A new Medicare initiative known as the Wasteful and Inappropriate Service Reduction (WISeR) Model is poised to launch in Ohio and five other states next year, with the potential to reshape accessibility to certain medical treatments for older Americans. The initiative has sparked significant backlash from healthcare professionals and patient advocacy groups due to its implementation of prior authorization and artificial intelligence in evaluating claims.
One major aspect of the WISeR Model is the introduction of prior authorization for approximately a dozen medical procedures under traditional Medicare. This change represents a major shift, as traditional Medicare has not required prior approval for most services in the past. The targeted procedures, which include critical treatments such as steroid injections for pain, knee arthroscopy, and cervical fusion, collectively accounted for up to $5.8 billion in spending in 2022. While officials assert that the aim of this measure is to reduce waste and fraud by confirming medical necessity, critics raise concerns that it could result in additional delays and administrative burdens for patients and healthcare providers.
The initiative has also stirred controversy due to its reliance on artificial intelligence to analyze patient records and determine whether certain procedures qualify for coverage. Although federal officials maintain that any denial of coverage must be corroborated by a human clinician, patient advocates express apprehension that biased algorithms might exacerbate healthcare disparities faced by older and minority populations. Furthermore, critics highlight potential conflicts of interest, as the companies tasked with managing the program may financially benefit from any savings obtained through denied claims.
Physicians and patient rights organizations have voiced strong opposition, warning that the new model could create significant barriers to medically necessary care. Judith Stein, founder of the Center for Medicare Advocacy, emphasized that the program positions algorithms between providers and the medical services they recommend. Charlotte Rudolph from UHCAN Ohio echoed these sentiments, arguing that the initiative would ultimately save the government money at the expense of patient health, placing additional strain on vulnerable populations in Ohio.
Additionally, the WISeR Model blurs the historical distinctions between traditional Medicare and private Medicare Advantage plans. Traditionally, patients selected original Medicare to evade the prior authorization requirements and administrative challenges associated with private plans. The introduction of this model may erode that distinction, causing concern among patients who prefer the less cumbersome nature of traditional Medicare.
In light of these impending changes, experts advise patients to take several steps to prepare. It is suggested that individuals confirm their enrollment in original Medicare, check whether the procedures they may need are included in the targeted list, and discuss the new requirements with their healthcare providers. Should a claim be denied, it is vital for patients to follow the appeals process diligently. Resources such as the Ohio Senior Health Insurance Information Program (OSHIIP), the Medicare Rights Center, and the National Council on Aging provide free assistance, while the National Association of Elder Law Attorneys can help patients find local legal support.
