Annual Conference Day 3: UnitedHealth, Optum executives discuss resilience strategies for healthcare

Especially after being on the front lines of the most impactful cyberattack to hit the healthcare industry, leaders with UnitedHealth Group (UHG) and Optum have plenty of thoughts on how stakeholders can shore up their defenses.

UHG is the parent company and Optum a sister company of Change Healthcare, which was the target of a cyberattack that has roiled the industry since beginning Feb. 21.

“Being prepared means more than just having a redundancy,” said Mike Peresie, CEO for software, network and data with Optum. “Being prepared means [knowing] what I’m going to do if I lose access to all my systems. What am I going to do if I have to get new laptops for my employees because they can’t log in anymore? What am I going to do if people can’t come into the building, or if I lose access to a critical care provider, like a lab that I use to support patient care delivery?

“I think it would behoove the entire industry just [to] take a step back and think about where we have those vulnerabilities.”

Peresie and Allison Miller, deputy CISO with UnitedHealth, shared insights during a talk with HFMA’s Shawn Stack on Wednesday at HFMA’s Annual Conference in Las Vegas.

In-depth contingency planning

Preparation for a disaster, whether a cyberattack, a hurricane or a global pandemic, includes planning for crisis response. For example, organizations should determine how they will maintain funding if cash flow is halted, as it largely was for some providers during the early part of the Change Healthcare outage.

“We have, in parts especially of our healthcare system, some very tight financial constraints around organizations’ ability to withstand prolonged periods of time without cash, and in some cases that can impact patient care,” Peresie said. “An example of that might be infusion where you’re buying really expensive drugs and you’re actually not getting reimbursed for those until way after the fact.

“Understanding some of those areas of vulnerability and thinking through what options you may have at your disposal in the event that you do have an impact, whether it’s to your own organization or to an organization that you partner with or work with, is really important.”

Added Miller, “Oftentimes, when you start building your resilience strategies and your disaster recovery plans and your business continuity plans, they focus on certain parts of the business in a silo or they focus on just what your company would do without thinking about the critical stakeholders that you engage with. If you’re a hospital, what are those lab, ancillary, radiology, pharmaceutical suppliers? What about [claim] submitters? Where are you going to get that information?”

Evolving dangers

For all the threats from hurricanes and the like, arguably the most alarming developments are happening through technology.

“Every technology is a double-edged sword,” Miller said. “All the good things it can do also have individuals that want to use it to do bad things.”

She’s heard AI described as data that can “hallucinate.”

“You look like it’s taking you in the right direction, but you were supposed to go left and [instead] you’re far down the right lane,” Miller said. “That can be disastrous when you think about a doctor who’s relying on the outcome of that to diagnose a patient or possibly have AI-driven surgery with a robotic arm.”

Beyond that, attackers use AI to “build social models and to create social constructs, to do deep fakes, to do voiceovers and start to socially engineer at a level that we haven’t seen before,” Miller said. “Not only business-email compromise, but they can grab your voice off a conference, they can grab your voice off social media. It allows them to rapidly start to create a plotter map of you. I’ve seen the ones on me, and it’s terrifying.”

Medical devices are another vulnerability where the impact could ripple across the industry if an exploit happens, especially as hospital-at-home becomes more prevalent, Stack noted.

Said Peresie, “If those are hacked, the impact on the patient, and specifically trust, I think is where it really comes home, because it’s not like just one event where something gets hacked and something happens [with] the robotic arm and there’s a patient [filing] a lawsuit. The issue is that patients lose trust in our healthcare delivery system because it’s not secure.

“Financially, the government can loan money, there are organizations that can loan money to entities if they’re impacted. So financially isn’t the biggest fear. It really is that loss of trust in the healthcare delivery system that I think is the biggest risk longer-term if cyber threats continue as we rely on technology.”

Continuing the conversation

The cyberattack and its aftermath were not the focus of the session, but Peresie mentioned them at the outset.

“I’d be remiss if I didn’t take this opportunity just to acknowledge the cyberattack that we did have in our organization and the impacts that it had for many of you in the audience,” Peresie said. “I just want to extend my sincere apology to you all, and know that we’ve been working as quickly as we can to fully recover from that event.”

He pledged to continue the conversation with the HFMA audience past the conference, as did Miller.

“I’m looking forward to a long relationship together and the art of the possible and what we can do to make healthcare safer and more reliable, especially from a cyber perspective,” she said.

— Nick Hut

On the eve of the presidential debate, political pundits break down the election

Just before the presidential election enters a new phase with tonight’s debate, HFMA’s Annual Conference brought together three prominent political analysts to assess the state of the race.

Donna Brazile, Michael Steele and Jonathan Karl gathered onstage to offer insights during Wednesday’s general session in Las Vegas. They discussed the matchup between Joe Biden and Donald Trump, with the two scheduled to debate on CNN tonight.

“This is the most important election in modern American history,” said Karl, chief Washington correspondent for ABC news. He cited “the stark differences between these two candidates, other than their age.”

Among presidential debates, this one is unique in modern annals.

“We have never seen, since the dawn of the television age, a presidential debate so early, even before the parties have had their conventions,” Karl said. “And this race, as bizarre and unprecedented as it is for so many different reasons, has been remarkably stable in polls for the last nine months,” essentially tied nationally with Trump holding leads in battleground states.

Steele, former chair of the Republican National Party and currently a political analyst for MSNBC, welcomed the distinct format of the debate, which will include no studio audience and a rule that when one candidate is talking, the other’s microphone will be muted.

“I think the election officially begins tomorrow night,” he said. “I think the American people for the first time will tune in to see these gentlemen in the raw.”

What’s at stake for healthcare

During the 2016 campaign, Trump promised to repeal and replace the Affordable Care Act (ACA). But he could not get a repeal through Congress during his term.

The ACA has become more entrenched since, with a record 20.3 million people signing up for insurance through the marketplaces in 2024, according to the Biden administration’s numbers.

Steele thinks Trump would take another crack at paring back the ACA and might well be more successful, even if Congress is not amenable. That’s because a second Trump administration could be expected to follow through on stated plans to scale back federal agencies such as HHS and CMS.

The plan would be to “get the people out of the way who would stand and say, ‘Mr. President, we can’t do that,’” Steele said. “Because when you take 27 million people off of healthcare, the system is designed to immediately revert back to what it was before.

“Meaning that preexisting conditions come back, meaning that 27 million people are no longer eligible or qualified for healthcare. So, it becomes a real problem for the healthcare professionals, our hospitals, our private care facilities, insurance — all of it gets tangled up.

“I have not heard any demonstrable policy with respect to what a repeal-and-replace of Obamacare looks like. The reality for organizations like [HFMA] is to get ahead of that for both administrations, quite honestly.”

Advocacy is vital

Even in the event of a Biden second term, Steele added, many healthcare policy issues would need to be navigated.

“There are still some aspects of Obamacare that have to be worked out, [aspects] largely controlled by insurance companies that need to be addressed,” he said. “Hospital costs are prohibitive in so many places. Hospitals are shutting down around the country, the network is getting squeezed and our federal government is not prepared to address that.

“It becomes important for you [provider representatives] to lay out what this next American century in healthcare should look like. Do not let others do it, because the people who are sitting in rooms making the decisions about what this system looks like are not hospitals and doctors. It’s insurance companies and politicians.”

It also remains to be seen whether Congress passes an extension of the ACA subsidies, which have boosted enrollment, when those expire at the end of 2025. Beyond that, Medicare rolls are spiking in tandem with an aging population, and the Medicaid redetermination process continues to play out.

“There are a lot of issues that I think the politicians and others should be talking about, but mainly it’s you [healthcare stakeholders] who should tell your story,” Brazile said.

— Nick Hut

Turning mandatory health plan pricing data into a profitable venture

Sifting through terabytes of health plan transparency files is no easy feat, but the rewards can be substantial, as the experience of UofL Health in Louisville, Ky., demonstrates.

“If you knew the prices that your competitors were contracted to receive for all of the same services that you provide, how would that change your tactics and strategy?” said Abraham Gage, system vice president for strategy and intelligence at UofL Health.

The impact has been noteworthy: With the negotiating advantage it gained from the information, UofL Health gained increases on rates for 20 DRGs. The projected year-over-year difference, assuming factors such as volume and service mix remain the same, is a 4-percentage-point jump in EBITDA margin.

“That’s very material,” Gage said.

Making sense of data overload

UofL Health has been ahead of the curve in capitalizing on the Transparency in Coverage files, a mandatory program from CMS for in which insurers have posted prices for every DRG and CPT code with all of their contracted providers since 2023 (a companion rule for hospitals has been in place since 2021).

When Gage accessed data for Anthem’s Kentucky PPO plan and unzipped the machine-readable file, it was 100 gigabytes. He soon encountered a physical-memory error that stymied his processing efforts. He ultimately found workarounds with the help of Michael Venable, senior director for business intelligence and analytics at the University of Louisville Health Science Center.

Venable said a single row of data would stretch around the entire perimeter of the large meeting room in which Wednesday’s presentation took place. However daunting it may be to parse, with such a large quantity of data “comes tremendous value,” he said.

“You need to develop an infrastructure to house this data,” Venable said. “What does that look like? That’s going to be an organizational decision.”

Venable and Gage said they see some “gamification” by health plans in the files. For example, in a JSON file, by adding an extraneous bracket or closing parenthesis, valuable rate information in a given row is rendered unreadable.

They found ways to overcome those hindrances with help from Venable’s high-powered laptop, and as a result they gained access to a wealth of insights on pricing data. The information helped health system leaders formulate negotiating strategies.

For example, “If we know that our competitors got these increases, and I know what we got, I can feel maybe a little bit better [about our rates],” Gage said. “Or I can feel a little bit worse. I can go back to my partners and say, ‘Hey, guys, we really didn’t do all that great. And here’s the evidence of that.’

“Another thing that’s really important is looking by code at your competitors. Where are our competitors focusing to get the highest lifts?”

In an example of another application, Gage saw that a competitor received a 33% increase in its rate for a particular type of spinal fusion. It turned out the competitor was hiring one of UofL Health’s own surgeons to bolster its capacity.

The time and resources that Gage and Venable devoted to the files cannot happen in isolation. “One thing to be exceptionally cautious of is: Do you have sufficient executive support to move forward?” Gage said. “Our IT environments are not robust, thriving development environments. What you’re asking for is substantial investment.”

— Nick Hut

Money doesn’t necessarily talk in population health efforts

An important takeaway from an Annual Conference session on patient engagement is that patients don’t always behave rationally, so wellness and health incentive plans should be designed carefully.

For instance, people don’t place the same value on $25 depending on whether they are gaining or losing the money, said Karen Horgan, co-founder and CEO of VAL Health, a patient-engagement-focused firm. If a $25 incentive payment is portrayed as a bonus for, say, walking a certain number of steps, the participation will be less than if the person is given the $25 and then penalized for not hitting the desired number.

“We hate to lose things,” Horgan said.

She offered up four tactics for ensuring that population health efforts are maximized, the first one being, make the right path the easy path. For example, if a patient needs to provide information to their provider, making them jump through hoops, such as logging in to an account, is self-defeating.

Horgan also recommended the use of words to compel action. An effort to reduce inappropriate use of antibiotics did much better after doctors were told they were lagging their peers, feeding into their competitive nature.

A third recommendation is to keep it simple, which is self-explanatory.

The fourth strategy ties into the behavioral quirks like the $25 valued differently in different circumstances: The design of the incentives matters more than the size.

— Paul Barr