That is half 3 of Jeff Goldsmith’s historical past of managed care. Should you missed it learn Half 1 & Half 2
By JEFF GOLDSMITH
Two main adjustments in medical insurance ensued because the US well being system entered the 21st century- a strategic shift of well being value threat from suppliers to sufferers and the emergence of machine pushed managed care.
Insurers Shift Technique from Sharing Danger with Hospitals and Docs to Markedly Implicating their “Sufferers’.
After the 2008 recession, employers and their well being plans shifted technique from placing physicians and hospitals in danger by way of delegated threat capitation to placing sufferers in danger by way of larger affected person value sharing. Within the wake of the recession, the variety of sufferers with excessive deductible well being plans almost quintupled–to over sixty million lives. By 2024, 32% of the lives in employer-based plans (50% amongst small employers’) have been in excessive deductible plans no matter affected person financial circumstances.
The acknowledged intention of the Excessive Deductible Well being Plan motion was to encourage sufferers to “store” for care. In actual care conditions, nevertheless, sufferers discovered it troublesome or not possible to find out precisely what their share of the price can be or which suppliers did the perfect job of taking good care of them. For an in depth evaluation of the literature on how healthcare “customers” wrestle to handle their monetary threat, learn Peter Ubel’s 2019 Sick to Debt: How Smarter Markets Result in Higher Care.
Employers and insurers, working collectively to “empower customers”, quickly shifted “self-pay” unhealthy money owed onto their supplier networks. Some 60% of hospital unhealthy money owed are actually from sufferers with insurance coverage. As a substitute of “searching for care”, customers discovered themselves saddled with virtually $200 billion in medical payments they may not pay, and hospitals and physicians ended up consuming most of it.
This escalating “insured unhealthy debt” downside compelled suppliers to rent income cycle administration (RCM) consultants to revise and strengthen their insurance policies relating to affected person monetary accountability, “income integrity” (that means crossing all of the “t’s” and dotting all of the “I’s” in every medical declare and ensuring care is coded correctly) and rigorously monitoring the circulate of claims to and from their main insurance coverage carriers. In consequence many suppliers discovered themselves spending 10-15% of their whole working bills on RCM!
Medicare Benefit Permits Insurer Market Dominance
The motion from Ellwood’s imaginative and prescient of regionally-based supplier sponsored well being plans to market dominance by large nationwide carriers was cemented by the emergence of Medicare Benefit as essentially the most vital and worthwhile medical insurance market section. In 2013, Medicare Benefit accounted for 29% of whole Medicare spending. A decade later, in 2024, it was 54% (of roughly a trillion greenback program). And till a federal crackdown on MA coding and fee insurance policies by the carriers, it was a 5% margin enterprise, considerably extra worthwhile than industrial insurance coverage, ObamaCare Change or managed Medicaid companies.
As Medicare Benefit emerged as the biggest medical insurance market, it was dominated by a cartel of huge publicly traded carriers.
Six publicly traded carriers (United, Humana, CVS/Aetna, Elevance/Anthem, CIGNA and Centene) accounted for 69% of MA’s 34.6 million enrollment as of November 2024. Kaiser, the “founder” of the motion, added one other 5.5%. The highest two MA plans, United and Humana, account for nearly 46% of MA’s enrollment! Sixty p.c of United and CVS/Aetna’s medical insurance premium circulate and 90% of Humana’s now come from this single program, in keeping with a latest Financial institution of America evaluation.
Nevertheless, owing to the aggressive promotional activism of consultants and personal fairness financed “administration providers organizations”, the median MA plan enrollment is lower than 2000 lives (!). Throughout the 2010’s, Medicare Benefit grew to become an trade in and of itself. A tremendous variety of small hospital and doctor sponsored plans are preventing over lower than 1 / 4 of MA enrollment, and, predictably, shedding cash on each subscriber (unfavorable 5% margins are typical). Some communities have as many as forty MA plans competing for his or her share of this profitable market.
The Rise of Machine Pushed Managed Care
The massive nationwide carriers rely, in flip, on a posh community of contractors to handle their Medicare Benefit care administration and fee. A shadowy trade populated with billion greenback excessive tech companies nobody within the care system had ever heard of–with names like Emdeon (now Change Healthcare,), Equian, MultiPlan (taken personal by Carlyle in 2024), naviHealth, Signify and Cotiviti–emerged to service well being plans with automated programs to evaluation hospital and doctor claims previous to fee.
These companies used AI pushed machine studying to investigate and course of the circulate of a whole bunch of billions of {dollars} in medical claims. A big fraction of these claims are denied, both due to knowledge errors within the claims themselves, or as a result of AI guidelines engines kicked them out for not conforming to continually evolving medical necessity standards.
Prior authorization, a forty-year-old HMO expense management device for managing “elective care”, has been augmented by “potential pre-payment evaluation” utilized after hospitals have admitted and cared for sufferers and submitted insurance coverage claims. In response to the American Medical Affiliation, every working towards doctor within the US is required to submit 45 prior authorization requests for his or her sufferers every week.
Hospitals noticed, in some instances, a doubling of claims denials or repricing in only a twelve to eighteen-month interval after 2016 based mostly on these automated “potential” opinions. This surge of machine-driven denials performed a serious function within the mysterious 39% plummet in hospital working earnings seen in 2016 and 2017.
A key issue within the wave of denials was the elevated centrality of hospital emergency admissions as the principle gateway to advanced and costly inpatient care. Upwards of 70% of sufferers in lots of well being programs are admitted by way of the emergency room and care is rendered to these sufferers on an pressing foundation.
With main care physicians withdrawing from hospital observe, choices to confess sufferers to hospitals have been more and more made by employed physicians or doctor contractors to the hospital, lots of whom are “out of community” with the insurance coverage carriers, and underneath restricted management by the hospitals themselves.
After-the-fact denials by insurers typically end in sudden larger payments to sufferers with excessive deductible plans in addition to vital new administrative bills for hospitals to trace and contest the surge of denials.
UnitedHealth Group Makes its Transfer
Following the greater than decade-long personal fairness rollup of those care managing tech companies after the yr 2000 dot-com/tech inventory crash, an incredible share of this shadowy sector ended up being owned by a single firm. In a shocking fast fireplace $20 billion acquisition spree from 2019 to 2021, UnitedHealth Group purchased Equian, Change Healthcare and naviHealth. The US Division of Justice unsuccessfully challenged the biggest of those transactions–the Change Healthcare acquisition– on anti-trust grounds.
By the point this blitz was over, United’s $19 billion OptumInsight enterprise intelligence subsidiary was processing one-third of all medical claims within the US with automated claims administration software program–a outstanding $1.5 trillion in well being supplier funds a yr. OptumInsight’s largest single buyer was United’s well being plans–63% of its whole revenues.
However OptumInsight’s different prospects have been opponents of United’s medical insurance enterprise (a lot for “vertical integration”). The RCM Trade, on behalf of doctor and hospital suppliers, and Optum Perception have locked horns in what might be referred to as The Struggle of the Robots–as dueling AI programs fought over the documentation, approval and fee of trillions of {dollars} in medical funds. Within the struggle between Skynet Medical and the RCM trade, sufferers and physicians have been diminished to mere datapoints.
COVID produced what proved to be a brief stop fireplace within the Struggle of the Robots. It’s because the shutdown of routine care in hospitals throughout 2020 produced a multi-hundred billion $$ windfall in money circulate for well being plans together with United’s. Denying care throughout a well being emergency would have additionally produced plenty of ugly headlines, so well being plans merely turned the denial machine off, in keeping with colleagues within the income cycle trade. Well being plans didn’t wish to be socked with a “windfall earnings” tax (for exceeding ObamaCare’s statutory medical loss ratio (MLR) limits. Nevertheless, when well being plans medical bills (so-called Medical Loss Ratios, or MLRs) started rising once more, the denial equipment cranked up once more, and the struggle resumed.
Physicians have been collateral harm on this struggle, as a result of an enormous fraction of their accessible observe time, as a lot as half of their whole hours, is now spent minutely documenting each single scientific determination they make of their digital well being file system, feeding the AI denial machine knowledge.
Digital well being data have been touted as a revolutionary device for enhancing scientific productiveness. As a substitute, they’ve turn into an all-seeing surveillance mechanism- a 24/panopticon surveilling doctor exercise of behalf of huge insurance coverage carriers, and depriving sufferers of direct care time spent with their physicians and different caregivers.
Skynet Crashes!
It didn’t take greater than eighteen months for the historic Optum roll-up of medical claims administration software program and providers to explode in United’s face. On Feb 21, 2024, a shadowy Russian hacker collective AlphV invaded and crippled Change Healthcare’s knowledge programs, shutting down $120 billion a month in healthcare funds. Solely eighteen months into proudly owning all this equipment, Optum’s knowledge programs have been a scorching mess, a extremely susceptible mashup of dozens of functions and databases rolled up from the handfuls of smaller firms that have been a part of Change.
AlphV operatives impersonated a senior Change govt, stealing his login credentials. The hackers used these phony credentials to search out and exfiltrate (e.g. obtain and steal) about 8 terabytes of well being claims info, together with personally identifiable well being info on 100 million People. Then they deleted Change’s back-up information so they may now not course of medical claims. United paid a $22 million ransom fee to revive their information, but it surely was stolen by one in every of AlphV’s members and their programs remained offline for months!
The impact was markedly uneven relying on the place suppliers have been positioned and who they contracted with. Some hospital programs whose medical insurance payers used different distributors than Change noticed no financial hurt. Different noticed 100% of their money circulate crash to zero {dollars} and started incurring, in some instances, seven or eight determine weekly working losses. Doctor practices all throughout the US have been crippled, and homeowners have been placing their payrolls for nurses and physicians on their private bank cards or acquiring private loans from their banks.
The Change outage was slowly restored over a 4 month interval. United/Optum has admitted up to now to $3 billion in direct bills for restoring their knowledge programs. Lawsuits in search of to get better damages from United for the additional value of months of submitting and monitoring paper medical claims stay unresolved.
Whereas 100 million sufferers and their households skilled violations of their medical privateness, the Change hack revealed a serious nationwide safety problem. Totally one-third of all medical funds and one fifth of US GDP have been flowing by way of a single personal firm’s leaky pipes. Overseas hackers have immediately the potential of reaching into United’s knowledge programs and principally crippling the US healthcare system. After a scorching Might Senate Finance Committee listening to, the US Congress took no motion to shut this gaping gap in knowledge safety for a key piece of US infrastructure. Skynet Medical is now again in operation.
Managed Care within the 21st Century
A managed care motion which started greater than seventy years in the past by empowering clinicians to handle take care of populations of their communities inside a set price range has devolved, by levels, into an more and more data-driven money administration system run by AI on behalf of huge, publicly traded well being care conglomerates. Physicians pay an enormous tax in time diverted from affected person care, and sufferers bear an unpredictable and unmanageable stage of financial threat for well being care over which they’ve restricted or no management. And a managed care trade devoted to lowering healthcare prices added tens of billions in administrative bills to hospitals and different care suppliers.
The early levels of this devolution spawned profitable, prime quality built-in well being programs and well being plans in some components of the nation. Nevertheless, the final decade has seen an enormous consolidation of medical insurance within the fingers of a small variety of immense companies, by way of the explosive development of the Medicare Benefit program.
In its latest 10Q SEC submitting, after complaining about suppliers’ aggressive coding practices and growing Medicare utilization, United stated, “We endeavor to mitigate these will increase by partaking hospitals, physicians and customers with info and serving to them make clinically sound selections . . .” This useful “recommendation” from United’s AI pushed claims administration system guarantees to revive United’s lagging earnings development.
Clinicians and hospitals are growing managed by machines, not colleagues and their choices dictated by algorithms they by no means see, relatively than considerate scientific tradition and human values. Dr. Ellwood is probably going rolling over in his grave.
Jeff Goldsmith is a veteran well being care futurist, President of Well being Futures Inc and common THCB Contributor. This comes from his private substack
