growing in popularity, even though the Biden administration has made it more difficult for the private health insurers in the system. If you’re considering a MA plan, be sure to check with your doctors to see if they participate in the plan or you may be looking for new doctors.