The front-page Seattle Times article “WA patients agonize as Medicare AI program continues to delay care,” on April 27, addressed Medicare’s attempts to moderate care costs and reduce inappropriate treatments through the WISeR, or Wasteful and Inappropriate Services Reduction, program. This artificial intelligence-supported pilot program evaluates the necessity and appropriateness of some physician care decisions and is likely to cause some delay in care that is medically indicated.
However, WISeR also blocks care that is not likely to benefit, and may even worsen, a patient’s condition. This second attribute is novel in traditional Medicare. Prior authorization is already used by Medicare Advantage and commercial plans.
There has been strong opposition to the WISeR program by Washington physicians, nurses and hospitals through their professional organizations, focused on delay in patient care. Not addressed in these positions is the economic and compassionate necessity of WISeR.
Ask any patient, “Would you participate in a program that uses the conclusions drawn from evaluation of numerous medical studies to be certain that the care you are being prescribed will benefit your health and not expose you to unnecessary risks?” and you can expect a resounding “Yes!”
Ask any physician, “Would you participate in a program to combat the overuse of questionable interventions that some of your colleagues are using, understanding that their wasteful spending is not only putting patients at risk but also adversely affecting the viability of the Medicare system?” Expect another resounding “Yes!”
The reality is programs with the goals of WISeR are overwhelmingly absent from the U.S. healthcare system. The underlying reason is money. Physician groups, if independent, do not have the funds or staff available to implement effective programs to assure their docs are doing high-quality work. Physicians rarely work together on surgeries or procedures (because of financial realities) so they no longer have the opportunity to guide colleagues whose decisions are suboptimal for the patient.
Hospitals give short shrift to quality and appropriateness of care delivered in their facilities provided that patient satisfaction surveys, and cursory quality checklists, have the appropriate boxes checked. Hospital profits are generated by keeping beds and operating rooms full. Hospitals rarely query doctors on their care decisions because every intervention, no matter how inappropriate for a given patient, means added revenue for the hospital.
Another unwitting actor in the dysfunctional ballet that is U.S. healthcare is the population of patients that Medicare is dedicated to serving. Many patients harbor increasingly unrealistic expectations about the success of surgeries and procedures and elect, often too quickly, for such interventions. This tendency is understandable given the system has minimized concern over risks of anesthesia (to increase procedure volumes) and the economics of physician compensation that rewards performing procedures over pursuing conservative care.
In the protestations against the WISeR program, the professed evils of AI-assisted decision-making in healthcare are exaggerated. AI is not used to command physician behavior. Here, AI assists by digesting huge volumes of medical studies and data to assist doctors and administrators in deciding what procedures are likely to have more benefit than risk. Were the human brain able to perform such daunting tasks, we would not have medical decisions tainted by the biases we see in current practice.
While some aspects of WISeR, such as paying a “bounty” to the operators of the program dependent on the volume of care denied, are not optimal, our current Medicare system needs constraints applied from the outside. The WISeR program is already morphing to become more user-friendly. For many reasons, principally the obsessive drive to maximize revenue, we can no longer expect that physicians and hospitals can or will effectively police their own.
The Seattle Times article outlined one procedure, epidural steroid injections, which are of questionable medical value. There are many other such interventions that generate revenue for doctors and hospitals that will be scrutinized by the WISeR program.
Until the medical profession and the hospital conglomerates ask, “What is truly in the best interest of patients?” we need programs such as WISer to make health care safer and more affordable.
