NYT ARTICLE:
Medicare Will Require Prior Authorization
A pilot program in six states will use a tactic employed by private insurers that has been heavily criticized for delaying and denying medical care. 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.
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. This practice, known as prior authorization, has drawn public scrutiny, which intensified after the murder of a UnitedHealthcare executive last December.
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 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.
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. Many companies say human employees are involved at the final stages, to review the A.I. evidence and approve the recommendations
For a period of time, I was in a Medicare Advantage plan because my retirement insurance required it. They eventually gave us a health benefit that we could use to choose our own plan including regular Medicare which I promptly chose to do. I spent a lot of Medicare money investigating my balance problem which could have been resolved earlier if they had allowed me more than six sessions of physical therapy a year.
ReplyDeleteWhen I went on the Medicare Advantage Plan on of my physicians who was very knowledgeable about the politics of healthcare said: "basically you no longer have Medicare, you have only what the insurance companies allow you to have." Of course, the insurance companies provide all sorts of easy fringe benefits and cheap dental and eye plans as well as an annual fund to by health care products cheaper at stores they promote (probably for a fee). But they are still stealing your benefits when you will most need them.
According to the Kaiser Family Foundation, about half of senior citizens are covered by traditional Medicare. The other half is in an Advantage plan. I expect that Advantage providers are already using AI to approve or deny various care decisions made by docs.
ReplyDeleteI expect that Advantage plans are also using AI to develop standards of care for various ailments. A few people in my cancer group are really mad because they can't just jump right to the newer meds, but have to first demonstrate intolerance for the cheap generic chemo, which is the standard of care.
And it's the standard of care cuz it costs $80 a month instead of $6,000.
I have a personal reason for thinking this is a very bad idea. As someone on Medicare I was able to have surgery less than a month after a cancer diagnosis, at the best hospital in the state for women's cancer. It was caught at stage 1, which means I don't need further treatment, just periodic check-ups. If I had to fart around until AI made up its mind that surgery was necessary, it could easily have progressed to a later stage, and required chemo and radiation in addition to surgery. Which would have cost Medicare more money and me additional pain and suffering.
ReplyDeleteI think the idea is that AI will make faster decisions that will save money for the company. It's more cost effective to catch cancer early and treat asap, so someone like you might be fine.
DeleteIt's the chronic illnesses, metastasized cancers, and experimental treatments that cost $$. I look for AI to start funneling elderly patients away from gene therapy, transplants, and new drug treatments in favor of palliative care.
In some cases, that might not be a bad thing. Stem cell transplants for elderly people with leukemia, for example, are approved by Medicare, but the five-year survival rate is about 50-50. AI can quickly identify co-morbidities that would reduce the odds even more and just take that option off the table for many people.
Having lived in Cancer World for 17 years, I see many older patients getting angry when their insurance won't pay for every last treatment option, even when the chances of it working are statistically next to nil. It's part of the American insistence that we "keep fighting," when, in fact, God may be calling us to take stock and prepare.
And, God aside, I honestly don't think that Medicare should pay for useless treatments at public expense if it means that younger people with better chances of survival are excluded.
However, if saving money is the only objective, and these AI programs are concocted by those ranting against the "gerontocracy" and "tyranny of the dying," look for the elderly to get denied a lot more than just the last-ditch expensive stuff.
I dunno.
Maybe I'm over thinking it. And it' s upsetting to think about, which is why I need to get offa here.
We chose Medicare plus the AARP supplement provided by United Healthcare. Thank goodness. We never expected that my husband would become a paraplegic in his old age, running up well more than $1 million in the year after his fall. He was completely covered- every penny - what Medicare didn’t pay, the supplement paid. We didn’t like the Advantage plans because they require using their network of providers. We traveled a lot then, both domestically and internationally. A network limitation wouldn’t help us. The $300 deductible for international medical care that isn’t covered by Medicare with everything else covered was a feature we liked. Any doctor, anywhere we traveled. No dental or vision, but we didn’t have either with my husband’s company health insurance policy so we weren’t bothered by that.
DeleteI don’t trust AI very much based on my limited knowledge and exposure.
Katherine, I too had excellent coverage for my cancer surgery a month or so after the biopsy at John’s Hopkins , not the most convenient for us, but one of the best hospitals in the country. It takes us about an hour door to door to go to Hopkins in Baltimore. I had 5 sessions of post- op radiation. Every penny covered and I chose my own doctors.
I have a brother in law who isn't quite old enough for Medicare, who has multiple autoimmune disorders. He is on one of the ACA plans. Every year it changes, some providers are in, some are out. They may keep their subsidy, they may not. Their rural hospital is a joke, every time he has a crisis they have to go to a medical center which is at least two or three hours away. The administration keeps saying they want to get rid of the ACA, but they have no idea what would take its place. I don't know how AI will affect thecACA plans.
DeletePeople with chronic serious illnesses, like your brother and Jean, are the most vulnerable to the serious weaknesses in our health care system.
DeleteI really wish people here were a little less smug about how smart they were when they chose their retirement insurance. When you are forced to retire early, you must choose the coverage you can afford. It's not that we chose our plan foolishly. It's that we just don't have $$ for a better plan.
DeleteMy cancer is advancing, and I have seriously considered discontinuing the chemo that's keeping me going as the price of care increases.
Death is preferable to debt, poverty, or the hellhole nursing home Medicare/Medicaid provides.
I’m sorry if sharing our individual stories comes across as smug. We weren’t smart, but we were lucky in our choice. ( of course, with no dental plan, after total neglect of our teeth, we had to cough up $10,000 out of pocket for dental work for both of us when we got home plus $6,000 for hearing aids: not covered by Medicare. Our retirement insurance plan is definitely not perfect). We chose what seemed the best match to our needs at the time. Little did we imagine that 17 years after my husband got his Medicare card that he would fall off a ladder, break his back, and become totally helpless because of being paralyzed from chest down. It was rotten luck. Just as choosing to have Medicare plus a supplement so that we could travel without being locked in to a network turned out to be a lucky choice for us because of circumstances that we never imagined.
DeleteYes, oversensitivity on my part. Projecting my own shame at poverty as contempt by others probably. Bad headspace these days. Too much frustration and lashing out that doesn't belong here. End of life is nothing like what the books say, where you gently drift into some sort of spiritualist state. Nope. Days of total apathy and feeling flu-y followed by periods of revved up anxiety and resentment. Apologies to all. Will take it elsewhere.
DeleteThe AI will be implemented by profit driven capitalists. No good can come of it. With AI, there’s no individual you can blame for whatever evil ensues. It also becomes this hallowed thing that takes away individual responsibility. The AI says that so-and-so shouldn’t get this treatment. The AI told us a HAMAS fighter was taking a nap in the basement of that children’s shelter.
DeleteI checked out an interesting sounding library book, The AI Con, "how to fight big tech's hype and create the future we want", by Emily Bender and Alex Hanna.
DeleteSounds interesting, Katherine. One thing that has to be considered is that we are being heavily sold AI. Other things the public has been sold on in the past is leaded gasoline, real women should smoke, Roundup, Israel is wonderful, McDonalds hamburgers. The energy requirements of AI are incredible. I think a lot of the hype is to drive up the worth of stocks and create the next bubble. Tesla self-driving is failing because it put all its faith in AI while limiting sensors to only video. Waymo works better because it uses scanning laser rangefinders, microwave radar, ultrasound in addition to cameras plus extra detailed maps of the locality. It ain’t cheap but it works and Waymo is, from what I read, marginally profitable. Musk put all his faith in AI so that Tesla and its self-driving cab are in trouble as a result. Musk has always been more promoter than businessman ir engineer but that patina is starting to show through.
DeleteI don't have a lot of faith that the current federal government will implement any medical program with a view to the common good. The current administration is more likely to exclude people here illegally, or even people in blue states. And to privilege treatments that don't have a foundation of rigorous research prior to approval.
ReplyDeleteI think the best we can hope for is that Trump ends up firing RFK Jr. Which is somewhat likely because he is hogging some spotlight that Trump may believe belongs to him. That and the fact that he is breaking all the promises he made to get confirmed as sec of HHS. RFK's anti-vaxxing is already biting the US, especially with Covid rates rising, going into autumn, and measles rising. RFK may be the single most unqualified nut job cabinet appointee of this administration, and that's saying a lot.
DeleteI don't know what Trump thinks about RFK Jr., but I think Trump thinks RFK Jr.'s views play well with his MAGA base, because Trump is permitting the lunacy to continue. Maybe Trump sees the CDC doctors going away as part of his project of "draining the swamp".
DeleteIt’s all about playing to the crowd. Trump has nothing else to give, if he’s even cognitive enough to be an origin of anything. I would say it’s more likely the producers of the TV show “The Return of Trump” that are feeding him lines and executive orders while keeping him out of the way with golf trips, personal duels and redecorating the White House. If he dies (maybe already has), they may replace him with AI generated CGI for the media or an obese android or both. If he suddenly looks like he’s getting healthier in meetings with actual heads of state, I’m voting for the android. And while they’re at it, as foreign heads of state visit Trumpbot, they can replace THEM with a replicant. I can’t wait until Thanksgiving to spring this conspiracy theory on my relatives.
DeleteIt’s a great theory, Stanley😂. At this point, I wouldn’t be surprised if it were true.
Delete"Many companies say human employees are involved at the final stages, to review the A.I. evidence and approve the recommendations"
ReplyDeleteThat human review/confirmation step will need to be mandatory, if people are going to trust the tool.
Stepping back for a moment: I guess this is an initiative to reduce Medicare costs. Perhaps this isn't the best way to accomplish it - but if there are better ideas, they should be brought forward post-haste, because Medicare, from all I've been reading for decades, is not on a sustainable path. Additional coverage limits are going to have to be imposed, or the government will have to find new ways of wringing more cost out of the system, or people will have to pay more for their Medicare coverage. Likely all of the above.
According to the Google machine, or at least its AI adjunct, the so-called 'trust fund' will stop being able to pay 100% of Part A hospital costs in 2033. That's pretty soon. Nothing is certain, but the actuarial tables think I should live quite a bit beyond that year.
Once again, this country refuses to look at how other rich countries handle this. Basically it comes down to raising taxes on all. Congress has borrowed from Medicare forever to fund things it wanted without raising taxes. We have by far the most expensive medical care system in the world. We are in the 30 something place for health outcomes. It’s not just Medicare that’s in trouble, our entire profit based healthcare system is in trouble. Other rich countries not only provide universal healthcare to their citizens, it’s on average better care, yet much cheaper care. Because they don’t look at healthcare as a profit making opportunity but as a right due their citizens.
DeleteActually I mis- stated. Since we’re discussing AI, here is the AI summary of what happens.
DeleteNo, Congress has not "borrowed" money from Medicare in the sense of embezzlement or misappropriation; however, the Medicare trust fund has invested its surplus funds in U.S. Treasury securities, which is functionally a loan to the Treasury that finances general government spending. This practice, mandated by law, involves the trust fund purchasing government bonds, so when the government needs to cover expenses, it pays back the trust funds by issuing new bonds or using other government funds.
How it works
Mandatory Investment:
.
The Social Security Act requires that any excess cash in the Social Security and Medicare trust funds be invested in special-issue U.S. Treasury bonds.
Special-Issue Bonds:
.
These are not unique government loans but are the same type of safe, interest-bearing securities held by investors worldwide and considered among the safest assets available.
Interest and Redemption:
.
The bonds earn interest for the trust funds, and when the trust funds need to pay benefits, they redeem these bonds, which is similar to how any other investor would redeem government bonds.
The misconception
The common belief that Congress "borrows" money from these trust funds is a myth that often leads to misinformation.
While the trust fund investments do finance government spending, the money is returned with interest. The funds do not simply disappear.
The funds used to pay out benefits are not an infusion of new money; rather, they are a withdrawal from the trust funds, which adds to the overall national debt, as The Cato Institute explains.
In summary
Congress doesn't take money for its own use without paying it back. Instead, the trust funds hold government bonds that are functionally loans to the Treasury, which then uses this money to finance government spending. When the time comes for Medicare to pay benefits, it is repaid by the government, which can be interpreted as borrowing from the trust funds.