By JEFF GOLDSMITH
A Forty 12 months Development Saga is Coming to an Finish
After market shut Wednesday April 16, UnitedHealth Group reported its First Quarter 2025 earnings. UNH missed their anticipated 1Q earnings by 9 cents a share, however the agency additionally lowered its full 12 months 2025 earnings estimate by 12%. On Thursday opening, traders reacted with an unbridled fury, and stripped UNH of greater than 100 billion in market capitalization in a matter of hours. Within the glare of hindsight, UNH was priced for perfection at a pre-crash trailing Worth Earnings ratio of 38, six factors greater than Amazon and eight factors greater than Microsoft, which could account for the savagery of the correction.
Definitive solutions to the query–what is going on to United’s sprawling mass of companies–are unimaginable as a result of the corporate is an $400 billion black field. The principle United companies–medical health insurance, care supply, pharmacy advantages administration and enterprise intelligence/providers–are so intertwined with each other that solely United CFO John Rex and some different senior managers truly know from whence United’s earnings truly stream. What follows is a few hypothesis on the foundation causes of United’s earnings drawback.
First, a serious driver of the final twenty years of United’s earnings development has been utilizing an enormous chunk of its astonishing month-to-month money stream (which was approaching $3 billion a month) shopping for different firms. This social gathering could be over. United has traditionally spent about half their gathered wealth on dividends and share buybacks, that’s, paying off shareholders to stay shareholders.
Nonetheless, an enormous and undisclosed contributor to UNH earnings development has been acquisitions, which have occurred in a virtually unbroken string for forty years. From 2019 to 2023, United spent an astonishing $118 billion shopping for different firms, practically all of which ended up in Optum. Because of nice self-discipline by UNH Govt Chair Stephen Hemsley and CFO-now-President John Rex, United nearly invariably purchased worthwhile companies in transactions that have been accretive to earnings.
United seems to be operating out of accretive transactions. With the dearth of main new transactions, United’s $81+ billion horde of money and quick time period investments (bigger than Exxon Mobil) is prone to plump up but extra. This can trigger people to surprise why United is elevating their charges to employers or shaking down suppliers for deeper reductions when they’re sitting on a rising mountain of money.
United can’t purchase extra well being insurers (each CIGNA and Humana been on the market for years) as a result of federal antitrust enforcers will cease them. There aren’t any extra accretive risk-bearing doctor group offers. Hospitals presently make use of greater than a 3rd of training physicians within the US (a really sad state affairs for each events). However these hospital acquisitions have restricted the universe of obtainable doctor transactions for United.
United’s passing on buying bankrupt Steward Healthcare’s doctor group (Stewardship) confirmed us they’re leery of shopping for hospital owned teams, most of that are shedding buckets of cash. UNH has additionally steered away from investor-owned doctor teams like Envision or Staff Well being that service , i.e. vampire-ize, hospitals. FTC/Justice have raised the crimson flag about UNH shopping for residence well being firms after their two multi-billion greenback offers in the course of the pandemic–LHC Group and Amedisys.
When OptumHealth was 1 / 4 of its current measurement, simply seven years in the past, it was a ten% margin enterprise. Since then, OptumHealth’s margins have declined by greater than 25%. As value chopping and a number of management modifications decimate OptumHealth’s company tradition, anticipate a wave of resignations and union exercise to comb by means of OH’s doctor teams, additional damaging each Optum Well being’s and UNH’s total margins.
OptumInsight–United’s enterprise intelligence and company providers business- was practically a 28% margin enterprise earlier than the hasty and reckless acquisitions of Equian, Change and naviHealth in the course of the pandemic. Now it’s a 16.5% margin enterprise. OptumInsight and United have been badly broken by the February 2024 Change Healthcare hack.
Change, which used to course of a staggering $1.5 trillion, or one-third of all US medical claims, misplaced a variety of indignant prospects after they found that Change truly was a steaming mass of poorly guarded and barely built-in roll-ups whose safety failures broken their very own companies’ money stream and working prices. UNH can be silly to purchase extra information companies because the Change episode proved conclusively that they can’t run them safely.
So UNH’s two largest companies, medical health insurance and well being providers, each of which have seen working margin declines within the final 5 years, can’t be rescued by extra accretive transactions. United stays steadfastly disinterested in proudly owning hospitals. Slightly, UNH has labored diligently to encompass and cannibalize hospitals.
Second, the kindness of strangers has run its course. One strategic problem posed by OptumHealth’s development was that when United purchased giant threat bearing doctor teams like Healthcare Companions, Atrius and Kelsey Seybold, it additionally purchased worthwhile threat contracts with rivals of United’s medical health insurance companies. Almost $23 billion of OptumHealth’s revenues (greater than a fifth) , and certain a better share of its income, got here from giant Medicare Benefit contracts with the likes of Blue Defend of California, Blue Cross Blue Defend of Massachusetts, and so forth.
For the reason that pandemic, OptumHealth has been experiencing the exact same value issues as all these hospitals–rampant nursing and doctor bills from turnover and temp companies, provide prices, and so forth, It’s possible that a variety of their “companions” lastly stated “nyet” to contract will increase that might allow OptumHealth to get better these prices.
OptumHealth can’t terminate contracts with competing well being insurers with out stirring up extra dangerous publicity and presumably triggering anti-trust inquiries. So UNH has critical leverage issues in negotiating with their rivals. Nearly actually, insufficient Medicare Benefit contract renewal charges for its owned medical teams lower OptumHealth MA margins. These competing well being plans are unlikely to make sustaining United/Optum’s margins a precedence.
And like the remainder of the trade, United awaits additional reductions in Medicaid managed care enrollment, and nearly sure cost reductions from the brand new administration. The earnings outlook for Optum as an entire is grim. Long run deterioration in Optum’s margins, which fell from 8.1% in 2018 to six.1% in 1Q25, have completed actual harm to United’s total earnings. Optum’s development was the principal contributor to United’s exceptional earnings development. That distinctive development streak is probably going over.
Third, the chilly hearted technique of managing care remotely by means of AI pushed algorithms has reached some extent of diminishing returns. Within the aftermath of Brian Thompson’s appalling assassination and brutal exposes in STAT and the Wall Avenue Journal on UNH’s enthusiastic denials and coding practices, some analysts have speculated that UNH could have dialed down the denial machine that was fattening their margins by niggling sufferers and physicians out of cost for medical providers, together with for providers lined by common Medicare.
Giving mislead this hypothesis, UNH’s medical health insurance margins truly rose in 1Q25, to six.1% vs. 5.2% for all of 2024. Nonetheless, claims denials to care suppliers are killing UNH politically. They’ll lead on to much more cancelled contracts by suppliers, lawsuits and continued mediocre shopper satisfaction rankings. United has a minus 12 internet promoter rating, suggesting that UNH isn’t delighting the its tens of hundreds of thousands of consumers.
We must always anticipate Sir Andrew Witty to cease pretending to be UNH’s CEO and return to England to have a tendency his flock and fly fish. It has been a sorry and unconvincing efficiency. And the 25% market cap loss after the Q1 earnings name has broken President/CFO John Rex’s nearly odds-on probabilities to succeed him. United’s sensible and reclusive Govt Chairman Stephen Hemsley, who has completed a exceptional job of rising this firm since he succeeded Invoice McGuire in 2006, has a satan of a succession problem.
The best development story within the historical past of US company well being enterprise seems to be coming to an finish. I’ve been a shareholder on this exceptional firm on a number of events however am not, having misplaced religion on this formidable managed care undertaking. As we await the Medicaid bloodletting from Trump47 and the unfortunate Republican Congress, it’s tough to discern a purpose to put money into UnitedHealth Group. Really turning United from a big pile of acquired healthcare belongings into an actual enterprise could show to be an unimaginable administration problem.
Jeff Goldsmith is a veteran well being care futurist, President of Well being Futures Inc and common THCB Contributor. This comes from his private substack
