Last Week Tonight With John Oliver (2014) s13e23 Episode Script
UnitedHealth Group
1
Welcome to "Last Week Tonight"!
I'm John Oliver. Thank you so much
for joining us. We are back!
And we've missed a lot
since we've been away.
The Iran war continued
to escalate with no end in sight,
we learned Don Jr.'s wedding weekend
was bankrolled by a Russian oligarch,
but don't worry,
his dad says he paid it all back,
so nothing to see there,
and Ted Cruz went on
ESPN's "College Game Day",
where the crowd gave him
the exact reception he deserves.
They're producing enormous
value and enormous skill…
Ted, you suck!
but it also puts reasonable
rules in place,
so for example, every
player gets one free trade.
I do not like that man Ted Cruz.
I do not like him on the news.
I do not like him talking sports.
I do not like him wearing shorts.
I do not like him on TV.
I do not like him trying to flee.
I do not like him in a tux,
but I love him being told he sucks.
Also this week, Kash Patel appeared
before the Senate Judiciary Committee
and answered questions
about changes to FBI hiring rules
making certain types of conduct
that'd previously been disqualifying
suddenly potentially okay.
And one of those types
of conduct was pretty striking.
Why would you even
get into bestiality?
We are not into bestiality.
Look, if you ever find yourself
defensively saying,
"We are not into bestiality",
you have already lost the argument.
And incredibly,
that exchange continued.
These changes didn't start
with you, did they?
No.
Somebody came to you
and recommended?
Yeah.
And when you saw bestiality,
I say this with respect,
the person who recommended it,
why didn't you just say,
"What planet did
you parachute in from?"
Well, that was
my initial response.
Why do I want to lead with
my chin and get into bestiality?
It's amazing. I just wish
Kennedy had kept going there,
"Mr. Patel, explain what constitutes
bestiality. Hand stuff? Mouth stuff?
Also, exactly when does
gentle petting cross the line?
And please speak
directly into the microphone
so history
can remember your answer."
And look, I would absolutely love
to spend the rest of this show
talking about that exchange.
I have a particular set of skills,
and discussing that clip for 40 minutes
would finally utilize all of them.
You think I don't want to show you
a clip of the ass-shaking donkeys
from "Encanto" live at
the Hollywood Bowl? Of course I do!
You think I don't want to show
you that other clip of Kennedy
talking about sex that we are
all thinking about right now?
I can't wait to have
your cock…
Stop!
We don't have time for it!
And I don't like it either,
but we don't have time!
As, unfortunately, we have
something different planned this week.
Because we're actually
gonna dive straight in
with our main and only story tonight,
which concerns health insurance.
The thing supposed to cover anything
bad that happens to your body,
except eyes and teeth,
as those cost extra.
They are the guacamole of the face.
Specifically, we're gonna talk
about UnitedHealthcare,
the country's largest
insurance company.
As you undoubtedly know,
almost two years ago,
its then-CEO, Brian Thompson,
was shot in midtown Manhattan
while going
to an investor conference.
And that killing was, noticeably, not
exactly met with universal sympathy.
In fact, in some quarters, there was
even support for Luigi Mangione,
the suspect who's since
admitted to the shooting.
This Ivy League hottie named Luigi
is the Robin Hood that
we never knew that we needed.
This is like, regular,
everyday person
becoming our hero, our vigilante.
Universal healthcare now
or free Luigi.
Yeah, Luigi had a lot of fans,
many of whom, like that guy,
supported him
by wearing green hats.
Which must be
so weird for Nintendo.
This guy has been Mario's sidekick
for decades now without controversy.
It'd be like finding out that
every Mario Kart game
had OJ Simpson
as a playable character.
But that was just the beginning.
A sign depicting Luigi as a saint
was projected on a New York building
like his album was about to drop.
And supporters showed up
at his arraignment
dressed in shirts that said things
like "I love Italian boys"
and "cougars for Luigi".
And look, let's just get this straight
out of the way: Luigi is hot.
There is no way around that.
In fact, he is so hot,
they even had to acknowledge it
on the news.
So much of the clips we were
watching at the top of this segment
are driven by the fact that
this is an attractive person.
You know, we've got to drop
the banner to show why.
And it is deeply troubling
that we are celebrating
this person who's committed
cold-blooded murder,
because, you know,
he clearly went to the gym.
Yeah, someone on that panel said
"drop the banner"
so viewers could understand the full
extent of Luigi's attractiveness.
"Cheeky pecs peeking out
is insufficient.
We are the fourth estate, and we
will show all four rows of abs."
But it's not just
that Luigi was handsome.
One reason many found it hard
to completely condemn the murder
is that so many Americans are furious
with UnitedHealthcare.
In fact, shortly after
the shooting, when a poll asked,
"How much responsibility each
of the following had for the killing?"
78% said the killer held some
responsibility, which, of course.
But 69% also blamed
"denials for healthcare coverage
by health insurance companies."
One of United's executives even
coincidentally alluded to public anger
at the investor meeting
taking place on the day of the murder,
and claimed
that it was all misdirected.
In no way you would design
something as complicated
and as contradictory
and as difficult to navigate
as the system we all find
ourselves in today,
because nobody designed it.
It simply evolved.
I get it, it's not United's fault
the system is like this.
Nobody designed it.
It just evolved naturally.
It presumably all started when this
nasty bitch crawled out of the ocean
and therefore, regrettably,
out of network.
And not long after that,
that same guy gave an address
to his company's employees,
and offered a pretty direct
piece of advice to them.
I encourage you to tune out
that critical noise
that we're hearing right now.
If someone shooting your insurance
division's CEO
won't make you
listen to "critical noise",
I'm not sure anything will.
Because that is pretty much
the ultimate Yelp review.
That man is Andrew Witty,
and at that point,
he was the CEO
of UnitedHealth Group.
That is the company
that owns UnitedHealthcare,
in the same way that Alphabet
owns Google
or Benson Boone
owns backflipping.
I know that other people must
have backflipped before him,
but I cannot name a single one.
And while you are familiar with
UnitedHealthcare as an insurer,
because it served almost
50 million people last year,
you may be less aware of the sheer
scope of its parent company,
UnitedHealth Group.
Last year,
it took in 447 billion dollars,
making it the third largest
company by revenue in the U.S.
That's behind only Amazon
and Walmart, and above Apple.
It's almost unimaginably massive, as it
doesn't just own UnitedHealthcare,
it now also has subsidiaries touching
every aspect of our healthcare system.
In fact, as the Washington Post put it,
"In many parts of the country,
a patient could be a UnitedHealth
customer from cradle to grave,
starting with obstetric care
and ending with hospice services."
And you should know,
that was their aim all along.
In fact, in 2007, UnitedHealth Group's
then-CEO, Stephen Hemsley,
who's recently returned to that role,
said the company was trying
to be "a healthcare
system unto itself."
Which is a pretty far cry from,
"Hey, nobody designed this,
the system evolved naturally from
the fertile crescent of Mesopotamia."
And the very fact that one company
controls so much of US healthcare
is what makes it so infuriating
when you see
just how bad people's
experiences with it can be.
In fact, if you just search for
UnitedHealthcare on TikTok,
it will not take you long
to find videos like these.
I am frustrated.
I'm living in pain.
And you guys are denying everything.
What is wrong with you?
UnitedHealthcare,
get it the fuck together.
I have a surgery that has already
been canceled four times
due to UnitedHealthcare
denying a claim.
I want somebody to go tell
UnitedHealthcare to eat a giant dick.
Yeah, telling UnitedHealthcare
to go fuck itself
has become an entire genre
of internet video,
like unboxing products,
or horny whispering,
or someone doing a dance trend
with their friend
who's not quite as good
at dancing as they are,
which you feel is why they picked
that friend in the first place.
And look, Luigi's upcoming sentencing
is obviously gonna get
a lot of media attention.
But it is really important
that that noise doesn't drown out
the broader frustration with United
that his case also revealed.
So given all of that, tonight,
let's talk about UnitedHealth Group:
how it makes so much money,
how big it's gotten,
and what
that means for all of us.
Let's start with the aspect of United
you're probably most familiar with:
the fact that its insurance division
has a well-earned reputation
for denying claims.
So much so, in fact,
the shell casings for the bullets
fired at Brian Thompson
were inscribed with
"deny, delay, depose",
a reference to a common criticism
of the insurance industry
that they "delay, deny, defend."
Basically, delay processing claims,
deny paying them out,
and, if necessary,
then defend that denial.
Now, United will say
that is completely unfair.
It loves to repeat the argument
that it actually pays out
98% of all eligible claims
under the terms of members' plans.
Which sounds great!
But remember, the company itself
is the one determining
what is and isn't eligible.
And the glimpses of data
that are publicly available
suggest a very different picture.
For instance, when KFF examined
a group of 37 million claims
under United's Obamacare plans,
they found that, in 2024,
nearly one in five
in-network claims were denied.
But it is not just denials. There's also
the practice of the company
requiring prior authorization
for certain treatments,
which can be the bane of both
patients' and doctors' existence.
Just listen to this doctor who had
to get permission from United
to prescribe someone a cheap,
basic blood pressure drug.
I got a prior authorization from
UnitedHealthcare for lisinopril.
I hope the whole board at
UnitedHealthcare gets diarrhea tonight.
Yeah, I get it.
And look, in the interest of balance,
I should say, that man
does not speak for all doctors.
One actually issued a response to
that video that took a different tack.
Now, as frustrating as it is for us
to have to do prior authorizations
and other ridiculous paperwork
for the insurance companies,
I don't think as healthcare
professionals it is appropriate for us
to be wishing ill
upon other people.
Except for the board
of UnitedHealthcare.
Yes, may they have explosive diarrhea,
not just tonight, but every night.
Perfect. In fact,
I'll even go a step further:
I hope they get diarrhea every night
and then have to pay a fuckton
of money out of pocket to treat it
because the gastrointestinal distress
associated with the guilt
of being a healthcare executive turns
out to be a pre-existing condition.
And on the patient side,
fighting claim denials
or seeking prior authorizations
can be a massive time suck, too.
Take these parents, whose workplace
insurance is administered by United,
and whose child has a rare
neurological disorder.
Your experience with your insurer,
if you had to sum it up in one word,
what would that word be?
Frustrating. Like, her physical
and occupational therapy,
it's the same claim every month,
and every month they'll deny it,
because instead of looking
at all of her diagnosis,
they look at the top line and go
punch it in the computer
and say, "Nope, denied."
It's hours a week, if not more.
And every time we have to call in,
it's a different claims rep
we have to deal with.
To bathe without drowning,
Emmy needs to be strapped
into this chair.
Amid the maddening fight
to get one covered,
Carrie says a UnitedHealthcare rep
had this suggestion.
They said that we should find
a way to give her a bath,
either us getting
in the bath with her
or just wiping her down
was sufficient enough.
Wipe her down? She's not
an iPhone you just sneezed on,
she's a fucking human being!
And while, thankfully, those
parents did finally get that chair,
it was only after
a prolonged back-and-forth.
In fact, when their daughter
outgrew that chair
and needed a new one
that cost 1,800 dollars,
they opted to skip the hassle
of dealing with United again
and paid for it with donations
coordinated by his employer.
But at that point,
having insurance sure looks
an awful lot like not having it.
Because if you are
paying premiums,
but still having to take up
a collection for medical equipment,
what exactly is your insurance for?
They're just sending you mail
you don't want to open
and forcing you to have phone calls
that make you angry,
and we all know that is supposed
to be your nana's job.
No. Nana, New York
is not under Sharia law. No.
Also, what do you mean,
I 'sound like I put on weight,
how is that possible, exactly?
And the thing is, far too often,
United's denials can seem to be
completely at odds with medical
advice patients are getting.
Take this story of a woman
who was fighting cervical cancer.
Several years ago, Kate Weissman
was diagnosed with cancer.
Because her cancer was
so close to her vital organs,
her doctors wanted to use
a very special type of treatment
called proton beam
radiation therapy.
Basically, the radiation is beamed
exactly where it needs to go
and it protects the organs.
But guess what?
Her insurance company,
UnitedHealthcare, said,
"Nope,
we're not paying for it."
Yeah, that is maddening.
That woman's own doctors
got overruled by people who had
no experience with her case.
Which is just ridiculous.
It's kind of like how sex ed
at Catholic school is taught
not by medical professionals,
but by Sister Henrietta,
who's never even had sex.
Except for, you know,
that one summer in Italy.
The convent sent her there
to study, but it was so hot,
and the sea was so sweet,
and Valentina was so beautiful.
They spoke in different tongues,
but connected in a way
that transcends language.
It was perfect, pure, one could
even say holy, but all too brief.
And when the air cooled,
and they parted for the final time,
the pain was like
nothing she'd ever known.
To this day, whenever
she sees a shock of red hair,
she yearns to sprint down the street,
to spin Valentina around,
to take her face in her hands.
But each time,
she lets the moment pass.
They probably wouldn't
even recognize each other now.
And yet Henrietta still keeps
her greatest treasure a secret
between the pages of her Bible:
a white lily,
browned and brittled with time,
nestled in the book of Psalms.
And that is why you should never,
ever have sex! Not even once!
Now, UnitedHealthcare insisted
in that woman's case
that "three independent radiation
oncologists agreed
that proton beam therapy
was not safer or more effective
than the proven standard of care."
But here's the thing about that:
she actually had six highly esteemed
oncologists advocating on her behalf,
including five who also teach
at Harvard Medical School,
with the sixth, presumably,
sick of having to hear about
how the other five teach at Harvard
during every fucking conversation.
Meanwhile, one of United's OBGYNs
who helped deny that woman's appeals
wasn't even board-certified
in gynecologic oncology.
She did, however, co-found
a tattoo laser removal business
and apparently once violated
the state's medical code
by allowing an unlicensed individual
to perform laser-based procedures.
And I'll be honest,
I personally would not want
my cancer treatment
being decided by that person,
even if they are probably
destined to become
deputy secretary
of Health and Human Services.
Now, in the end, her parents paid
95,000 dollars out of pocket
to cover the treatment, which,
in happy news, did actually work!
But having access to wealthy parents
just cannot be the system to get
badly needed healthcare.
Even if it is, apparently, the system
that lets you be in charge of HBO.
Yeah, my soon-to-be business daddy
has a literal business daddy.
And to be very clear:
I deeply respect that.
And I would never
make fun of you for it,
unlike that pesky Stephen Colbert.
And look, it is frustrating enough
when United's medical experts
are coming to bad decisions.
But in some cases, there's evidence
people are barely involved at all.
Because former employees of one
United company have said
that, when determining how long
to cover patients' stays
in skilled nursing facilities
to recover from injuries,
they'd rely heavily on an algorithm
called nH Predict,
which would routinely come up
with a date earlier
than they felt was appropriate
under Medicare guidelines.
And as this former
case manager explains,
there were real problems
if she tried to contest that.
You've got all this experience.
Can you use your human judgment
instead if you saw that it was wrong?
Wouldn't that be great?
Unfortunately, no.
The expectation was I would stay within
3% of that estimated discharge date.
But by the time I stopped working,
it was down to 1%.
- 1%.
- 1%.
That's true. And employees have said
that deviating from that 1%
could mean
"exposing themselves to discipline,
including possible termination."
UnitedHealth Group will claim
those were individualized decisions
made by the company's
medical directors,
and that they were consistent
with Medicare coverage criteria.
But here's the thing:
if a company essentially forbids
its case managers
from deviating more
than 1% from an algorithm,
that company
is run by an algorithm.
And that is very dangerous,
because as we all know,
algorithms can make huge mistakes.
It is why, for instance, HBO suggested
that you watch this show
after you caught up
with "Euphoria".
Why would it do that?
No one is hot here,
no one's on drugs
and no one is getting laid.
I am the ontological
opposite of "Euphoria".
And look,
everything you've seen so far
is basically par for the course
in the insurance industry.
United may be worse in some ways,
but they're not that much of an outlier.
Where United is genuinely different,
though, is in its size.
Because remember, it is the third
largest company in America.
And the way it got that big
was by expanding into other,
non-insurance areas of healthcare.
Over the years, it's engaged in
something called "vertical integration",
basically, instead of acquiring more
competitors in the insurance field,
United's focused on acquiring
more and more parts
of the healthcare industry.
And to be fair, it's not
the only company doing this:
CVS Health, for instance,
has built a similar vertically
integrated behemoth
as, in addition to its drugstores,
it also owns a massive insurer, Aetna,
and a pharmacy benefit manager,
CVS Caremark,
while also having
its own medical clinics,
all of whom subtly share
the same heart in their logo.
And honestly?
I do appreciate that.
When I'm picking up
my prescriptions at CVS
after spending 45 minutes asking
someone to unlock every shelf for me,
it is nice to feel loved.
I'm so sorry
for wanting to shop at your store.
But amazingly,
United is even bigger.
It has about 2,700 subsidiaries,
including "primary care clinics,
surgical centers, urgent care centers,
home health agencies,
hospice agencies, mental health
agencies, a pharmacy benefit manager
and plenty more."
To name just a few:
through its subsidiary Optum,
UnitedHealth Group directly
employs about 9,000 physicians
and has non-exclusive contracts
with some 80,000 more.
Meanwhile,
another United subsidiary, OptumRx,
manages 62 million
patients' prescriptions.
The company even has its own
bank, Optum Bank,
which has 20 billion dollars
in assets.
And the company will claim
that all of its acquisitions
have helped it "coordinate
and align incentives"
to deliver what industry leaders
refer to as "value-based care".
And that notion,
that all its subsidiaries
really add up to more
than the sum of their parts,
is something they love to hammer
home in upbeat ads like this one,
about the company's
prescription benefits.
Before Mark even
picks up his prescription,
UnitedHealth Group
goes into action.
Mark's doctor gets real-time
information to prescribe
the most effective,
lowest-cost medication.
Mark's medical and pharmacy
information are connected,
allowing clinical experts to hone in on
any possible risks with prescription.
And Mark's about to get a discount
at the counter.
Working behind the scenes
to ensure quality and savings:
this is what healthcare can do
when it's caring and smart.
UnitedHealth Group.
That sounds nice, doesn't it?
It almost makes United sound
more like a farm-to-table restaurant
instead of a massive
data-sharing panopticon.
But owning all these companies is
hugely helpful to United's bottom line
and in ways
that you might not expect.
For instance: if you ask
UnitedHealthcare, the insurer,
they'll insist they
barely make money at all.
They'll claim their insurance
profits are only around 5%.
They'll also point out that
their insurance profits are capped,
because under
the Affordable Care Act,
they're required to spend 80 to 85%
of the premiums they collect
directly on patient care
or on quality improvements.
What they don't say
quite as loudly, though,
is that that only applies to
the insurance side of the company.
UnitedHealth Group, on the other hand,
makes a shit-ton of money.
And one of the key ways
that it can do that
is through
its vertically integrated model,
because it is often on both sides
of billions of dollars in transactions.
Very basically, when United's
insurance arm is paying out
that mandatory
80 to 85% on healthcare,
the company on the other end of that
transaction is often also United.
And it can use its ownership
of one part of the healthcare system
very much
to its advantage in another.
Take "upcoding". It is the practice
of making a patient
look as sick as possible on paper
to make more money.
For an example of this concept,
just watch this scene
from the Fox medical drama
"The Resident",
where an outside consultant
is telling a roomful of doctors
how she wants them to upcode.
Now, to simplify,
doctors and nurses at Chastain
need to charge more per procedure.
For example: ear infection.
Typically billed to insurance as
service code one at about…
- Yeah?
- 200 dollars.
But what if that ear infection
took a trip to the brain?
That's now a code four.
Serious. Costly.
We can bill in the thousands.
Illness is unpredictable, so billing
must be proactive. Right?
It's called upcoding.
Think CUTE.
Code. Up. To. Excellence.
Yeah, it turns out
upcoding is so common,
they're making fun of it
on network TV.
Which is just wild to me.
It is being explained in the same place
where people watch "Survivor",
"Dancing with the Stars"
and "Tracker".
I'm sorry, you've never
heard of "Tracker"?
Over 16 million people watch it.
More people have watched "Tracker"
than have ever watched
a single episode of this show.
What's it about? I dunno.
Jeremy Tracker tracking things?
There's just no way to know.
But people fucking love it.
And while it is not strictly necessary
to understand the rest of this story,
I would be remiss if I didn't tell you
that, in that same episode,
that consultant gets in trouble
after ordering a patient
get an expensive MRI that he doesn't
need, and then this happens.
Mr. Reynolds, do you know
how an MRI works?
It has incredibly powerful magnets.
Magnets that will rip anything
metal out of your body.
Anything at all.
Do you have anything metal
in your body, Mr. Reynolds?
Mr. Reynolds has a penile implant,
a metal-based penile implant.
How much is your penis
worth to you, Mr. Reynolds?
- In a lawsuit? A million, 5 million?
- Stop the machine!
Yes!
More shows should be brave enough
to have a character ask the question,
"How much is your penis
worth to you?"
You know how many times "The Pitt"
has asked that? Fucking zero.
Take back that Emmy!
Now, in that clip, doctors were
the ones being encouraged to upcode
so that their hospital
could charge insurers more.
But as we discussed in our episode
on Medicare Advantage,
insurance companies
can also benefit from upcoding
to get more money
from the government.
Very basically,
under Medicare Advantage,
the government will pay insurers
a higher rate
for patients
with more serious conditions.
That was meant to discourage them
from cherry-picking
only the healthiest people.
But obviously, that also means
that the sicker insurance companies
can make their customers look,
the more money
they can then claim.
And it turns out, as UnitedHealth
has gobbled up medical practices
through its Optum subsidiary,
doctors at those clinics have said
it's placed enormous pressure on them
to code patients intensively,
although, fun fact, they don't use
the acronym "CUTE".
That would obviously
be ridiculous.
Instead, their coding guidebook
tells doctors to use the mnemonic
"treatment, assessment, monitor,
plan, evaluation, and referral"
or TAMPER.
And I don't know, guys.
I might've picked an acronym
with a less negative connotation.
Because what kinds of things
does someone tamper with?
So far,
I've got evidence and end of list.
And while United will claim
they have robust safeguards
to ensure accurate coding,
it's reportedly pressured its doctors
to code
as many conditions as possible
by offering bonuses
to those who coded aggressively,
and reviewing the performance of those
who weren't coding as much.
In fact, doctors have even described
being emailed a kind of leaderboard
that compared them locally
and nationally
by the percentage of their
Medicare Advantage patients
that they'd diagnosed
with certain chronic diseases.
And all this aggressive coding
has made United a fuckton of money.
In fact, one study found it receives
12 billion dollars a year
in additional payments, because
of higher coding intensity alone.
That's by no means the only way
that United pressures doctors.
Those in formerly independent
practices acquired by Optum
have said it's also overhauled
their schedules,
with some required to see
three to four patients an hour,
and complaining that "they
barely found time to eat or pee."
One doctor in Massachusetts, retired
after Optum acquired her practice
said, "I feel just like
an Amazon warehouse worker,
where all I'm doing is 20 minutes,
20 minutes, 20 minutes, 20 minutes."
Which obviously is not great.
Doctors should not feel like
Amazon warehouse workers.
Not even Amazon warehouse workers
should feel like Amazon
warehouse workers,
but that is a story for another show
that we have already done.
And the thing is,
because United is so massive,
even doctors
who don't work directly for them
can wind up being
negatively impacted by them,
and sometimes
in surprising ways.
Take Change Healthcare.
It's a United-owned clearinghouse
that processes more than a third
of all U.S. claims between pharmacies,
doctors, hospitals and insurers.
That is a lot!
But there are real hazards to letting
one company be that dominant,
something that became
painfully clear in February 2024
when it was subject to a massive
Russian ransomware attack.
At this busy New Hyde Park medical
practice, claims cannot get submitted,
doctors aren't getting paid,
procedures aren't getting
needed pre-authorization.
Change Health,
owned by UnitedHealth,
which handles much
of the nation's medical records,
was hacked three weeks ago.
A huge part of that system is down
and the people responsible
for making it work
aren't stepping up to the plate.
Ronald Laszlo went 10 days
without medicine he needs
to prevent a transplanted kidney
from being rejected
because the pharmacy
couldn't get authorization.
The bottom line is, it could kill you.
That is obviously awful. But
what makes it especially infuriating
is that apparently, one reason
the system was so easy to hack
is that the company's portal did
not have multi-factor authentication.
Which is just insane.
As a rule, medical record platforms
should be required
to have operational security
at least as good
as the Buffalo Wild Wings app.
And, notice, I didn't
even say "better" there.
I said "at least as good"
as the app that lets you order
a bacon-smashed hatch chili burger
with a whole chocolate fudge
cake for dessert.
At least meet that fucking bar.
Now, the good news
for all those doctors' offices
whose businesses were so massively
disrupted by that hack is that United,
through its bank subsidiary,
quickly offered them
no-interest bridge loans.
Basically, it was using one part
of its company
to clean up a mess
that another part had just made.
Unfortunately, that bank
then caused a different problem
by demanding full repayment
of those loans
little more than a year later,
threatening to withhold insurance
payments from UnitedHealthcare
if providers didn't pay up.
And this caused a serious crisis
for practices
like the one owned
by this pediatric brain surgeon,
which got a loan
of just over half a million dollars.
I really believed that Optum
would give physicians
a reasonable amount of time
to repay the loan
with the understanding that this
financial crisis almost bankrupted us.
Despite United saying the loans
didn't need to be repaid
until doctors' practices
were back to normal,
UnitedHealth told Mazzola
in January
that she had
five days to pay the money,
or it might start
clawing back reimbursements.
We easily lost over a million
dollars because of that hack.
I'm just a pediatric brain
surgeon, right? So, what do I know?
But we didn't cause this problem.
We were just
financially devastated by it.
Okay, first, "I'm just
a pediatric brain surgeon"
is one hell of a flex, but second,
that is one of those professions
where, if you are fighting
with them for any reason,
you're gonna come out
looking bad.
It's like when Katy Perry was in court
with those nuns
over buying their former convent.
That would've been a tough PR battle
even if one of them hadn't begged,
"Katy Perry, please stop",
before then collapsing and dying
in the middle of court.
It is amazing to me
that we don't talk about that more!
And by the way, that nun?
Henrietta.
Her final words were,
"I'm coming, Valentina!"
A sentence
she hadn't uttered in 50 years.
But that is the thing about
UnitedHealth Group,
whatever corner of its business
you poke into,
you can find something appalling.
Which brings us
to our final example tonight,
which concerns its pharmacy
benefit manager, OptumRx.
Pharmacy benefit managers, or PBMs,
are basically companies
that serve as middlemen between
drug companies and insurers.
And they have a lot of power,
because they decide which drugs
your insurance will cover.
That is why drug companies will give
PBMs. what are essentially kickbacks,
in the form of "rebates"
of a percentage of their sales,
to try and stay
on their good side.
And over the years,
OptumRx has engaged
in some truly unsavory practices.
For instance, when the opioid crisis
was spiraling out of control,
there were some who argued
that PBMs. should remove drugs
like OxyContin from their lists,
but Optum very much
did not do that.
Instead, it asked Purdue Pharma
to pay them higher rebates,
going from about 23% of every
sale to about 60%.
And when a manager
at OptumRx suggested removing it
from their list of covered drugs,
saying of Purdue,
"They basically
caused the opioid epidemic,
and we're essentially
rewarding their bad behavior",
another manager wrote back,
"Valid point.
We as a company looked into this,
but the amount of utilization
on OxyContin
and the rebates we collect
prevented us from doing it."
And honestly? I almost
respect that level of honesty.
It is not often that you get
a confession that's essentially just,
"We knew we shouldn't do this, but in
our defense: we did really want to."
If Luigi's lawyers had just told him
to plead that way instead,
there's a non-zero chance
he'd be walking free right now.
But it's not just opioids.
The company's decisions
to abruptly switch out
what drugs it'll cover has had
utterly devastating consequences.
Take what happened
to Cole Schmidtknecht,
a 22-year-old with severe asthma
who showed up at a pharmacy
with a prescription
for an Advair Diskus inhaler.
Then this happened.
Cole had insurance
through his Wisconsin employer.
What he didn't know,
his parents say, is that OptumRx,
the pharmacy benefit manager
for his plan,
changed its list of covered drugs.
The preventative Advair Diskus inhaler
he had used for years
cost Cole no more
than 66.86 dollars.
Suddenly, its price tag:
over 539 dollars.
Holy shit, that is a nasty surprise.
'Cause there are things
that you expect to cost 500 dollars,
like a Nintendo Switch, or tickets
to see Ed Sheeran two weeks ago.
They're cheaper now, apparently.
No idea why!
But being able to breathe
is not one of them.
And frustratingly,
OptumRx even later admitted
that it replaced that Advair Diskus
on its coverage list
not for medical reasons,
but based on rebates
the manufacturers of similar
competitor drugs agreed to pay.
Now, apparently, I have to tell you,
the company claims
its electronic system instructed
the pharmacy to contact Cole's doctor
to get him a prescription for
a more affordable alternative.
Which they apparently didn't.
But the thing is, even if they had,
as anyone who's ever dealt with an
overworked doctor's office can tell,
getting a new prescription
is not a quick process. It takes time.
And unfortunately, Cole needed
those meds immediately.
Because I'll let his father
pick up the story from there.
He says Cole called him minutes
after leaving the Walgreens.
I could sense that he was having
an asthma attack.
His purpose of the call was simply
to ask about his insurance.
And I said, "Don't worry about that,
just get to the hospital."
A roommate
drove Cole to the hospital,
but Cole was unconscious
by the time they got there.
He died days later.
He couldn't get his Advair that night,
and we were told by his roommate
that it was over 500 dollars
and Cole had to make
a decision that night
of paying that exorbitant price
for his medicine or other bills,
and apparently, well, not apparently,
he walked out without it.
That is an absolute tragedy, and
it was completely preventable.
This is the richest country
in the history of the world,
and yet, for some reason,
our current health system
still forces people to walk away from
medicine that will keep them alive
because
they can't fucking afford it.
So, what can we do
about all of this?
Well, as I have said before,
I would argue the broadest solution
is to find a way to transition to
a single-payer healthcare system.
That would solve many of the
problems that you've seen tonight.
Though getting anywhere close to
that feels a ridiculously long way off,
I don't think it's unreasonable
to say that, at the very least,
UnitedHealth Group
should not be allowed to exist
in the form
that it currently does.
There's actually a bipartisan bill
right now,
sponsored by Elizabeth Warren
and Josh Hawley,
that would separate the payer
and provider roles in healthcare,
so that United couldn't be
in the situation
where it can just pay itself.
And while that is clearly not
going nearly far enough,
it is at least a start.
And I know United may well continue
to try to "tune out the critical noise"
or argue that "nobody designed
this system, it simply evolved."
But what is clear is that everybody but
them wants it to work very differently.
Because right now,
the way companies like United exist,
they are, at best, pointless,
time-wasting middlemen,
and at worst, algorithmically driven,
ruthless arbiters
of who lives and who dies.
And until such time as they've made
significant changes,
or much more likely, had those
changes forced upon them,
then, in the words of my new
favorite healthcare provider…
May they have explosive diarrhea,
not just tonight, but every night.
Exactly. And now, this.
And Now:
Behold the Symphony of Chaos
That is Post-Game Interviews
in Women's College Softball.
I knew I had to come
through with my team.
I feel like this year more than ever,
I've kind of been…
I've taken on kind
of a leadership role
and I know how to get it done.
And I was just thinking about
Megan and this team
and how much they've had
my back this whole year.
And I just wanted
to make something happen.
No, I think it's just trusting
my preparation and the coaches,
just having a plan for us
and getting us ready to compete.
Caroline, you had great speed.
You were mixing your speed.
You had great movement,
just hitting some key spots.
Tell me
about sort of the scouting report.
Whoever we have to play next week,
we're gonna prepare.
I mean, cages, everything that we
need to do for whoever we play.
Did you know coming up
to the plate in your final at-bat
that you were only
a double shy of a cycle?
No, I don't think you heard that,
did you?
I heard a little bit of it.
You've had
to really battle through a lot.
What does a game like this evening
mean to you to come out
and be so dominating?
I'm just so blessed. I want to give
all the credit to my Lord and Savior.
We just try every single day
to be there for each other
and have each other's backs.
Coming into it, we knew that
they were gonna be a great team,
they're gonna attack.
We knew we were gonna come back
and get this run rule right here.
But, you know, we never
have doubt in our dugout.
I think it was
just our preparation before.
We watched
a lot of film before the game.
We're super excited to get to it.
We couldn't wait to start playing.
So, we were just super
excited and focused on that.
All of us were really excited
for each other's success
and we were naming things
that we were ready to see.
I think we saw a lot of them. KT on
the mound… They all came through.
That's our show,
thanks so much for watching,
we'll see you next week,
good night!
Yeah, thanks. That was obviously
a tough show to put together.
UnitedHealthcare's
a difficult opponent.
But we at the show just tried
to be there for each other.
I really want to thank Megan
and the whole team,
all of us were really excited
for each other's success.
We never have doubt in our dugout.
That's something I always say.
We never have doubt in our dugout.
That's my classic phrase.
Thanks. Thanks, guys.
…cock in my mouth.
Welcome to "Last Week Tonight"!
I'm John Oliver. Thank you so much
for joining us. We are back!
And we've missed a lot
since we've been away.
The Iran war continued
to escalate with no end in sight,
we learned Don Jr.'s wedding weekend
was bankrolled by a Russian oligarch,
but don't worry,
his dad says he paid it all back,
so nothing to see there,
and Ted Cruz went on
ESPN's "College Game Day",
where the crowd gave him
the exact reception he deserves.
They're producing enormous
value and enormous skill…
Ted, you suck!
but it also puts reasonable
rules in place,
so for example, every
player gets one free trade.
I do not like that man Ted Cruz.
I do not like him on the news.
I do not like him talking sports.
I do not like him wearing shorts.
I do not like him on TV.
I do not like him trying to flee.
I do not like him in a tux,
but I love him being told he sucks.
Also this week, Kash Patel appeared
before the Senate Judiciary Committee
and answered questions
about changes to FBI hiring rules
making certain types of conduct
that'd previously been disqualifying
suddenly potentially okay.
And one of those types
of conduct was pretty striking.
Why would you even
get into bestiality?
We are not into bestiality.
Look, if you ever find yourself
defensively saying,
"We are not into bestiality",
you have already lost the argument.
And incredibly,
that exchange continued.
These changes didn't start
with you, did they?
No.
Somebody came to you
and recommended?
Yeah.
And when you saw bestiality,
I say this with respect,
the person who recommended it,
why didn't you just say,
"What planet did
you parachute in from?"
Well, that was
my initial response.
Why do I want to lead with
my chin and get into bestiality?
It's amazing. I just wish
Kennedy had kept going there,
"Mr. Patel, explain what constitutes
bestiality. Hand stuff? Mouth stuff?
Also, exactly when does
gentle petting cross the line?
And please speak
directly into the microphone
so history
can remember your answer."
And look, I would absolutely love
to spend the rest of this show
talking about that exchange.
I have a particular set of skills,
and discussing that clip for 40 minutes
would finally utilize all of them.
You think I don't want to show you
a clip of the ass-shaking donkeys
from "Encanto" live at
the Hollywood Bowl? Of course I do!
You think I don't want to show
you that other clip of Kennedy
talking about sex that we are
all thinking about right now?
I can't wait to have
your cock…
Stop!
We don't have time for it!
And I don't like it either,
but we don't have time!
As, unfortunately, we have
something different planned this week.
Because we're actually
gonna dive straight in
with our main and only story tonight,
which concerns health insurance.
The thing supposed to cover anything
bad that happens to your body,
except eyes and teeth,
as those cost extra.
They are the guacamole of the face.
Specifically, we're gonna talk
about UnitedHealthcare,
the country's largest
insurance company.
As you undoubtedly know,
almost two years ago,
its then-CEO, Brian Thompson,
was shot in midtown Manhattan
while going
to an investor conference.
And that killing was, noticeably, not
exactly met with universal sympathy.
In fact, in some quarters, there was
even support for Luigi Mangione,
the suspect who's since
admitted to the shooting.
This Ivy League hottie named Luigi
is the Robin Hood that
we never knew that we needed.
This is like, regular,
everyday person
becoming our hero, our vigilante.
Universal healthcare now
or free Luigi.
Yeah, Luigi had a lot of fans,
many of whom, like that guy,
supported him
by wearing green hats.
Which must be
so weird for Nintendo.
This guy has been Mario's sidekick
for decades now without controversy.
It'd be like finding out that
every Mario Kart game
had OJ Simpson
as a playable character.
But that was just the beginning.
A sign depicting Luigi as a saint
was projected on a New York building
like his album was about to drop.
And supporters showed up
at his arraignment
dressed in shirts that said things
like "I love Italian boys"
and "cougars for Luigi".
And look, let's just get this straight
out of the way: Luigi is hot.
There is no way around that.
In fact, he is so hot,
they even had to acknowledge it
on the news.
So much of the clips we were
watching at the top of this segment
are driven by the fact that
this is an attractive person.
You know, we've got to drop
the banner to show why.
And it is deeply troubling
that we are celebrating
this person who's committed
cold-blooded murder,
because, you know,
he clearly went to the gym.
Yeah, someone on that panel said
"drop the banner"
so viewers could understand the full
extent of Luigi's attractiveness.
"Cheeky pecs peeking out
is insufficient.
We are the fourth estate, and we
will show all four rows of abs."
But it's not just
that Luigi was handsome.
One reason many found it hard
to completely condemn the murder
is that so many Americans are furious
with UnitedHealthcare.
In fact, shortly after
the shooting, when a poll asked,
"How much responsibility each
of the following had for the killing?"
78% said the killer held some
responsibility, which, of course.
But 69% also blamed
"denials for healthcare coverage
by health insurance companies."
One of United's executives even
coincidentally alluded to public anger
at the investor meeting
taking place on the day of the murder,
and claimed
that it was all misdirected.
In no way you would design
something as complicated
and as contradictory
and as difficult to navigate
as the system we all find
ourselves in today,
because nobody designed it.
It simply evolved.
I get it, it's not United's fault
the system is like this.
Nobody designed it.
It just evolved naturally.
It presumably all started when this
nasty bitch crawled out of the ocean
and therefore, regrettably,
out of network.
And not long after that,
that same guy gave an address
to his company's employees,
and offered a pretty direct
piece of advice to them.
I encourage you to tune out
that critical noise
that we're hearing right now.
If someone shooting your insurance
division's CEO
won't make you
listen to "critical noise",
I'm not sure anything will.
Because that is pretty much
the ultimate Yelp review.
That man is Andrew Witty,
and at that point,
he was the CEO
of UnitedHealth Group.
That is the company
that owns UnitedHealthcare,
in the same way that Alphabet
owns Google
or Benson Boone
owns backflipping.
I know that other people must
have backflipped before him,
but I cannot name a single one.
And while you are familiar with
UnitedHealthcare as an insurer,
because it served almost
50 million people last year,
you may be less aware of the sheer
scope of its parent company,
UnitedHealth Group.
Last year,
it took in 447 billion dollars,
making it the third largest
company by revenue in the U.S.
That's behind only Amazon
and Walmart, and above Apple.
It's almost unimaginably massive, as it
doesn't just own UnitedHealthcare,
it now also has subsidiaries touching
every aspect of our healthcare system.
In fact, as the Washington Post put it,
"In many parts of the country,
a patient could be a UnitedHealth
customer from cradle to grave,
starting with obstetric care
and ending with hospice services."
And you should know,
that was their aim all along.
In fact, in 2007, UnitedHealth Group's
then-CEO, Stephen Hemsley,
who's recently returned to that role,
said the company was trying
to be "a healthcare
system unto itself."
Which is a pretty far cry from,
"Hey, nobody designed this,
the system evolved naturally from
the fertile crescent of Mesopotamia."
And the very fact that one company
controls so much of US healthcare
is what makes it so infuriating
when you see
just how bad people's
experiences with it can be.
In fact, if you just search for
UnitedHealthcare on TikTok,
it will not take you long
to find videos like these.
I am frustrated.
I'm living in pain.
And you guys are denying everything.
What is wrong with you?
UnitedHealthcare,
get it the fuck together.
I have a surgery that has already
been canceled four times
due to UnitedHealthcare
denying a claim.
I want somebody to go tell
UnitedHealthcare to eat a giant dick.
Yeah, telling UnitedHealthcare
to go fuck itself
has become an entire genre
of internet video,
like unboxing products,
or horny whispering,
or someone doing a dance trend
with their friend
who's not quite as good
at dancing as they are,
which you feel is why they picked
that friend in the first place.
And look, Luigi's upcoming sentencing
is obviously gonna get
a lot of media attention.
But it is really important
that that noise doesn't drown out
the broader frustration with United
that his case also revealed.
So given all of that, tonight,
let's talk about UnitedHealth Group:
how it makes so much money,
how big it's gotten,
and what
that means for all of us.
Let's start with the aspect of United
you're probably most familiar with:
the fact that its insurance division
has a well-earned reputation
for denying claims.
So much so, in fact,
the shell casings for the bullets
fired at Brian Thompson
were inscribed with
"deny, delay, depose",
a reference to a common criticism
of the insurance industry
that they "delay, deny, defend."
Basically, delay processing claims,
deny paying them out,
and, if necessary,
then defend that denial.
Now, United will say
that is completely unfair.
It loves to repeat the argument
that it actually pays out
98% of all eligible claims
under the terms of members' plans.
Which sounds great!
But remember, the company itself
is the one determining
what is and isn't eligible.
And the glimpses of data
that are publicly available
suggest a very different picture.
For instance, when KFF examined
a group of 37 million claims
under United's Obamacare plans,
they found that, in 2024,
nearly one in five
in-network claims were denied.
But it is not just denials. There's also
the practice of the company
requiring prior authorization
for certain treatments,
which can be the bane of both
patients' and doctors' existence.
Just listen to this doctor who had
to get permission from United
to prescribe someone a cheap,
basic blood pressure drug.
I got a prior authorization from
UnitedHealthcare for lisinopril.
I hope the whole board at
UnitedHealthcare gets diarrhea tonight.
Yeah, I get it.
And look, in the interest of balance,
I should say, that man
does not speak for all doctors.
One actually issued a response to
that video that took a different tack.
Now, as frustrating as it is for us
to have to do prior authorizations
and other ridiculous paperwork
for the insurance companies,
I don't think as healthcare
professionals it is appropriate for us
to be wishing ill
upon other people.
Except for the board
of UnitedHealthcare.
Yes, may they have explosive diarrhea,
not just tonight, but every night.
Perfect. In fact,
I'll even go a step further:
I hope they get diarrhea every night
and then have to pay a fuckton
of money out of pocket to treat it
because the gastrointestinal distress
associated with the guilt
of being a healthcare executive turns
out to be a pre-existing condition.
And on the patient side,
fighting claim denials
or seeking prior authorizations
can be a massive time suck, too.
Take these parents, whose workplace
insurance is administered by United,
and whose child has a rare
neurological disorder.
Your experience with your insurer,
if you had to sum it up in one word,
what would that word be?
Frustrating. Like, her physical
and occupational therapy,
it's the same claim every month,
and every month they'll deny it,
because instead of looking
at all of her diagnosis,
they look at the top line and go
punch it in the computer
and say, "Nope, denied."
It's hours a week, if not more.
And every time we have to call in,
it's a different claims rep
we have to deal with.
To bathe without drowning,
Emmy needs to be strapped
into this chair.
Amid the maddening fight
to get one covered,
Carrie says a UnitedHealthcare rep
had this suggestion.
They said that we should find
a way to give her a bath,
either us getting
in the bath with her
or just wiping her down
was sufficient enough.
Wipe her down? She's not
an iPhone you just sneezed on,
she's a fucking human being!
And while, thankfully, those
parents did finally get that chair,
it was only after
a prolonged back-and-forth.
In fact, when their daughter
outgrew that chair
and needed a new one
that cost 1,800 dollars,
they opted to skip the hassle
of dealing with United again
and paid for it with donations
coordinated by his employer.
But at that point,
having insurance sure looks
an awful lot like not having it.
Because if you are
paying premiums,
but still having to take up
a collection for medical equipment,
what exactly is your insurance for?
They're just sending you mail
you don't want to open
and forcing you to have phone calls
that make you angry,
and we all know that is supposed
to be your nana's job.
No. Nana, New York
is not under Sharia law. No.
Also, what do you mean,
I 'sound like I put on weight,
how is that possible, exactly?
And the thing is, far too often,
United's denials can seem to be
completely at odds with medical
advice patients are getting.
Take this story of a woman
who was fighting cervical cancer.
Several years ago, Kate Weissman
was diagnosed with cancer.
Because her cancer was
so close to her vital organs,
her doctors wanted to use
a very special type of treatment
called proton beam
radiation therapy.
Basically, the radiation is beamed
exactly where it needs to go
and it protects the organs.
But guess what?
Her insurance company,
UnitedHealthcare, said,
"Nope,
we're not paying for it."
Yeah, that is maddening.
That woman's own doctors
got overruled by people who had
no experience with her case.
Which is just ridiculous.
It's kind of like how sex ed
at Catholic school is taught
not by medical professionals,
but by Sister Henrietta,
who's never even had sex.
Except for, you know,
that one summer in Italy.
The convent sent her there
to study, but it was so hot,
and the sea was so sweet,
and Valentina was so beautiful.
They spoke in different tongues,
but connected in a way
that transcends language.
It was perfect, pure, one could
even say holy, but all too brief.
And when the air cooled,
and they parted for the final time,
the pain was like
nothing she'd ever known.
To this day, whenever
she sees a shock of red hair,
she yearns to sprint down the street,
to spin Valentina around,
to take her face in her hands.
But each time,
she lets the moment pass.
They probably wouldn't
even recognize each other now.
And yet Henrietta still keeps
her greatest treasure a secret
between the pages of her Bible:
a white lily,
browned and brittled with time,
nestled in the book of Psalms.
And that is why you should never,
ever have sex! Not even once!
Now, UnitedHealthcare insisted
in that woman's case
that "three independent radiation
oncologists agreed
that proton beam therapy
was not safer or more effective
than the proven standard of care."
But here's the thing about that:
she actually had six highly esteemed
oncologists advocating on her behalf,
including five who also teach
at Harvard Medical School,
with the sixth, presumably,
sick of having to hear about
how the other five teach at Harvard
during every fucking conversation.
Meanwhile, one of United's OBGYNs
who helped deny that woman's appeals
wasn't even board-certified
in gynecologic oncology.
She did, however, co-found
a tattoo laser removal business
and apparently once violated
the state's medical code
by allowing an unlicensed individual
to perform laser-based procedures.
And I'll be honest,
I personally would not want
my cancer treatment
being decided by that person,
even if they are probably
destined to become
deputy secretary
of Health and Human Services.
Now, in the end, her parents paid
95,000 dollars out of pocket
to cover the treatment, which,
in happy news, did actually work!
But having access to wealthy parents
just cannot be the system to get
badly needed healthcare.
Even if it is, apparently, the system
that lets you be in charge of HBO.
Yeah, my soon-to-be business daddy
has a literal business daddy.
And to be very clear:
I deeply respect that.
And I would never
make fun of you for it,
unlike that pesky Stephen Colbert.
And look, it is frustrating enough
when United's medical experts
are coming to bad decisions.
But in some cases, there's evidence
people are barely involved at all.
Because former employees of one
United company have said
that, when determining how long
to cover patients' stays
in skilled nursing facilities
to recover from injuries,
they'd rely heavily on an algorithm
called nH Predict,
which would routinely come up
with a date earlier
than they felt was appropriate
under Medicare guidelines.
And as this former
case manager explains,
there were real problems
if she tried to contest that.
You've got all this experience.
Can you use your human judgment
instead if you saw that it was wrong?
Wouldn't that be great?
Unfortunately, no.
The expectation was I would stay within
3% of that estimated discharge date.
But by the time I stopped working,
it was down to 1%.
- 1%.
- 1%.
That's true. And employees have said
that deviating from that 1%
could mean
"exposing themselves to discipline,
including possible termination."
UnitedHealth Group will claim
those were individualized decisions
made by the company's
medical directors,
and that they were consistent
with Medicare coverage criteria.
But here's the thing:
if a company essentially forbids
its case managers
from deviating more
than 1% from an algorithm,
that company
is run by an algorithm.
And that is very dangerous,
because as we all know,
algorithms can make huge mistakes.
It is why, for instance, HBO suggested
that you watch this show
after you caught up
with "Euphoria".
Why would it do that?
No one is hot here,
no one's on drugs
and no one is getting laid.
I am the ontological
opposite of "Euphoria".
And look,
everything you've seen so far
is basically par for the course
in the insurance industry.
United may be worse in some ways,
but they're not that much of an outlier.
Where United is genuinely different,
though, is in its size.
Because remember, it is the third
largest company in America.
And the way it got that big
was by expanding into other,
non-insurance areas of healthcare.
Over the years, it's engaged in
something called "vertical integration",
basically, instead of acquiring more
competitors in the insurance field,
United's focused on acquiring
more and more parts
of the healthcare industry.
And to be fair, it's not
the only company doing this:
CVS Health, for instance,
has built a similar vertically
integrated behemoth
as, in addition to its drugstores,
it also owns a massive insurer, Aetna,
and a pharmacy benefit manager,
CVS Caremark,
while also having
its own medical clinics,
all of whom subtly share
the same heart in their logo.
And honestly?
I do appreciate that.
When I'm picking up
my prescriptions at CVS
after spending 45 minutes asking
someone to unlock every shelf for me,
it is nice to feel loved.
I'm so sorry
for wanting to shop at your store.
But amazingly,
United is even bigger.
It has about 2,700 subsidiaries,
including "primary care clinics,
surgical centers, urgent care centers,
home health agencies,
hospice agencies, mental health
agencies, a pharmacy benefit manager
and plenty more."
To name just a few:
through its subsidiary Optum,
UnitedHealth Group directly
employs about 9,000 physicians
and has non-exclusive contracts
with some 80,000 more.
Meanwhile,
another United subsidiary, OptumRx,
manages 62 million
patients' prescriptions.
The company even has its own
bank, Optum Bank,
which has 20 billion dollars
in assets.
And the company will claim
that all of its acquisitions
have helped it "coordinate
and align incentives"
to deliver what industry leaders
refer to as "value-based care".
And that notion,
that all its subsidiaries
really add up to more
than the sum of their parts,
is something they love to hammer
home in upbeat ads like this one,
about the company's
prescription benefits.
Before Mark even
picks up his prescription,
UnitedHealth Group
goes into action.
Mark's doctor gets real-time
information to prescribe
the most effective,
lowest-cost medication.
Mark's medical and pharmacy
information are connected,
allowing clinical experts to hone in on
any possible risks with prescription.
And Mark's about to get a discount
at the counter.
Working behind the scenes
to ensure quality and savings:
this is what healthcare can do
when it's caring and smart.
UnitedHealth Group.
That sounds nice, doesn't it?
It almost makes United sound
more like a farm-to-table restaurant
instead of a massive
data-sharing panopticon.
But owning all these companies is
hugely helpful to United's bottom line
and in ways
that you might not expect.
For instance: if you ask
UnitedHealthcare, the insurer,
they'll insist they
barely make money at all.
They'll claim their insurance
profits are only around 5%.
They'll also point out that
their insurance profits are capped,
because under
the Affordable Care Act,
they're required to spend 80 to 85%
of the premiums they collect
directly on patient care
or on quality improvements.
What they don't say
quite as loudly, though,
is that that only applies to
the insurance side of the company.
UnitedHealth Group, on the other hand,
makes a shit-ton of money.
And one of the key ways
that it can do that
is through
its vertically integrated model,
because it is often on both sides
of billions of dollars in transactions.
Very basically, when United's
insurance arm is paying out
that mandatory
80 to 85% on healthcare,
the company on the other end of that
transaction is often also United.
And it can use its ownership
of one part of the healthcare system
very much
to its advantage in another.
Take "upcoding". It is the practice
of making a patient
look as sick as possible on paper
to make more money.
For an example of this concept,
just watch this scene
from the Fox medical drama
"The Resident",
where an outside consultant
is telling a roomful of doctors
how she wants them to upcode.
Now, to simplify,
doctors and nurses at Chastain
need to charge more per procedure.
For example: ear infection.
Typically billed to insurance as
service code one at about…
- Yeah?
- 200 dollars.
But what if that ear infection
took a trip to the brain?
That's now a code four.
Serious. Costly.
We can bill in the thousands.
Illness is unpredictable, so billing
must be proactive. Right?
It's called upcoding.
Think CUTE.
Code. Up. To. Excellence.
Yeah, it turns out
upcoding is so common,
they're making fun of it
on network TV.
Which is just wild to me.
It is being explained in the same place
where people watch "Survivor",
"Dancing with the Stars"
and "Tracker".
I'm sorry, you've never
heard of "Tracker"?
Over 16 million people watch it.
More people have watched "Tracker"
than have ever watched
a single episode of this show.
What's it about? I dunno.
Jeremy Tracker tracking things?
There's just no way to know.
But people fucking love it.
And while it is not strictly necessary
to understand the rest of this story,
I would be remiss if I didn't tell you
that, in that same episode,
that consultant gets in trouble
after ordering a patient
get an expensive MRI that he doesn't
need, and then this happens.
Mr. Reynolds, do you know
how an MRI works?
It has incredibly powerful magnets.
Magnets that will rip anything
metal out of your body.
Anything at all.
Do you have anything metal
in your body, Mr. Reynolds?
Mr. Reynolds has a penile implant,
a metal-based penile implant.
How much is your penis
worth to you, Mr. Reynolds?
- In a lawsuit? A million, 5 million?
- Stop the machine!
Yes!
More shows should be brave enough
to have a character ask the question,
"How much is your penis
worth to you?"
You know how many times "The Pitt"
has asked that? Fucking zero.
Take back that Emmy!
Now, in that clip, doctors were
the ones being encouraged to upcode
so that their hospital
could charge insurers more.
But as we discussed in our episode
on Medicare Advantage,
insurance companies
can also benefit from upcoding
to get more money
from the government.
Very basically,
under Medicare Advantage,
the government will pay insurers
a higher rate
for patients
with more serious conditions.
That was meant to discourage them
from cherry-picking
only the healthiest people.
But obviously, that also means
that the sicker insurance companies
can make their customers look,
the more money
they can then claim.
And it turns out, as UnitedHealth
has gobbled up medical practices
through its Optum subsidiary,
doctors at those clinics have said
it's placed enormous pressure on them
to code patients intensively,
although, fun fact, they don't use
the acronym "CUTE".
That would obviously
be ridiculous.
Instead, their coding guidebook
tells doctors to use the mnemonic
"treatment, assessment, monitor,
plan, evaluation, and referral"
or TAMPER.
And I don't know, guys.
I might've picked an acronym
with a less negative connotation.
Because what kinds of things
does someone tamper with?
So far,
I've got evidence and end of list.
And while United will claim
they have robust safeguards
to ensure accurate coding,
it's reportedly pressured its doctors
to code
as many conditions as possible
by offering bonuses
to those who coded aggressively,
and reviewing the performance of those
who weren't coding as much.
In fact, doctors have even described
being emailed a kind of leaderboard
that compared them locally
and nationally
by the percentage of their
Medicare Advantage patients
that they'd diagnosed
with certain chronic diseases.
And all this aggressive coding
has made United a fuckton of money.
In fact, one study found it receives
12 billion dollars a year
in additional payments, because
of higher coding intensity alone.
That's by no means the only way
that United pressures doctors.
Those in formerly independent
practices acquired by Optum
have said it's also overhauled
their schedules,
with some required to see
three to four patients an hour,
and complaining that "they
barely found time to eat or pee."
One doctor in Massachusetts, retired
after Optum acquired her practice
said, "I feel just like
an Amazon warehouse worker,
where all I'm doing is 20 minutes,
20 minutes, 20 minutes, 20 minutes."
Which obviously is not great.
Doctors should not feel like
Amazon warehouse workers.
Not even Amazon warehouse workers
should feel like Amazon
warehouse workers,
but that is a story for another show
that we have already done.
And the thing is,
because United is so massive,
even doctors
who don't work directly for them
can wind up being
negatively impacted by them,
and sometimes
in surprising ways.
Take Change Healthcare.
It's a United-owned clearinghouse
that processes more than a third
of all U.S. claims between pharmacies,
doctors, hospitals and insurers.
That is a lot!
But there are real hazards to letting
one company be that dominant,
something that became
painfully clear in February 2024
when it was subject to a massive
Russian ransomware attack.
At this busy New Hyde Park medical
practice, claims cannot get submitted,
doctors aren't getting paid,
procedures aren't getting
needed pre-authorization.
Change Health,
owned by UnitedHealth,
which handles much
of the nation's medical records,
was hacked three weeks ago.
A huge part of that system is down
and the people responsible
for making it work
aren't stepping up to the plate.
Ronald Laszlo went 10 days
without medicine he needs
to prevent a transplanted kidney
from being rejected
because the pharmacy
couldn't get authorization.
The bottom line is, it could kill you.
That is obviously awful. But
what makes it especially infuriating
is that apparently, one reason
the system was so easy to hack
is that the company's portal did
not have multi-factor authentication.
Which is just insane.
As a rule, medical record platforms
should be required
to have operational security
at least as good
as the Buffalo Wild Wings app.
And, notice, I didn't
even say "better" there.
I said "at least as good"
as the app that lets you order
a bacon-smashed hatch chili burger
with a whole chocolate fudge
cake for dessert.
At least meet that fucking bar.
Now, the good news
for all those doctors' offices
whose businesses were so massively
disrupted by that hack is that United,
through its bank subsidiary,
quickly offered them
no-interest bridge loans.
Basically, it was using one part
of its company
to clean up a mess
that another part had just made.
Unfortunately, that bank
then caused a different problem
by demanding full repayment
of those loans
little more than a year later,
threatening to withhold insurance
payments from UnitedHealthcare
if providers didn't pay up.
And this caused a serious crisis
for practices
like the one owned
by this pediatric brain surgeon,
which got a loan
of just over half a million dollars.
I really believed that Optum
would give physicians
a reasonable amount of time
to repay the loan
with the understanding that this
financial crisis almost bankrupted us.
Despite United saying the loans
didn't need to be repaid
until doctors' practices
were back to normal,
UnitedHealth told Mazzola
in January
that she had
five days to pay the money,
or it might start
clawing back reimbursements.
We easily lost over a million
dollars because of that hack.
I'm just a pediatric brain
surgeon, right? So, what do I know?
But we didn't cause this problem.
We were just
financially devastated by it.
Okay, first, "I'm just
a pediatric brain surgeon"
is one hell of a flex, but second,
that is one of those professions
where, if you are fighting
with them for any reason,
you're gonna come out
looking bad.
It's like when Katy Perry was in court
with those nuns
over buying their former convent.
That would've been a tough PR battle
even if one of them hadn't begged,
"Katy Perry, please stop",
before then collapsing and dying
in the middle of court.
It is amazing to me
that we don't talk about that more!
And by the way, that nun?
Henrietta.
Her final words were,
"I'm coming, Valentina!"
A sentence
she hadn't uttered in 50 years.
But that is the thing about
UnitedHealth Group,
whatever corner of its business
you poke into,
you can find something appalling.
Which brings us
to our final example tonight,
which concerns its pharmacy
benefit manager, OptumRx.
Pharmacy benefit managers, or PBMs,
are basically companies
that serve as middlemen between
drug companies and insurers.
And they have a lot of power,
because they decide which drugs
your insurance will cover.
That is why drug companies will give
PBMs. what are essentially kickbacks,
in the form of "rebates"
of a percentage of their sales,
to try and stay
on their good side.
And over the years,
OptumRx has engaged
in some truly unsavory practices.
For instance, when the opioid crisis
was spiraling out of control,
there were some who argued
that PBMs. should remove drugs
like OxyContin from their lists,
but Optum very much
did not do that.
Instead, it asked Purdue Pharma
to pay them higher rebates,
going from about 23% of every
sale to about 60%.
And when a manager
at OptumRx suggested removing it
from their list of covered drugs,
saying of Purdue,
"They basically
caused the opioid epidemic,
and we're essentially
rewarding their bad behavior",
another manager wrote back,
"Valid point.
We as a company looked into this,
but the amount of utilization
on OxyContin
and the rebates we collect
prevented us from doing it."
And honestly? I almost
respect that level of honesty.
It is not often that you get
a confession that's essentially just,
"We knew we shouldn't do this, but in
our defense: we did really want to."
If Luigi's lawyers had just told him
to plead that way instead,
there's a non-zero chance
he'd be walking free right now.
But it's not just opioids.
The company's decisions
to abruptly switch out
what drugs it'll cover has had
utterly devastating consequences.
Take what happened
to Cole Schmidtknecht,
a 22-year-old with severe asthma
who showed up at a pharmacy
with a prescription
for an Advair Diskus inhaler.
Then this happened.
Cole had insurance
through his Wisconsin employer.
What he didn't know,
his parents say, is that OptumRx,
the pharmacy benefit manager
for his plan,
changed its list of covered drugs.
The preventative Advair Diskus inhaler
he had used for years
cost Cole no more
than 66.86 dollars.
Suddenly, its price tag:
over 539 dollars.
Holy shit, that is a nasty surprise.
'Cause there are things
that you expect to cost 500 dollars,
like a Nintendo Switch, or tickets
to see Ed Sheeran two weeks ago.
They're cheaper now, apparently.
No idea why!
But being able to breathe
is not one of them.
And frustratingly,
OptumRx even later admitted
that it replaced that Advair Diskus
on its coverage list
not for medical reasons,
but based on rebates
the manufacturers of similar
competitor drugs agreed to pay.
Now, apparently, I have to tell you,
the company claims
its electronic system instructed
the pharmacy to contact Cole's doctor
to get him a prescription for
a more affordable alternative.
Which they apparently didn't.
But the thing is, even if they had,
as anyone who's ever dealt with an
overworked doctor's office can tell,
getting a new prescription
is not a quick process. It takes time.
And unfortunately, Cole needed
those meds immediately.
Because I'll let his father
pick up the story from there.
He says Cole called him minutes
after leaving the Walgreens.
I could sense that he was having
an asthma attack.
His purpose of the call was simply
to ask about his insurance.
And I said, "Don't worry about that,
just get to the hospital."
A roommate
drove Cole to the hospital,
but Cole was unconscious
by the time they got there.
He died days later.
He couldn't get his Advair that night,
and we were told by his roommate
that it was over 500 dollars
and Cole had to make
a decision that night
of paying that exorbitant price
for his medicine or other bills,
and apparently, well, not apparently,
he walked out without it.
That is an absolute tragedy, and
it was completely preventable.
This is the richest country
in the history of the world,
and yet, for some reason,
our current health system
still forces people to walk away from
medicine that will keep them alive
because
they can't fucking afford it.
So, what can we do
about all of this?
Well, as I have said before,
I would argue the broadest solution
is to find a way to transition to
a single-payer healthcare system.
That would solve many of the
problems that you've seen tonight.
Though getting anywhere close to
that feels a ridiculously long way off,
I don't think it's unreasonable
to say that, at the very least,
UnitedHealth Group
should not be allowed to exist
in the form
that it currently does.
There's actually a bipartisan bill
right now,
sponsored by Elizabeth Warren
and Josh Hawley,
that would separate the payer
and provider roles in healthcare,
so that United couldn't be
in the situation
where it can just pay itself.
And while that is clearly not
going nearly far enough,
it is at least a start.
And I know United may well continue
to try to "tune out the critical noise"
or argue that "nobody designed
this system, it simply evolved."
But what is clear is that everybody but
them wants it to work very differently.
Because right now,
the way companies like United exist,
they are, at best, pointless,
time-wasting middlemen,
and at worst, algorithmically driven,
ruthless arbiters
of who lives and who dies.
And until such time as they've made
significant changes,
or much more likely, had those
changes forced upon them,
then, in the words of my new
favorite healthcare provider…
May they have explosive diarrhea,
not just tonight, but every night.
Exactly. And now, this.
And Now:
Behold the Symphony of Chaos
That is Post-Game Interviews
in Women's College Softball.
I knew I had to come
through with my team.
I feel like this year more than ever,
I've kind of been…
I've taken on kind
of a leadership role
and I know how to get it done.
And I was just thinking about
Megan and this team
and how much they've had
my back this whole year.
And I just wanted
to make something happen.
No, I think it's just trusting
my preparation and the coaches,
just having a plan for us
and getting us ready to compete.
Caroline, you had great speed.
You were mixing your speed.
You had great movement,
just hitting some key spots.
Tell me
about sort of the scouting report.
Whoever we have to play next week,
we're gonna prepare.
I mean, cages, everything that we
need to do for whoever we play.
Did you know coming up
to the plate in your final at-bat
that you were only
a double shy of a cycle?
No, I don't think you heard that,
did you?
I heard a little bit of it.
You've had
to really battle through a lot.
What does a game like this evening
mean to you to come out
and be so dominating?
I'm just so blessed. I want to give
all the credit to my Lord and Savior.
We just try every single day
to be there for each other
and have each other's backs.
Coming into it, we knew that
they were gonna be a great team,
they're gonna attack.
We knew we were gonna come back
and get this run rule right here.
But, you know, we never
have doubt in our dugout.
I think it was
just our preparation before.
We watched
a lot of film before the game.
We're super excited to get to it.
We couldn't wait to start playing.
So, we were just super
excited and focused on that.
All of us were really excited
for each other's success
and we were naming things
that we were ready to see.
I think we saw a lot of them. KT on
the mound… They all came through.
That's our show,
thanks so much for watching,
we'll see you next week,
good night!
Yeah, thanks. That was obviously
a tough show to put together.
UnitedHealthcare's
a difficult opponent.
But we at the show just tried
to be there for each other.
I really want to thank Megan
and the whole team,
all of us were really excited
for each other's success.
We never have doubt in our dugout.
That's something I always say.
We never have doubt in our dugout.
That's my classic phrase.
Thanks. Thanks, guys.
…cock in my mouth.