Donald Trump’s pledge to “Make America Great Again” raises concerns for many, hinting at a potential decline in efficiency and affordability in public services. It appears that the administration is taking steps that might undermine the century-old social welfare programs, including Social Security and Medicare, making them less effective for those who rely on them.
This week’s announcement of a new pilot program by the Centers for Medicare and Medicaid Services (CMS) exemplifies these concerns. Set to launch next year in six states, this initiative will utilize artificial intelligence to assess the appropriateness of certain healthcare coverages. As reported by the New York Times, the CMS aims to “Target Wasteful, Inappropriate Services in Original Medicare,” suggesting a shift in how Medicare beneficiaries will access essential care.
The Centers for Medicare & Medicaid Services (CMS) is announcing a new Innovation Center model aimed at helping ensure people with Original Medicare receive safe, effective, and necessary care.
While the intention behind avoiding unnecessary care is commendable, the details indicate a troubling trend. The press release continues:
Through the Wasteful and Inappropriate Service Reduction (WISeR) Model, CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars.
Prior authorization is a process requiring medical providers to verify with insurance companies before proceeding with specific treatments. Traditionally, beneficiaries of Original Medicare haven’t faced this hurdle, whereas those utilizing the more modern Medicare Advantage plan often do. Unfortunately, with the upcoming pilot program, even Original Medicare users will need to navigate this new requirement. AI algorithms will judge whether a patient’s needed care amounts to an “appropriate” use of taxpayer dollars. This initiative, framed as beneficial, raises significant skepticism. The press release elaborates:
The WISeR Model will test a new process on whether enhanced technologies, including artificial intelligence (AI), can expedite the prior authorization processes for select items and services that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use.
Critically, the prior authorization process has faced controversies, especially concerning the motivations behind AI companies involved. Concerns have emerged about their financial incentives to deny claims, leading critics to label this pilot program as equivalent to “AI death panels.” The New York Times points to past legal challenges faced by similar algorithms, amplifying fears about the implications for patient care.
What could this mean for you? It’s vital to stay informed and proactive regarding changes in Medicare and the potential impacts on your coverage and care options.
Is prior authorization necessary for everyone on Medicare? No, traditionally, those with Original Medicare have not had to deal with prior authorization, but this new pilot aims to change that.
Can AI effectively assess healthcare needs? While AI has its benefits, concerns arise about its ability to accurately judge medical necessity without human oversight, especially if financial incentives come into play.
Will patients be denied necessary care under this new model? It’s unclear, but critics worry that financial motivations may lead to greater denial of claims, raising the stakes for those dependent on timely care.
As these developments unfold, it’s important to critically evaluate any shifts in policy and actively participate in discussions about the future of healthcare. For broader insights and in-depth analysis on healthcare policies, consider exploring more at Moyens I/O.