Episode 12: The Killing of the UnitedHealthcare CEO

Be forewarned, we will be discussing the killing of Brian Thompson (no graphic detail) and the nefarious practices of the health insurance industry (some graphic detail). Emotions will be elicited.

Articles mentioned:
https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations

https://www.propublica.org/article/unitedhealth-mental-health-care-denied-illegal-algorithm

https://www.propublica.org/article/malpractice-settlements-doctors-working-for-insurance-companies

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Transcript

Let’s just start. Forget the music. This is not that kind of episode. Hello, my name is Padraic Gerety and this is Inside the ER.  You already know from the title what we’re going to talk about, so be forewarned. I am not going to go into any graphic details about the death, if that helps. We’ll be focusing more on the health insurance industry and thus why someone would do this.

Let’s go over the basics for those of you completely disconnected from the news or social media. On Dec 4 2024, in Midtown Manhattan, a man named Brian Thompson was gunned down in the street. Thompson was walking towards the Hilton Midtown Hotel for a meeting when an assailant shot him from behind, took nothing, and escaped. Thompson was later taken to and declared dead at the same hospital where John Lennon was…and it just so happens I did part of my residency there. It’s horrifying to see a targeted assassination in an area I lived in for years and consider safe.

The reason we’re talking about this is because Thompson was the CEO of UnitedHealthcare. UnitedHealthCare is the largest health insurer by market share in the United States, covering over 40 million Americans. When it became evident who this man was, there were several theories floating around about the motive. Corporate take over? Personal vendetta? But anyone familiar with UnitedHealthCare had a strong suspicion why someone would do this.  

If you’re not familiar with how private health insurance works in the US, well for starters let me tell you it is reviled by many as a for profit industry where predatory insurers make more money if they refuse to pay for care. These companies can say no when a doctor tries to get a procedure or test for their patient preauthorized, forcing the patient to suffer, or they can refuse after the fact to pay for care that’s already happened, forcing the patient to pay. I’m going to refer to both of these as “denying care” going forward. 

These companies do have a process to appeal their decisions but it is very complicated, confusing, and time consuming. Clinicians, let alone the public, have a difficult time navigating it. And even if one manages an appeal, what’s to stop the insurer from saying no again? The effect is that patients pay both with their health and their money. Did you know that medical debt is the leading cause of bankruptcy in the Untied States?

So while all health insurance companies do this crap, UnitedHealthcare is well known anecdotally among clinicians for maddening denials of care. It has been suggested that UnitedHealthCare may deny almost a third of claims, which would be double the industry average. That number is impossible to verify, but UnitedHealthCare’s record earnings would suggest it’s plausible. Under Brian Thompson, profits increased from 12 billion in 2021 to 16 billion in 2023. Thompson himself was making upwards of 10 million a year. The entire industry in fact has been making money hand over fist…all while their “clients” suffer. 

But how exactly are they doing it? Propublica wrote in October 2024 of how health insurers outsource the review of preauthorizations and claims to third party companies. These third parties are accused of using various tactics to deny care more often so the insurer sees profits go up. One such company, Carelon employed the infuriatingly childish idea of setting their fax machines to accept only up to 10 pages, so if a doctor’s prior authorization request went longer than that, they could reject it out of hand for being incomplete. 

Another similar company, the suspiciously named EviCore, which is owned by Cigna, employed a purposefully restrictive algorithm it promised would increase denials and therefore profits. EviCore apparently claimed that for every dollar spent on its services, the insurer would have to pay out 3 bucks less due to more efficient denials. EviCore insiders said by turning the dial, insurers could adjust the rate of denials…and presumably how evil they wanted to be.

The use of algorithms or AI to deny care seems to be running rampant among these insurers. ProPublica wrote in November 2024 that UnitedHealthCare had ghoulishly repurposed an algorithm originally designed to identify patients at high risk for suicide, but now it’s being used to find and deny mental health therapy it deems excessive. Therapy, as in talking, they’re trying to stop clinicians from talking to patients. And right now United HealthCare is embroiled in a lawsuit filed in 2023, alleging it used an AI driven algorithm with a high error rate to block nursing home care.

But even if it’s not AI denying the care, there may be a nurse, PA, physician, whoever, who’s eager to do the insurer’s bidding. There are clinicians who worked for these insurance companies and later quit and exposed their secrets, and I commend them. But those staying in these jobs need to have a long, hard look in the mirror. These providers spent years learning and training how to heal, but then turn around work for these companies. Yes…we all need health insurance, but these insurers do not hire these clinicians to provide care. Anyone taking that job knows what their role will be: to provide reasoning the company can use to deny care. If the insurance companies just covered people’s care and trusted the judgement of the clinician on the ground taking care of the patient, they wouldn’t need these providers at all.

ProPublica, again the front line on this reporting, wrote in December 2023 of insurance companies hiring physicians who themselves were notorious for poor care and forced to leave clinical practice and find work elsewhere. One such example was that of a former orthopedic surgeon, banned from performing surgery due to putting in a hip replacement backwards, now responsible for deciding if a surgery that a competent surgeon wanted to perform was necessary or not. The vast majority of clinicians do not do this, they do what I do, they stay in practice and help patients. So if there’s a doctor working for an insurer, they may be unskilled or unprincipled, who knows, and now they have the power to override the judgement of a doctor who’s actually taking care of patients. This kinda crap really sticks in my craw.

This all goes back to the true philosophy of every for profit insurance company: the more claims they deny, the more money they keep. Why would they actually pay out your claim when they can simply say no and leave you with almost no recourse. Now add that to the fact that most Americans do not have much control over their healthcare. They can only afford what they’re offered from their job or a health care marketplace. That means most people can’t boycott one insurer over another; these companies are free to act with impunity.

All right, I think I’ve driven this point home by now. The anger many feel towards the health insurance companies is no mystery. Was this the reason for the killing? Well it was basically confirmed when we learned the shell casings had scrawled upon them the words Delay, Deny, and Depose, probably referencing the popular book “Delay, Deny, Defend,” and tactics of insurers to avoid paying out. I suspect Depose refers to putting patients through depositions, because these insurers also do that. Or was Depose written as a call to arms, as in to depose the heads of these companies? Perhaps time will tell. 

The way you know the elite are disconnected from the rest of us was their apparent shock at how the public reacted. Media and politicians were horrified to see the countless comments online showing no sorrow for Thompson or even celebrating the assassination. Comments calling Thompson, United Healthcare, or the entire industry murderers. Snarky posts saying Thompson’s coverage was denied because the gunshot wounds were determined to be a pre-existing condition, or because the ER he went to was out of network. Thousands of people sharing their stories of care being denied and the resulting misery. Re-emerging articles about how many Americans go bankrupt due to medical debt, and how UnitedHealthCare specifically appears to be the worst actor. 

What is my own experience in this realm? Well besides being surprised billed three thousand dollars after I needed an endoscopy, I’ve had poor patients refuse care due to the feared cost. I’ve had nervous patients ask me to estimate their costs, crestfallen when I can’t. I’ve had international patients baffled at the system and the ridiculous bill. And I’ve had ill patients shuffled into the ER by their doctor because the insurer denied care for so long that the patient’s condition worsened into a true emergency. In fact, my first shift after the killing, one of our surgeons was forced to bring his patient to the ER because the insurer would not preauthorize a needed surgery. Now the patient underwent an unnecessary ER visit, contributing to overcrowding and incurring extra cost all around. 

The system is broken, propped up by lobbyists, politicians, and the American fear of anything remotely resembling socialism, as in single payer healthcare. These insurance companies are profiting off of that disorder and so I understand why sympathy for Thompson was not the prevailing emotion. But let’s make something clear. Thompson was not a murderer. He was the CEO of a company that along with its peers, has inflicted untold suffering yes, but he’s not a murderer. If a murderer is removed from the picture, future murders they would have committed won’t happen. But what happens with a CEO? Someone else steps right into their place. The gears of industry will continue grinding people up. Nothing will change. These insurers aren’t going to learn their lesson, they’re just going to hire more security. 

Do I support what happened? No. Of course not. No one should be shot in the street. Gun violence is a plague in this country. And regardless this corrupt industry will be carrying on as usual. As long as you have for profit healthcare, they will continue to inflict suffering on their customers because it is in their interest to do so. We live in a world where the rich and powerful are rarely held accountable for their actions. If an insurance company gets sued or fined because what they did that caused immense pain and even death, so what? Maybe they get slapped with a fine, what does that accomplish? No one goes to jail, no one individual is really punished. The profit they make in denying and obfuscating care is immense compared to whatever restitution they may be forced to pay.

The world is not fair. There is no inherent justice. And for some people this gets to be too much and they feel compelled to act. I’m not saying I condone what happened, I don’t. At the end of the day, this is not the fix. The fix is a complete overhaul of our healthcare system and barring that, heavy regulation of these insurers. That will only happen with immense societal pressure and hopefully this event has spotlighted that.

I don’t want to delve too much into the suspect, Luigi Mangione, this episode. It seems he has chronic pain from a back injury, which could be relevant. Personally I’ve found his behavior to be odd, but that doesn’t matter. His innocence or guilt is yet to be determined in court. I’d warn anyone against idolizing whoever did it, it may take a disturbed mind to pull this kind of thing off.

Before we wrap up, I’d like to share a quote by Dr. William Flanary, aka Dr. Glaucomflecken on social media, about the true motivation of these insurance companies:

“They don’t care about you. They want to extract as much money as possible from your healthy body. Then when you’re no longer healthy they want you to die as quickly as possible to make room for other money producing bodies.”

So that leaves me with my final point: You can feel however you want about what happened to Brian Thompson. Be it anger, or glee, or horror, or pity. But the one thing none of us should have been is surprised. An entity can only exact so much suffering before there’s a reaction. 

This is Inside the ER, my name is Padraic Gerety, and thank you for joining us.

Next episode will be a revisit of psych emergencies, there’s a few things I missed. Unless you want me to keep ranting about this, lemme know.

And if you want to share your own health insurance horror story, write me at  insidetheer@gmail.com.

Be safe out there. Thanks for listening and all the best.