In two recent stories, the Wall Street Journal (WSJ) mischaracterizes the purpose of UnitedHealthcare’s in-home clinical assessment and preventive visit program and inaccurately claims the company received payment under the Medicare Advantage program for diseases that were misdiagnosed or never treated.
The WSJ gives its readers an incomplete and inaccurate picture of HouseCalls specifically and Medicare Advantage more broadly. Medicare Advantage consistently outperforms traditional Medicare in cost and quality, and it helps care for America’s seniors, especially those with complex health needs. The WSJ’s core thesis, methodology and conclusions are flawed, and we believe stakeholders across the health sector deserve a more complete picture.
First, the WSJ fundamentally misrepresents HouseCalls, which provides in-home clinical assessments at no cost to millions of seniors each year to better understand their current health status, identify conditions, and connect patients to necessary specialists and high-quality medical care. It’s a critical touchpoint in the care continuum, supplementing annual physician visits — not replacing them — and ensuring people have access to needed services, including housing, food and social support.
The professionally licensed and highly trained HouseCalls clinicians — many of whom have been dedicated to visiting Medicare Advantage seniors for years as part of this program — perform health, home and environmental assessments and offer preventive services, but they do not prescribe or order treatments. They may refer members to other services or providers, but they always direct members back to their chosen, treating physician for treatment. HouseCalls is meant to identify new or emerging conditions earlier, identify opportunities for preventive care and invest in condition management.
More broadly, the shortcomings of the current fee-for-service system — which is inefficient and ineffective, and consistently underdiagnoses serious health conditions — leaves patients with fewer options to treat diseases after they have progressed. For example, the WSJ cites higher rates of peripheral artery disease diagnoses through HouseCalls without mentioning early detection is critical to helping patients avoid unnecessary ICU admissions and, in some cases, amputations.
Ultimately, we believe this move from fee-for-service to value-based care, championed by Medicare Advantage, is a paradigm shift for a health system that historically pays for volume, not value. It requires a new way of thinking about early detection and disease prevention.
We recognize this directly challenges the status quo, which has relied on treating a constant influx of sick patients and is burdened with the wrong financial incentives. But we also see a different way forward - one that cares for patients before they are too sick for viable treatment and provides higher-quality outcomes at a lower cost.
A look at the real numbers
Given the WSJ’s unfounded allegations about the quality of our care for some of our most vulnerable patient populations, our clinical research teams examined our own internal Medicare Advantage plan data to conduct a rigorous, multiple-cohort epidemiological study of the treatment rates singled out in their reporting. We believe the findings — along with some additional widely-accepted context explaining how the program works — speak for themselves.
Care Delivery: Unfounded Claims about Diagnoses and Treatment
Claim: The WSJ claims UnitedHealthcare's HouseCalls program is simply a way to add codes and increase payment.
Reality: HouseCalls provides one-on-one, in-home clinical assessments to more than 2.7 million patients each year. It allows advanced practice clinicians to identify and address gaps in care, ensuring patients receive important health screenings and connecting them with needed care.
- The majority of diagnoses made during a home visit do not result in increased Medicare Advantage (MA) risk adjustment payments.
- Within 90 days of a HouseCalls visit, 75% of patients receive additional primary care in a clinic.
- Last year, the program closed more than 3 million gaps in care by addressing medical, behavioral and social needs.
Claim: “Insurer-driven HIV diagnoses” were made during home visits, and HouseCalls clinicians diagnosed HIV without informing patients.
Reality: HouseCalls clinicians document and report previously diagnosed HIV. They do not make new HIV diagnoses, a test that would require a blood draw. HouseCalls is intended to identify and document new conditions (many undiagnosed or underdiagnosed) for physician follow-up.
- If a patient has a history of HIV, it is standard medical practice for a clinician to examine the patient, review past medical history and medication reconciliation, and document the condition.
Claim: Fewer than 17% of patients with insurer-driven HIV diagnoses were on antiretroviral therapy, the WSJ found.
Reality: Our research team conducted a rigorous, methodologically validated analysis of antiretroviral therapy (ART) rates for UnitedHealthcare’s Medicare Advantage population of patients with HIV.
- Our analysis found a much higher rate of documented ART than what the WSJ reported:
- HouseCalls: 67.4% ART rate when we did a manual chart review of claims, something the WSJ would not be able to do in their analysis.
- Few studies exist of seniors with HIV and medication compliance trends. Centers for Disease Control and Prevention data shows that nationwide, at least 65% of those living with HIV have undetectable levels of the disease, likely due to adherence with ART regimens.
- HouseCalls and chart review identify a population of patients with lower health care utilization due to their higher social risks.
- The percentage of treated patients could be much higher based on individuals receiving ART from other sources, such as the Ryan White Foundation, the VA, or other avenues that don’t show up in a pharmacy claim database.
- Evidence of treatment through these alternative sources would not show up in the WSJ analysis.
- For the total UnitedHealthcare MA beneficiary population, the documented ART rate was 91%.
Claim: UnitedHealthcare is inaccurately coding diabetic cataracts during HouseCalls visits, resulting in overpayment.
Reality: Centers for Medicare & Medicaid Services (CMS) guidelines advise that if a patient has confirmed diabetes as well as cataracts, they should be coded for diabetic cataracts. Our HouseCalls clinicians follow these well-established CMS coding guidelines when they conduct assessments and refer the member to their physician.
Claim: UnitedHealth Group uses a device called QuantaFlo to “find more cases of peripheral artery disease.”
Reality: QuantaFlo is an FDA-approved device “intended to aid clinicians in the diagnosis and monitoring of Peripheral Arterial Disease (PAD).” Our Optum clinicians are trained with respect to PAD screenings and interventions based on medical society guidance and are instructed to use their independent clinical judgement based on the totality of the patient’s circumstance. They are never required to screen for PAD.
- Peripheral artery disease is underdiagnosed and associated with high rates of morbidity, which is why we screen people to intervene early and get them the help they need.
- Peripheral artery disease is also a marker for generalized vascular disease. These patients are at higher risk for stroke, heart attack and cardiovascular death, highlighting the need for early diagnosis.
- As with all conditions identified during a HouseCalls visit, when we identify someone with peripheral artery disease, we inform the patient’s primary care provider and refer them to other providers as appropriate.
Incomplete Data and Flawed Methodologies
Claim: The WSJ consulted more than a dozen experts, including academics, actuaries and policy analysts, about its analysis of the Medicare data, who said the methodology was sound.
Reality: The WSJ’s analysis was not designed based on how the CMS payment system actually works, so there is no way to reconcile the data used by the WSJ.
- The WSJ tries to make an apples-to-apples comparison between A) people whose diagnosis is reported on a claim from a doctor’s office (people who are more likely to be already in active treatment) and B) people whose diagnosis is documented by the provider in the medical record but not included in a current claim or whose diagnosis is identified during an in-home clinical visit — two very different populations.
- The WSJ’s data source is incomplete. The WSJ used Hierarchical Condition Category, or HCC, codes based on the encounter data from the CMS Chronic Conditions Data Warehouse (CCW). This data does not include correction submissions that occur after the data was extracted from the Medicare Encounter Data System for upload to the CCW.
A Fundamental Misunderstanding of HouseCalls, Medicare Advantage Payments and Accountability
Claim: Private insurers involved in the government’s Medicare Advantage program made hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments from 2018 to 2021.
Reality: This assertion is unsubstantiated, and the WSJ presented no credible evidence to support this claim. UnitedHealthcare complies with strict CMS protocols. CMS has systems and processes in place to help ensure that data submitted meets the established program rules. We follow these processes thoroughly.
- CMS audits and validates the documentation of the diagnosis and does so through a variety of oversight mechanisms.
Overall Value of Medicare Advantage for American Seniors and Taxpayers
Claim: Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said.
Reality:
- Medicare Advantage is more affordable for patients and reduces costs for the broader health system.
- Seniors in MA save 45% on premiums and out-of-pocket costs each year, which translates to an average savings of $2,800 annually compared to those in fee-for-service (FFS) Medicare.
- In 2023, 73% of MA enrollees, including those in UnitedHealthcare plans, pay no monthly premium.
- The MedPAC analysis cited in the WSJ’s story is not consistent with findings from other third-party studies, raising serious questions around the accuracy and methodology. For example, an analysis from Milliman showed that, assuming similar populations, the government’s cost to fund Medicare Advantage is approximately 96% of the cost to fund FFS and provides $60 billion annually in additional value through lower out-of-pocket costs and additional services.
Share This Story