Latest / Bitesize Retirement / Medicare introduced AI-assisted prior authorization, and some medical procedures dropped by nearly 20%！

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Medicare introduced AI-assisted prior authorization, and some medical procedures dropped by nearly 20%！ · Bitesize Retirement

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  SPEAKER_00: Medicare started using AI-assisted technology to review certain medical treatments.
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  SPEAKER_00: And within just six months, the use of some medical services dropped by nearly 20%.
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  SPEAKER_00: Now, here's the question.
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  SPEAKER_00: Did artificial intelligence help Medicare eliminate unnecessary medical procedures?
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  SPEAKER_00: Or did it make it harder for older Americans to get the care they actually need?
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  SPEAKER_00: The answer could change how we think about Medicare in retirement.
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  SPEAKER_00: My name is Jean.
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  SPEAKER_00: I am a Chartered Retirement Planning Counselor, and this is bite-sized retirement.
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  SPEAKER_00: For years, one of the biggest advantages of Original Medicare has been freedom.
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  SPEAKER_00: Patients generally have more flexibility in choosing doctors and hospitals that accept Medicare.
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  SPEAKER_00: And unlike Medicare Advantage,
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  SPEAKER_00: Original Medicare has historically required relatively little prior authorization.
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  SPEAKER_00: Prior authorization means that even when a doctor recommends a treatment,
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  SPEAKER_00: the insurance plan may require approval before covering it.
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  SPEAKER_00: This has long been a major concern with Medicare Advantage plans.
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  SPEAKER_00: But in January 2026,
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  SPEAKER_00: the federal government introduced a new program that brought similar requirements
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  SPEAKER_00: to certain services under Original Medicare.
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  SPEAKER_00: It's called WISER, short for Wasteful and Inappropriate Service Reduction.
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  SPEAKER_00: The program began in six states, Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
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  SPEAKER_00: It covers a population of approximately 6.4 million original Medicare beneficiaries.
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  SPEAKER_00: The goal sounds reasonable.
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  SPEAKER_00: Use technology,
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  SPEAKER_00: including artificial intelligence,
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  SPEAKER_00: to identify unnecessary,
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  SPEAKER_00: inappropriate, or potentially fraudulent medical procedures.
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  SPEAKER_00: The program focuses on selected treatments,
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  SPEAKER_00: including certain spinal injections,
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  SPEAKER_00: procedures for back pain,
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  SPEAKER_00: and other services that Medicare officials believe deserve closer review.
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  SPEAKER_00: Importantly, AI does not independently make every coverage decision.
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  SPEAKER_00: Contractors use technology to support the review process,
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  SPEAKER_00: with human oversight required for medical necessity denials.
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  SPEAKER_00: So what happened after the program started?
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  SPEAKER_00: Researchers from the University of Minnesota
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  SPEAKER_00: and Brown University examined medical service utilization during
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  SPEAKER_00: the first six months of 2026.
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  SPEAKER_00: Their findings were published in JAMA in October, and the results were striking.
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  SPEAKER_00: The use of epidural steroid injections for back pain fell
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  SPEAKER_00: by approximately 15 percent relative to comparison states.
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  SPEAKER_00: Other medical services affected by the new authorization requirements declined by
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  SPEAKER_00: about 19.5 percent.
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  SPEAKER_00: The largest changes happened During the first quarter of 2026,
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  SPEAKER_00: utilization in both categories dropped by roughly 21%.
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  SPEAKER_00: By the second quarter,
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  SPEAKER_00: the decline in epidural injections had moderated to approximately 9%,
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  SPEAKER_00: while the other affected services remained down around 18%.
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  SPEAKER_00: Meanwhile,
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  SPEAKER_00: comparison procedures that weren't subject to
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  SPEAKER_00: the new requirements did not experience the same sharp decline.
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  SPEAKER_00: That suggests the authorization policy itself played an important role.
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  SPEAKER_00: But here's what the numbers don't tell us.
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  SPEAKER_00: Were these unnecessary treatments that patients were better off avoiding?
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  SPEAKER_00: Or were some patients unable to receive appropriate care because
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  SPEAKER_00: of additional paperwork, delays, or denials?
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  SPEAKER_00: The study could not answer that question.
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  SPEAKER_00: And that's the distinction that matters.
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  SPEAKER_00: Imagine a 70-year-old retiree dealing with severe persistent back pain.
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  SPEAKER_00: After evaluating the patient,
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  SPEAKER_00: the doctor recommends a spinal injection to help manage the Under
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  SPEAKER_00: the previous process,
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  SPEAKER_00: assuming the procedure met Medicare's coverage requirements,
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  SPEAKER_00: the treatment might have been scheduled without
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  SPEAKER_00: an additional prior authorization review.
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  SPEAKER_00: Under the new pilot,
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  SPEAKER_00: if that particular procedure requires authorization,
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  SPEAKER_00: the doctor must first submit documentation explaining why
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  SPEAKER_00: the treatment is medically necessary.
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  SPEAKER_00: If everything goes smoothly, the patient receives approval and proceeds with treatment.
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  SPEAKER_00: But what happens if the paperwork is incomplete?
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  SPEAKER_00: What if the review takes longer than expected?
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  SPEAKER_00: What if the request is denied?
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  SPEAKER_00: And what if the doctor's office decides that pursuing authorization is simply too burdensome?
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  SPEAKER_00: In each situation, the number of procedures performed could decline.
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  SPEAKER_00: But that decline doesn't necessarily tell us whether patients are healthier or worse off.
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  SPEAKER_00: It's also possible that the program successfully prevented some treatments
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  SPEAKER_00: that were unlikely to benefit patients.
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  SPEAKER_00: Both possibilities deserve serious consideration.
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  SPEAKER_00: There's another part of this program that deserves attention.
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  SPEAKER_00: The contractors participating in WISER can receive financial rewards tied to Medicare savings.
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  SPEAKER_00: That creates an incentive to reduce unnecessary spending.
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  SPEAKER_00: But it also raises an important question.
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  SPEAKER_00: How do we make sure the incentive to save money doesn't interfere with
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  SPEAKER_00: the obligation to provide medically necessary care?
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  SPEAKER_00: A successful Medicare reform shouldn't be measured only by how much money the government saves.
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  SPEAKER_00: It should also be measured by what happens to patients.
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  SPEAKER_00: Are treatments delayed?
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  SPEAKER_00: Are necessary procedures being denied?
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  SPEAKER_00: Do health outcomes improve or deteriorate?
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  SPEAKER_00: And how much additional administrative work are doctors being asked to perform?
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  SPEAKER_00: Those are the questions that will determine whether this program is truly successful.
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  SPEAKER_00: Now, what does this mean for someone approaching retirement?
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  SPEAKER_00: When comparing original Medicare with Medicare Advantage, most people focus on three things.
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  SPEAKER_00: Monthly premiums, freedom to choose doctors, and potential out-of-pocket costs.
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  SPEAKER_00: But there's a fourth Weiser is currently a pilot
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  SPEAKER_00: And it certainly doesn't mean that Medicare has denied 20% of necessary medical care.
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  SPEAKER_00: The study measured changes in service utilization,
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  SPEAKER_00: not the percentage of patients whose treatment requests were rejected.
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  SPEAKER_00: The pilot is scheduled to continue through the end of 2031.
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  SPEAKER_00: Whether it eventually expands and what it means for the future
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  SPEAKER_00: of Original Medicare remains to be seen.
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  SPEAKER_00: But the larger issue is already clear.
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  SPEAKER_00: As Americans plan for retirement,
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  SPEAKER_00: Healthcare decisions cannot be based on premiums and coverage benefits alone.
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  SPEAKER_00: We also need to understand how easily that coverage translates into actual medical care.
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  SPEAKER_00: Because the ultimate goal of Medicare shouldn't simply be to spend less money.
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  SPEAKER_00: It should be to eliminate unnecessary care while protecting access to necessary treatment.
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  SPEAKER_00: And those are two very different outcomes.