\n\tDan Weissmann<\/span><\/p>\n

Covering the American health care system means we tell some scary stories. This episode of \u201cAn Arm and a Leg\u201d sounds like a real horror movie.\u00a0<\/p>\n

It uses one of Hollywood\u2019s favorite tropes: machines taking over. And the machines belong to the private health insurance company UnitedHealth Group.\u00a0<\/p>\n

Host Dan Weissmann talks to Stat News reporter Bob Herman about his investigation into Medicare Advantage plans that use an algorithm to make decisions about patient care. The algorithm is owned by a subsidiary of UnitedHealth Group.<\/p>\n

Herman tells Weissmann that some of UnitedHealth\u2019s own employees say the algorithm creates a \u201cmoral crisis\u201d in which care is unfairly denied.<\/p>\n

Scary stuff! Such reporting even has caught the eye of powerful people in government, putting Medicare Advantage plans under scrutiny.<\/p>\n

\tDan Weissmann<\/p>\n

\t\t\t
\n\t\t\t\t@danweissmann\t\t\t<\/a><\/p>\n

\t\t\tHost and producer of “An Arm and a Leg.” Previously, Dan was a staff reporter for Marketplace and Chicago’s WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.\t\t<\/p>\n

\n\t\tCredits\t<\/h3>\n
\tEmily Pisacreta
\n\tProducer<\/p>\n
\tAdam Raymonda
\n\tAudio Wizard<\/p>\n
\tEllen Weiss
\n\tEditor<\/p>\n
\t\t\t\t\tClick to open the Transcript\t\t\t\t<\/p>\n
\t\t\t\t\t\tTranscript: Son of Medicare: Attack of the Machines<\/strong>\t\t\t\t<\/p>\n
Note: \u201cAn Arm and a Leg\u201d uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.<\/em><\/p>\n
Dan:<\/strong> Hey there\u2013<\/p>\n
So this is kind of a horror story. But it\u2019s not quite the kind of story it might sound like at first.<\/p>\n
Because at first, it might sound like a horror story about machines taking over, making all the decisions\u2013 and making terrible, horrifying choices. Very age-of-Artificial Intelligence.<\/p>\n
But this is really a story about decisions made by people. For money.<\/p>\n
It\u2019s also kind of a twofer sequel\u2013 like those movies that pit two characters from earlier stories against each other. Like Godzilla vs King Kong, or Alien vs Predator.<\/p>\n
Although in this case, I\u2019ve gotta admit, the two monsters are not necessarily fighting each other.<\/p>\n
Let\u2019s get reacquainted with them.\u00a0<\/p>\n
On one side, coming back from our very last episode, we\u2019ve got Medicare Advantage: This is the version of Medicare that\u2019s run by private insurance companies.\u00a0<\/p>\n
It\u2019s got a bright and appealing side, compared to the traditional Medicare program run by the federal government, because: It can cost a lot less, month to month \u2014 saving people money on premiums. And it often comes with extra benefits, like dental coverage, which traditional Medicare doesn\u2019t offer. [I know.]<\/p>\n
But Medicare Advantage can have a dark side, which is basically: Well, you end up dealing with private insurance companies for the rest of your life. You need something \u2014 a test, a procedure, whatever \u2014 they might decide not to cover it.<\/p>\n
Which can be scary.\u00a0<\/p>\n
Our other returning monster \u2014 am I really calling them a monster? \u2014 well, last time we talked about them, in 2023, we had an expert calling them a behemoth. That\u2019s United HealthGroup. You might remember, they\u2019re not only one of the biggest insurance companies\u00a0<\/p>\n
\u2014 and maybe not-coincidentally the very biggest provider of Medicare Advantage plans \u2014<\/p>\n
they\u2019ve also got a whole other business\u2013 under the umbrella name Optum. And Optum has spent the last bunch of years buying up a gazillion other health care companies of every kind.\u00a0<\/p>\n
That includes medical practices \u2014 they employ more doctors than anyone else, by a huge margin. It includes surgery centers, and home-health companies, and every kind of middleman company you can imagine that works behind the scenes \u2014 and have their hands in a huge percentage of doctor bills and pharmacy visits.\u00a0<\/p>\n
A few years ago, United bought a company called NaviHealth, which provides services to insurance companies that run Medicare Advantage plans.\u00a0<\/p>\n
NaviHealth\u2019s job is to decide how long someone needs to stay in a nursing home, like if you\u2019re discharged from a hospital after surgery, but you\u2019re not ready to go home yet.<\/p>\n
And the horror story\u2013 the stories, as dug up by reporters \u2014 starts after United bought NaviHealth.<\/p>\n
And according to their reports, it involves people getting kicked out of those nursing homes who aren\u2019t ready to go home.\u00a0<\/p>\n
People getting sent home who can\u2019t walk up the stairs in their house. Who can\u2019t walk at all. Who are on feeding tubes. People who NaviHealth\u2019s own employees are saying, \u201cWait. This person isn\u2019t ready to go home.\u201d<\/p>\n
But their new bosses have told them: You\u2019re not really making these decisions anymore.\u00a0<\/p>\n
This is where machines do enter the picture.<\/p>\n
NaviHealth\u2019s distinctive offering has always been its proprietary algorithm\u2013 an algorithm that makes predictions about how long any given patient might need to stay.\u00a0<\/p>\n
Before United bought the company, that algorithm was used as a guide, a first-guess. Humans weighed in with their own judgment about what patients needed.<\/p>\n
After United bought the company, people inside have told reporters, that changed: The new owners basically told their employees, If the algorithm says someone can go home after x days, that\u2019s when we\u2019re cutting them off.<\/p>\n
\u00a0Like pretty much any horror movie, this story\u2019s got people running around trying to tell everyone: HEY, WATCH OUT! THERE\u2019S SOMETHING BIG AND DANGEROUS HAPPENING HERE.<\/p>\n
And in this case, they\u2019ve actually gotten the attention of some people who might have the power to do something about it. Now, what those people will do? We don\u2019t know yet.\u00a0<\/p>\n
And, by the way: Yes, I said at the end of our last episode that we\u2019d be talking about Medicaid this time around. That\u2019s coming! But for now, strap in for this one.\u00a0<\/p>\n
This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I\u2019m Dan Weissmann. I\u2019m a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful.<\/p>\n
So. I said that, like every horror movie, this one has people who are seeing what\u2019s going on and are trying to warn everybody?<\/p>\n
Like those movies, we\u2019re gonna follow one of those people, watch them discover the problem, see how deep it goes, and start ringing alarm bells. Let\u2019s meet our guy.<\/p>\n
Bob Herman: <\/strong>My name is Bob Herman. I\u2019m a reporter at STAT News<\/p>\n
Dan:<\/strong> Stat is an amazing medical news publication. Bob covers the business of medicine there. Bob started working on this story in November 2022, after talking to a source who runs nursing homes. Bob\u2019s source was complaining about Medicare Advantage.\u00a0<\/p>\n
Bob Herman: <\/strong>There were a lot of payment denials. They just weren\u2019t able to get paid. And just offhandedly, the source mentioned like, um, you know, and they\u2019re attributing everything to this algorithm. This algorithm said, You know, only 17 days for our patients and then time\u2019s up and I went running to Casey Ross\u00a0<\/p>\n
Dan:<\/strong> Casey is a reporter at Stat who focuses on tech and AI in healthcare. Bob said, hey, what do you think of this? Wanna team up?<\/p>\n
Bob Herman: <\/strong>And he was hooked.<\/p>\n
Dan:<\/strong> They started talking to people who worked at nursing homes, talking to experts, and talking to families. And it was clear: They were onto something.\u00a0<\/p>\n
Bob Herman<\/strong>: It took so many families by surprise to be like, what do you mean we\u2019re going home? The, you know, my husband, my wife, my grandma, my grandpa, they can\u2019t go to the bathroom on their own. Like, what do you? It was just, it was so confusing to people. It seemed like such a, a cold calculation,\u200b<\/strong><\/p>\n
Dan:<\/strong> One person they ended up talking with was Gloria Bent. Her husband Gary was sent to a nursing home for rehab after brain surgery for cancer. He was weak. He couldn\u2019t walk. And he had something called \u201cleft neglect\u201d: His brain didn\u2019t register that there was a left side of his body. Here\u2019s Gloria testifying before a Senate committee about how \u2014 when Gary arrived at the nursing home \u2014 the first thing he got was a discharge date. That is\u2026<\/p>\n
Gloria Bent: <\/strong>Before the staff of the facility could even evaluate my husband or develop a plan of care, I was contacted by someone who identified themselves as my Navi Health Care Coordinator<\/p>\n
Dan:<\/strong> Gloria says when she told the nursing home staff she\u2019d heard from NaviHealth, they groaned. And told her what to expect.\u00a0<\/p>\n
Gloria Bent:<\/strong> I was told that I had just entered a battlefield, that I could expect a series of notices of denial of Medicare payment accompanied by a discharge date that would be two days after I got that notice.<\/p>\n
Dan:<\/strong> Yeah, they said she\u2019d get two days notice. Gloria says the nursing home staff told her she\u2019d have 24 hours to appeal each of those, but even if she won, the denials would keep coming. In fact, they said,<\/p>\n
Gloria Bent: <\/strong>If we won a couple of appeals, then we could expect that the frequency with which these denials were going to come would increase.<\/p>\n
Dan:<\/strong> All of which happened. NaviHealth started issuing denials July 15, 2022, after Gary had been at the home for a month.<\/p>\n
Gloria appealed. She told senators what the doctor who evaluated the appeal found: Gary couldn\u2019t\u00a0 walk. He couldn\u2019t even move \u2014 like from bed to a chair \u2014 without help from two people.. That reviewer took Gloria\u2019s side.<\/p>\n
Her husband\u2019s next denial came a week after the first. Gloria won that appeal too. She says the reviewer noted that Gary needed maximum assistance with activities of daily living.\u00a0<\/p>\n
The third denial came four days later, and this time Gloria lost.\u00a0<\/p>\n
Gary came home in an ambulance: As Gloria testified, he couldn\u2019t get into or out of a car without assistance from someone with special training.\u00a0<\/p>\n
And when he got into the ambulance, he had a fever. The next morning, he wound up in another ambulance \u2014 headed to a hospital with meningitis. He lost a lot of the functioning he\u2019d picked up at the nursing home.\u00a0<\/p>\n
He died at home a few months later. When Gloria testified in the Senate, all of it was still fresh. She told them that as awful as Gary\u2019s illness and decline had been, the fights with insurance were an added trauma.<\/p>\n
Gloria Bent: <\/strong>This should not be happening to families and patients. It\u2019s cruel. Our family continues to struggle with the question that I hear you asking today. Why are people who are looking at patients only on paper or through the lens of an algorithm<\/p>\n
making decisions that deny the services judged necessary by health care providers who know their patients.<\/p>\n
Dan:<\/strong> Bob Herman calls Gloria\u2019s story heartbreaking, like so many others he\u2019s seen.\u00a0<\/p>\n
And his attention goes to one part of Gloria\u2019s story beyond denial-by-algorithm.\u00a0<\/p>\n
Because: It\u2019s not just one denial. It\u2019s that series of denials. You can appeal, but as Gloria testified, the denials speed up. And you have to win every single time. The company only has to win once.\u00a0<\/p>\n
I mean, unless you\u2019re ready to get a lawyer and take your chances in court\u2013 which, in addition to being a major undertaking, also means racking up nursing home bills and legal bills you may never get reimbursed for, while the court process plays out.\u00a0<\/p>\n
Bob Herman: <\/strong>This appeal system is designed in such a way that people will give up. If you have a job, you know, even if you don\u2019t, and you\u2019re, and you\u2019re also trying to take care of a family member, um, it\u2019s a rigorous monotonous process that will chew people up and spit them out and then the people are inevitably going to give up. And I think in some ways insurers know that.<\/p>\n
Dan:<\/strong> Going out on a limb to say: I think so too. So Bob and Casey\u2019s first story on NaviHealth came out in March of 2023. They were the characters in the movie who go, \u201cHEY, I THINK THERE\u2019S SOMETHING REALLY BAD HAPPENING HERE.\u201d<\/p>\n
And people started paying attention. Like the U.S. Senate. which held that hearing where Gloria Bent told her story.\u00a0<\/p>\n
And like the federal agency that runs Medicare \u2014 the Centers for Medicare and Medicaid Services, CMS.\u00a0<\/p>\n
CMS finalized a rule that told insurers: You can\u2019t deny care to people just from using an algorithm.\u00a0<\/p>\n
And something else happened too: Bob and Casey started suddenly getting a lot MORE information.\u00a0<\/p>\n
Bob Herman: <\/strong>We received so many responses from people and it just opened the floodgates for former employees, just patients and family members, just everyone across the board.<\/p>\n
Dan:<\/strong> And not just former employees. Current employees. And what they learned was: There was absolutely a strategy at work in how this algorithm was being used. It was strategy some people on the inside didn\u2019t feel good about.\u00a0<\/p>\n
And this strategy got developed after United HealthGroup \u2014 and its subsidiary, Optum\u2013 bought NaviHealth in 2020. And here\u2019s what NaviHealth employees started telling Casey and Bob about that strategy.<\/p>\n
Bob Herman: <\/strong>For some of us, it\u2019s creating this moral crisis. Like we know that we are having to listen to an algorithm to essentially kick someone out of a nursing home, even though we know that they can barely walk 20 feet.<\/p>\n
Dan:<\/strong> What Bob and Casey learned from insiders\u2013 and how it connects to United\u2019s role as a health care behemoth\u2013 that\u2019s next.<\/p>\n
This episode of An Arm and a Leg is produced in partnership with KFF Health News. That\u2019s a nonprofit newsroom covering healthcare in America. Their reporters do amazing work, and I\u2019m honored to work with them. We\u2019ll have a little more about KFF Health News at the end of this episode.<\/p>\n
So, NaviHealth \u2014 the company with the algorithm \u2014 got started in 2015.. And the idea behind it was to use data to get people home faster from nursing homes if they didn\u2019t actually need to be there.\u00a0<\/p>\n
Because there was a lot of evidence that some people were being kept longer than they needed.\u00a0<\/p>\n
Bob Herman: <\/strong>There is some validity to the idea that there\u2019s, there\u2019s wasteful care in Medicare, like, you know, there\u2019s been cases in the past proving that people stay in a nursing home for way longer than is necessary. And obviously there\u2019s financial incentives for nursing homes to keep people as long as possible.\u00a0<\/p>\n
Dan:<\/strong> Traditional Medicare does have limits on nursing home care \u2014 but if you need \u201cpost-acute care\u201d \u2014 help getting back on your feet after leaving a hospital traditional Medicare pays in full for 20 days\u2013 pretty much no questions asked. One of the selling points of Medicare Advantage \u2014 like selling points to policy nerds and politicians \u2014 was that it could cut waste, by asking those kinds of questions. NaviHealth and its algorithm were designed to help Medicare Advantage plans ask those questions in a smart way.\u00a0<\/p>\n
Bob Herman: <\/strong>There were\u2026 a lot of believers within NaviHealth that were like, okay, I think we\u2019re doing the right thing. We\u2019re trying to make sure people get home sooner because who doesn\u2019t want to be at home.\u00a0\u00a0<\/p>\n
Dan:<\/strong> And as those employees told Bob and Casey: Before United and Optum came in, the algorithm had been there as a guide \u2014 a kind of first guess \u2014 but not the final word.\u00a0<\/p>\n
NaviHealth has staff people who interact directly with patients. And back in the day, the pre-United day, Bob and Casey learned that those staff could make their own judgments.\u00a0<\/p>\n
Which made sense, because the algorithm doesn\u2019t know everything about any individual case. It\u2019s just making predictions based on the data it has.<\/p>\n
Bob Herman: <\/strong>And there was just, just this noticeable change after United and OptiMentor that it felt more rigid. There\u2019s no more variation.\u00a0<\/p>\n
Dan:<\/strong> If the algorithm says you go, you are pretty much going.<\/p>\n
Bob Herman: <\/strong>United has said, no, that\u2019s not the case, but obviously these documents and other communications that we\u2019ve gotten kind of say otherwise.<\/p>\n
Dan:<\/strong> Because these employees weren\u2019t just talking. They were sharing. Internal memos. Emails. Training materials. All making clear: The company wanted people shipped out on the algorithm\u2019s timetable.\u00a0<\/p>\n
Bob Herman: <\/strong>Documents came in showing that like this was a pretty explicit strategy. You know, UnitedHealth was telling its employees. Listen, we have this algorithm. We think it\u2019s really good. So when it tells you how many, how many days someone should be in a nursing home, stick to it.<\/p>\n
Dan:<\/strong> Stick to it or maybe be fired. Bob and Casey got documents \u2014 employee performance goals\u2013 saying: How close you stick to the algorithm\u2019s recommendations? That\u2019s part of how we\u2019re evaluating your job performance.\u00a0<\/p>\n
Bob Herman: <\/strong>It\u2019s okay. Algorithm said 17 days, you better not really go outside of that because your job is on the line.\u00a0<\/p>\n
Dan:<\/strong> Here\u2019s how closely people were expected to stick to it. In 2022, employee performance goals shared with STAT showed that workers were expected to keep actual time in nursing homes to within three percent of what the algorithm said it should be. Across the board.<\/p>\n
So, say you had 10 patients, and the algorithm said they each should get 10 days. That\u2019s 100 days. Your job was to make sure that the total actual days for those patients didn\u2019t go past 103 days.<\/p>\n
Then, in 2023, the expectations got more stringent: Stay within one percent of the algorithm\u2019s predictions. 10 patients, the algorithm says 100 days total? Don\u2019t let it get past a hundred and one.\u00a0<\/p>\n
Bob Herman:<\/strong> Like that is, almost nothing. Like what, what, your hands are tied. If you\u2019re that employee, what are you going to do? Are you going to get fired? Are you going to do what you\u2019re told?<\/p>\n
Dan: And one person who ended up talking, to did get fired.\u00a0<\/strong><\/p>\n
Bob Herman:<\/strong> Correct. Yes. Uh, Amber Lynch did get fired And what she said was what we had also heard just more broadly was it, it created this internal conflict, like, Oh my God, what I\u2019m doing doesn\u2019t feel right.\u00a0<\/p>\n
Dan:<\/strong> Amber Lynch was a case manager. She told Bob and Casey about onepatient who couldn\u2019t climb the stairs in his home after knee surgery. But the algorithm said he was ready. Amber\u2019s supervisor said, \u201cHave you asked the nursing home staff if they\u2019ve tried to teach him butt bumping?\u201d Amber grit her teeth and made the suggestion to the rehab director.<\/p>\n
Amber Lynch: <\/strong>And she looked at me like I had two heads. She\u2019s like, he is 78 years old. He\u2019s not going to do that. He\u2019s not safe to climb the stairs yet. He\u2019s not doing it. We\u2019re not going to have it butt bump the stairs.<\/p>\n
Dan:<\/strong> Amber told Bob and Casey that when she got fired, it was partly for failing to hit the one percent target and partly for being late with paperwork\u2013 which she told Bob and Casey she fell behind because her caseload was so heavy.<\/p>\n
She wasn\u2019t the only one with that complaint.\u00a0<\/p>\n
Bob and Casey\u2019s story shows another NaviHealth case manager\u2013 not named in the story because they\u2019re still on the job \u2014 in their home office, struggling to keep up.\u00a0<\/p>\n
That week, they were supposed to work with 27 patients and their families. Gather documents, hold meetings. Another week, shortly before, they\u2019d had 40 patients.\u00a0<\/p>\n
\u201cDo you think I was able to process everything correctly and call everyone correctly the way I was supposed to?\u201d the case manager asked. \u201cNo. It\u2019s impossible. No one can be that fast and that effective and capture all of the information that\u2019s needed.\u201d<\/p>\n
Bob and Casey watched this case manager fill out a digital form, feeding the algorithm the information it asked for on a man in his 80s with heart failure, kidney disease, diabetes and trouble swallowing, who was recovering from a broken shoulder.\u00a0<\/p>\n
A few minutes later, the computer spat out a number: 17 days.\u00a0<\/p>\n
The case manager didn\u2019t have a lot of time or leeway to argue, but they were skeptical that the algorithm could get that number exactly right based on only the data it had.\u00a0<\/p>\n
And what data is the algorithm working with? What\u2019s it comparing the data on any given patient TO? Bob Herman says that\u2019s a big question.<\/p>\n
Bob Herman: <\/strong>It\u2019s something that for sure, like Casey and I, it\u2019s been bothering us. Like, what, how is this whole system? Like, what is it based on? And we were never really given straight answers on that. NaviHealth and Optum and United have said it\u2019s based on millions of patient records over time. The sources of that, it\u2019s, it\u2019s a little unclear, where all that\u2019s coming from.\u00a0<\/p>\n
Dan:<\/strong> Bob and Casey talked with an expert named Ziad Obermeyer, a professor at the University of California Berkeley School of Public Health, who is not anti-algorithm. He actually builds algorithmic tools for decision making in public health.\u00a0<\/p>\n
AND he\u2019s done research showing that some widely-used algorithms just scale up and automate things like racial bias.<\/p>\n
He told Bob and Casey: Using an algorithm based on how long other, earlier patients have stayed in a nursing home \u2014 that\u2019s not a great idea.<\/p>\n
Because people get forced out of nursing homes, in his words, \u201cbecause they can\u2019t pay or because their insurance sucks.\u201d He said, \u201cSo the algorightm is basically learning all the inequalities of our current system.\u201d<\/p>\n
And leaving aside that kind of bias, it seems unlikely to Bob that any algorithm could predict exactly what every single patient will need every single time.\u00a0<\/p>\n
No matter how much data it\u2019s got, it\u2019s predicting from averages.<\/p>\n
Bob Herman:<\/strong> It reminds me of, like, a basketball game where let\u2019s say someone averages 27 points per game. They don\u2019t have 27 points every single, the game they go out there. It just varies from time to time.<\/p>\n
Dan:<\/strong> But the NaviHealth algorithm doesn\u2019t have to be right every time for United to make money using it.\u00a0<\/p>\n
Using it to make decisions can allow United to boost profits coming and going.<\/p>\n
Bob Herman: <\/strong>United health and the other insurance companies that use Navi health. Are using this technology to more or less kick people out of nursing homes before they\u2019re ready. And that is the claims denial side where it\u2019s like, okay, let\u2019s save as much money as we can instead of having to pay it to a nursing home.<\/p>\n
Dan:<\/strong> And that\u2019s just one side of it. The insurance side. Claims denial. But United isn\u2019t just in the insurance business.\u00a0<\/p>\n
United\u2019s Optum side is in every other part of health care.\u00a0<\/p>\n
Including \u2014 in the years since United took over NaviHealth \u2014 home health services. The kind of services you\u2019re likely to need when you leave a nursing home.<\/p>\n
In 2022, Optum bought one top home health company in what one trade publication called a \u201cmonster, jaw-dropping mega-deal\u201d \u2014 more than 5 billion dollars. In 2023, Optum made a deal to buy a second mega-provider.\u00a0<\/p>\n
Bob and Casey\u2019s story says NaviHealth\u2019s shortening nursing home stays is integral to United\u2019s strategy for these acquisitions. It does seem to open up new opportunities.<\/p>\n
Bob Herman: <\/strong>You\u2019re out of the nursing home because our algorithm said so. Now we\u2019re going to send you to a home health agency or we\u2019re going to send some home health aides into your home. And by the way, we own them.\u00a0<\/p>\n
Dan:<\/strong> Oh, right, because: If you\u2019re in a Medicare Advantage plan, your insurer can tell you which providers are covered.\u00a0<\/p>\n
Bob Herman: <\/strong>So the real question becomes, how much is United potentially paying itself?<\/p>\n
Dan:<\/strong> That is: How much might United end up taking money out of one pocket \u2014 the health insurance side \u2014 and paying itself into another pocket, Optum\u2019s home-health services?<\/p>\n
We don\u2019t know the answer to how much United is paying itself in this way, or hoping to. And United has said its insurance arm doesn\u2019t favor its in-house businesses.<\/p>\n
But it seems like a reasonable question to ask. Actually, it\u2019s a question the feds seem to be asking.<\/p>\n
Optum hasn\u2019t wrapped up its purchase of that second home-health company yet, and in February 2024, the Wall Street Journal and other outlets reported that the U.S. Department of Justice had opened an anti-trust investigation.\u00a0<\/p>\n
And you don\u2019t have to be in a Medicare Advantage plan run by United to get kicked out of a nursing home on an algorithm\u2019s say-so.\u00a0<\/p>\n
Bob Herman says NaviHealth sells its algorithm-driven<\/em> services to other big insurance companies\u00a0<\/p>\n
He says, put together, the companies that use NaviHealth cover as many as\u00a0 15 million people \u2014 about half of everybody in Medicare Advantage.<\/p>\n
Bob Herman: <\/strong>Odds are, if you\u2019re in a Medicare Advantage plan, there\u2019s a, there\u2019s a really good shot that your coverage policies, if you get really sick and need nursing home care, for example, or any kind of post acute care, an algorithm could be at play at some point.<\/p>\n
Dan:<\/strong> This is the dark side of Medicare Advantage.\u00a0<\/p>\n
Bob Herman: <\/strong>Everyone loves their Medicare Advantage plan when they first sign up, right? Because it\u2019s offering all these bells and whistles. It\u2019s, here\u2019s a gym membership. It\u2019s got dental and vision, which regular Medicare doesn\u2019t have. And it\u2019s also just, it\u2019s, it\u2019s cheaper. Like, if it\u2019s just from a financial point of view, if, if you\u2019re a low income senior, How do you turn it down? There\u2019s, there\u2019s so many plans that offer like free, there\u2019s no monthly premiums in addition to all the bells and whistles. But Nobody understands the trade offs , When you\u2019re signing up for Medicare and Medicare Advantage, you\u2019re on the healthier side of, of being a senior, right?<\/p>\n
Dan:<\/strong> And none of us can count on staying healthy forever. When you sign up for Medicare\u00a0 you\u2019re signing up your future self \u2014 whether that\u2019s ten or twenty or more years out. That future you, might really need good medical care.\u00a0<\/p>\n
And at that point, as we explained in our last episode, if Medicare Advantage isn\u2019t working for you, you may not be able to get out of it.<\/p>\n
Bob Herman: <\/strong>You could potentially not fully get the care that you need. We shouldn\u2019t assume that, that this couldn\u2019t happen to us because it can.\u00a0<\/p>\n
Dan:<\/strong> So, yeah. Kind of a horror story. But: Unlike some horror movies, when Bob and Casey started publishing their stories, they started getting people\u2019s attention.<\/p>\n
We mentioned the new rules from the feds and the senate hearings after Bob and Casey\u2019s first story in March 2023<\/p>\n
Later in the year, when Bob and Casey published their story with documents and stories from inside NaviHealth, a class-action lawsuit got filed.<\/p>\n
Since then, CMS has said it will step up audits under its new rules.\u00a0<\/p>\n
Bob Herman: <\/strong>There was a memo that CMS sent out to Medicare advantage plans that said, Hey, listen, we\u2019re telling you again, do not deny care solely on any AI or algorithms. Like just don\u2019t do it.\u00a0<\/p>\n
Dan:<\/strong> And in February 2024, the Senate held another hearing.\u00a0<\/p>\n
Here\u2019s Senator Elizabeth Warren at that hearing, saying these CMS rules aren\u2019t enough. We need stronger guardrails.<\/p>\n
Elizabeth Warren: <\/strong>Until CMS can verify that AI algorithms reliably adhere to Medicare coverage standards by law, then my view on this is CMS should prohibit insurance companies from using them in their MA plans for coverage decisions. They\u2019ve got to prove they work before they put them in place.<\/p>\n
Dan:<\/strong> So people \u2014 people with at least some power\u2013 are paying some attention.\u00a0<\/p>\n
Bob Herman<\/strong>: I don\u2019t think this is necessarily going to escape. Political scrutiny for a while.\u00a0<\/p>\n
Dan: <\/strong>So, basically, the story isn\u2019t over.\u00a0<\/p>\n
This isn\u2019t one of those horror movies where the monster\u2019s been safely defeated at the end, and everybody just starts cleaning up the mess. And it\u2019s not one where the monster is just on the loose, unleashing the apocalypse.\u00a0<\/p>\n
Because it\u2019s not a movie. There\u2019s no ending. There\u2019s just all of us trying to figure out what\u2019s going on, and what we can maybe do about it.<\/p>\n
One last thing: I got a lot of emails after our last episode, where we laid out a lot of information about Medicare Advantage and traditional Medicare. Most of it was along the lines of, Thank you! That was really helpful! Which made me feel really good.<\/p>\n
And we got a couple notes about things we could have done better. Especially this: We said Traditional Medicare leaves you on the hook for 20 percent of everything, without an out of pocket limit.\u00a0<\/p>\n
Which is true \u2014 but only for Medicare Part B: Doctor visits, outpatient surgeries and tests. Which can add up, for sure.<\/p>\n
Medicare Part A \u2014 if you\u2019re actually hospitalized \u2014 covers most services at 100 percent, after you meet the deductible. In 2024 that\u2019s one thousand, six hundred thirty-two dollars.\u00a0<\/p>\n
Thanks to Clarke Lancina for pointing that out.\u00a0<\/p>\n
There have been a bunch of other, amazing notes in my inbox recently, and I want to say: Please keep them coming.\u00a0<\/p>\n
If you go to arm and a leg show dot com, slash, contact, whatever you type there goes straight to my inbox. You can attach stuff too: documents\u2026 voice memos.\u00a0<\/p>\n
Please let me hear from you. That\u2019s arm and a leg show dot com, slash contact.<\/p>\n
I\u2019ll catch you in a few weeks.\u00a0<\/p>\n
Till then, take care of yourself.<\/p>\n
This episode of an arm and a leg was produced by me, Dan Weissmann, with help from Emily Pisacreta, and edited by Ellen Weiss.\u00a0<\/p>\n
Adam Raymonda is our audio wizard. Our music is by Dave Weiner and blue dot sessions. Extra music in this episode from Epidemic Sound.<\/p>\n
Gabrielle Healy is our managing editor for audience. She edits the first aid kit newsletter.\u00a0<\/p>\n
Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager.\u00a0<\/p>\n
And Arm and a Leg is produced in partnership with KFF Health News. That\u2019s a national newsroom producing in depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling and journalism.\u00a0<\/p>\n
Zach Dyer is senior audio producer at KFF Health News. He\u2019s editorial liaison to this show.\u00a0<\/p>\n
And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax exempt donations. You can learn more about INN at INN. org.\u00a0<\/p>\n
Finally, thanks to everybody who supports this show financially\u2013 you can join in any time at arm and a leg show dot com, slash, support \u2014 and thanks for listening.<\/p>\n
\u201cAn Arm and a Leg\u201d is a co-production of KFF Health News and Public Road Productions.<\/p>\n
To keep in touch with \u201cAn Arm and a Leg,\u201d\u00a0subscribe to the newsletter<\/a>. You can also\u00a0follow the show on\u00a0 Facebook<\/a>\u00a0and\u00a0 the social platform X<\/a>. And if you\u2019ve got stories to tell about the health care system, the producers\u00a0 would love to hear from you<\/a>.<\/p>\n
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