By Binyamin Rubin
For decades, Medicare has provided 65 million Americans with reliable healthcare from physicians. Now, for the first time, that reliability will depend on what an algorithm thinks.
The Center for Medicare and Services (CMS) announced that starting in January, a new pilot program will require pre-approval from an AI-assisted authorization tool for certain treatments before they can be given to a patient.
The program, named the Wasteful and Inappropriate Service Reduction (WISeR) Model, aims to reduce waste within the program while bringing Medicare into the current era by using technology that will streamline prior authorization to deliver efficient care for their patients. CMS administrator Dr Mehmet Oz said, “Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures.”
While the CMS praises its modernization effort, the rollout will begin cautiously. The pilot program will be limited to a small scope, both in treatments and location, before it will expand. The CMS says that only a dozen procedures will be part of the pilot program, which were determined from the database to have a minimal effect on patient outcomes. Additionally, the program will begin only in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.
Many Democratic lawmakers, doctors and former Medicare employees oppose such a change to the system. Prior authorization is common in private insurance, forcing doctors and patients to waste hours appealing denied claims. Medicare used to have standard practices for things deemed “medically necessary,” which means prior authorization was not needed. As Medicare adopts a prior authorization process, many are concerned that this is a way to privatize standard Medicare which millions rely on, while also placing more work on doctors to give standard care for their patients. The American Medical Association said that prior authorization “has consistently been identified by physicians as one of the most burdensome and disruptive administrative requirements they face in providing quality care to patients.”
Additionally, there is a big ethical concern when it comes to using AI software as part of the prior authorization process. While artificial intelligence is rapidly advancing, there are still flaws that can arise based on faulty algorithms, false positives and negatives that can be dangerous to apply to something of a larger scale at this point. According to the WISeR model, the private companies that program the AI will be able to share in the profits earned from denying claims. This creates a blaring incentive structure for AI companies to deny as many as they can get away with so that they can profit.
This shift to AI to reduce spending is not only happening when it comes to Medicare but throughout the entire federal government. Recent policies within other departments of the Trump administration have focused on cutting costs and spending less while still providing the same care. For example, The Internal Revenue Service (IRS) had nearly 25% of its workforce bought out in an effort to reduce costs and rely more on AI to select specific cases to audit by human staffers. However, recent news indicates that the IRS plans on rehiring some of its laid off workers as they struggle to deal with implementing new AI.
If implemented, this program could cause long-term damage as doctors are already struggling to keep up with modernization of technology, making them spend more time taking notes than actually meeting with patients. There has already been a growing concern that doctors are refusing to accept some insurances as they experience fatigue when dealing with the prior authorization that comes with them. For Medicare Advantage, which requires prior authorization on some treatments beyond the scope of standard Medicare, some hospitals have stopped accepting it at all.
While there is waste and fraud in the medical field that should be cut, alternative strategies need to be considered before things trend in the direction of a broken system of prior authorization and inherently biased AI models. If this plan is implemented, we risk these things being in control of your treatment, rather than your doctor.
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