Like millions of older adults, Frances L. Ayres faced a choice when picking health insurance: Pay more for traditional Medicare, or opt for a plan offered by a private insurer and risk drawn-out fights over coverage.
Private insurers often require a cumbersome review process that frequently results in the denial or delay of essential treatments that are readily covered by traditional Medicare. This practice, known as prior authorization, has drawn public scrutiny, which intensified after the murder of a UnitedHealthcare executive last December.
Ms. Ayres, a 74-year-old retired accounting professor, said she wanted to avoid the hassle that has been associated with such practices under Medicare Advantage, which are private plans financed by the U.S. government. Now, she is concerned she will face those denials anyway.
The Centers for Medicare and Medicaid Services plans to begin a pilot program that would involve a similar review process for traditional Medicare, the federal insurance program for people 65 and older as well as for many younger people with disabilities. The pilot would start in six states next year, including Oklahoma, where Ms. Ayres lives. Even worse, the new Trump plan would use artificial intelligence to decide who gets medical treatment and who doesn't.
The federal government plans to hire private companies to use artificial intelligence to determine whether patients would be covered for some procedures, like certain spine surgeries or steroid injections. Similar algorithms used by insurers have been the subject of several high-profile lawsuits, which have asserted that the technology allowed the companies to swiftly deny large batches of claims and cut patients off from care in rehabilitation facilities.
The companies selected to oversee the program would have a strong financial incentive to deny claims-- Medicare plans to pay them a share of the savings generated from the rejections.
The government said the A.I. screening tool would focus narrowly on about a dozen procedures, which it has determined to be costly and of little to no benefit to patients. Those procedures include devices for incontinence control, cervical fusion, certain steroid injections for pain management, select nerve stimulators and the diagnosis and treatment of impotence.
Abe Sutton, the director of the Center for Medicare and Medicaid Innovation, said that the government would not review emergency services or hospital stays.
Mr. Sutton said the government experiment would examine practices that were particularly expensive or potentially harmful to patients. “This is what prior authorization should be,” he said. So who would know best what would be harmful to a patient? The patient's doctor, or a soulless computer algorithm?
The government may add or subtract to the list of treatments it has slated for review depending on what treatments it finds are being overused, Sutton said. So as people get older, and certain treatments become more common, the Trump medicare could decide to ration that treatment in order to save money.
The program, called the Wasteful and Inappropriate Service Reduction Model, is already drawing opposition from lawmakers, former Medicare officials, physician groups and others. Patients are also leery. “I think it’s the back door into privatizing traditional Medicare,” Ms. Ayres said.
People enrolled in traditional Medicare who live in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington State will be included in the experiment, which is expected to start in January and last for six years.
Private plans under Medicare Advantage have become increasingly popular, with a little more than half of older Americans and people with disabilities eligible for the program and some 34 million enrolled. But many, like Ms. Ayres, are willing to forgo some of the additional benefits the Medicare advantage plans offer (like dental checkups and gym memberships) to avoid having to jump through numerous hoops to get care. “It’s really surprising that we are taking the most unpopular part of Medicare Advantage and applying it to traditional Medicare,” said Neil Patil, a senior fellow at Georgetown and a former senior analyst at Medicare.
The American Medical Association wrote in a letter that doctors view prior authorization “as one of the most burdensome and disruptive administrative requirements they face in providing quality care to patients.” Most patients who appeal are successful, but a vast majority never appeal.
In announcing the new model, Dr. Mehmet Oz, the administrator of the Medicare agency, said the goal was to root out fraud, waste and abuse. The new model relies on an additional set of private companies for traditional Medicare that have a very clear incentive to deny care. The companies represent “a whole new bounty hunter,” said David A. Lipschutz, the co-director for the Center for Medicare Advocacy, one of the groups that has urged government officials to abandon the program.
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