⛔ My worst client
The UnitedHealthcare CEO shooting says more about us than about health insurance
If you’ve clicked through to find out if “my worst client” is you, I have a disclaimer: I’m going to write here about a large insurance company, but this insurance company was actually the client of a client.
My working relationship with this insurer may have been indirect, but it was nevertheless a window into the many frustrations and challenges of working with a large private health insurance company in America.
And, with the murder of the UnitedHealthcare CEO currently dominating news headlines, I wanted to say what small part I can about what this says, if anything, about the state of both our country and our healthcare system.
I will say at the outset: no part of anyone should be cheering the murder.
I think this for exactly the same reason that I don’t think any part of anyone should cheer the attempt to murder a presidential candidate: because the last thing I would want is for someone to take a shot at my candidate the next time around. First, they came for the health insurance CEOs; then they came for me, sort of thing.
The reality is there’s not an industry in the world that doesn’t have at least some unwanted—some might say immoral—externalities that are harmful to society. We should argue about which those are, and how we might mitigate the bad—not condone murder based on our own personal morality.
Sadly, we’ve lost the plot in this country: we no longer believe reasonable people can disagree, whether about politics or healthcare. We need to recapture that ability, and moralizing about the evils of a gigantic health insurance provider isn’t going to help.
Moralizing about almost anything isn’t going to help.
That said, I have some non-moralizing comments to make about working with the client of my client, the aforementioned large, private health insurance company.
Physicians, patients, and the culture of healthcare
The project with the health insurer was last year, and until then, nearly all my experience in healthcare had been working with physician groups.1
I had a front-row seat to the Surprise Billing Wars of 2019 — 2022, which continue to have ongoing skirmishes in court up to this day. The debate over so-called “surprise billing” is essentially a battle with private insurers on one side, physician groups on the other, and patients stuck in the middle. Everyone agrees patients need certain protections, but the agreement breaks down the moment you have to start operationalizing those protections through actual rules and regulations.
I of course had a biased viewpoint having worked with so many physician groups, but even then I could see that the insurance companies had a point (which is why the very few consumer advocate groups to weigh in on surprise billing generally took the insurance company side). Their point was that when physician groups have too much negotiating power, that could actually drive up prices for the patients.
To take the most charitable defense of the health insurers’ argument: when an insurer denies a claim (as when Anthem Blue Cross Blue Shield recently tried to limit coverage for anesthesia during surgeries), they are in effect pushing back against pressure from both patients and their doctors to deliver whatever care they want, whenever they want, in whatever quantity they want, regardless of whether it actually promotes health and well-being.
And there is a lot of care that does not protect either health or well-being.
As Matt Yglesias just wrote, there is a lot of “genuine waste” in the healthcare industry:
Those who are ailing will gladly pay money for things that don’t actually work. Many people are interested in getting tests that aren’t well-supported by evidence or statistics. David Cutler says that “between one-quarter and one-half of medical spending is not associated with improved health.”
Doctors are well aware of this dynamic, especially the emergency room doctors on the front lines of the surprise billing fight.
In fact, a long-time client of mine wrote as much in a post I still think about, 12 years later. He said Americans basically want their healthcare like they want their McDonald’s:
We want [healthcare], we want it now, we are not willing to wait for it and we don’t want to miss anything on the first visit – sort of like the drive-through lane at your local fast food joint.
In America, virtually any effort to restrict healthcare is met with condemnation, protest, and outrage, on both the left and the right.
During the debates over the Affordable Care Act, just to take one famous example, Republicans weaponized the so-called “death panels” contained in the bill, claiming that committees of doctors and/or bureaucrats would decide whether to “pull the plug” on grandma. In actuality, the bill called for Medicare to pay for voluntary end-of-life counseling sessions that would help seniors make end-of-life care decisions (incidentally one of the core recommendations in Atul Gawande’s excellent book, Being Mortal). Considering that approximately 25-28% of all Medicare spending is spent in the last year of a beneficiary’s life, I can certainly see the value in giving seniors the option to talk to someone about it for free. But even this provision was ultimately dropped from the bill.
Outrage and the role of health insurers
The problem is that sometimes, the outrage is entirely justified (as in recent high-profile denials of care to women suffering a miscarriage)—but again, we are not all going to agree on which cases are justifiably outrageous and which aren’t. Your outrage at the denial of care could be my entirely reasonable cost containment measure.
It is no small task to decide which is which—but this is exactly the role of a health insurance company. How do we keep them accountable in this weighty task? In theory, private insurers are responsible to their customers—however, I would strain to point to an actual, functioning market for private health insurance in this country (most of us get whatever our employer chooses; others have very limited options available off the exchange).
Regardless, these companies are literally in the business of deciding which healthcare to pay for and which to not pay for. Sadly, they do everything they can to obscure their decision-making. None of it is transparent. Sometimes bad behavior extends even to the point of setting up thinly veiled shell companies to provide so-called third-party analysis on what is a “fair” price for health services (see here).
Government payors, for their part, are in the same business—the Centers for Medicare and Medicaid Services (CMS) essentially decide which procedures they’ll pay for, and at what price. Recently, as part of the Inflation Reduction Act, CMS was also given the power to negotiate on certain prescription drug pricing, long a cause of the left—but negotiating on pricing means you have the power to walk away from negotiations if you feel the other side isn’t giving you a fair deal. Another name for that?—denial of care.
The point is that Americans are generally very confused about how our healthcare system works. Many doctors are too. And sometimes so am I, despite working in healthcare for 15 years, interviewing and ghostwriting for healthcare executives all that time. It’s a hugely complex and complicated system that defies easy answers.
Still, one thing is pretty clear if you look at the incentive structures: while doctors want to get paid for their services and to be trusted as to which of those services are necessary, insurers have a different incentive to save money, which means trying to identify when and where those services aren’t needed.
In other words, it’s the insurers who have the incentive to reduce costs to the system. And one might be forgiven for thinking that one huge, important way to do that is to look after the health and wellness of their own members. The people who buy the health insurance.
So why don’t insurers do this in any kind of meaningful way?
Why it sucked doing work for an insurance company
This brings me to the client of my client.
As usual, I was working with a doctor who had started their own company. He had developed a kind of AI assistant for seniors, delivered through a tablet. The AI assistant would help them keep in touch with family, remind them to take their medication, ask them daily questions related to their health and well-being, and in general help try to keep them healthy and—importantly for cost reduction—out of the hospital.
The obvious target audience to pay for such a program would be an insurance company. My client had pitched it to a long-term care insurance provider, who wanted to run a trial campaign. If their members could stay out of long-term care, the insurer would save money. And since seniors overwhelmingly prefer to age in place, the whole thing felt like a win-win-win. Good for the insurance company, good for seniors, and good for overall cost reduction in the system.
I was brought in to help market the AI assistant to the insurance company’s members. Finally, I thought, a health insurer working constructively to reduce costs by actually keeping people healthy and out of the hospital.
It all started well enough. We had a kick-off call. Excitement was expressed. Initial parameters discussed.
My client and I felt that in order to learn whether the program worked, we would need a critical sample size of seniors to sign up for the AI assistant, as the program would of course be voluntary. Backing out from that group meant we needed to target an even greater number with the marketing materials, knowing that only a fraction would sign up.
We also needed sign-off on the marketing materials, including messaging, mailer design, landing page, call scripts, and the marketing funnel process itself.
Unfortunately, it soon became apparent that when you get enough people together at a big health insurance company, the most likely outcome is for nothing to happen rather than something.
In the beginning, the idea was to have a two-month “sprint” to get everything up and on our way to launch. So once a week, my client and I found ourselves on a call with around 10-12 employees from the insurance company, a mix of marketing, operations, and compliance people. In addition to these calls, my client was having separate calls just to discuss the operations side of things: how the call centers would work, who would control what information, where analytics would be housed, and much more.
The team we were working with were all well-intentioned. Indeed, they had some obviously smart marketing people, including good designers and copywriters. Their feedback certainly improved upon my initial ideas for the campaign.
Things did drag a little, as you would expect, but by the end of three months, we had everything more or less ready to go.
And then… delay.
What precisely was going on between my client and the insurance company I’m not sure, but it was always something. Week by week, piece by piece, it seemed control over the campaign was shifting from our hands and into the insurance company’s. Meanwhile, the number of potential members they were willing to share for the initial campaign kept shrinking. Soon, the number was so small we weren’t sure there would be any statistically significant learnings to be had.
Four months passed. Then five. It seemed more and more people inside still needed to give their input, still needed to give the final OKs.
My initial contract had been for six months of marketing support to design and launch the campaign, and then be there to revise as needed after the first few rounds of mailers. But by the time six months rolled around, we still hadn’t launched, and it wasn’t clear either to me or my client when it would happen, or even if it would.
By then, I had little emotional stake in the project, but I could feel his frustration. It was his company, he had invested a lot of his own money, and still, the insurance company hadn’t pulled the trigger.
At the end of the day, I was left only with questions and confusion. Did the insurance provider even want this campaign to work? Or did they only want to be seen as experimenting? Was the whole point of this so they could send out a press release?— Innovative program to help seniors age in place launched.
It seemed by then that it would be such a small experiment, that it was so negligible in the grand scheme of what the insurance company was doing, that it had little chance of success. That is, if the program ever got launched in the first place.
And the big question remained: if insurers have an incentive to keep their members healthy, why don’t they respond to that incentive in any meaningful way?
I’m still confused about it.
What the UnitedHealthcare shooting tells us
“The line between a normal, functioning society and catastrophic decivilization can be crossed with a single act of mayhem,” writes Adrienne LaFrance.
Indeed, the murder of the UnitedHealthcare CEO tells us a lot about our society and culture as it is at this moment. Unfortunately, it tells us virtually nothing about the causes of our broken healthcare system.
As Graeme Wood writes, the alleged shooter’s politics are a bit of a jumbled mess, a series of clichés revealing “the absence of thought” more than anything else:
It sometimes seems that activists have learned nothing and forgotten everything. Consider Womack’s sophisticated theory of social and economic change, born from careful study of electricians’ unions in Mexico—and compare it with the theory that to achieve health-care reform, one should put on a hoodie, shoot a guy in the back, and then get caught a few days later while eating an Egg McMuffin. From this action, and the glee that it has elicited, one learns not that the health-care system is broken but that many of us are.
This is not to say that the healthcare system in America isn’t broken. It most certainly is. Doctors know it. Patients know it. I’m sure the group of good people I was on the calls with at the insurance company also know it.
And when so many people know something is broken and yet the problem persists, I’m tempted to point the finger right back at us. Look in the mirror. For a long time now, America has been unwilling to make hard decisions that involve difficult tradeoffs. This is true not just when it comes to healthcare but in nearly all areas of public and private life.
We want what we want, we don’t want to wait, and we want it without compromise. We think we deserve it.
I suppose the good news is that somewhere, buried deep down, I believe the qualities of dynamism, competence, self-reliance, and good sense are all still present in the American psyche. If any country is capable of escaping the trap of rich decadence, I think it is America.
But only time will tell, of course. We have a lot to dig ourselves out from.
P.S. In case you missed it, I’ve recently introduced a new service for enterprise-level healthcare clients: full-stack Substack management, covering everything from strategic positioning to ghostwriting, publishing, and engagement on Notes.
Right now most corporate blogs and/or thought leadership pieces are posted either on your own website, or Medium (totally dead), or sent via email through Mailchimp, Constant Contact, Hubspot, etc.
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📩 Email me at russell@rmshealthadvisors.com if you want to talk.
From 2016 - 2019 I was Director of Content Marketing for US Acute Care Solutions. Since then, I’ve worked with at least three different physician groups on their marketing and content strategy.