AI, Medical Debt and the Murder of Brian Thompson

Someone shot dead is rare but not unusual: About 46 people are murdered every day in the United States by someone with a gun, according to Gun Violence Statistics. In a country with more than 337 million people, it’s unlikely it’ll happen to you.

But if an upper crust 50-year-old white male is gunned down on New York City’s Sixth Avenue, in the heart of swanky midtown Manhattan, it’s a very different story. The usual gun victim in the United States is black, a Native American or an Alaska Native, statistics say.

 

Brian Thompson was, by some accounts, a mild-mannered individual, approachable, likeable and a solid colleague, too. His murder is a tragic, criminal event that can never be justified. 

 

On the video recording his death, he was stalked, shot and killed around 6:45 a.m. on Wednesday, Dec. 4^th.

 

Two days ago, 26-year-old Luigi Mangione was picked up at a McDonald’s in Altoona, Pa., after a customer spotted what they thought was someone looking very similar to the man who killed Thompson. He’s been charged with murder.

Given Thompson’s title, CEO of UnitedHealthcare, the health insurance arm of UnitedHealth Group, the courtroom hosting this trial could very well take on a very different tone other than a murder trial. Besides arguing over the obvious – did the police pick up the right man? – other issues could arise.

 

What’s At Stake

 

“Delay,” “deny” and “depose” were written on the casings of the bullets that are thought to have been used in Thompson’s murder, police say. Add to what’s also been reported, and there’s every chance this could turn into a show trial about health insurance, maybe even the medical industry. 

 

As with another high-profile trial in New York City, involving a former Marine, defense attorneys will need to work hard at gaining a jury’s sympathy if they hope for any leniency should their client be convicted – and this approach might work.

 

Recent numbers on the amount of medical debt Americans carry are staggering. 

 

Two months ago, the Consumer Financial Protection Bureau reported that 100 million Americans are carrying about $220 billion in medical debt, and it may not be their fault.

 

“Medical billing is often riddled with errors, including inflated or duplicative charges, fees for services the patient never received, or charges already paid,” said CFPB Director Rohit Chopra in the news release reporting the $220 billion in medical debt. “The CFPB is taking action to ensure that Americans are not unfairly chased by debt collectors over unsubstantiated or invalid medical bills.”

 

Every year, about 530,000 bankruptcies in the United States are due to medical costs, according to the National Library of Medicine.

 

Looking Under The Hood

 

A U.S. Senate report, published about eight weeks ago, puts UnitedHealth Group in a bad light. Looking at the claims of senior citizens in the Medicare Advantage program, the U.S. Senate Permanent Subcommittee on Investigations found that in 2019, UnitedHealthcare “issued an initial denial to 8.7% of the post-acute care prior authorization requests it received; by 2022, it denied 22.7% of all such requests.”

 

The report also says UnitedHealthcare tested “Machine-Assisted Prior Authorization (MAP)” to determine the care that would be covered or not covered. Was this an AI program? 

 

Emails seeking clarification and comment from UnitedHealth Group about this report weren’t immediately returned. Telephone calls seeking a response from U.S. Sen. Richard Blumenthal’s office (D-Conn.), who chairs the Senate Subcommittee, weren’t returned either.

 

The report said, “The minutes for the Utilization Management Program Committee (UMPC) (an internal UnitedHealth Group committee) described MAP generally and noted that while it was ‘never a valid source to justify approval or denial of a case,” it was a ‘tool’ that ‘points the clinician to significant sources of primary evidence’ used in evaluating a prior authorization request. When Committee members asked ‘whether the software creates the potential risk of bias, ‘they were told that the doctor or nurse reviewing the case was responsible or verifying that ‘the primary evidence is acceptable.’”

 

The UMPC committee “while discussing the auto authorization model, expressed concern about the costs of ‘increasing manual review rates’ in the UnitedHealthcare division responsible for Medicare Advantage plans,” the report says.

 

“Taken together,” the report says, “these documents suggest that (1) UnitedHealthcare was evaluating the use of automated prior authorization procedures; (2) the company knew from testing that at least one of these automation technologies resulted in an increase in the share of those requests being denied; (3) this model was associated with less time spent evaluating prior authorization requests; and (4) the company was interested in reducing the money it spent on human reviewers of cases for the group covering Medicare Advantage plans.”

 

The Senate Subcommittee’s conclusion might be the most damning part:

 

“Medicare Advantage has grown rapidly in recent years and is, as of 2023, larger than Traditional Medicare. Despite the enormous growth in enrollment, some two dozen health systems have announced over the past year that they will stop accepting Medicare Advantage beneficiaries, with hospitals and providers overwhelmingly citing frustration with prior authorization. Prior authorization was one of the tools given to insurers participating in the program to help them prevent harmful or unnecessary medical services, but as HHS (U.S. Department of Health & Human Services) OIG (Office of the Inspector General) and others have warned, the structure of Medicare Advantage can incentivize companies to use the process to deny care to which patients are entitled.”

 

Another report, from The Commonwealth Fund, published in August, details a recent survey of Americans and their issues with being denied coverage from their health insurer. 

 

Does exasperation and indignation over health insurance justify Brian Thompson’s murder? Of course not!

 

But with hundreds of millions of Americans feeling the weight of medical debt, and a sizable amount unable to pay it, Luigi Mangione might very well receive a sympathetic hearing from a compassionate jury and, quite possibly, a lesser sentence if convicted. 

Our Three Tragedies -- The Ancient Greeks and the Affordable Care Act

The debate over the Patient Protection and Affordable Care Act, commonly referred to as Obamacare, is looking like a Greek tragedy – not one but three.

The first tragedy is President Obama’s age and experience. 

While no one chooses his or her birthday, Obama’s lack of political experience, especially guiding something as tricky as a near overhaul of health care in the United States, is his responsibility.

Had he not been a young man in a hurry in 2008 – and certainly a better student of American history – he would have delayed his presidential ambitions. 

Instead of seeking his party’s presidential nomination, Obama would have gained executive suite experience as either a governor or a Cabinet member in a Hillary Clinton Administration.  But he pressed on, winning his current post.

Which is unfortunate.  Because if Obama was a better history student, he would know the most effective presidents – the ones with the chops for the job – came to the White House with one or two characteristics:  Prior executive experience as either a governor, a general or a Congressional leader and, usually, 50 years old.

George Washington, Thomas Jefferson, Andrew Jackson, James Polk, Abraham Lincoln, William McKinley, Woodrow Wilson, Franklin Roosevelt, Harry Truman, Lyndon Johnson and Ronald Reagan – some of the country’s best presidents – possessed one, if not both, attributes when they became the country’s leader.

If Obama demonstrated patience, he’d be watching this debate from the sidelines, not find himself in the middle of it, showing what he really is – a political novice whose inability to manage the new law may very well sink his presidency and his party, too.

The second tragedy is the law’s name.  The citizenry is finally hearing – loud and clear – it’s called the Affordable Care Act. 

But when there are, potentially, as many as 50 million people facing cancelled health insurance plans because theirs don’t cover every disease, test and possible treatment required under the new law – and facing large increases in their monthly premiums – then this new law doesn’t look “affordable.”

It looks expensive.

In California, the Los Angeles Times reported, some self-employed people paying less than $100 a month for their monthly health insurance premium are looking at an increase of about $140 a month so their plan is in synch with the new law.

The McClatchy News Service reported as many as 40 million people in the United States, buying health insurance through their employers, may see their policies cancelled because they don’t stack up with the law and another 11 million people buying policies on their own are also likely facing the same problem.

And, of course, everyone heard – or saw by now – the infamous video of President Obama saying, “If you like your health insurance plan, you can keep it.”

That statement didn’t come with any caveats. The American people took him for his word.

But now Obama’s eating his words, attempting to find wiggle room to keep that promise while, at the same time, attempting to maintain his signature legislation, something that’s more difficult by the day.  Especially when he’s receiving “help” from former President Bill Clinton, who also made a run at changing how health care is managed and paid for.

The third tragedy is economics.  Its first law is that there’s no such thing as a free lunch and if that isn’t understood by now, it may never be.

A to Z health care coverage – and then some – is costly.  This isn’t like buying a liability policy for your car – usually sold for fewer dollars – so anyone you hit is paid off.

The new law requires you to buy a comprehensive health care policy covering you for anything and everything even though the likelihood of you needing such coverage might be statistically remote.

So what everyone is suddenly learning is that the Obama Administration, through the Affordable Care Act, sold off the American public to the insurance industry.

You’ll pay their rates – and you’ll enjoy it!

And given the Supreme Court’s ruling, there are few legal challenges available.

The Ancient Greeks thought no tragedy was meaningless.  There’s always a lesson. 

Maybe we’re finally learning that if we paid own doctors, out of our own pockets, with our own money, instead of receiving a subsidy from the insurance industry, as we have since World War II, then health care’s prices will drop.

We need to stop acting like crack addicts and wean ourselves off the insurance industry.  If we don’t, health care prices will continue to be inflated.

Sources:

http://www.latimes.com/business/la-fi-health-sticker-shock-20131027,0,2756077.story#axzz2kj7MCbYZ

http://www.mcclatchydc.com/2013/11/07/207909/analysis-tens-of-millions-could.html

http://itsfourthandlong.blogspot.com/2008/03/history-of-american-president-what.html

That useless brain

Why ask why? 

For those old enough to remember, that was the question posed

in a television commercial in a bygone era, and one that should

be asked again today.

But the problem with asking why is that it presupposes you’ll

actually think.

And, hey, why do that? 

It’s so much easier to follow the crowd.

That’s what Holman W. Jenkins Jr., writes about in one of his latest

columns in The Wall Street Journal. (http://online.wsj.com/article/SB10001424127887324634304578539453974685238.html)

That journalism suffers from a lack of mental dexterity or that

people are more easily swayed by their emotions or habits they

picked up from their parents and ancestors– anything but their brains!

– in deciding their votes or other important issues should come as no surprise.

After all, if your parents were Democrats, you’ll likely be one, too;

the same goes for Republicans. 

Religious beliefs are similar.  If you were brought up Catholic, you’ll

likely be one as an adult; and the same holds for every other religion.

It’s easy to simplify problems.  All we need is demon and a solution.

The fact that medical care is expensive is the demon.  The easy

solution – as brought to us by Congress and President Obama -- is to

make health insurance affordable and, thus, accessible to all. 

The fact that healthcare, as provided by the doctors and

the nurses, might suffer is not something you should think about.

And, whatever you do, don’t think about basic economics and the

fact that, at any time, you introduce a third-party payer – as the

current health care system is set up – the provider of any service,

medical care included, is given the ability to raise their prices, thereby

making healthcare unaffordable to anyone who doesn’t buy a

health insurance policy.

Or the fact that insurance companies, forced to cover any and

all illnesses, might compel some doctors to leave the system so

they're able to only accept private money for their services

isn’t something you should worry about either.  

The easier thing, instead, is to go along with the people who have

a complication to solve the complication.  It comes to us as the

Affordable Care Act, which, essentially, sells us to the health

insurance industry. 

Which means, other than allowing you to buy health insurance,

nothing’s been resolved.

But don’t think about that.

A better solution – if someone really wanted to lower the

doctors’ fees, hospital prices and drug prices – would have

been to eliminate insurance companies.

But that would have been too radical.

And since you’re struggling with basic thinking, Senators,

Members of Congress and the President know you can’t

handle hard solutions that require arduous thinking.

If everyone in the healthcare industry was forced to compete on

price – like the car companies are – drugs and doctor visits

wouldn’t cost nearly as much. 

Sure, there would some high-priced doctors and hospitals just like

there are high-priced cars and houses.  Those on the high end

would sell better service.

At the lowest tier, doctors charging far less would offer economy care.

And most doctors would likely fall somewhere in the middle for things

like physicals and urgent care.

But, hey, why think? 

It’s so much easier to leave that to someone else.