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The WISeR trial in 6 states is a trojan horse for privatizing Traditional Medicare.
Most of us who pick Traditional Medicare do it so our health insurer doesn't have a profit motive for denying our care (unlike the for-profit Advantage plans). The ongoing WISeR trial in 6 states incentivizes insurers to deny claims from Traditional Medicare patients.
This is from Rep. Suzan Delbene of WA state, who is among those fighting on our behalf.
Earlier this year, Joanne, a Medicare patient from Quilcene, Washington, went to her doctor for severe pain in her lower back, down her leg and on the top of her foot. An MRI showed that a herniated disc was pressing on her sciatic nerve. Joanne’s doctor prescribed an epidural steroid injection to help alleviate the pain. Before this year, getting that procedure done would have been quick and routine.
But in January, Medicare started a new pilot program in Washington and five other states: Arizona, New Jersey, Ohio, Oklahoma and Texas. This program, called the Wasteful and Inappropriate Service Reduction (WISeR) Model, allows for-profit companies to use artificial intelligence to review and deny Medicare claims. In just the first few months, the number of stories like Joanne’s, in which care is delayed or denied, have exploded across these six states. Joanne’s doctor recommended this injection more than six weeks ago and it still hasn’t been approved. For over a month, she has had to use crutches or a wheelchair, worsening the arthritis in her hands, knees and ankles and adding to her chronic pain. Joanne is now looking to see if she can pay out of pocket for the procedure because, as she told my office, she “can’t keep living like this.”
WISeR isn’t just making it harder for seniors to get the care their doctors prescribe. It also opens the door to something more troubling. Under WISeR, outside companies are paid a share of the costs they “save” by rejecting claims. This creates a pervasive incentive to deny care. By injecting private companies into traditional Medicare with the goal of limiting care, the Trump administration is testing a new avenue to privatize the program. Congress must recognize and reject this Trojan horse before it fundamentally reshapes Medicare as we know it.
SNIP
The practice of requiring procedures to be preapproved, known as prior authorization, is extremely rare in traditional Medicare but already widespread in employer-sponsored health plans and privately run Medicare Advantage plans. Under this deeply flawed process, patients and doctors routinely spend hours fighting on the phone for approval of basic care. Many seniors choose traditional Medicare precisely so they don’t have to deal with this red tape. By injecting prior authorization into traditional Medicare, the differences between it and private Medicare Advantage grow slimmer.
But in January, Medicare started a new pilot program in Washington and five other states: Arizona, New Jersey, Ohio, Oklahoma and Texas. This program, called the Wasteful and Inappropriate Service Reduction (WISeR) Model, allows for-profit companies to use artificial intelligence to review and deny Medicare claims. In just the first few months, the number of stories like Joanne’s, in which care is delayed or denied, have exploded across these six states. Joanne’s doctor recommended this injection more than six weeks ago and it still hasn’t been approved. For over a month, she has had to use crutches or a wheelchair, worsening the arthritis in her hands, knees and ankles and adding to her chronic pain. Joanne is now looking to see if she can pay out of pocket for the procedure because, as she told my office, she “can’t keep living like this.”
WISeR isn’t just making it harder for seniors to get the care their doctors prescribe. It also opens the door to something more troubling. Under WISeR, outside companies are paid a share of the costs they “save” by rejecting claims. This creates a pervasive incentive to deny care. By injecting private companies into traditional Medicare with the goal of limiting care, the Trump administration is testing a new avenue to privatize the program. Congress must recognize and reject this Trojan horse before it fundamentally reshapes Medicare as we know it.
SNIP
The practice of requiring procedures to be preapproved, known as prior authorization, is extremely rare in traditional Medicare but already widespread in employer-sponsored health plans and privately run Medicare Advantage plans. Under this deeply flawed process, patients and doctors routinely spend hours fighting on the phone for approval of basic care. Many seniors choose traditional Medicare precisely so they don’t have to deal with this red tape. By injecting prior authorization into traditional Medicare, the differences between it and private Medicare Advantage grow slimmer.
https://delbene.house.gov/news/documentsingle.aspx?DocumentID=4303