Brian Klepper

A class action legal ruling this month, on a case originally filed in 2014, found that UnitedHealthCare’s (UHC) mental health subsidiary, United Behavioral Health (UBH), established internal policies that discriminated against patients with behavioral health or substance abuse conditions. While an appeal is expected, patients with legitimate claims were systematically denied coverage, and employer/union purchasers who had paid for coverage for their employees and their family members received diminished or no value for their investments.

Central to the plaintiff’s argument was the fact that UBH developed its own clinical guidelines and ignored generally accepted standards of care. In the 106 page ruling, Judge Joseph C. Spero of the US District Court in Northern California wrote, “In every version of the Guidelines in the class period, and at every level of care that is at issue in this case, there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.” He concluded that the emphasis was “pervasive and result[ed] in a significantly narrower scope of coverage than is consistent with generally accepted standards of care.” Judge Spero found that UBH’s cost-cutting focus “tainted the process, causing UBH to make decisions about Guidelines based as much or more on its own bottom line as on the interests of the plan members, to whom it owes a fiduciary duty.”Read More

William Bestermann, MD

No matter how far up the food chain you are, the failure to reform US healthcare puts you and those you care about squarely in the crosshairs of physical and financial catastrophe. Almost everything that you love about life depends on your health. You may have the wherewithal to have a vacation home and a yacht. You may have access to the best interventional cardiologist, but almost no one has access to optimal medical therapy to treat and prevent chronic conditions.  

No one has access to the best new science and systems because of an abject failure of leadership at multiple levels. If you don’t get best practice medical treatment and develop a heart attack with congestive heart failure, your endurance and enjoyment of life will be diminished. The failure to improve health and lower costs creates a medical financial bubble that puts every segment of our economy at risk. Men will frequently ignore their own health for a dollar, but are you really ready to throw your spouses, parents, and best friends under the bus? Are you ready to put national security at risk? Really?

Moneyball tells the story of a team manager who turned baseball on it’s ear by using data, evidence, and systems to do more with less. Money medicine isn’t like that. Money medicine defends old expensive treatments that are proven ineffective, while failing to apply new data, evidence, and systems.

We know how to do this. We know how to develop a system that serves patients and voters. The way forward has been spelled out in detail years ago. The Institute of Medicine (IOM) brings together the best and brightest in American healthcare to provide advice on health policy. In 2001, the IOM called for drastic change and provided a roadmap for reform that has been entirely ignored. Nothing has changed 18 years later.Read More

Al Lewis

The wellness withhold provision in the Affordable Care Act codifies the CDC’s  2009 “Call to Action” about chronic disease: The Power to Prevent, the Call to Control. On the summary page, we learn some of what the CDC calls “arresting facts”:

  1.  “Chronic diseases cause seven in 10 deaths each year in the U.S.”
  2.   “About 133 million Americans — nearly one in two adults — live with at least one chronic illness.”
  3.   “75% of our healthcare spending is on people with chronic conditions.”

More recently, they decided that 75% was not a high enough statistic to get people’s attention, so they changed it to 86%. Most recently, they’ve upped the third statistic to 90%. More on that later.

The most “arresting fact” is how head-scratching these CDC claims are…and of how they created the wellness legend.

Take the first statement — “chronic diseases cause seven in 10 deaths.” We have to die of something. Would it be better to die of suicides and homicides? Mercury poisoning? Barbecuing rattlesnakes?

The CDC’s second statistic is also a head-scratcher. Only 223 million Americans were old enough to drink in 2009; divide 133 million into that number, and you see that a whopping 60% of adults, not “nearly one in two,” live with at least one chronic illness. So they got that part wrong but…Read More

Brian Klepper It seems inevitable that, in the near future, an innovative health care organization is going to seize the market opportunity, gradually cobble all the pieces together, and demonstrate to organizational purchasers that it consistently delivers better health outcomes at significantly lower cost than has...