UnitedHealth Group (UHG), one of the nation’s largest healthcare insurers, is facing fresh allegations of systematically denying nursing home patients necessary hospital care through incentive programs designed to cut costs. These accusations, detailed in a recent investigation by The Guardian, paint a troubling picture of financial motives potentially overriding critical patient needs within the nursing home sector.
The report alleges that UnitedHealth offered “Premium Dividend” and “Shared Savings” payments to nursing homes, essentially rewarding facilities for keeping hospital admission rates (measured as “admits per thousand” or APK) low. A low APK, according to the investigation, qualified nursing homes for bonus payments, while a high APK could disqualify them. This system, critics argue, created a perverse incentive for nursing homes to avoid hospital transfers, even when clinically indicated.
Disturbing examples cited in the Guardian’s report include two separate incidents where residents exhibiting stroke symptoms were allegedly advised against hospital visits by a UnitedHealth remote provider. One resident reportedly suffered permanently slurred speech and facial droop, while the other sustained brain damage. “In several cases identified by the Guardian, [UnitedHealth’s] insertion of itself into nursing home emergency protocols helped delay or avert transfers for patients who could have benefited from immediate hospital care,” the investigation stated.
A former UHG executive, quoted in the report, bluntly put it: “APK drove everything. You gain profitability by denying care, and when profitability suffers for the shareholders, that’s when people get crazy and do things that are not appropriate.” The investigation further uncovered internal UHG emails reportedly showing supervisors imposing “budgets” on their teams, limiting the number of nursing home resident hospital admissions they could approve.
These new claims add to a growing list of concerns surrounding UnitedHealth’s business practices. Just weeks prior, the company became the target of a Department of Justice investigation for alleged criminal Medicare fraud within its Medicare Advantage division. Furthermore, an October Senate report heavily criticized the nation’s three largest Medicare Advantage insurers, including UnitedHealthcare, for increasingly restricting access to post-acute care through prior authorization denials, forcing vulnerable patients into “impossible choices” to protect profits.
The Impact on Nursing Home Quality
The potential ramifications of such practices on nursing home residents are significant. Denials for post-acute care can force seniors into difficult decisions about their health and finances, especially right after hospital discharge when they are most vulnerable. A recent report by West Health and Gallup revealed that more than four in ten U.S. adults (42%) believe nursing homes are ineffective in preventing avoidable harms such as infections, pressure wounds, and abuse and neglect. This figure underscores the existing public skepticism regarding the quality of care in these facilities, which could be exacerbated by financial incentives that disincentivize necessary hospital transfers.
UnitedHealth Group has categorically denied all claims of impropriety, stating on its website that the U.S. Department of Justice investigated similar allegations previously and declined to pursue the matter, citing “significant factual inaccuracies.”
However, the consistent stream of allegations and ongoing investigations underscore a critical tension within the healthcare system: the balance between cost containment and ensuring optimal patient care. As the nursing home industry grapples with ongoing workforce challenges and the need for quality improvement, these accusations against major payers like UnitedHealth highlight the complex financial dynamics that can influence resident outcomes.
For nursing home administrators and staff, navigating these pressures while upholding their commitment to resident well-being remains paramount. The ongoing scrutiny of insurer practices will undoubtedly continue to shape the regulatory landscape and potentially drive changes in how care is authorized and compensated in the future.