Sentient Intelligence to Rescue Healthcare? Reflections on the Commercial Side of Healthcare

On December 04, 2024, the cold-blooded murder of the Health Care CEO on a midtown Manhattan street near his hotel raised national and international headlines. While the shock and condemnation of the ruthlessness killing appropriately prevailed, there were many unsettling commentaries, especially in Social Media circles, that found reason to praise this horrific act as some form of justifiable political statement against the ‘capitalist’ side of healthcare in the United States. ¹ For our Spine surgery community there is a potential tie-in as the suspected murderer may have experienced failed Spine surgery for a Grade 1 isthmic spondylolisthesis and experienced general dissatisfaction with the care as dictated by his health insurance company, UnitedHealth. In the wake of this murder the pretty astonishing profits of commercial US health insurance corporations received much wider public exposure and subsequent discourse. To be fair, the ethics of financial gains derived from the delivery of health care has been a point of contention dating back to antiquity and across global cultures and has involved exchanges by philosophers like Aristoteles and Plato in Ancient Greece. ² Over time, literally any imaginable financial health care funding model has been tried, such as population-based medicine, volunteer delivery models, outcomes-based payment systems (with punishment in case of adverse events), and fixed salaried as opposed to fee-for service or profit sharing plans. ³ It is safe to say that through time and across cultures there has not been one single care delivery system shown to be clearly superior as well as sustainable over time, and acceptance of one model over another has been as much one of cultural and pragmatic principles. In our modern era of aging and sicker populations with a concomitantly increasing disease burden across societies the affordability and ethical delivery of quality healthcare has become a critical challenge for societies to resolve across the globe.

Proponents of a private sector in health care delivery tout a societal benefit derived from forces of market dynamics. Such benefits include applying principles of efficiency and process optimization and as well as the autoregulatory effects of supply and demand mechanisms prevalent in free market systems. Certain specialty services that require more involved specialization, extended training, expertise and resources and that involve greater risk exposure accordingly can rightfully expect a premium reimbursement according to flexible ‘fair market’ determinations. And as to progress, there is clearly a fundamentally greater incentive to develop and then apply new technologies in a free-market economy compared to a rigid government-controlled system. Put together, such principles can create a far more dynamic access to quality care to than any governmental system could ever dream of providing.

The fundamental problem brought to the front pages following the murder of the Insurance company CEO is how and where to apply necessary checkreins to balance the mere pursuit of profits in health care with patient interests. For instance, the company behind the slain CEO, UnitedHealth reported revenues of US $400.3 billion in 2024, with profits of $14.4 or, if adjusted for one-time write off, $25.7 billion covering over 50 million US lives.^4,5 Among other aspects of their business practices, this company has been accused of having much higher claims denial rates than other companies. The phrases ‘DENY – DELAY-DEFEND’ have become the motto for the business methods of this company. United Health has contested reports of denying almost a third of claims reported by several outlets, which if true, would be incrementally higher than that of other private insurance companies in the U.S.^6-8 These insights, again clearly do not exculpate violence or murder against another human being but deserve further investigation. Unfortunately, independent data on this subject matter is highly proprietary and difficult to assess so the public is left with contrasting statistics and personal experiences and hopefully more transparency in reporting in the future.

Dissatisfaction with insurance companies among U.S. Americans, who pay by far the highest premiums among any country in the world for their health care, seems to be at an unprecedented high. The overly callous application of profit-oriented business principles into medical care has seemingly reached an inflection point. One of the most blatant sources of discontentment is the direct interference of insurance companies with the medical care of patients on an individual level without actually being licensed to practice medicine or possessing hospital accreditation in the states or hospitals where patients are being treated. Fighting back against these insurance practices has become a frustrating and unreimbursed daily chore for practitioners in the United States especially in more contentious and expensive specialties like Spine surgery. For Spine practitioners this means that every step in the care process of their patients, literally every diagnostic test, every physical therapy session, every brace or injection and certainly every surgical procedure, has become a contested resource-intense game of documentation and argumentation – full of delays and frustrations, especially on the part of practitioners and clearly adversely impacting patients and their families. Ultimately this boils down to a battle of who has more intricate and complete documentation available, which in this era of electronic medical health allows for the ultimate technological invention of our times – artificial intelligence (AI) – to be applied as a weapon of choice for commercial health care insurers vs care providers.^9,10 As reported by ProPublica, the topic of AI generated claim denials have become so significant that some of the United States largest health care insurers have actually outsourced claims review to specialized AI companies like ‘EviCore’ which seek to maximize chances identify claims for denial and elevate them for secondary review by insurance physicians. The application of this cynical method of ‘deny/delay/defend’ is – of course – incented by insurance companies. ¹¹

The denial of care – even if clearly indicated and based on good common sense – for a profit motive to the detriment of patients and to the emotional injury of those charged with actually providing care in an orderly and licensed fashion is without doubt unethical and deeply troubling. The reality of specifically trained AI systems to deny care, and the emerging AI counter weapons to empower the health care delivery side, is a fascinating and frankly scary application of these technologies and inherently shows how AI systems cannot be trusted to provide impartial and above-board decisions in matters affecting patient’s wellbeing as they are completely dependent upon their human programmers/trainers. Another example of the use of AI by hospitals and insurance companies alike has been the race to add diagnoses to patient’s medical records with intent to ‘upcode’ transactions in exchange for higher reimbursements from large, automated AI driven government insurance programs. ¹²

The failings of the unchecked profit in US health care delivery systems have expanded beyond insurance companies into the field of Private Equity (PE), which has predictably expanded (or invaded?) into health care. The recent bankruptcy failure of Steward Health Care, a sizeable US Healthcare system assembled by a private equity firm serves as a noteworthy warning. Here a PE firm apparently gained robust profits for its investors from real estate transactions after serial hospital acquisitions, yet reportedly severely rationed health care delivery expenses in the facilities they were entrusted to manage. ¹³ Similarly, there have been reports of not-for-profit hospital systems, who benefit from special tax exemptions in the US, pursuing financial charges most aggressively against some of the socio-economically most vulnerable patients. A thoughtful essay on this subject was recently published by a fellow physician in the New Yorker December 2024 titled ‘The gilded age of medicine is here.’ ¹²

Before we as Spine surgeons around the world look for blame directed at profit seeking entities like insurance companies, we would do well to not exempt ourselves from critical self-reflection. Are we truly delivering the best possible spine care for our patients free of self-interest? Do our patients really need the surgery we have envisioned or is there room for far simpler comprehensive nonsurgical means to be pushed harder from the authoritative position of an experienced and caring Spine surgeon? From indications and timing for procedures to selection of surgical technique we hold control over substantial direct and indirect health care and societal expenses. As we stand to gain increased reimbursement by using instrumentation and biologics with ever more expensive technologies, we ourselves are in the middle of an ethics debate surrounding utilization of our services. In concrete example, fusions generally are reimbursed much higher than decompression surgeries and incrementally higher than motion preserving surgical techniques such as disc replacements or laminoplasties, even if direct costs, outcomes, revision rates and downstream sequelae seem to favor nonfusion approaches for certain conditions.

So how can we overcome our shortcomings as humans as to deciding on delivery of medical care of the future? We ourselves are inherently susceptible to the lure of profit in healthcare – regardless of our roles as physicians, administrators or the business community. Much would be gained by an honest recognition and discussion of this. Placing hope in the current iterations of AI alone as a decision-making instance is unrealistic as this technology is evidently too dependent upon its human trainers and therefore inadequate to render objective decision-making help.

Options for resolution are not simple and will involve political, societal and legislative initiatives. A potent technological option may, however, emerge with the advent of sentient intelligence , a next generation AI system capable of thinking and feeling like a human being. ¹⁴ In difference to a pure logic-based algorithm determinations decision-making in healthcare involve some degree of cultural and personal determinations. For these to be taken into consideration and yet to assure objectivity, some degree of feelings and appreciation for cultural values and human experiences is necessary. As AI currently is evolving rapidly beyond linear predictable dimensions the expansion into emotional and cultural dimensions is not a mere fantasy but would be necessary to achieve a higher level of acceptance for us humans (and patients) in the future as a decision-making entity for deeply personal issues like health care. The emergence of sentient intelligence can truly be a milestone in the application of AI for the benefit of humans if done on an ethically and culturally sensitive basis.

And for us in the present-day Spine community, the upcoming trial of the alleged CEO murderer will further reveal the role that Spine care and its potential failings in the setting of an emerging profit-based healthcare malaise have played in this tragedy. Stay tuned.