I’m starting this with a personal story. My mother was a teacher in a New York City public school for many years. When she joined the school system, part of her deal was that when she retired, many of the costs of her traditional Medicare plans would be subsidized by her union and the city. So far, so good. However, now the city, to save money, is moving all of its retirees, including public school teachers, to a Medicare Advantage plan.
(If you don’t know what Medicare is or the difference between traditional Medicare and Medicare Advantage, don’t worry, a lot of people don’t. I’ll explain that in a moment.)
Many retirees in the city are not happy with this change and, in fact, they’ve been fighting this in court during the last two years. Because? Because, among other things, Advantage plans give health insurance companies much more power to deny coverage, and those denials are based on predictive algorithmic tools rather than medical personnel.
So what is Medicare?
To understand Medicare Advantage, it might help to know some background. (Stick with me; this is something you’ll hopefully need to know eventually.) Medicare started as a government run health insurance program which was established in 1965 to help finance care for people age 65 and older who were no longer covered by employers and were generally considered too risky by private insurers. It was funded by taxes taken from employees’ paychecks and matched by employers. And with today’s atmospheric increases in the price of healthcare, it has become a necessity for most of today’s seniors.
Like all government programs, Medicare is, to say the least, complicated. Do you think you have problems doing your annual taxes? Try to find out how to deal with Medicare. There’s Medicare A, which handles hospitalization, Medicare B, which handles payments to doctors (and has an annual fee), Medicare D, which handles drugs (and it’s not free either), and various other alphabetical Medicare payment programs . But even with all the extra complications and fees, Medicare means that if you’re lucky enough to live past age 65, you should be able to pay to go to a doctor and get care.
Glassy eyes yet? Wait, now we are going to get into Medicare Advantage and its algorithms.
As you can imagine, health insurance companies don’t like traditional Medicare. Although they handle Medicare B and other payment aspects of the program, they are limited by government regulations and rules in how much they can charge for services and how much power they have over doctors’ recommendations for care. So, in 1997, Medicare Advantage (also known as Medicare Part C) was created.
Medicare Advantage means that a private insurance company controls all parts of your Medicare benefits: the hospital part, the doctor part, the drug part, and everything else. Advantage has, well, advantages, at least in the beginning: it costs you less than government programs, it’s easier to run (because it’s a single entity), and there are all those great ads showing active, carefree gray-haired people. people golfing, vacationing, hugging their grandkids, so happy to have turned responsibility for their health care over to Big Health Insurance, Inc.
However, because an insurance company that administers your Medicare Advantage program has more control over payment, it can require you, and your doctors, to get approval in advance for almost anything except a checkup. And since the fewer procedures you have to pay for, the more benefits you can keep, there is a strong incentive to deny as many procedures as possible.
Who decides what care you need?
According to a recent medical journal report Statistics, insurance companies have been using these algorithmic tools, rather than doctors or other medically trained individuals, to determine if patients who are enrolled in their Medicare Advantage programs deserve care. These tools are being used, according to the report, “to pinpoint the precise moment when they can cancel payment for a patient’s treatment. The refusals that follow are sparking heated disputes between doctors and insurers, often delaying treatment for seriously ill patients who don’t know the algorithms or can’t question their calculations.” Since appeals challenging those denials can take months or even years to complete the various necessary steps, some of those appeals can take longer than the patient. Which certainly saves money.
And the ads for these tools aren’t shy about what they’re supposed to do. A brochure for nH Predictone of the products used for this purpose, states: “With the nH Predict tool, case managers now first determine whether lower levels of care can meet patients’ clinical needs and then recommend higher levels of care individual when medically necessary. .”
However, it now appears that the case managers mentioned in that quote are apparently saving time by skipping the “individual” part and taking the tool’s recommendations at face value. Last year, the Center for Medicare Advocacy issued a special report which stated: “Although most AI-powered decision-making tools claim to offer only recommendations that are not intended to be a substitute for clinical or medical judgment or Medicare law, in the Center’s experience, users often implement the recommendations of tools without any critical examination of their impact on patients.
In other words, if your doctor thinks you need a procedure to, say, prevent you from having a stroke, and your insurance company’s algorithmic tool comes up saying you don’t need that procedure (and therefore the insurance company may deny payment for es), you have a couple of options. You can pay for the procedure, go into serious debt, and hope that you and your doctor can successfully challenge those denials. Or if you can’t pay on your own, you can wait and hope your appeals come through before you have that stroke.
Or there’s always GoFundMe.
It is not easy being the caregiver of an older adult or a parent. It’s going to get much worse if, when my mother needs medical care in the future, I (and her doctor) have to fight an algorithm to determine if she deserves the prescribed care. I’m not looking forward to it. And I’m not the only one dealing with this problem. There are many, many people whose parents are on Advantage plans who may one day be informed that, based on the judgment of an unnamed statistical tool, the treatment their parents’ doctor says is necessary is not.
