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

 

Seventy-one And Counting

 

I turned seventy-one last week, a milestone birthday.  For many of us, anything over 65 is truly a milestone and we tend to celebrate among strangers in medical office waiting rooms.  Last week I had a CT scan on Monday, two Ultrasounds on Tuesday, and an MRI on Thursday.  This week features two doctors’ visits and lab work.  It costs a lot of time and money to prove I’m still here. 

My primary doctor asked me about the differences between Original Medicare paired with a Medicare Supplement vs. a Medicare Advantage plan.  He had a pretty good idea, but he wanted to confirm the reasons why I am on Original Medicare.  Actually, he really understood how this choice had worked so well for me and was trying to learn whether my decision had been well-planned or just a happy accident.  Really?  There are no accidents.  We talked for a few minutes.  Medicare is about 20 years away for him.  He hopes to have the choices I had when I turned 65.  I made no promises. 

My Original Medicare and Medicare Supplement Cards have gotten quite the workout this year.  Over and above the usual stuff, I had a little eye issue in late June.  It started on a Thursday evening.  I felt like I was in my late teens and my then shoulder length hair was flopping in front of my eyes.  I could see these dark waves in front of my face.  The problem was that there was nothing there!  It was not much better the next day.  Dots.  Lines.  My right eye was seeing lots of stuff that wasn’t there.  My secretary looked for these symptoms online.  Ruling out pregnancy, she was positive that it was definitely a serious eye condition. 

·         I called the optometrist that did my last eye exam.  He was too busy to talk.

·         I called a friend, an ophthalmologist at the Cleveland Clinic.  He was not available.

·         I called University Hospital.  I was told that the emergency room at main campus has an ophthalmologist on-call.  I drove to UH, but instead of going to the E/R, I went directly to the ophthalmology department.  They viewed me with a little healthy skepticism but listened to my description of my symptoms.  They took my insurance information and started to exam my eyes.

Let’s stop here for a moment.  You may have noticed that I attempted to see doctors from the two competing medical centers.  I didn’t waste any time verifying network participation.  I didn’t have a referral.  I haven’t asked nor received anyone’s or any insurance company’s permission to pursue care.  I have access to any doctor any facility anywhere in the country that accepts Medicare.  The payment issue has already been addressed and resolved.  Back to my eye care. 

·         The first tests got everyone’s attention.  There were more tests.  I was brought into an exam room and introduced to Dr. K, an experienced ophthalmologist and another doctor on his team.  After another exam he explained that I had four tears in my retina.  One was horseshoe shaped and of real concern.  He outlined a treatment plan that included an immediate laser retinopexy followed by surgery as soon as possible.  He was trying for the following Tuesday.

·         I had two questions:  What is the success rate of these procedures and is this all covered by Medicare?  He quickly answered that there was no problem with MY Medicare coverage.  He pegged the success rate at well over 90%, but if I was in the less than 10% failure rate, I could have a permanent problem.  I would not have believed him if he had said that there was a 100% chance of success.

·         The tests and procedures of that Friday, the surgery on the following Tuesday, and the subsequent follow-up visits and testing have all been covered.  Would a Medicare Advantage plan have covered all of this?  Probably, but I would have been limited to a network doctor, their availability, the possibility of pre-authorization, and I would have had co-payments every step of the way. 

Original Medicare coupled with a Medicare Supplement provide greater access to care.  Would a Medicare Advantage plan have approved all of last week’s tests?  It depends on the company.  As agents we all knew of companies that had the reputation of throwing up roadblocks.  The pre-certification process can take months.  Stall.  Deny.  Submit for “review”.  The insertion of Artificial Intelligence when common sense might be the better choice.  I am bringing this up today because it is front and center in my mind after the experiences some of my friends and I have had recently and because our government wants to insert A I into Original Medicare claims’ management. 

The Center for Medicare Advocacy sounded the alarm this past September.  The program will be tested in Ohio and five other states. 

“The model, designed in theory to cut down on “fraud” and “unnecessary” services, would introduce AI-powered Prior Authorization requirements for about a dozen procedures into Traditional Medicare. What the model would likely do – as has been the case with Prior Authorization in Medicare Advantage – is complicate, delay and even outright deny necessary care.”

This is the link to a recent article posted by the Centers for Medicare and Medicaid (CMS).  WISeR (Wasteful and Inappropriate Service Reduction) Model.  Will I still have the same access this time next year?  I hope so, but there are no guarantees.  What happens if the same people who discourage parents from vaccinating their children suddenly take a jaundiced view of CT scans?  Medical imaging costs a lot of money.  It doesn’t take a lot of effort to convince yourself to not spend the money, once you are predisposed to cutting care. 

Our nation’s leaders are wrestling with the cost of healthcare.  Some, OK a few, really are concerned about the health and wellbeing of their constituents.  Most see this as a line item and the challenge to balance the competing desires of the people pounding on their office doors.  And we are in the middle.  If you, like me, spend a lot of time with strangers in medical office waiting rooms, your concerns are personal and time-sensitive. 

I’m seventy-one and counting.  I hope to have the opportunity to show how good a counter I can be. 

Dave 

Health Insurance Issues With Dave  

Picture – I Couldn’t Find A Stunt Double – David L Cunix