UnitedHealth sued over alleged use of AI to deny elderly patients care

https://www.msn.com/en-us/money/companies/unitedhealth-sued-over-alleged-use-of-ai-to-deny-elderly-patients-care/ar-AA1kfHQ0

The families of two now-deceased former beneficiaries of UnitedHealth have filed a lawsuit against the health care giant, alleging it knowingly used a faulty artificial intelligence algorithm to deny elderly patients coverage for extended care deemed necessary by their doctors. 

The lawsuit, filed last Tuesday in federal court in Minnesota, claims UnitedHealth illegally denied “elderly patients care owed to them under Medicare Advantage Plans” by deploying an AI model known by the company to have a 90% error rate, overriding determinations made by the patients’ physicians that the expenses were medically necessary.

“The elderly are prematurely kicked out of care facilities nationwide or forced to deplete family savings to continue receiving necessary medical care, all because [UnitedHealth’s] AI model ‘disagrees’ with their real live doctors’ determinations,” according to the complaint. 

Medicare Advantage plans, which are administered by private health insurers such as UnitedHealth, are Medicare-approved insurance plans available to elderly people as an alternative to traditional federal health insurance plans, according to the U.S. Centers for Medicare and Medicaid Services. 

The use of the allegedly defective AI model, developed by NaviHealth and called “nH Predict,” enabled the insurance company to “prematurely and in bad faith discontinue payment” to its elderly beneficiaries, causing them medical or financial hardships, the lawsuit states.

Use of AI to determine health coverage

Aaron Albright, a spokesperson for NaviHealth told CBS MoneyWatch that the AI-powered tool is not used to make coverage determinations but as “a guide to help [UnitedHealth] inform providers … about what sort of assistance and care the patient may need.” 

Coverage decisions are ultimately “based on CMS coverage criteria and the terms of the member’s plan,” Albright said, adding that the lawsuit “has no merit.”

In their complaint, however, the families accuse UnitedHealth of using faulty AI to deny claims as part of a financial scheme to collect premiums without having to pay for coverage for elderly beneficiaries it believes lack the knowledge and resources “to appeal the erroneous AI-powered decisions.”

UnitedHealth continues “to systemically deny claims using their flawed AI model because they know that only a tiny minority of policyholders (roughly 0.2%)1 will appeal denied claims, and the vast majority will either pay out-of-pocket costs or forgo the remainder of their prescribed post-acute care.”

Lawyers for the family are looking to represent “All persons who purchased Medicare Advantage Plan health insurance from Defendants in the United States during the period of four years prior to the filing of the complaint through the present.” 

AI’s utility in health insurance industry 

Implementing AI algorithms may help health insurance companies automate between 50% and 75% of the manual work involved in approving insurance requests, such as gathering medical information and cross-validating date with patient records, resulting in faster turnaround times that may benefit beneficiaries, consulting firm McKinsey said last year. 

Still, some medical professionals have advised health insurers to rein in their expectations of AI’s utility in the health insurance industry. 

In June, the American Medical Association (AMA) praised the use of AI to “speed up the prior authorization process,” but called for health insurers to require human examination of patient records before denying their beneficiaries care.

“AI is not a silver bullet,” AMA Board Member Marilyn Heine, MD, said in a statement. 

According to a ProPublica review, doctors at health insurer Cigna rejected more than 300,000 claims over the course of two months in a review process that used artificial intelligence. 

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Will complex/high acuity pts be the first KICKED TO THE CURB?

Apparently, according to Medicare reimbursement to physicians, all pts – regardless of the complexity of their health issues – deserve the same amount of physician’s time. Unless the physician is an employee of a large hospital system and the system gets paid more for the physician’s time, than those physicians that are in private practice!

The Broken Medicare System Is Forcing Physicians Out

https://www.medpagetoday.com/opinion/second-opinions/107450

Yet another physician pay cut will prevent timely access to care

In any career, 25 years of dedicated work is a lot to let go of. In medicine, it amounts to hundreds of patient relationships, and the blood, sweat, and tears that go into starting and maintaining a practice.

Yet, after all that time, one of my physician colleagues recently had to let go of her beloved private practice — not by choice and not without tears for her dear, elderly Medicare patients who now face fewer options for care. Her story is unfortunately not unique.

Physicians and their patients have suffered through more than 2 decades of uncertainty caused by precarious Medicare funding. We’ve seen how these cuts have forced unwanted changes in medical practices. While their practices stay open, the Medicare system underpays our nation’s physicians to the point that some are forced to make difficult decisions about which patients they can care for. Eventually, when these practices barely have their heads above water, that “next round of cuts” proves to be the last straw.

Like clockwork, another Medicare physician payment cut is on the horizon for January.

I’m afraid the day is near — if not already here — that there will not be enough physicians to take care of Medicare patients. Physicians who participate in the program are forced to do more with less, which leaves no good choices. The situation hinders our ability as physicians to provide the complex, quality care these elderly and sometimes disabled patients need, and prevents us from seeing as many Medicare patients as we would like. Furthermore, it contributes to burnout and moral distress because we can’t do what we swore an oath to do, which is to put our patients first.

Medicare Physicians’ Plight

As president of the Texas Medical Association (TMA), I hear concerns from our physician members as they face ongoing practice viability challenges.

“If this additional [Medicare] payment cut goes through, in the midst of inflation and COVID causing rising costs for staff salaries and benefits, I would have no choice but to stop caring for these patients,” a worried physician shared with TMA.

“We are dying,” said another. “I can’t even keep a full staff. All the doctors I have referred patients to are leaving or gone.”

“I’m terrified for what this will mean for my elderly patients and their access to care,” yet another concerned doctor said.

“The mental stress of making ends meet is not good for patient care,” another colleague warned.

An Unsustainable, Unfair System

Not only is this system unsustainable for our nation’s physicians, but it’s also unfairly stacked against them.

It’s the same system that concurrently pays

hospital-based clinics more for some of the same services an independent, community physician provides. On top of that, Medicare helps hospitals cover uncompensated care.

I’m not saying hospitals don’t deserve to be paid for what they do. But when independent physician practices get swallowed up by a hospital or bought out by another entity just to survive, the cost of care can go up, creating ripple effects on our economy. This kind of rapid consolidation is now rampant in our healthcare system, in part because of payment incentives like those in Medicare.

“Our practice is already shutting its clinic doors as we instead focus on being a purely hospital-based practice due to already meager reimbursement,” another worried Texas physician shared with TMA. “We simply cannot afford the overhead. Ongoing cuts to [Medicare] physician reimbursement not only hurt us — the physicians trying to provide the best quality care to our patients — but it ultimately hurts the patients and their loved ones suffering from life-altering conditions.”

“I barely scrape through making payrolls every pay period. Any more [Medicare] reimbursement [cuts are] going to put me and thousands of physicians like me under water and force us to shut down or join [a private] equity company or [insurer-owned] clinics who put their wallets ahead of patient care,” said another frustrated physician.

We should be preserving independent medicine and patient choice — not undermining it. It’s time for Congress to address the root of the problem.

Solutions

The first simple step physicians and other healthcare professionals can take is to advocate for Congress to enact laws directed at paying physicians fairly for services provided to Medicare patients. At a minimum, that entails pay that keeps pace with inflation. Just like other industries’ labor costs are tied to the Consumer Price Index (CPI), Medicare physician payments should at least be tied to a similar measure of physician practice cost inflation, the Medicare Economic Index (MEI).

Several physician members of Congress are leading the charge on such a reform with a bipartisan House bill that behooves support: H.R. 2474, the Strengthening Medicare for Patients and Providers Act. The centerpiece of that legislation is an annual, inflation-based Medicare physician payment update based on the full MEI.

Our current predicament is tied to the fact that Medicare physician payments haven’t even come close to keeping up with inflation over more than 20 years. Since 2001, Medicare physician payments have lagged 26% behind inflation while hospital and other health industry payments have kept pace, according to American Medical Association data. Over the same period, the CPI for physician services in U.S. cities increased by 65%

Just think about that: What would you say if you worked more than 20 years with no raise and pay cuts to boot? I know what my colleagues across Texas are saying:

“If [another cut is] enacted, our [Medicare] reimbursement rate will be lower than what we received in 2012,” one physician calculated.

Another said, “My Medicare reimbursement, factoring for inflation, is less than half of what it was in 1998.”

The frustration is real, and so is the effect of Medicare payment cuts on physician practice viability. Likewise, access to care concerns for Medicare patients are therefore very real, too.

Don’t let a broken Medicare system break the backbone of the healthcare system for our most vulnerable patients.

Rick W. Snyder II, MD,is a cardiologist and president of the Texas Medical Association.

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A CAMPAIGN OF INTIMIDATION STATE OF CALIFORNIA vs. Guven Uzun, MD (WALGREENS AT THEIR VERY BEST)

UKUTHULA !!: TARGETING PACKAGES, A CAMPAIGN OF INTIMIDATION: STATE OF CALIFORNIA vs. DR. GUVEN UZUN, MD *(WALGREENS AT THEIR BEST!!)

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Take Care of Maya

This is video documentary available on Neflix and is about 105 minutes long. This family lived in Florida and the hospital involved is John Hopkins All Children Hospital in St Petersburg, FL  https://www.hopkinsmedicine.org/all-childrens-hospital  This story is apparently not that unusual where parents take their child to an emergency room and the parents are charged with child abuse abuse and one or both parents are charged with child abuse and possibly jailed and the kid(s) put into foster care. This appears to be a classic example of various parts of a “state’s system” – medical practitioners, judicial system, bureaucrats – with apparently good intentions – goes seriously off the rails.

Maya Kowalski sobs as jury awards family over $200M after hospital treatment led to mom’s suicide

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VA reduces number of Veterans prescribed opioids by 67% since 2012

https://news.va.gov/press-room/va-reduces-opioids-by-67-since-2012/

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I wonder how many tens of thousands of email, calls, faxes a Senator would have to receive from constituents to nullify a one-on-one visit from the head of the DEA?

DEA Administrator Briefs Senator Collins on Illegal Chinese Marijuana Operations, Efforts to Combat Opioid Epidemic, and Increase of Meth Use in Maine

Washington, D.C. – On Thursday, U.S. Senator Susan Collins received a briefing from Drug Enforcement Administration (DEA) Administrator Anne Milgram on efforts to address illegal Chinese marijuana operations, combat the opioid epidemic, and fight the rise of crystal meth use in Maine.

“No community is immune from the opioid epidemic, and I commend the men and women of the DEA for their work to combat illicit opioid trafficking and distribution. While we continue to target deadly opioids, we must not lose sight of the need to protect our communities from other emerging threats. The significant increase of crystal meth seizures in Maine – from 3 kilograms in 2021 to 72 kilograms in 2022 – is incredibly shocking,” said Senator Collins. “Administrator Milgram and I also discussed the recent reporting on the illegal Chinese marijuana growing operations in Maine and the potential harm they pose to our public health and national security. We must put an end to these criminal enterprises that are flooding our State and infiltrating our rural communities. I will continue to push the Department of Justice, including the DEA, to work with state and local law enforcement and shut down these illegal operations.”

In August, Senator Collins and the Maine Delegation wrote to Attorney General Merrick Garland requesting information on what the Department of Justice is doing to shut down these illegal Chinese marijuana growing operations. Following an investigation by Maine Wire that uncovered more than 100 foreign-owned drug houses throughout rural Maine earlier this month, Senator Collins renewed her call for federal action.

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this is the website provided by Medicare.gov  https://www.medicare.gov/plan-compare/#/?year=2024&lang=en

I found that this website  and the content regarding comparing various Part D prgms that are being offered are lacking some information about what is covered, math is incorrect.  Seems like whoever put these info pages together, either didn’t know what they were doing or intentionally putting out incomplete or confusing information. Remember, part D prgms are all being provided by FOR PROFIT INSURANCE COMPANIES.

From Silver Scripts Evidence of Coverage – basically the 99 page the Part D “policy”.

New prescriptions the pharmacy receives directly from your doctor’s office. The pharmacy will automatically fill and deliver new prescriptions it receives from health care providers, without checking with you first, if either:· You used mail-order services with this plan in the past, or · You sign up for automatic delivery of all new prescriptions received directly from health care providers. You may request automatic delivery of all new prescriptions at any time by continuing to have your doctor send us your prescriptions. No special request is needed. Or you may contact Customer Care to restart automatic deliveries if you previously stopped automatic deliveries.If you receive a prescription automatically by mail that you do not want, and you were not contacted to see if you wanted it before it shipped, you may be eligible for a refund.If you used mail-order in the past and do not want the pharmacy to automatically fill and ship each new prescription, please contact Customer Care. If you have never used our mail-order delivery and/or decide to stop automatic fills of new prescriptions, the pharmacy will contact you each time it gets a new prescription from a health care provider to see if you want the medication filled and shipped immediately. It is important that you respond each time you are contacted by the pharmacy, to let them know whether to ship, delay, or cancel the new prescription. Refills on mail-order prescriptions. For refills of your drugs, you have the option to sign up for an automatic refill program. Under this program we will start to process your next refill automatically when our records show you should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to make sure you are in need of more medication, and you can cancel scheduled refills if you have enough of your medication or if your medication has changed.If you choose not to use our auto-refill program but still want the mail-order pharmacy to send you your prescription, please contact your pharmacy 15 days before your current prescription will run out. This will ensure your order is shipped to you in time. To opt out of our program that automatically prepares mail-order refills, please log on to your Caremark.com account or contact us by calling Customer Care.

The vast majority of electronic Rxs, sent by prescribers goes thru a “switch”, which is basically a electronic routing of any/all communications between pharmacies and prescribers. Now there is only ONE SWITCH since Sure Scripts & Rxhub merged with Rxhub being the “survivor ” of the merger and Rxhub is owned by CVS Health/Caremark and Express Script PBMs and those two PBMs, manage > 50% of all Rxs filled in pharmacies.

In the RED TEXT above from Silver Scripts, to me, suggests that Caremark may just divert any e-RX from a prescriber to your pharmacy of choice and send it to their mail-order pharmacy and they will contact pt if they want the mail order pharmacy to fill the new Rx. And apparently your only options once they contact you – let them know whether to ship, delay, or cancel the new prescription – if you don’t want them to fill it, you will need to contact your prescriber to send another E-Rx and hope that Caremark doesn’t snag it again.

I went to Caremark’s website looking for the place where I could opt-out of mail-order. Could not find anywhere to do it. So, I called their Customer Care and talk to their representative ( Lucy) who said that there was no OPT-OUT. If  your prescriber designated your pharmacy of choice, your Rx will be sent to that Pharmacy.

Now choosing a Part D plan that is accepted by your pharmacy of choice.  Normally with health insurance, there are providers in-network and out-of-network, but in the Medicare.gov site, Silver Scripts only show if a pharmacy in-network or out-of network, but when you get Silver Scripts pharmacy network guide – you find out that they have  in-network and IN-NETWORK  (preferred) pharmacies. The “preferred” pharmacies – you get lower co-pays than just in-network pharmacies. In the county where we live, the only “preferred” pharmacies are CVS, and big box or grocery store pharmacies.  Missing from the “preferred group” is CVS’ largest community competitor – WALGREEN – that has more stores in my county than CVS!

If you use CVS mail order pharmacy – they promise – Usually, a mail-order pharmacy order will be delivered to you in no more than 10 days.

Now you go to their drug formulary. Notice under column Tier Requirements/Limits, the vast majority of meds -especially generics have the limits of MO – and MO stands for MAIL ORDER.  On the Medicare.gov website, Silver Scripts didn’t mention REQUIRED MAIL ORDER. Back to my conversation with Customer Care Representative (Lucy), when I questioned mandatory mail order – according to Lucy – NOPE.

Back to the first section copied above from their 99 page policy explanation and in RED TEXT.. that if you never use their mail order it would appear that they are going to snag new e-Rxs and contact you if you want their mail order to fill it.  If you routinely, tell them to delete the new order, will the time frame from when they get the next new e-Rx and they contact you.. get LONGER & LONGER ?

Here is a page out of Silver Scripts formulary

Drug Name       Drug            Tier Requirements/Limits

NSAIDS
celecoxib capsule 400mg 4 QL (30 EA per 30 days) MO
celecoxib capsule 100mg, 200mg, 50mg 4 QL (60 EA per 30 days) MO
diclofenac potassium tablet 50mg 2 QL (120 EA per 30 days) MO
diclofenac sodium dr 2 MO
diclofenac sodium er 2 QL (60 EA per 30 days) MO
diclofenac sodium/misoprostol tablet delayed release 50mg; 200mcg 4 QL (120 EA per 30 days) MO
diclofenac sodium/misoprostol tablet delayed release 75mg; 200mcg 4 QL (90 EA per 30 days) MO
diflunisal 2 QL (90 EA per 30 days) MO
ec-naproxen tablet delayed release 375mg 2 QL (120 EA per 30 days)
ec-naproxen tablet delayed release 500mg 2 QL (90 EA per 30 days) MO
etodolac er tablet extended release 24 hour 600mg 4 QL (30 EA per 30 days) MO
etodolac er tablet extended release 24 hour 400mg, 500mg 4 QL (60 EA per 30 days) MO
etodolac capsule 300mg 2 QL (120 EA per 30 days) MO
etodolac capsule 200mg 2 QL (90 EA per 30 days) MO
etodolac tablet 500mg 2 QL (60 EA per 30 days) MO
etodolac tablet 400mg 2 QL (90 EA per 30 days) MO
FENOPROFEN CALCIUM CAPSULE 400MG 4 QL (240 EA per 30 days) MO
fenoprofen calcium tablet 600mg 4 QL (150 EA per 30 days) MO
flurbiprofen tablet 100mg 2 QL (90 EA per 30 days) MO
ibu 1 MO
ibuprofen tablet 400mg, 600mg, 800mg 1 MO
ibuprofen suspension 2 MO
ketoprofen extended release capsule 200mg 4 QL (30 EA per 30 days) MO
ketorolac tromethamine tablet 10mg 2 QL (20 EA per 30 days) PA MO
meloxicam tablet 1 MO
nabumetone 2 MO
naproxen sodium tablet 275mg, 550mg 2 MO
naproxen tablet 250mg, 375mg, 500mg 1 MO
naproxen suspension 4 MO
naproxen tablet delayed release 375mg 2 QL (120 EA per 30 days) MO
naproxen tablet delayed release 500mg 2 QL (90 EA per 30 days) MO
oxaprozin 2 QL (90 EA per 30 days) MO
piroxicam capsule 20mg 2 QL (30 EA per 30 days) MO

What is a pt to do?

what I may end up doing is to use the discounted cash price that the independent pharmacy that we patronize offers.  If we stayed with the Humana Part D that we have had for the last 3-4 yrs, as opposed to signing up with Silver Scripts.  The difference between premiums and annual deductible would be abt $2100 for a year. Both Part-Ds are not paying for two meds each of us take. By, paying cash, we don’t have to deal with prior authorizations, daily dose limits, step therapy, and other PBM’s BS.  Our prescriber will not have to deal with getting prior authorizations on your meds.  Our pharmacy will not have to pay the PBM a charge per Rx submitted electronically and they will not get any claw back in DIR fees ( direct and indirect remuneration fees).  https://www.pharmacytimes.com/view/white-paper-dir-fees-simply-explained.  The first week of Jan, 2024, I am going to request a refill on what should be a fairly inexpensive med, that one of us takes, to see if Silver Scripts rejects payment because mail order is mandatory.

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