You can pay more for traditional Medicare, or opt for a plan offered by a private insurer and risk drawn-out fights over coverage. Patients are leery andI think it’s the back door into privatizing traditional Medicare.
Private insurers often require a cumbersome review process that frequently results in the denial or delay of essential treatments that are readily covered by traditional Medicare.
The Centers for Medicare and Medicaid Services plans to begin a pilot program that would involve a similar review process for traditional Medicare, the federal insurance program for people 65 and older as well as for many younger people with disabilities. The pilot would start in six states next year.
The federal government plans to hire private companies to use artificial intelligence to determine whether patients would be covered for some procedures, like certain spine surgeries or steroid injections.
Similar algorithms used by insurers have been the subject of several high-profile lawsuits, which have asserted that the technology allowed the companies to swiftly deny large batches of claims and cut patients off from care in rehabilitation facilities.
The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims. Medicare plans to pay them a share of the savings generated from rejections.
The government said the A.I. screening tool would focus narrowly on about a dozen procedures, which it has determined to be costly and of little to no benefit to patients.
Abe Sutton, the director of the Center for Medicare and Medicaid Innovation, said that the government would not review emergency services or hospital stays. Mr. Sutton said the government experiment would examine practices that were particularly expensive or potentially harmful to patients. “This is what prior authorization should be,” he said.
The government may add or subtract to the list of treatments it has slated for review depending on what treatments it finds are being overused, he said.
People enrolled in traditional Medicare who live in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington State will be included in the experiment, which is expected to start in January and last for six years.
It’s basically the same set of financial incentives that has created issues in Medicare Advantage and drawn so much scrutiny,
Typically, these A.I. models scan a patient’s records to determine if a requested procedure meets an insurer’s criteria. For instance, before authorizing back surgery, the system might search for proof that a patient first tried physical therapy or received an MRI showing a bulging disc.
Insurers defend these tactics as being effective in reducing inappropriate care, such as by preventing someone from getting back surgery at tremendous cost instead of another treatment that would work just as well. Government officials said that any denials would be done by “an appropriately licensed human clinician, not a machine.”
A group of House Democrats, including Representative Alexandria Ocasio-Cortez of New York, warned in a letter to government officials in late July that giving for-profit companies a “veto” over care “opens the door to further erosion of our Medicare system.”
Private plans under Medicare Advantage have become increasingly popular, with a little more than half of older Americans and people with disabilities eligible for the program and some 34 million enrolled.
But many are willing to forgo some of the additional benefits the private plans offer, like dental checkups and gym memberships, to avoid having to jump through numerous hoops to get care.
The American Medical Association wrote in a letter that doctors view prior authorization “as one of the most burdensome and disruptive administrative requirements they face in providing quality care to patients.” Most patients who appeal are successful, but a vast majority never appeal.
In announcing the new model, Dr. Mehmet Oz, the administrator of the Medicare agency, said the goal was to root out fraud, waste and abuse.
But if the algorithm used to authorize those procedures proves to save the government money C.M.S. may feel justified in broadening the program to include services that are not such “low-hanging fruit.”
How insurers make their decisions remains opaque. A spokesman for Health and Human Services, which oversees the Medicare agency, declined to identify which companies had submitted applications for the contract.
Contractors hired by the government are supposed to watch over payments to ward against inappropriate or wasteful coverage. Those reviews generally happen after someone has received a treatment.
The new model relies on an additional set of private companies for traditional Medicare that have a very clear incentive to deny care.
The companies represent “a whole new bounty hunter,” said David A. Lipschutz, the co-director for the Center for Medicare Advocacy, one of the groups that has urged government officials to abandon the program.
Source: NYT
