The Intelligence Is Artificial. The Pain Is Real.

 

 

"Dave, I know you are retired, but can I ask you a Medicare question?"

My answer, of course, was “Yes’.  The fact that we were in Costco and any time I spent talking with her was time I didn’t spend by the samples, was a bonus.  

Lori (name changed) has been on Medicare for several years.  She also suffers from significant neck and shoulder pain.  She has seen doctors affiliated with both of our major hospital systems.  Her Original Medicare and Medicare Supplement have provided excellent access to care.  She has been to doctors, pain management specialists, and the sports medicine departments.  Her current doctor prescribed a cortisone shot in her neck.  Please follow this link if you are not familiar with this procedure. 

“How much pain do you have to be in to accept a cortisone shot in your neck?”  

Her question painted a picture.  Her shot was scheduled for early January.  We were talking during the first week of March.  She was still waiting for the shot.  And she was not alone.  Lori’s current doctor, a pain management specialist, has over a dozen patients waiting for government approval. 

“Why do we suddenly have this pre-approval step in Ohio, but residents of other states don’t?  And why are they doing this?” 

The “Why” is an easy question to answer.  MONEY.  The details are a touch more complicated. 

This article appeared in the KFF News in September 2025:  AI Will Soon Have a Say in Approving or Denying Medicare Treatments - KFF Health News. 

Taking a page from the private insurance industry’s playbook, the Trump administration will launch a program next year to find out how much money an artificial intelligence algorithm could save the federal government by denying care to Medicare patients. 

The pilot program, designed to weed out wasteful, “low-value” services, amounts to a federal expansion of an unpopular process called prior authorization, which requires patients or someone on their medical team to seek insurance approval before proceeding with certain procedures, tests, and prescriptions. It will affect Medicare patients, and the doctors and hospitals who care for them, in Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington, starting Jan. 1 and running through 2031.

Yes, Ohio.  Your friends in Michigan or in G-d’s waiting room, Louisiana, don’t have to jump through AI hoops to access care.  Yet.  Lori’s shot is one of the procedures Dr. Oz wants to target. 

The program is WISeR which stands for “Wasteful and Inappropriate Service Reduction”.  That link is to the Centers for Medicare and Medicaid (CMS) website.  The best real-world explanation of the ins and outs of WISeR can be found on the website of Davis Wright Tremaine LLP.  And yes, if you need to review the attorney’s analysis first, you already know that none of this has anything to do with anyone’s health.   From their website: 

Services Targeted for Prior Authorization

The services eligible for prior authorization under WISeR include:

·         Electrical Nerve Stimulators

·         Sacral Nerve Stimulation for Urinary Incontinence

·         Phrenic Nerve Stimulator

·         Deep Brain Stimulation for Essential Tremor and Parkinson's Disease

·         Vagus Nerve Stimulation

·         Induced Lesions of Nerve Tracts

·         Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

·         Epidural Steroid Injections for Pain Management, Excluding Facet Joint Injections

·         Percutaneous Vertebral Augmentation for Vertebral Compression Fracture

·         Cervical Fusion

·         Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee

·         Incontinence Control Devices

·         Diagnosis and Treatment of Impotence

·         Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis

·         Skin and Tissue Substitutes

·         Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds

·         Wound Application of Cellular and/or Tissue-Based Products, Lower Extremities 

All of these could be wasteful and unnecessary, unless you are the person afflicted.  The AI companies are supposedly not being directly compensated for denying claims, but there is a shared savings arrangement for the vendors.  Your pain is their gain. 

Hospitals are preparing strategies to work with WISeR.  U.S. News recently interviewed Mike Levin, general counsel and chief information security officer at the digital healthcare technology company, Solera Health. 

So the first principle is non-negotiable: Human clinical authority must always be preserved. AI can serve us information, can flag patterns and can generate recommendations. But any coverage determination has to come back to a human: a licensed clinician must review it.

There's an old IBM presentation from 1971 that says a machine can never make a management decision because a machine cannot be held accountable. I feel like that's more applicable now than ever 50-plus years later.

Humans must have the final say.  If you have doubts, you might appreciate this recent article in the Atlantic - My Tesla Was Driving Itself Perfectly—Until It Crashed - The Atlantic. 

Lori and her fellow patients at our local pain clinic are not the only people impacted by this new AI intrusion into Original Medicare.  This was a segment from last weekend’s Velshi - Jacob Ward: AI is being used to ‘disenfranchise’ people on Medicare.  

What are the possible outcomes?  Some people will eventually get the care they need and feel better.  For some, care delayed is care denied.  Their situation will deteriorate and they will never recover.  Some will just give up.  And in the case of unrelieved pain, some will just resort to higher doses of pain medications.  It is hard to feel positive about this.  We chose Original Medicare to avoid the greed of the Medicare Advantage insurers (I don’t need to name them.  You know their names.)  I don’t think any of us ever expected Dr. Oz to implement this controversial cost saving method into Medicare. 

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This has been quite a year.  There was an unusual growth on my right ear.  Thankfully this was not one of the issues being reviewed by AI.  The dermatologist got me in, examined it, and removed the growth right in the office.  She was sure that it was skin cancer.  The biopsy confirmed her diagnosis.  I had a Mohs surgery on March 5^th.  Everything looks great and I’m fully recovered.  And on a positive note, I am only two procedures away from my own parking spot! 

Dave 

Health Insurance Issues With Dave 

Picture – I ordered the van Gogh – David L Cunix