UnitedHealth Group, a major player in the US healthcare industry, has come under scrutiny for its practices surrounding Medicare Advantage—a system where private insurers manage government-funded healthcare for seniors and people with disabilities. A recent investigation reveals how doctors working directly for UnitedHealth are contributing to higher government payouts by diagnosing patients with conditions that may not directly impact their treatment, reported the Wall Street Journal.
Pre-generated diagnoses: A system under question
Nicholas Jones, a former UnitedHealth physician in Eugene, Oregon, recounts how the company provided him with checklists of potential diagnoses for Medicare Advantage patients before he even examined them. While UnitedHealth claimed this process improved care by identifying potential conditions, Jones noted many diagnoses were irrelevant or incorrect. For instance, he often encountered obscure conditions like secondary hyperaldosteronism, which he had to research to understand.
These practices are tied to how Medicare calculates payments: higher “sickness scores” result in larger reimbursements to insurers. UnitedHealth’s system pressures doctors to confirm diagnoses, with software blocking them from moving to the next patient until they address every suggested condition.
Sickness scores and financial incentives
An analysis by The Wall Street Journal revealed that Medicare sickness scores for patients under UnitedHealth plans rose sharply—by 55% in their first year. This is significantly higher than the average 7% increase for patients in traditional Medicare. The inflated scores have reportedly generated billions in additional government payments for UnitedHealth, raising concerns about whether patient care or financial gain is the driving force behind these practices.
Internal push and external impact
Doctors working for UnitedHealth have also reported internal pressures to confirm diagnoses. Some were urged to consider conditions they had never previously identified in their patients. For example, the diagnosis of senile purpura—a harmless skin condition—was reported 28 times more often for UnitedHealth’s Medicare Advantage patients compared to those in traditional Medicare. Critics argue this doesn’t improve care but rather boosts the company’s revenue.
Mixed reactions
UnitedHealth defends its approach, stating that accurate diagnoses lead to better care and improved outcomes, such as fewer hospitalizations and better chronic disease management. However, some former doctors disagree. Dr. Emilie Scott, who left UnitedHealth, criticized the system as being more focused on maximizing financial returns than prioritizing patient care.
The federal government is now studying the relationship between insurers and medical providers under Medicare Advantage. Critics argue that stricter oversight is needed to ensure the system is not exploited at the expense of patients and taxpayers.
