The Murder of a CEO and the Complicated Truth About Healthcare

Is it okay to have mixed feelings about his death? (TL;DR yes)

This morning, I received several early AM text messages about Brian Thompson’s untimely death. He was the CEO of the largest health care company (by revenue) in the United States, UnitedHealthCare (UHC).

Before today, I had never heard of this man. After this morning, I still know very little — biographical details appear to be hard to come by. He was 50 years old. He went to college in Iowa and majored in accounting. He had worked at UHC for about 20 years and had been in executive leadership there for some time, before being named CEO in April 2021. He appears to have a wife and two children. That’s about all I could find.

United HealthCare is one of the most despised companies in American health care. An ophthalmologist, Dr. Glaucomflecken (Dr. Will Flanary), has made satirizing UHC into a cultural phenomenon. This influencer has a history with them denying diagnostics during his cancer journey and created beloved videos mocking the payor to the delight of millions. Physicians and patients alike have a story about UHC. Some have many. This is a company that makes $20B in profit some years on hundreds of billions of revenue. They provide and administer insurance, they run clinics, they employ physicians, they perform prior authorization; it is nearly a vertically integrated health care unit that receives significant government funding and tax breaks. While it’s true that we mostly hear the negative stories about companies like UnitedHealthCare, their reputation is emblematic of systemic issues in American healthcare, where profits are valued more than patient care.

So, how do I feel about this? The instinctual response was “Well, maybe he got what he deserved.” I then had a visceral response of guilt for feeling this way. Almost everyone I spoke to had the same mixed feeling about this. I read the comments on the tweets and news stories and I at least felt a little better about my response, as these folks have been savage in their reactions. It is truly a marker of this company that the vast majority of people responding had either harsh comments or jokes about his demise. I am not justifying my feelings because other people feel the same way. I want to try to look at this a little more objectively. What does it say about our system that a human tragedy is met with such anger and schadenfreude?

I am not an impartial observer; I work part-time in prior authorization as a medical director for radiation oncology. Since joining, I’ve focused on eliminating unnecessary barriers, such as removing authorization requirements for IGRT and streamlining IMRT approvals in most curative cases. My philosophy is simple: the treating physician and patient know best. When I do deny requests, it’s only for egregious outliers—like 60 Gy in 60 fractions BID for stage I breast cancer or 20 fractions of IMRT for a bone metastasis in a patient with poor performance status. I strive to limit peer-to-peer calls by conducting thorough case reviews upfront and ensuring that all clinical information is considered. In cases of gray areas, I defer to the treating physician, recognizing that guidelines aren’t always absolute.

Our company operates with a “how do we get to yes?” mindset, and I’ve worked to align my practices with this ethos. I give physicians my direct contact information, allow them to submit additional materials (additional clinical information or supporting evidence) when needed, and prioritize timeliness and fairness. Many have told me, even after adverse determinations, that they felt respected and treated fairly during peer-to-peers. I take pride in my work because I know these physicians are working hard to provide the best care for their patients, and I aim to make the process as collaborative and supportive as possible.

But still, denials and modifications are what most frustrate doctors and patients. UHC is well known for senseless algorithmic denials. They have an exceedingly low accuracy rate for what is considered appropriate and should be paid for versus what should be denied. They go out of their way to make it challenging to understand the process, what the options are, how appeals work. On the other hand, I’ve been begging residencies and institutions to allow me to give a talk on all this information (I have had no takers! Email me if interested!). Many thousands of people have been harmed by this company. Health care companies are purportedly in the health care business, not in the harming-patients business.

Who do we fault? Blaming individual staff or even mid-level management for these failings misses the point. Physicians that review and deny cases arbitrarily are part of the problem. A small number of physicians bilk the system and they share some blame, yet I have come across very few radiation oncologists that appear to be doing so. A small minority of patients demand unreasonable care (protons for prostate, breast and other diseases where there is minimal benefit), but they are scared and well intentioned. The most significant proportion of the blame is on the American health care system - a mish-mash of public and private financing, public and private providers. It is very complicated and not something we would have created from scratch. It is beyond the scope of this brief post to discuss the history from WWII to price controls to the development of Medicare/Medicaid to ObamaCare to where we are today. Roughly 50% of American medicine is delivered via non-governmental entities, both profit and non-profit. Boards of directors and shareholders demand financial returns, and companies respond to this by implementing cost-saving measures, often at the expense of patient care. They are led by boards that behave in profit maximizing ways. If half of all medicine is profit-motivated, then it follows that many decisions will be less patient-focused and instead be directed towards increasing shareholder value.

Executive leadership shoulders some of the blame for UHC’s bad behavior. The CEO sets the tone, values, and mission of an organization. Although he is beholden to the board, he is the public face of the leadership of the company. It is worth noting that he was executing the decisions made by the board, rather than directly being in charge of operations. I don’t know this man and I don’t know what individual decisions he has made. I know that he is aware of public anger at his company. I know he is aware of the class action lawsuits and the patients harmed and the algorithm that generates these denials. Should he have said something or done something? I think so. That’s leadership. Even if he could not directly influence change, he could have publicized his own views or resigned his post if he felt that they weren’t achieving the mission of the company. Thompson’s role in UHC’s failings is both significant and symbolic, but he was far from the sole architect. The board and the CEO could have re-aligned the mission to match what the company claims the mission is.

Now, back to where I started. Is it okay to feel relief or even satisfaction at the death of someone associated with so much harm? This is emotionally complicated. Is his death a reasonable punishment for the atrocities this company has committed? I think the obvious answer is no. No one I know would support extra-judicial vigilante acts to avenge the failings of UHC. While Thompson’s passing may feel symbolic, it does nothing to address the systemic issues that allow companies like UHC to thrive. If he was not murdered, patients would continue to be denied cardiac caths and IMRT for their curable cancers. Patients would continue to be discharged inappropriately due to an algorithmic decision. Yet, he is dead. His family will suffer not only from his death, but the outpouring of glee and celebration that we are seeing on social media. The sad truth — another CEO will step in, burdened with the same incentives and constraints, and the cycle will continue. Justice was and will not be served.

Real justice lies not in schadenfreude over one man’s death but in advocating for systemic reform.

Our outrage should be a catalyst for change, not a justification for celebrating tragedy.

It’s okay to have mixed feelings about this. I’m still sorting mine out.

Love you all. Prayers for Mr. Thompson and his family.

Sim