The nH Predict algorithm, developed by NaviHealth (a subsidiary of UnitedHealth Group), is an AI-based tool designed to assess the post-acute care needs of patients. Here's an overview of key aspects and issues related to nH Predict:
Function and Purpose:
Purpose: nH Predict uses patient data like age, diagnosis, physical function, and living situation to match individuals with similar profiles from a large database. It then predicts the patient's medical needs, including expected length of stay and discharge date, aiming to streamline care management and reduce costs.
Function: By analyzing historical medical data, the algorithm generates reports that detail mobility, cognitive capacity, and precise timelines for care, supposedly to help insurers and providers manage patient care more efficiently.
Controversy and Legal Issues:
Error Rate: There have been allegations, notably in lawsuits against UnitedHealthcare and Humana, claiming that nH Predict has a high error rate, around 90%, leading to wrongful denials of necessary care. This has resulted in patients being discharged prematurely or having to pay for continued care out-of-pocket.
Lawsuits: Several class action lawsuits have been filed, accusing insurers like UnitedHealthcare and Humana of using nH Predict to deny claims "prematurely and in bad faith." These lawsuits argue that the algorithm overrides medical expertise, leading to inappropriate care decisions, particularly for elderly and disabled Medicare Advantage beneficiaries.
Ethical and Legal Concerns: The use of nH Predict has raised ethical questions about the extent to which AI should influence medical decisions, especially when it potentially leads to denials of care against medical advice. There are concerns about transparency, the algorithm's accuracy, and whether it prioritizes cost-saving over patient welfare.
Public and Regulatory Response:
Public Sentiment: Social media and news reports have highlighted a growing concern and negative sentiment towards the application of nH Predict, with many posts on X criticizing the algorithm for its impact on patient care.
Regulatory Actions: The Centers for Medicare & Medicaid Services (CMS) have issued guidelines stating that insurers must base coverage decisions on individual patient circumstances, not solely on algorithms like nH Predict. This suggests a regulatory pushback against the automated denial of care.
Company Response:
UnitedHealthcare's Stance: UnitedHealthcare and NaviHealth have defended the use of nH Predict, claiming it is not used to make final coverage decisions but rather as a tool to inform care planning. They emphasize that actual coverage decisions are made based on broader criteria and individual patient assessments.
Purpose: An AI tool by NaviHealth (UnitedHealth Group) to predict post-acute care needs.
Function: Analyzes patient data to forecast care duration and outcomes, aiming to optimize care management.
Controversy:
Error Rate: Accused of having a 90% error rate, leading to inappropriate care denials.
Lawsuits: Class actions against UnitedHealthcare claim the algorithm's use results in wrongful denials, prioritizing cost over care.
Ethical Concerns: Raises questions about AI's role in healthcare, particularly when it overrides medical expertise.
Public Reaction: Negative sentiment on social media regarding its impact on patient care.
Regulatory Response: CMS guidelines stress decisions should be based on individual patient needs, not just AI predictions.
Company Defense: UnitedHealthcare states nH Predict informs but does not dictate coverage decisions.
Comments