This faulty device, which the media largely overlooked, should be a crucial piece of evidence in UnitedHealth's latest upcoding fraud investigation, launched by the DOJ on Friday.
Sergei, You know I love your stuff. But I think you are missing a major aspect here that applies to worldwide health: people will run the system, any system, to maximize reimbursement. For example, there is nothing in the rules that says a person needs to be "suffering" from something to be paid if the diagnosis is legitimate. Heaven knows, the covid debacle showed that the government can decide to impact the lives of perfectly asymptomatic and well people by diagnosing them with a lab test. And the government did this to the tune of trillions of YOURS and MY dollars.
So if a health plan/medical practice reads the rules and says "if we can document this diagnosis using community standard tools we will make more money" this behavior is entirely to be expected. It is the behavior of all people in all circumstances for practical purposes.
I am a physician who has fought against many of these things for many years. I have worked in many countries and have discovered that the health cadence (e.g., number of visits for a diagnosis) is absolutely determined NOT by the disease but by the reimbursement for the disease. In EVERY case.
So it seems mildly disingenuous to now throw the book at United (and the others) for doing what could confidently be expected from a well run business. One can have many conversations about whether health care should be a business or whether it should be completely run by Florence Nightingales, but the fact that good businesspeople will use the rule sets they are given (setting aside any real fraud which does not seem the case here) to optimize things deserves less scorn than you attach here, I think.
But keep on piling on the HIT and H-AI vendors. That IS fraud and they deserve whatever you can find.
Dr. K: I appreciate your insights, and I respect your points. However, let's not rationalize the (alleged) crime. A crime is a crime. UnitedHealth and three other insurers, with the help of Matrix and Signify, chose this particular PAD device for a reason—of all the devices on the market, this one brings in the most revenue for them. The higher the false positive rate, the more money they make.
Do you know how high an 80% error rate is? Well, it certainly sounds high. But in the article I also quote a study that benchmarks these kinds of devices against the industry standard. And the industry standard is 10%.
Do you know how bad QuantaFlo is? I don't need a patent. Hypothetically, if I have a sample of 100 patients—20 with PAD and 80 without—and I simply tell every single one of them, "I'm sorry, you've tested positive for PAD," guess what? I have the same false positive error rate as the "patented" QuantaFlo, without doing any work or research. I think I should work for UnitedHealth. 😉
This is blatant fraud—horrible, unjustifiable, and something that should have no place in healthcare.
Sergei, You could certainly be right. My point was that if the payment system says that this instrument is OK to use to document this payable diagnosis, one has to expect that is what people will do. Might be "bad medical practice" but would not be fraud unless someone said "this instrument does not work for this because it sucks so do not use it". The use may have been deliberate or just good salesmanship by the company making the devices, and we both may find the end results repugnant, but really the precise payment scheme characteristics would determine if it was fraud or just "sharp" business practices. I have no idea what the actual fact pattern is in this case, but I have been enough places to know how aggressively any collector of government monies will go to make sure they wring every last cent out of any particular payment structure.
Sergei, You know I love your stuff. But I think you are missing a major aspect here that applies to worldwide health: people will run the system, any system, to maximize reimbursement. For example, there is nothing in the rules that says a person needs to be "suffering" from something to be paid if the diagnosis is legitimate. Heaven knows, the covid debacle showed that the government can decide to impact the lives of perfectly asymptomatic and well people by diagnosing them with a lab test. And the government did this to the tune of trillions of YOURS and MY dollars.
So if a health plan/medical practice reads the rules and says "if we can document this diagnosis using community standard tools we will make more money" this behavior is entirely to be expected. It is the behavior of all people in all circumstances for practical purposes.
I am a physician who has fought against many of these things for many years. I have worked in many countries and have discovered that the health cadence (e.g., number of visits for a diagnosis) is absolutely determined NOT by the disease but by the reimbursement for the disease. In EVERY case.
So it seems mildly disingenuous to now throw the book at United (and the others) for doing what could confidently be expected from a well run business. One can have many conversations about whether health care should be a business or whether it should be completely run by Florence Nightingales, but the fact that good businesspeople will use the rule sets they are given (setting aside any real fraud which does not seem the case here) to optimize things deserves less scorn than you attach here, I think.
But keep on piling on the HIT and H-AI vendors. That IS fraud and they deserve whatever you can find.
Dr. K: I appreciate your insights, and I respect your points. However, let's not rationalize the (alleged) crime. A crime is a crime. UnitedHealth and three other insurers, with the help of Matrix and Signify, chose this particular PAD device for a reason—of all the devices on the market, this one brings in the most revenue for them. The higher the false positive rate, the more money they make.
Do you know how high an 80% error rate is? Well, it certainly sounds high. But in the article I also quote a study that benchmarks these kinds of devices against the industry standard. And the industry standard is 10%.
Do you know how bad QuantaFlo is? I don't need a patent. Hypothetically, if I have a sample of 100 patients—20 with PAD and 80 without—and I simply tell every single one of them, "I'm sorry, you've tested positive for PAD," guess what? I have the same false positive error rate as the "patented" QuantaFlo, without doing any work or research. I think I should work for UnitedHealth. 😉
This is blatant fraud—horrible, unjustifiable, and something that should have no place in healthcare.
Sergei, You could certainly be right. My point was that if the payment system says that this instrument is OK to use to document this payable diagnosis, one has to expect that is what people will do. Might be "bad medical practice" but would not be fraud unless someone said "this instrument does not work for this because it sucks so do not use it". The use may have been deliberate or just good salesmanship by the company making the devices, and we both may find the end results repugnant, but really the precise payment scheme characteristics would determine if it was fraud or just "sharp" business practices. I have no idea what the actual fact pattern is in this case, but I have been enough places to know how aggressively any collector of government monies will go to make sure they wring every last cent out of any particular payment structure.