Ohio is one of six states in a new federal pilot program that’s using artificial intelligence to help decide whether certain medical procedures should be approved for Medicare patients.
The Wasteful and Inappropriate Service Reduction (WISeR) Model began in January of this year. Advocates praise it as a tool to cut waste, while detractors worry about its potential to delay care for patients.
While it’s early days, people who work with Medicare are mixed on what its implementation could mean.
What’s changing?
Some Medicare patients in Ohio will have to get prior approval for about a dozen outpatient procedures before they can move forward. That’s new for Medicare, which has historically used very little prior authorization.
Those requests will first be reviewed by artificial intelligence systems run by private companies hired by the federal government. The AI looks for patterns that suggest a procedure may be overused or doesn’t match typical clinical guidelines and denies it.
Ohio Medicare officials say human doctors will still make the final decisions, but the artificial intelligence will conduct the first screening step.
How could it affect patients?
For most Ohio Medicare recipients, nothing changes unless their doctor orders one of the procedures on Medicare’s list. For those patients, it could mean waiting days, or longer, for approval.
Doctors in Ohio say even short delays can affect patients.
“Anytime you add a layer into the process of having to get approval to deliver care to someone, that can slow down the process,” said Todd Baker, CEO of the Ohio State Medical Association. “It has the potential to add layers of administrative hassle, burden.”
Delays can mean people stay in pain longer or their condition worsens before they get treated, Baker said. Patient advocates also worry that some seniors may assume a denial is final and not pursue an appeal.
Baker said he also questions whether the savings will outweigh the added administrative costs needed to process these added steps. He doubts there’s enough fraud to justify the new system.
The way Baker sees it, the system stands mainly to save money when doctors or patients give up navigating the process.
What do supporters say?
Supporters say AI could help cut down on unnecessary care. They argue the technology could help flag treatments that don’t benefit patients and drive up Medicare costs.
The list of procedures is limited and most patients probably won’t lose access to care, according to Jay Rayl, who runs Medicare Made Simple, a Medicare insurance agency in Cleveland.
“I think that overall, when you really start looking at the kind of things that Medicare is starting to look at doing some authorizations with, it’s something that people do need to adjust to a little bit. It doesn’t typically become a huge problem,” he said.
Rayl said prior authorization usually causes delays rather than outright denials. He believes it’s a better way to control costs than cutting benefits, for example.
He and other supporters also point to traditional Medicare’s counterpart, Medicare Advantage, which already uses prior authorization. He said AI could help streamline the process as long as humans remain involved in final decisions.
What are the concerns around artificial intelligence?
Patient advocates worry the automated process incorporating AI could lead to mistakes.
Instead of a doctor focusing on one patient at a time, an algorithm is comparing cases to thousands of others. That raises concerns that people with complex health problems could be flagged simply for being outside the norm.
The biggest concern, however, is the growing norm of prior authorizations.
New polling from the nonpartisan health policy organization KFF shows people cite prior authorization review as their top health care problem, with about a third calling it a major burden.
If successful, this pilot has the potential to shape in a big way how much influence technology has over Medicare patients’ care in the future, whether patients and doctors like it or not.