United Healthcare (UHC) is an insurance company that sells medical insurance plans to businesses and individuals. However, UHC’s business model has changed due to the self-inflicted stress on its bottom line by choosing to participate in the Affordable Care Act (Obamacare) exchanges. United Healthcare has determined that the most effective way to recover its losses is to inject itself into the delivery of medical care to the people who subscribe to UHC health insurance plans.
When people enroll in a health insurance plan whether via their employer or outside of a group plan, they do so with a mere expectation that they receive coverage for medical care they receive from sufficiently educated, trained, licensed physicians. People covered under a UHC plan can expect UHC to do much more than just serve as the third party that pays claims related to the care they receive from licensed physicians.
There are medical conditions that are permanent and expensive to treat due to the severity of the illnesses and the services necessary to care for the patients. For instance, chronic kidney disease (CKD) is a permanent, life-altering diagnosis that must be detected early to slow its progress otherwise it deteriorates into end-stage renal disease (ESRD). According to the National Kidney Foundation, thirty million Americans suffer from CKD. Unfortunately, serious conditions such as heart disease, high blood pressure, and diabetes lead to CKD, so treating CKD patients is a complicated task that requires a nephrologist (kidney doctor) whose credentials are extensive, and beyond reproach, seems obvious; UHC disagrees.
United Healthcare has transitioned from a company that sells insurance products to one that delivers patient care. The company’s first foray into care delivery is a program it calls Kidney Resource Service (KRS). Apparently, UHC has correctly determined that kidney patients are expensive to treat, hence the need to get involved in the treatment of CKD by circumventing the physician-patient relationship and making direct contact with patients, not to discuss issues related to their insurance plans, but rather to discuss their diagnoses and courses of treatment. The KRS program is designed to aggressively manage the costs associated with treating CKD patients by intervening in their care.
There isn’t any public information on the KRS program, but nephrologists who participate in UHC plans are well aware of the program and its efforts to interfere with the care of their patients. The KRS program is staffed by “provider specialists” and registered nurses who work in tandem to try to obtain and review medical records from physicians. Nephrologists receive requests for medical records from a provider specialist that reads: KRS registered nurses have requested the following information for the member (patient) listed above:
- current medication list
- recent progress notes or treatment plan
- most recent lab results with dates
- recent test results or procedure results (kidney biopsies, ultrasounds, etc.)
- next appointment date.
Why do you suppose an insurance company needs this information? The requested information is personal health information related to particular patients that have nothing to do with processing claims for payment. The nurses who staff the KRS program want the clinical information because they are going to circumvent the physician-patient relationship to actively treat the patients to reduce costs to the detriment of the patients. In other words, the nurses are going to practice medicine without a license, a crime in all fifty states.
If/When a nurse receives the requested information on a patient, she calls the patient and says, “This is _______ at United Healthcare, I am calling because I received your medical records from Dr. ________ and I want to talk to you about your CKD.” The patient thinks his nephrologist is working in partnership with UHC because the nurse at KRS has his medical record.
United Healthcare is not a physician practice or hospital; it is nothing more than an insurance company that sells health insurance plans that due to high out-of-pocket costs (see copays, co-insurance, and deductibles) for subscribers are nothing more than catastrophic care plans. The leaders at UHC routinely make bad decisions such as banking on Obamacare to bring more customers, therefore more money. Obamacare did not turn out to be the financial boon UHC’s leaders expected, so desperation has set in and they are scrambling to find ways to save money; enter nurses undermining the physician-patient relationship by meddling in the care of very sick patients that will result in harm to those patients.