Dubious diagnoses, delayed hospitalizations
UnitedHealth pitches its nursing home initiative as a positive for long-term residents. It provides them access to UnitedHealth nurse practitioners via in-person visits as well as to remote medical professionals who provide guidance to facility nurses at night and on weekends.
This “enhanced care coordination”, as the company puts it, is supposed to help reduce unnecessary hospitalizations, which are costly for UnitedHealth and can expose patients to additional complications.
In several cases identified by the Guardian, the company’s insertion of itself into nursing home emergency protocols helped delay or avert transfers for patients who could have benefited from immediate hospital care.
In one incident from 2019, a remote UnitedHealth medical provider working for the program received a report shortly after midnight about a nursing home resident in Renton, Washington, who was slurring her words and unable to move her arm – textbook stroke symptoms.
In stroke cases, every minute counts. When blood flow to the brain is blocked or interrupted, brain cells quickly die. The sooner patients get to the hospital, the better the chance doctors have to prevent long-term neurological damage.
In this case, the nurse at her nursing home reported to UnitedHealth that it looked like a stroke, according to an incident log. But instead of greenlighting an immediate hospitalization for a possible stroke, the remote UnitedHealth employee suggested the resident might be suffering from a less serious condition called a transient ischemic attack (TIA), a temporary loss of brain function caused by blood flow blockage.
The remote employee then advised the nurse to run a blood test and update the company again in four hours, confidential UnitedHealth records show.
The patient’s independent primary care doctor told the Guardian she was never informed of this failure to transfer her patient.
“I would have wanted them to contact me right away so that I could have made a decision,” she said, speaking on the condition of anonymity to discuss sensitive patient matters. “The time frame matters.”
The independent doctor also said she was disturbed by the remote UnitedHealth employee’s working diagnosis, which called for ruling out a TIA, rather than a stroke. The remote employee was an early-career nurse practitioner, not a physician.
“Their diagnosis says TIA, [but] nobody can say that so early,” the patient’s doctor said.
In another incident that year, a nursing home nurse in Puyallup, Washington, delayed hospitalizing a resident also exhibiting potential stroke symptoms because of UnitedHealth protocols that pushed facility staff to wait for guidance from the company.
According to confidential nursing home records obtained by the Guardian, the nurse phoned a remote UnitedHealth provider, who was unsure about what to do and failed to call for an immediate transfer. Tired of waiting for a callback, the nurse finally bypassed the remote provider and called an independent doctor, who ordered the patient to be transferred.
But the delay meant that about an hour passed before the resident was actually taken to the hospital, which was only a few minutes away from his facility.
After the belated hospitalization, the patient suffered permanent verbal slurring and facial droop on the right side of his face, audio recordings and photos obtained by the Guardian show.
Citing confidentiality rules, UnitedHealth declined to comment on the specific patient cases. But the company noted that it does not prevent nursing homes themselves from contacting residents’ independent doctors, and that hospitalization decisions can depend on many factors including a patient’s goals of care, symptoms and the input of their care team.
UnitedHealth’s pressure on nursing home staff
UnitedHealth denied that its employees prevented hospital transfers and said it was the responsibility of the treating physician and the facility to decide on a patient’s best course of care.
But in practice, the company’s tactics put pressure on facility nurses to turn over patient care decisions to UnitedHealth staffers, according to internal documents and interviews with current and former UnitedHealth medical providers.
“There was never any caveat, given, like, ‘It’s up to you all,’” said one former UnitedHealth doctor involved in the program. Nurses at the long-term care facilities “were calling the nurse practitioner or on-call provider who was responsible. The implication was that they were calling for advice that was meant to be followed.”
A lot of times the nurses want to send people out and we have to go in and try to stop it,” said another current UnitedHealth nurse practitioner, who also spoke to the Guardian anonymously citing fears of retaliation. “And if we don’t, it’s on us. They take us out on to the carpet.”
In one patient case identified by the Guardian, nursing home staff sent a resident to the hospital because she was found unresponsive, drooling and with a “slant to the side” – possible stroke symptoms. She was admitted to the intensive care unit for a brain bleed, according to a UnitedHealth email reviewed by the Guardian.
But after the incident, instead of praising the facility team for the prompt hospitalization, a UnitedHealth manager alerted her subordinates that the facility team had bypassed the company’s protocol, failing to contact UnitedHealth’s remote on-call team first to receive guidance.
The manager met with the nursing home’s director of nursing services, and scheduled training to re-educate the facility’s nurses, the email shows.
UnitedHealth notes that unnecessary hospitalizations can expose patients to pressure injuries, falls and other complications. In response to questions from the Guardian, UnitedHealth pointed to one 2019 study which heralded the program’s success in reducing hospitalizations and noted the potential harms of hospital care.
But in an interview with the Guardian, Ollivant, the former UnitedHealth nurse practitioner turned whistleblower, argued such analyses fail to account for the negative health outcomes that patients suffer from missing hospital care.
“How many of those people were further harmed because they never received the care that they needed?” he said. “When you just look at the percentage reductions in hospitalizations, it doesn’t say anything about patient outcomes.”
A plan of care, an ailing patient
Kevin Keep never knew – until the Guardian called him last month and told him – that his father had suffered a possible stroke at a nursing home that partnered with UnitedHealth.
On the evening of 23 February 2019, a UnitedHealth remote employee received a report about Keep’s father, Donald Keep, a retired auto mechanic with dementia and an amputated leg living at a nursing home in Bremerton, Washington.
On that day, Keep was experiencing forgetfulness and drooping on the right side of his face – “possible stroke symptoms”, according to a confidential UnitedHealth incident log.
But instead of sending the octogenarian straight to the hospital, the remote employee referred to a plan of care that called for bloodwork and giving Keep an aspirin – a course of action which one former UnitedHealth doctor said “doesn’t make sense”, given the risk of brain damage.
“That’s not useful when it might be a stroke,” said the doctor, who spoke on the condition of anonymity to comment on Keep’s confidential patient records that he reviewed at the request of the Guardian. “What they really need is a physical exam and an MRI of the brain, and it needs to be done expeditiously.”
The incident log, which doesn’t mention a hospital transfer, suggests that the UnitedHealth team didn’t treat the case with the urgency that a possible stroke would require.
Keep’s symptoms were logged shortly before 10pm on a Saturday night. The next afternoon, a UnitedHealth employee emailed the company’s nurse practitioners a follow-up note to look into what was wrong with Keep.
The email lists the proposed work-up as being for a “TIA” – the transient, less serious neurological condition, not a stroke.
As of 4pm on that Sunday, more than 18 hours after Keep was found with his face drooping, the work-up was still listed as “pending”.
Citing patient confidentiality, UnitedHealth did not respond to an inquiry about whether the retiree was ever sent to the hospital.
Hannah Recht contributed data reporting
Tomorrow, part two of UnitedHealth investigation: A tale of three whistleblowers
. I went through the 18 page bill and there were services listed for things I sure don't remember her getting. but who knows. Her out of pocket cost---zero.
