Kevin is chief managed care and revenue strategy officer at Unlock Health.
This post is the fourth in a series on the state of managed care by Kevin Thilborger. Check out the first post here.
Anyone familiar with the U.S. healthcare system recognizes Kaiser Permanente (KP) as a closed system in certain geographies. In fact, KP is usually the top-rated health plan in its markets, and it demonstrates excellent patient satisfaction scores. Now, we see the evolution of UnitedHealth Group into a closed system, with the ambition of dominating the country’s 75 largest metropolitan statistical areas (MSAs). Notably, member satisfaction and patient satisfaction scores are more than a little bit different, and so are the impacts on the healthcare system.
According to a January 2024 report by Health Care un-covered:
“There are multiple reasons why UnitedHealth may be increasingly functioning like a closed system. First, Optum is a dominant provider of all healthcare services [other than hospital care]. One subdivision, Optum Health, acquired or hired 20,000 physicians over the past year and now has 90,000 on its roster, or about 10% of all doctors in the U.S. Another subdivision, Optum Rx, is the third-largest [pharmacy benefit manager] PBM, a kind of company that comes up with and administers drug benefit plans for insurers, or about 22% of the market. It’s also the fourth-largest pharmacy, with about 7% of the market. And its final major subdivision, Optum Insight, is considered by several market research firms to be among the top healthcare analytics providers, especially following its 2022 acquisition of Change Healthcare.
So, it makes sense that as Optum gains more market share performing the kinds of services that an insurer and its members seek, UnitedHealthcare would increasingly end up doing business with Optum.
But Optum’s growth may not be sufficient to explain why eliminations are rising as a share of UnitedHealth revenue. To pull the curtain back, experts have noted that there may be some financial engineering motivating UnitedHealthcare to use Optum vendors rather than independent ones. By steering patients to Optum doctors, for example, UnitedHealthcare avoids the “medical loss ratio” (MLR), the 80-85% of premium revenue that the Affordable Care Act requires health insurers to spend on patient care. This high percentage means UnitedHealthcare doesn’t get to keep as many profits, but its parent company can compensate for that by making sure patients are using Optum doctors rather than external ones.”
This point is too important to gloss over. United can pull so many different levers to manage MLR. United could impose low reimbursement rates on independent providers and then pay its owned and controlled providers exactly the amounts needed to hit the MLR target on the nose. It’s also really hard to see how this flywheel is good for anyone except United, the world’s fifth-largest corporation.
The implications extend beyond pricing to access, too. The Health Care un-covered report continues:
“The data shows that Optum generates the majority of its revenue from UnitedHealthcare, not external insurers. This is not necessarily surprising, given that UnitedHealthcare is a dominant player in the insurance market, like Optum is in its sectors. In fact, UnitedHealthcare is the largest commercial health insurer, with 14% of the market, and the largest Medicare Advantage insurer, with 28% of the market, according to the American Medical Association. So it makes sense that a significant number of customers that Optum serves, and thus makes money from, are insured or owned by UnitedHealthcare. That said, UnitedHealthcare’s large share is still less than half of the overall insurance market, meaning its position is not sufficient to explain why it makes up the majority of Optum’s revenue. This could suggest Optum is giving preferential treatment to UnitedHealthcare. Or that UnitedHealthcare is sending most of its patients to Optum, and that makes up the bulk of Optum’s capacity.
Again, doing business with a subsidiary is not illegal, but when it eliminates choice and can reduce quality, it becomes a problem. There have been a number of lawsuits that call out UnitedHealthcare for dropping providers (making them out of network) and in turn steering patients to Optum care. One suit described it as "lining their own pockets by terminating providers and referring patients to ... a provider owned and controlled by them."
Hospitals, health systems, and all types of healthcare providers need to protect themselves with the right contract payment rates and language. United’s strategy may also cause certain providers to consider whether they should do business with United Medicare Advantage specifically or even more broadly.
Unlock Health is here to help providers set managed care strategy and negotiate contracts in the complex world of payor-provider relations. Our full-service managed care consulting group helps providers set their managed care strategy, negotiate contracts, and handle all the contract modeling, analytics, and contract performance. And when negotiations are difficult or contentious, we pioneered the use of strategic marketing communication campaigns to protect providers’ brands and create pressure on payors for fair and reasonable settlements of contract negotiations. Email Kevin Thilborger, our chief managed care and revenue strategy officer, at [email protected].