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A class action lawsuit has been filed against UnitedHealth Group (NYSE: UNH) in Minnesota. That lawsuit pertains to two issues that home health providers have long griped over: algorithms dictating care, and conveners’ role in between payers and providers.
The lawsuit follows an investigation from STAT News, which alleged that UnitedHealth Group – through naviHealth – used algorithms to deny care for Medicare Advantage (MA) beneficiaries, even against the better judgment of its own clinicians.
UnitedHealth Group’s Optum first acquired naviHealth – a post-acute care convener – in May of 2020.
naviHealth was founded in 2012, and after the onset of COVID-19, became much more involved in home-based care management specifically. It’s one of the largest conveners in the space, along with myNEXUS and CareCentrix. myNEXUS is now owned by Elevance Health (NYSE: ELV), while CareCentrix is owned by Walgreens Boots Alliance (Nasdaq: WBA).
Optum is the provider side of UnitedHealth Group, with the payer side being UnitedHealthcare.
naviHealth was brought into Optum before the home health platform LHC Group, or the house call company Landmark Health. But it is a part of Optum’s Home and Community services, which will serve over 40 million Americans in 2023, Dr. Patrick Conway – then the CEO of Care Solutions at Optum, and now the CEO of Optum Rx – said this past June.
Reports have suggested over the last month that UnitedHealth Group was discontinuing the naviHealth brand, but Conway also said in June that the company was in process of rebranding it.
“The home platform is going to serve north of 40 million people this year,” Conway said. “And it has things like naviHealth, which we now call Care Transitions.”
Home health services are not at the center of the allegations made in the STAT investigations or lawsuit.
But the claims within the lawsuit strike a similar tone to complaints home health providers have been making for years about conveners and, more broadly, predictive analytics.
This week’s exclusive, members-only HHCN+ Update covers the lawsuit, why it’s relevant to home health providers and the growing influence of AI in health care services. Before reading on, it’s important to note that Optum refutes allegations made in STAT and the lawsuit, which representatives from the company have said “has no merit.”
“The [naviHealth] predict tool is not used to make coverage determinations. The tool is used as a guide to help us inform providers, families and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home,” Aaron Albright, a spokesperson for Optum, told HHCN sister publication Skilled Nursing News. “Coverage decisions are based on CMS coverage criteria and the terms of the member’s plan.
In August 2021, I connected with Dr. Jay LaBine – then the chief medical officer of naviHealth – to see what the company was up to just over a year after being acquired by Optum.
“We’re now deploying home health management,” he told me. “Because we’ve been involved with post-acute care for so long — we saw that many people could get their needs met, not by inpatient facility care, but by home health care agencies coming to their home. And so we always asked that question, ‘Well, why not home?’”
LaBine moved onto another role shortly after, in December 2021.
“If we have good partnerships with home health agencies that have visiting nurses, we can be sure that patients are getting their needs met,” he continued. “We’re now expanding our services so that we can help identify the right types of agencies. We can collect data on the agencies that do their start of care well and are timely in getting the nurse into the home.”
Post-acute conveners, like naviHealth, have a strong value proposition.
Health plans cannot possibly closely manage all of the health care episodes they authorize. They also can’t sit down and deal with each home health provider – for example – that they contract with.
Conveners are supposed to work out those issues as a middleman. Their algorithms also help guide clinicians. At best, those algorithms end up identifying the patients that need more care to keep them out of the hospital. What’s more, they also, in theory, help deploy resources to those patients that need them most – a critical benefit when providers across health care are turning individuals away due to capacity constraints.
At worst, and as STAT’s investigation alleges, they end up denying care to seniors that need it.
AI systems, and the algorithms fed into them, will continue to play a key role in the delivery of health care services. For instance, The Vistria Group-backed Medalogix is a predictive analytics company that works with hundreds of home health and hospice agencies.
Elliot Wood, its CEO and president, told HHCN in early 2020 that using its tools without clinician oversight and supervision was an “irresponsible use of technology, unequivocally.”
The lawsuit against UnitedHealth Group alleges that it and naviHealth did just that.
Keith Myers, who is now a senior advisor at Optum – in addition to being the chairman and CEO Emeritus of LHC Group – strongly criticized the role conveners played in home health care delivery back in July of 2022.
LHC Group, where he was then CEO, was officially acquired by Optum in February 2022.
“I think we’ve done a lot more with managed care [because of our JVs with hospitals], and I have really good relationships with executives,” Myers said. “But I think our biggest problem are the conveners in the middle of all of this.”
For context, my reporting on conveners at HHCN has garnered more reaction from home health executives than almost any other topic over the last four years.
They, too, see conveners as utilization suppressors, but also believe they skim money off the top of each episode, which brings MA rates for home health services down even further.
Amedisys Inc. (Nasdaq: AMED) Chairman Paul Kusserow is now in almost the exact same situation as Myers was when he made those comments about conveners. He’s moved from the CEO seat to chairman, and his company is also under the process of being acquired by Optum.
Whether or not the lawsuit could intensify the ongoing scrutiny over that deal is yet to be seen.
But Kusserow also detailed to me, albeit in January, the problem with conveners in this day and age.
“Conveners are, fundamentally, very classic delegated risk,” he said. “You give everything over to these people, you give them 85 cents on the dollar. And their job is to go manage that.”
His following point, though, is what stood out to me.
“The conveners continue to push on very difficult pricing and managing visits where they don’t really have the knowledge of producing the best outcomes,” Kusserow said.
In essence, that’s what this lawsuit alleges, but in a different area of care. It could be a step toward doing away with conveners as we currently know them, which would elate home health providers.
It also could mean more litigation in the future against conveners and their parent companies for how they’ve managed care, whether in home health care or otherwise.