It said its bonus payments to nursing homes help prevent unnecessary hospitalizations that are costly and dangerous to patients and that its partnerships with nursing homes improve health outcomes.
To reduce residents’ hospital visits, UnitedHealth has offered nursing homes an array of financial sweeteners that sounded more like they came from stockbrokers than medical professionals.
Over the past seven years, the company has shelled out “Premium Dividend” and “Shared Savings” payments that boosted nursing homes’ bottom lines.
But a full accounting of UnitedHealth’s cost-cutting push inside nursing homes has not previously surfaced amid government and media investigations into the company’s conduct.
UnitedHealth declined to answer questions about how much it has paid out to nursing homes through the secret contract clauses.
According to a Guardian investigation, UnitedHealth Group, the biggest healthcare conglomerate in the country, has secretly given nursing homes bonuses totaling thousands of dollars to help reduce hospital transfers for sick residents. This is part of a series of cost-cutting measures that have saved the company millions of dollars, but occasionally put the health of the residents at risk.
These covert bonuses were given out as part of a UnitedHealth initiative that places the company’s own medical teams in assisted living facilities and encourages them to reduce care costs for residents who are insured by the massive insurance company.
The Guardian found that in multiple instances, UnitedHealth employees intervened to prevent nursing home residents who required immediate hospital care under the program from receiving it. A private nursing home incident log, audio recordings, and photographic evidence show that at least one person suffered permanent brain damage as a result of his delayed transfer.
Nobody is actually looking into patient injuries. No one at all,” stated a current nurse practitioner with UnitedHealth who recently complained to Congress regarding the nursing home program. These occurrences are concealed, minimized, and played down. It’s like, “Well, they’re medically frail, and nobody lives forever.”. “.”.
Thousands of private company and patient documents gathered through public records requests and court documents, interviews with over 20 current and former UnitedHealth and nursing home staff, and two whistleblower declarations filed with Congress this month via the nonprofit legal organization Whistleblower Aid are the foundation of The Guardian’s investigation.
A never-before-seen window into the company’s successful attempt to integrate itself into the daily operations of almost 2,000 nursing homes in small towns and urban commercial strips across the country is offered by the documents and sources. This strategy has helped UnitedHealth secure a significant amount of federal funding from Medicare Advantage plans, which cover over 55,000 long-term nursing home residents.
The claim that UnitedHealth staff members have avoided hospital transfers “is verifiably false,” the company said. Additionally, it claimed that its partnerships with nursing homes improve health outcomes and that its bonus payments to nursing homes help prevent unnecessary hospitalizations that are expensive and dangerous for patients.
Insurance companies receive lump sum payments from the federal government under Medicare Advantage to pay for the care of elderly people. However, when it comes to long-term nursing home residents, UnitedHealth executives have consistently attempted to take advantage of the advantage that insurers have when they spend less on care.
UnitedHealth has provided nursing homes with a variety of financial sweeteners that sound more like they were created by stockbrokers than by medical professionals in an effort to decrease the number of hospital visits made by residents.
The company’s “Premium Dividend” and “Shared Savings” payments over the last seven years have improved nursing homes’ bottom lines. According to internal corporate documents and former employees, UnitedHealth, through its “Quality and Shared Risk” program, offered an even larger cut to nursing homes that reduced medical spending while threatening to recoup funds from those that did not.
Executives at UnitedHealth were particularly fixated on the term “admits per thousand,” or APK for short. It was a gauge of how frequently residents of nursing homes were admitted to the hospital. A nursing home that had a low APK was eligible for the different bonus payments that the insurer provided under the “Premium Dividend” program. A nursing home received nothing if the APK was high.
One former national UnitedHealth executive who worked on the initiative with nursing homes in over two dozen states and spoke about the confidential contracts on condition of anonymity said, “APK drove everything.”. “You can increase profitability by denying care, and when shareholders’ profits suffer, people lose their minds and act inappropriately.”. “”.
The revelations come at a critical moment for UnitedHealth, which was rocked by public indignation following the shooting death of top executive Brian Thompson in December and the apprehension of Luigi Mangione, a suspect.
The murder rekindled worries about the healthcare behemoth’s Medicare windfalls and patient care denials. But despite government and media investigations into the company’s actions, a complete accounting of UnitedHealth’s cost-cutting drive inside nursing homes has not yet come to light.
techniques for reducing costs.
Among the various strategies UnitedHealth developed to monitor and reduce costs in its nursing home program were the covert bonuses.
For instance, internal emails reveal that supervisors at UnitedHealth provided their teams with “budgets” that illustrate the number of hospital admissions they had “left” to use up on nursing home patients.
The organization additionally kept an eye on nursing homes with fewer patients with “do not resuscitate” (DNR) and “do not intubate” orders on file. Patients are waiting for some life-saving procedures without such orders, which could result in expensive hospital stays.
According to three former and two current UnitedHealth nurse practitioners who spoke to the Guardian, UnitedHealth managers pressured nurse practitioners to convince Medicare Advantage members to change their “code status” to DNR, even in cases where patients had made it crystal clear that they wanted all available treatments to keep them alive.
Another current UnitedHealth nurse practitioner stated, “They’re acting as though it’s in the member’s best interest.”. However, it isn’t. “.”.
UnitedHealth responded to inquiries by stating that its nursing home program offers “on-site nurse practitioners, customized care plans for chronic conditions, and improved communication between staff, families, and providers” to help older residents receive better care.
The business denied that it improperly encouraged patients to change their code status to DNR or stopped hospital transfers.
The program’s cost-cutting initiatives were only made possible by UnitedHealth’s extensive reach. UnitedHealth is a $300 billion+ conglomerate that has become one of the largest businesses in the world as a result of its unrelenting efforts to establish itself in almost every sector of the healthcare sector. Optum, a subsidiary of UnitedHealth, employs or affiliates with tens of thousands of physicians and nurse practitioners, and the insurance division covers millions more Medicare Advantage seniors than any of its competitors.
Under the bonus program, nursing homes permitted medical teams from a single UnitedHealth subsidiary to work on-site, giving the corporate behemoth the ability to directly affect the insurance division of its business by influencing residents’ important healthcare decisions.
According to The Guardian’s reporting, the program provided nursing homes with even greater amounts for each senior who was enrolled in the insurer’s “Institutional Special Needs Plans,” which are designed for long-term nursing home residents. According to a whistleblower lawsuit pending in federal court in Georgia, internal nursing home records, and interviews with over a dozen current and former nursing home employees and UnitedHealth salespeople, these payments in some cases encouraged nursing homes to divulge private resident records to UnitedHealth sales teams so they could directly solicit senior citizens and their families.
According to a former UnitedHealth employee in Georgia who spoke to the Guardian, she obtained nursing home employees to divulge her private resident records and then backdated permission-to-contact forms in order to get around federal regulations designed to shield elderly people from pushy salespeople. A former coworker claims that the employee was let go because she didn’t reach her sales target.
Federal court filings in Georgia, a former UnitedHealth executive, and leaked patient files examined by the Guardian all claim that families complained that their loved ones were transferred to the company’s Medicare Advantage plan despite the fact that they lacked the mental capacity to make such decisions after a nursing home near Savannah, Georgia, gave UnitedHealth access to private patient records.
According to the sources, a typical midsize nursing home could receive hundreds of thousands of dollars a year in various payments associated with boosting UnitedHealth enrollments and reducing medical costs.
However, the nursing home residents were unaware of the private incentive payments and anti-hospitalization strategies that were influencing their care, even though they had enrolled in UnitedHealth’s Medicare Advantage program and their federal funds were funding it.
When asked how much it has paid out to nursing homes under the covert contract clauses, UnitedHealth refused to comment. The company stated that its payments reward residents for efforts that result in better care and encourage high-quality outcomes for them.
Using Whistleblower Aid, former UnitedHealth nurse practitioner Maxwell Ollivant filed a congressional declaration this month, requesting that the federal government hold the healthcare behemoth responsible.
In his first-ever public statement on the nursing home initiative, Ollivant stated in an interview with the Guardian that lawmakers should ensure that UnitedHealth was “not skimping out on care” and that patients were not “signing up for a service and not receiving the service when the time comes.”.
Ollivant previously sued UnitedHealth in a federal court in Washington state, alleging that the company had violated the federal False Claims Act by failing to provide nursing home residents with essential services, thereby preventing them from receiving Medicare payments. The lawsuit was dropped by the nurse practitioner in 2023 after the Department of Justice refused to step in. New details about his experience are revealed in his congressional declaration.
Ollivant “lacks both the necessary data and expertise” to evaluate the efficacy of its programs, according to a statement from UnitedHealth. “Our programs consistently receive high satisfaction ratings from our members, and we stand firmly behind their integrity,” the statement read.
Unreliable diagnoses and postponed hospital stays.
The nursing home initiative is marketed by UnitedHealth as beneficial for long-term residents. It enables them to consult with UnitedHealth nurse practitioners in person as well as with remote medical specialists who advise facility nurses on the weekends and at night.
According to UnitedHealth, this “enhanced care coordination” will help cut down on avoidable hospital stays, which can expose patients to more problems and are expensive for the organization.
The Guardian found multiple instances where the company’s integration into nursing home emergency protocols prevented or postponed transfers for patients who would have benefited from immediate hospital care.
One instance from 2019 involved a remote UnitedHealth medical provider who works for the program. Shortly after midnight, the program received a report about a resident of a nursing home in Renton, Washington, who was exhibiting the symptoms of a textbook stroke: slurred speech and lack of arm movement.
Every minute matters when someone has a stroke. When the brain’s blood supply is cut off or blocked, brain cells rapidly perish. Doctors have a better chance of preventing long-term neurological damage the sooner patients arrive at the hospital.
According to an incident log in this instance, the nurse at her assisted living facility informed UnitedHealth that it appeared to be a stroke. However, the remote UnitedHealth employee suggested that the resident might be experiencing a less serious condition called a transient ischemic attack (TIA), which is a temporary loss of brain function caused by blood flow blockage, rather than authorizing an immediate hospitalization for a potential stroke.
According to private UnitedHealth records, the remote worker then instructed the nurse to perform a blood test and provide another update to the organization in four hours.
The Guardian was informed by the patient’s independent primary care physician that she was never notified of the patient’s failure to be transferred.
According to her, who spoke on condition of anonymity to discuss delicate patient matters, “I would have wanted them to contact me right away so that I could have made a decision.”. “The timeline is important. “.”.
The UnitedHealth employee’s working diagnosis, which called for ruling out a TIA rather than a stroke, also disturbed the independent physician. Instead of being a doctor, the remote worker was a nurse practitioner in the early stages of their career.
The patient’s doctor stated, “Their diagnosis is TIA, [but] nobody can say that so early.”.
Another incident that year involved a nursing home nurse in Puyallup, Washington, who postponed hospitalizing a resident who was also displaying symptoms of a possible stroke due to UnitedHealth policies that forced facility employees to wait for company directives.
The nurse called a distant UnitedHealth provider, but the provider was unclear of what to do and did not call for an immediate transfer, according to private nursing home records that the Guardian was able to obtain. After a long wait for a callback, the nurse called an independent doctor instead of the remote provider, who then directed the patient to be transferred.
But because of the delay, it took around an hour before the resident was actually brought to the hospital, which was just a short drive from his facility.
Audio recordings and pictures acquired by the Guardian reveal that the patient experienced permanent facial droop on the right side of his face and verbal slurring following the delayed hospitalization.
Regarding the individual patient cases, UnitedHealth declined to comment, citing confidentiality regulations. Nonetheless, the company pointed out that it does not preclude nursing homes from getting in touch with their residents’ private physicians, and that hospitalization choices can be influenced by a variety of factors, such as a patient’s care objectives, symptoms, and the opinions of their care team.
pressure on nursing home employees from UnitedHealth.
According to UnitedHealth, the facility and the treating physician should determine the best course of treatment for each patient. The company denied that its staff prevented hospital transfers.
However, internal documents and interviews with current and former UnitedHealth medical providers reveal that the company’s strategies forced facility nurses to defer patient care decisions to UnitedHealth employees.
“There was never any caveat, given, like, ‘It’s up to you all,’” remarked a former UnitedHealth physician who participated in the initiative. In long-term care facilities, nurses “were calling the responsible nurse practitioner or on-call provider.”. Essentially, they were requesting guidance that was supposed to be adhered to. “.”.
Another current UnitedHealth nurse practitioner told the Guardian, anonymously, that “we have to go in and try to stop it a lot of times when the nurses want to send people out,” citing concerns about reprisals. It’s our responsibility if we don’t. They lead us out onto the carpet. “”.
The Guardian reported on a patient case in which nursing home staff sent a resident to the hospital after discovering her unconscious, drooling, and “slant to the side”—symptoms of a potential stroke. A UnitedHealth email examined by the Guardian stated that she was admitted to the intensive care unit due to a brain bleed.
A UnitedHealth manager, however, informed her subordinates that the facility team had circumvented the company’s protocol by neglecting to contact UnitedHealth’s remote on-call team first to obtain guidance following the incident, rather than congratulating them for the timely hospitalization.
The email reveals that the manager met with the director of nursing services at the nursing home and arranged for training to retrain the staff.
According to UnitedHealth, patients may be at risk for pressure injuries, falls, and other complications if they are admitted to the hospital needlessly. UnitedHealth responded to inquiries from the Guardian by citing a 2019 study that highlighted the program’s effectiveness in lowering hospitalizations while also pointing out the possible drawbacks of hospital treatment.
However, Ollivant, the former UnitedHealth nurse practitioner who turned whistleblower, claimed in an interview with the Guardian that these analyses do not take into consideration the detrimental health effects that patients experience when they miss hospital care.
He asked, “How many of those people suffered additional harm as a result of never receiving the care they required?”. Merely examining the percentage decreases in hospitalizations doesn’t provide insight into patient outcomes. “”.
A sick patient, a treatment plan.
Before being contacted by the Guardian last month, Kevin Keep was unaware that his father had possibly had a stroke at a UnitedHealth-affiliated nursing home.
A UnitedHealth remote worker was notified on the evening of February 23, 2019, that Keep’s father, Donald Keep, was a retired auto mechanic who was living in a Bremerton, Washington, nursing home with dementia and an amputated leg.
Keep had “possible stroke symptoms” that day, including drooping on the right side of his face and forgetfulness, according to a private UnitedHealth incident log.
However, rather than immediately transporting the octogenarian to the hospital, the remote worker referred to a treatment plan that included blood work and aspirin administration, which one former UnitedHealth physician stated “doesn’t make sense” due to the possibility of brain damage.
Speaking on condition of anonymity, the doctor said, “That’s not useful when it might be a stroke.” He was reviewing Keep’s private medical records at the Guardian’s request. “They actually need a brain MRI and a physical examination, and they need it done quickly. “”.
The fact that the incident log makes no mention of a hospital transfer raises the possibility that the UnitedHealth team did not handle the case with the urgency that a potential stroke would demand.
Few minutes before ten o’clock on a Saturday evening, Keep’s symptoms were recorded. An employee of UnitedHealth sent a follow-up email to the company’s nurse practitioners the following afternoon, asking them to investigate Keep’s condition.
Instead of a stroke, the email states that the suggested work-up is for a “TIA,” which is a temporary, less serious neurological condition.
The work-up remained marked as “pending” at 4 p.m. on that Sunday, over 18 hours after Keep was discovered with his face drooping.
A question about whether the retiree was ever admitted to the hospital was not answered by UnitedHealth, citing patient confidentiality.
