Medicare

 

Medicare

Healthcare and AI formed an unbreakable bond years ago. Tech industry trends and investments in technology helped a lot in moving us out from the dark ages, notably by eliminating diseases that had plagued humanity since the dawn of time.

There is still a long way to go, though.

In the near future, Big Pharma companies will be employing AI-driven technologies to optimize the drug delivery process, which will improve the interaction between clients and drug providers. We will be able to get personalized information straight from medical specialists, and they will, in turn, benefit from our immediate feedback.

The healthcare industry is directly influenced by many digital technology trends. Just last year the FDA approved companies like IDx (who researches in autonomous eye disease detection), Viz.AI (diagnostics for life-threatening diseases), and Imagen (AI application in medical image analysis).

Maybe considerably longer life expectancy is another thing to make the transition from sci-fi books to reality.

The use of artificial intelligence (AI) in healthcare is capturing headlines as a potential tool to streamline operations and predict patient needs for favorable health outcomes, among other things. The Center for Medicare Advocacy, however, has increasingly become aware of how AI-powered decision-making tools may be used by Medicare Advantage (MA) plans to make coverage decisions. Those decisions may be more restrictive than Medicare coverage guidelines, potentially leading to premature terminations of coverage or continuation of care for beneficiaries.

The Center recently published a report, The Role of AI-Powered Decision-Making Technology in Medicare Coverage Determinations, which outlined areas of growing concerns. Issues around the use of AI have also been highlighted by the Commonwealth Fund as part of a series of blogs focusing on different aspects of the MA program. A recent blog post noted, “A related concern is that plans are using proprietary, algorithm-driven systems to make decisions (including those requiring prior authorization) about approving coverage for services.”

The issues around prior authorization and persistent denials of coverage potentially have devastating impacts on patients. The Center is hearing alarming cases of Medicare beneficiaries suffering from impacts of AI decision-making tools despite the fact that Medicare is adamant that no claim should be based on a screening tool alone. Furthermore, Medicare requires an individualized assessment of each beneficiary’s qualification for coverage in certain care settings.[6] The AI tools, however, provide recommendations based on previous patient experiences.

One beneficiary in Connecticut, Ms. M, was hospitalized after she underwent a hip replacement. The 80-year-old was transferred to a skilled nursing facility (SNF) for short-term rehab. Ms. M’s UnitedHealthcare Medicare Advantage plan touts that it offers coverage of unlimited days in a SNF.