Recently, the media and many organizations have reached out to understand why Duke Health has not come to an agreement with UnitedHealthcare (UHC) on a contract to provide ongoing coverage for 172,000 patients covered by the insurer. UHC said that Duke Health is one of the most expensive health systems in the southeast. This is simply untrue. Duke is a low-cost health system. In a comparison based on available transparency and benchmark data of 14-hospitals that are either academic medical centers or tertiary providers, Duke is reimbursed by United Healthcare below the 25th percentile of this North Carolina peer group. This is unacceptable. In addition, UHC has not provided Duke physicians a payment increase since 2019, even while UHC continues to post record profits.

Here’s what has transpired: On Sept. 13th Duke offered material concessions to UHC as a means to reach a new agreement for our patients. On Oct. 1st, UHC responded with zero movement, even though Duke is asking for increases far below inflation. Further exacerbating the financial and operational strain placed on Duke, UHC has an excessively high claims denial rate, which requires tremendous administrative investment to make challenges on behalf of our patients who need care.

Duke continues to make great strides in providing cutting edge, quality-oriented and efficient care to a growing population, even when facing a pandemic, inflation, strikes, and catastrophic weather events that impact staffing, supplies and services. Further, Duke has one of the most successful value-based accountable care organizations – saving the government, patients, and payors significant amounts of money annually, while delivering some of the highest quality care in the country.

Our relationships with patients are based on trust and we believe you deserve the truth. We have decided to share our CEO’s comments that were published in Becker’s Healthcare, so you understand this goes far beyond the rates that UHC pays us. We urge you to read and share this information so that you can make important decisions about your health care for you and your loved ones.

1. What are the most pressing difficulties you've faced during negotiations with UnitedHealthcare, and what strategies are in place to minimize disruption for the 172,000 patients affected?

Leaders providing health care services want to help those in need and keep our communities healthy. Patients, using their voice, want three things from their health care providers: “Heal me, don’t hurt me and be kind to me.” Of course, access to their trusted providers is also paramount. While we do as the patient requests, and more, UnitedHealthcare continues to add burden. All the headaches to get paid when we provide quality-oriented, patient-first, 24-hour care should not be part of the insurance process.

We continue to have significant concerns regarding our contract with UnitedHealthcare. Both parties agreed that the primacy of patient care and the value of said care are paramount. However, UnitedHealthcare has created significant barriers that affect patient access to Duke Health, and additional barriers that keep Duke Health from receiving fair payment – which ultimately impacts our patients and our mission. Across the nation, many health systems have had to terminate contracts with UHC due to the administrative burden, which people are now calling “administrative harm.”

UHC’s system appears to be designed to delay and deny fair payment. At Duke, UHC denies payment for care 40% more than other national insurance carriers we contract with. Duke Health overturns 97% of these denials after significant effort (people, time and technology). Imagine a world where those resources were deployed to help patients and provide for healthier communities? At Duke, we employee 236 people full time to appeal all denials from payors, which is frankly outrageous and is not in the spirit of both parties partnering to provide value to beneficiaries, patients, communities. Finally, UHC has been 57% slower to pay claims than our other payors and takes over 60 days to respond to claims they deny. Thus, Duke Health spends substantial time and money to collect payment that should have been made, and made promptly.

Our chief concern is our patients, and we have been working diligently to ensure that their care needs are fulfilled. We continue to help educate patients about their Continuity of Care rights and encourage those who may qualify for continuity care to apply through UnitedHealthcare. Of course, Duke Health will continue to provide emergency services to United Healthcare patients. We’ve also been proactively communicating with patients since August to help ensure everyone has the information and lead time they might need to plan, particularly during open enrollment, so they are not left without options and can make the best forward-facing decisions for their and their family’s health care needs. .

2. How are you balancing patient care access with the need to secure beneficial contract terms?

Duke’s publicly reported data support the high level of quality, safe, and patient-centered care to support the health care needs for all who come to us for hope, health, and healing. As a not-for-profit academic leader in health care delivery, it is deplorable that we have to fight such a high level of administrative burden. Regardless, we have been and are always here for our patients. As Duke continues to recover from the effects of the pandemic and inflation, we are steadfast in our efforts to expand patient access in a myriad of cost-efficient ways, such as opening additional outpatient clinics, expanding on-line scheduling, providing in-home care, and enhancing our telehealth programs to ensure our patients have access to the best value health care. In addition, and right now, we have proudly joined others to assist in the relief efforts for the hurricane ravaged communities of Western North Carolina.

3. What strategies is Duke Health implementing to protect its financial health during the negotiation process?

We are having clear and transparent conversations with all of our stakeholders. It is a compelling story when we focus on the data and our patient needs. People want to come to Duke and to be treated by Duke physicians. We participate with as many insurance plans as possible to enable this access. However, when UHC expects Duke Health to be paid less than costs, that is not a viable model. After years of increases that were significantly less than labor and other costs, Duke is making the choice to protect its future. We must protect the communities we serve by being fair but firm with this payer, especially since Duke is the safety net health system for its community. Here’s the good news: the amount of local support has been amazing and humbling. People want to be able to access Duke Health and have their UHC insurance cover it.

4. When do you expect negotiations to wrap? Do you have contingency plans in place should negotiations be prolonged, or an agreement cannot be reached by Nov. 1?

We had every hope that we would have been done by now and we communicated a deadline with multiple weeks’ notice to UHC. We are not there. We were willing to make reasonable changes in our last offer as a means to expedite negotiations for our patients. UHC responded with zero movement. Therefore, we are actively working with brokers, employers, and patients on next steps, either through continuing care with Duke or when needed supporting a transition to other providers. We want this to be resolved but cannot risk our financial well-being based on UHC’s offer—it is a paradox, but we owe this to our patients to stand firm and to fight for them, even if standing firm causes us to be out of network with UHC for the short or long term. UHC can make this go away but they have chosen not to.

5. What advice do you have for other health system leaders who are or might go through this same experience?

Lead with the patient in mind, validate and communicate with UHC why these practices of deny and delay are so detrimental to the health care system and move forward to a viable solution. Inform your patients, employers and brokers so they can make informed decisions about their insurance company.

Duke Health is far from the first and definitely not the only health system to experience this situation with UHC. We would encourage other health systems to be as prepared as possible for the fallout that these negotiations cause. We have been and are focused on communication with our patients, providers and staff at each phase of the negotiation. We are now explaining to our community of patients and providers the next steps in a very complicated process – continuity of care. This education is the responsibility of UHC. Yet, UHC’s staff has recently called the Duke Health team for advice and education of how to handle this very difficult situation.

6. What data can health systems best arm themselves with when sitting down with commercial payers for contract negotiations?

There is no secret here. Be meticulous about your data—volume, service mix, quality, safety, patient experience. Bring forth the delay, deny and underpay data and the burden that it has on your organization. These are negotiations—they are never perfect, never joyful. There is always give and take—each organization will determine for themselves the lines that should not be crossed.

7. How will the relationship between health systems and large insurers like UnitedHealthcare evolve over the next 2-3 years, particularly as more health systems take a firmer stance in contract negotiations?

We want to have a relationship, yet our definitions seem different. Our mission at Duke Health is to provide the highest value care to our patients. UHC’s response is that it is “protecting” health care costs when in reality, if they actually paid what was owed without Duke Health fighting denials, we might have a better relationship - a partnership, if you will. More and more health systems are going public with these problems because these administrative burdens are increasing and they disrupt care to patients who are simply wanting to access their providers whom they know and trust.