Under Medicare rules, each condition that triggers extra payments has to be diagnosed annually. UnitedHealth doctors said patients whose records showed past diagnoses that hadn't been re-documented were frequently called in for office visits, and the company's software would spool out lists of potential diagnoses.
The list UnitedHealth sent one doctor included a potential diagnosis of a lower-leg amputation, citing prior records, even though the patient wasn't missing a limb. The company told another doctor it suspected a patient had heart failure "based on prevalence of this condition in our patient population."
Jones, the former UnitedHealth doctor in Oregon, said the suggestions included diagnoses based on scant evidence, such as long-term insulin use for patients who had received the drug only once during a long-ago hospital stay. For patients regularly taking aspirin, he said, the technology would propose a clotting disorder.
To finish a visit, he had to check a box to confirm or rule out each possible diagnosis -- or defer it for later. At first, he said, the checklists were optional, but then they became mandatory. He usually rejected the hyperaldosteronism diagnoses, he said, if he didn't see any testing or treatment for the condition.
The design of the system, he said, could lead to good-faith errors as doctors clicked through all the boxes. "The system is made to have these happy little accidents that end up resulting in a lot of money from taxpayers," he said.
Bonus pay
A December 2023 compensation plan for one UnitedHealth-owned practice offered doctors bonuses of up to $37.50 a year for each of their Medicare Advantage patients if they confirmed or ruled out more than 90% of the suggested diagnoses. That means a doctor seeing 800 Medicare Advantage patients in a year could see a bonus of as much as $30,000 a year.
Tom Lin, a former UnitedHealth physician in Oregon, said it was easier to say yes than no, particularly with diagnoses that another doctor had previously confirmed and placed in the patient record.
"You didn't have time to rule it out," he said, given the volume of patients each day. He said he did his best to remove from patients' charts diagnoses that he questioned such as secondary hyperaldosteronism, which UnitedHealth often suggested for heart-failure patients, "because I had no idea what the hell they were talking about."
Shweta Bansal, a nephrologist at UT Health San Antonio who studies that disease, said "the treatment of heart failure is the same" regardless of whether secondary hyperaldosteronism is diagnosed.
UnitedHealth said a company study found that patients of medical providers under its Optum umbrella had better outcomes than patients in traditional Medicare, including an 18% lower risk of inpatient hospital admissions and an 11% lower risk of emergency department visits. The company said its model improved management of chronic diseases, including diabetes.
Like other Medicare Advantage companies, UnitedHealth also contracts with outside doctors in ways that can increase their payments when they diagnose more conditions. That includes arrangements where doctors receive a portion of the Medicare payments insurers get for their patients. Other Medicare Advantage insurers also suggest diagnoses to independent doctors examining their patients.
In some contracts with independent doctors reviewed by the Journal, UnitedHealth linked bonuses to sickness scores and quality ratings derived partly from patient surveys. For patients with sickness scores 20% higher than average and good quality ratings, doctors could get an extra $40 per patient each month, one contract shows. Scores 50% above average and top quality ratings could yield $65 per patient a month. For a doctor with 100 patients covered by the contract, that would amount to a $78,000 annual bonus.
Andy Pasternak, an independent family doctor in Reno, Nev., has lower-than-average sickness scores across his practice, records show. He said he gets a per-patient bonus of $2 a month, or $2,256 annually, for the 94 Medicare Advantage patients covered by his contract with UnitedHealth.
Pasternak said UnitedHealth offered to send nurses to visit those patients to diagnose them more fully. The company would pay him $250 for each patient their nurses examined, he said.
"That's more than I get paid for treating my own patients," he said. He said the focus on diagnosing has soured him on Medicare Advantage, and made him grateful when patients younger than 65 come to his office.
One UnitedHealth document reviewed by the Journal projected Pasternak could receive as much as $23,250 a year in such payments. A UnitedHealth executive in his area told him in an email his practice also would benefit from any additional diagnoses made by the nurse.
Valerie O'Meara, a former UnitedHealth nurse practitioner, said she never provided treatment for the patients she saw in doctors' offices in Washington state. "Your job is finding diagnoses, that was clear as a bell," she said. "I was like, am I finding all these things that the doctors who are taking care of these people didn't find?"
She said a Minnesota-based UnitedHealth manager urged her to make new diagnoses beyond what doctors had treated. Patients were often confused, she said, about why she, not their own doctor, was examining them. "They don't tell the patient, the nurse needs to see you to make sure your high-scoring medical problems are checked off this year."
Suspicious patient
Chris Henretta, a UnitedHealth Medicare Advantage plan member who lives in The Villages, a retirement community in central Florida, was suspicious when his primary-care doctor diagnosed him as morbidly obese during his annual exam in October.
He is a lifelong weightlifter, plays water volleyball five times a week and has an athletic build.
"I told her I didn't think I was obese," Henretta said. When she recorded morbid obesity anyway, he said, he began to "suspect my doctor may have a financial incentive to portray people as higher risk."
The diagnosis can trigger payments of about $2,400 a year to Medicare Advantage insurers.
A widely used measure to diagnose obesity, body-mass index, has been criticized for sometimes mischaracterizing muscular people as overweight. Henretta's medical record shows that even by that standard, he didn't qualify as morbidly obese. His BMI was 32.3 at the time of his October visit, nearly three points below the minimum threshold for morbid obesity.
Henretta's doctor at The Villages Health, a clinic that contracts with UnitedHealth, also diagnosed him with qualitative platelet disorder, a condition that affects blood clotting.
Henretta said his doctor added the diagnosis after he agreed that his blood seemed to clot slightly more slowly after he started taking baby aspirin several years earlier. His doctor had recommended the baby aspirin after he was diagnosed, in 2021, with aortic atherosclerosis -- which could trigger Medicare payments of about $2,700 a year at the time.
Dr. Rachel Bercovitz, a hematologist and professor at Northwestern University's medical school, said aspirin inhibits platelet function, so Henretta's doctor is "diagnosing the intended effect of the medication" as a separate disease.
A qualitative platelet disorder diagnosis can trigger extra payments of about $2,000 a year to insurers.
The Villages Health, its top executives and Henretta's doctor didn't respond to phone calls and emails requesting comment.
Dr. Coleen Madigan, who worked for a UnitedHealth medical practice in Texas for a little over a year before leaving in 2020, said one of her patients there didn't know what she was talking about when she asked when he had been diagnosed with chronic obstructive pulmonary disease, and got upset when she told him his chart included the illness.
The patient was a smoker who had bronchitis in the past, but he had never been tested to confirm COPD, Madigan said. She added a note to his record saying there wasn't documentation to support the lung disease diagnosis, she said, but it was difficult to remove completely.
During her time at UnitedHealth, Madigan, now mostly retired, said she felt "an insidious pressure" to document diagnoses. "It distracts you from focusing on the patient."
--Mark Maremont contributed to this article.
Write to Christopher Weaver at Christopher.Weaver@wsj.com, Anna Wilde Mathews at Anna.Mathews@wsj.com and Tom McGinty at Tom.McGinty@wsj.com
(END) Dow Jones Newswires
December 29, 2024 21:00 ET (02:00 GMT)
Copyright (c) 2024 Dow Jones & Company, Inc.
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