This is literally the plot of the “computer says no” sketch.
The health care industry in the US has a … record of problematic AI use, including establishing algorithmic racial bias in patient care. But, what sets this situation apart is that the dubious estimates nH Predict spits out seem to be a feature, not a bug, for UnitedHealth. Since UnitedHealth acquired NaviHealth in 2020, former employees told Stat that the company’s focus shifted from patient advocacy to performance metrics and keeping post-acute care as short and lean as possible. Various statements by UnitedHealth executives echoed this shift, Stat noted. In particular, the UnitedHealth executive overseeing NaviHealth, Patrick Conway, was quoted in a company podcast saying: “If [people] go to a nursing home, how do we get them out as soon as possible?” The lawsuit argues that UnitedHealth should have been well aware of the “blatant inaccuracy” of nH Predict’s estimates based on its error rate. Though few patients appeal coverage denials generally, when UnitedHealth members appeal denials based on nH Predict estimates—through internal appeals processes or through the federal Administrative Law Judge proceedings—over 90 percent of the denials are reversed, the lawsuit claims. This makes it obvious that the algorithm is wrongly denying coverage, it argues. But, instead of changing course, over the last two years, NaviHealth employees have been told to hew closer and closer to the algorithm’s predictions. In 2022, case managers were told to keep patients’ stays in nursing homes to within 3 percent of the days projected by the algorithm, according to documents obtained by Stat. In 2023, the target was narrowed to 1 percent. And these aren’t just recommendations for NaviHealth case managers—they’re requirements. Case managers who fall outside the length-of-stay target face discipline or firing. Lynch, for instance, told Stat she was fired for not making the length-of-stay target, as well as falling behind on filing documentation for her daily caseloads.