The Trump administration is set to launch a pilot program next year that mirrors practices used in the private insurance industry. The program aims to determine the potential cost savings of using an artificial intelligence algorithm to deny care to Medicare patients for certain services deemed as “low-value”. This initiative is an expansion of the prior authorization process, which requires approval from insurance before certain medical procedures, tests, or prescriptions can proceed.
The pilot program, named WISeR (Wasteful and Inappropriate Service Reduction), will focus on services like skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy. The goal is to identify and prevent fraud, waste, and abuse in these areas. However, services that are inpatient-only, emergency, or pose a substantial risk to patients if delayed will not be subject to the AI model’s assessment.
While the use of AI in health insurance is not new, Medicare has been slow to adopt such tools from the private sector. The pilot program has raised concerns among politicians, policy experts, patients, and healthcare providers. Critics worry about the potential negative impact on patient care, as well as the lack of transparency and oversight in the decision-making process.
Some experts question the effectiveness of AI algorithms in making healthcare decisions, citing concerns about bias, errors, and the potential for denial of medically necessary care. The use of AI in healthcare has been a topic of debate, with some arguing that it can streamline processes and reduce costs, while others raise ethical and practical concerns about its implementation.
The pilot program will be closely monitored for its impact on patient care, cost savings, and overall effectiveness. Politicians from both parties are seeking more information about the program and its implications for Medicare beneficiaries. While AI technology in healthcare is evolving, the success of the WISeR pilot program remains to be seen, with stakeholders emphasizing the importance of prioritizing patient well-being and ensuring access to quality care.
