The publication found “sickness” scores spiked when patients moved from traditional Medicare to Medicare Advantage, leading to billions of dollars in extra Medicare payments to insurers. But patients seen by physicians who worked for UnitedHealth had some of the biggest increases in scores. UnitedHealth says the report is misleading.
A new Wall Street Journal investigation puts the spotlight on Medicare Advantage patients’ unusually high sickness or risk adjustment factors, particularly those generated by UnitedHealth.
Medicare will pay insurers more money to care for sicker patients to cover the cost of treatment and to prevent payers from “cherry picking” healthier, less-costly patients to enroll in their plans.
The agency calculates scores based on the information physicians provide about their patients’ specific health needs and insurers submit.
The publication found that Medicare Advantage patients treated by doctors who work for UnitedHealth had some of the biggest increases in sickness scores after the patients left traditional Medicare for the Medicare Advantage plan. The higher scores led to approximately $4.6 billion more in Medicare payments to UnitedHealth.
WSJ calculated the scores using Medicare’s methodology based on claims and encounter data from 2019 through 2022. It was able to access the data under a research agreement with the federal government. It then examined UnitedHealth Group’s filings to state insurance regulators to identify which medical groups it owned as of the end of 2018.
According to the publication’s analysis, UnitedHealth patients’ scores went up by 55 percent, on average, in their first year in the plans. The scores for patients who stayed in traditional Medicare increased seven percent year-over-year. And across Medicare Advantage plans operated by all insurers, including United Health, scores increased by 30 percent in the patients’ first year.
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UnitedHealth’s Optum unit employs approximately 10,000 physicians and contracts with tens of thousands more. One doctor who previously worked for UnitedHealth and was interviewed by WSJ said that the company would frequently send him a checklist of potential diagnoses before he saw the Medicare Advantage patient. The software required him to weigh in on each diagnosis, which were often obscure or wrong. However, he told the publication that the company didn’t suggest diagnoses for patients he treated who weren’t enrolled in its Medicare Advantage plan.
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But in a December 30th written response to the publication’s report, UnitedHealth Group said the WSJ’s series of articles about Medicare Advantage are misleading, one-sided, and biased. The Medicare Advantage program, it said, is designed to proactively identify health risks before seniors have major health problems. Medicare Advantage insurers focus on coordinated care models that identify, document, and treat chronic conditions early on, which leads to better health outcomes.
CMS constructed Medicare Advantage to incent the early identification and treatment of conditions to help seniors avoid more serious health issues and get the care they need,” the insurer wrote. “The WSJ fails to understand or accept that MA plans are doing exactly what the program was designed to do–meet the government’s objective of delivering better health outcomes and lower costs for seniors.”
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Furthermore, it said the Medicare Advantage patients served by its Optum health services arm had demonstrated healthier outcomes than those in traditional Medicare. These patients had an 18 percent lower risk of inpatient admissions, 11 percent lower risk of emergency department visits, 44 percent reduction in hospital admissions for COPD or asthma complications, six percent lower risk of inpatient acute admission from the emergency department, nine percent lower rate of 30-day hospital readmission, and a 10 percent lower risk of admission for stroke or myocardial infarction.
The insurer also touted its delivery of clinical quality, noting that nearly three-fourths of its Medicare Advantage patients in value-based care models were screened for breast cancer and colorectal cancer. In addition, more than 90 percent of its Medicare Advantage patients with hypertension adhere to medication recommendations and 70 percent of its diabetic patients have control of their A1c levels, an 11-point increase year over year.
“We have provided overwhelming evidence demonstrating the value of MA to seniors, the government and taxpayers, offering data and third-party analysis to encourage a more complete and accurate representation of the Medicare Advantage program–evidence the WSJ has chosen to ignore,” the company wrote.