Medicare to Require Prior Authorization Using AI
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About that "if done well" question, @Mik if you don't mind opining more ...
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For "routine approvals," does AI do better (lower error rate, faster, cheaper) compare to rule-based automated systems?
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Does the AI also spits out explanation/rationale for its decision to approve or reject an authorization request?
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I think it is able to consider more factors and ask better questions without them being hard-coded than a simple rules-based software, and yes, the stuff I have seen produces a better explanation in plain language. Whether these improvements materialize in this case remains to be seen.
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Because federal computer systems have done little but improve in the last 10 years or so, especially citizen-facing applications. It would, however, be interesting to see the discussions and the written goals leading up to this.
@Mik said in Medicare to Require Prior Authorization Using AI:
federal computer systems
I don't think "done well" depends on the computer systems (because you're right, the systems are getting better and better). I think it depends on the people involved.
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Yeah, but remember there's financial incentives for some health care people to order more tests, do procedures and use the higher priced drugs for a kickback - so there is a need on the other side to try and sort that out. The "done right" part for human intervention will be critical. My spouse's bout with cancer has helped to showcase how thoughtless the first round of review can be -whether AI or human.
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No system will satisfy everyone. We're trying to balance the cost effectiveness of treatment against the "flat of the curve" approach most physicians and patients want. If you're not familiar with the flat of the curve argument, it's an inherent problem in 3rd party payer systems like ours.
Patients pay a co-pay and have out of pocket caps, so once they're done with those the marginal out of pocket cost of more treatment is zero. The incentive, then, is to push till the marginal benefit of treatment is zero as well. That's privately good but socially bad. Society pays the high marginal cost (to doctors, pharmacies, and hospitals) for further -- often useless -- treatments. Doctors and patients are essentially in cahoots against the 3rd party payer (insurers, including the government via medicaid and medicare). This is why we have these reviews. It's an expensive attempt at finding the right balance where the marginal cost of the treatment (to society) is close to the marginal benefit. (to the patient).
A good system should err on the side of treatment, within reason. United Health suggests that the erring is often on the other side, especially if the patient has little free choice (competition) and even less information.
I can see a case for AI in the first round because that should save money by letting a lot of humans whose jobs are mechanical find more productive employment. But the AI is only as good as the incentives of the people programming how it evaluates cases.
And speaking of AI, Google's AI does a very thorough job of explaining the flat of the curve argument in a healthcare system with 3rd party payers...
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This is my Congressman, Greg Landsman. Ohio is one of the states piloting this. While I do not fully trust him yet I have seen a lot of good signs. If what he says is true about the incentives for the tech company, it's a bad thing.
Link to video
