The following article, published on March 13,2023, describes how the insurance industry is using Artificial Intelligence algorithms to determine when treatment is no longer medically necessary. It is truly a horror story. Is it geriatric genocide?
https://www.statnews.com/2023/03/13/medicare-advantage-plans-denial-artificial-intelligence/
The full article is behind a paywall so if you don't subscribe, here's a summary:
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Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need. March 13, 2023.
From STAT, the health industry news site produced by Boston Globe Media.
Health insurance companies have rejected medical claims for as long as they’ve been around.
But a STAT investigation found artificial intelligence is now driving their denials to new heights in Medicare Advantage, the taxpayer-funded alternative to traditional Medicare that covers more than 31 million people.
Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying treatment of seriously ill patients who are neither aware of the algorithms, nor able to question their calculations.
Older people who spent their lives paying into Medicare, and are now facing amputation, fast-spreading cancers, and other devastating diagnoses, are left to either pay for their care themselves or get by without it. If they disagree, they can file an appeal, and spend months trying to recover their costs, even if they don’t recover from their illnesses.
“We take patients who are going to die of their diseases within a three-month period of time, and we force them into a denial and appeals process that lasts up to 2.5 years,” Chris Comfort, chief operating officer of Calvary Hospital, a palliative and hospice facility in the Bronx, N.Y., said of Medicare Advantage. “So what happens is the appeal outlasts the beneficiary.”
The algorithms sit at the beginning of the process, promising to deliver personalized care and better outcomes. But patient advocates said in many cases they do the exact opposite — spitting out recommendations that fail to adjust for a patient’s individual circumstances and conflict with basic rules on what Medicare plans must cover.
“While the firms say [the algorithm] is suggestive, it ends up being a hard-and-fast rule that the plan or the care management firms really try to follow,” said David Lipschutz, associate director of the Center for Medicare Advocacy, a nonprofit group that has reviewed such denials for more than two years in its work with Medicare patients. “There’s no deviation from it, no accounting for changes in condition, no accounting for situations in which a person could use more care.”
Medicare Advantage has become highly profitable for insurers as more patients over 65 and people with disabilities flock to plans that offer lower premiums and prescription drug coverage, but give insurers more latitude to deny and restrict services.
Elevance, Cigna, and CVS Health, which owns insurance giant Aetna, have all purchased these capabilities in recent years. One of the biggest and most controversial companies behind these models, NaviHealth, is now owned by UnitedHealth Group.
In comments to federal regulators and interviews with STAT, many providers described rigid criteria applied by NaviHealth, which exercises prior authorization on behalf of the nation’s largest Medicare Advantage insurers, including its sister company UnitedHealthcare as well as Humana and several Blue Cross Blue Shield plans.
“NaviHealth will not approve [skilled nursing] if you ambulate at least 50 feet. Nevermind that you may live alon(e) or have poor balance,” wrote Christina Zitting, a case management director for a community hospital in San Angelo, Texas.
She added: “MA plans are a disgrace to the Medicare program, and I encourage anyone signing up..to avoid these plans because they do NOT have the patients best interest in mind. They are here to make a profit. Period.”
“I’ve still got friends who say, ‘Oh, I’ve got UnitedHealthcare Advantage, and it’s wonderful.’”
“Well, it is,” she said. “Until you need the big stuff.’”
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This is a 3/15/23 "Here & Now" broadcast from WBUR (NPR) interviewing one of the authors of the article (Bob Herman):
https://www.wbur.org/hereandnow/2023/03/15/ai-algorithms-medicare-advantage
Centers for Medicare Advocacy is a stellar non-profit and reported on this issue in April 2022. It has taken media organizations over a year to do investigative reporting. Meanwhile, NOTHING changed. Medicare eligible people are still being sold Medicare Advantage plans as a godsend, while the sellers force the sick ones out of rehabilitation without impunity:
https://medicareadvocacy.org/ai-plus-ma-equals-bad-care-decisions/
"Skilled Nursing News" also discusses the issue in their publication:
https://skillednursingnews.com/2023/03/ai-use-by-medicare-advantage-blamed-for-increased-denial-of-nursing-home-services/
Updated 3/17/23:
This Vox report in the following link is an easy to understand, concise analysis of Medicare Advantage plans. It includes a reference to the use of AI. The only aspect missing, is an analysis of the deceptive ways Medicare Advantage insurance agents lure seniors into the plans, much of which is illegal. Seniors don't have the wherewithal to know what's happening. In fact, many seniors rely on their insurance agents the way they rely on their doctors. They believe the agents are working for their best interests. Often, if/when they discover the truth, it's because they are in failing health.
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