I’m starting this with a personal story. My mother worked as a teacher in New York City for many decades. When She joined the school systems, and was told that when she retired many of her Medicare plan costs would be subsidised. by She and her husband were by This is the city. So far, so good. The city is now trying to cut costs. is Moving all of its pensioners, which includes the teachers at public schools, to a Medicare Advantage plan

(If you don’t know what Medicare is, or the difference between traditional Medicare and Medicare Advantage, don’t worry about it — a lot of people don’t. I’ll explain in a moment.)

Retired NYC employees are being switched to a Medicare Advantage plan — and many aren’t happy about it.
Erik McGregor/LightRocket, via Getty Images

A lot of city retirees are not happy about this switch — and, in fact, have been fighting this in court For the past couple of years. Why? Because, among other things, Advantage plans give health insurance companies much more power to deny coverage — and those denials are being based on predictive algorithmic tools rather than medical personnel.

So, what’s the point? is Medicare?

It might be helpful to have some background information in order to understand Medicare Advantage. This is what I’m talking about. is This is stuff that you will probably need. Medicare was originally created as an insurance policy. government-run health insurance program This fund was created in 1965 to provide care for those over 65. who They are no longer covered by Employers and employees were generally considered to be too high a risk. by Private insurers. It was paid for by taxes pulled from employees’ paychecks and matched by employers. And with today’s atmospheric increases in the price of healthcare, it has become a necessity for most of today’s older people.

Medicare is like all other government programs. isIt is, at the very least, complex. Do you think it is difficult to do your annual taxes? You might want to learn how Medicare works. There’s Medicare A, which handles hospitalization, Medicare B, which handles payments to doctors (and which has an annual fee), Medicare D, which handles medications (and is The list also includes several for-pay, alphabetical Medicare programs. But even with all the complications and extra fees, Medicare means that, if you’re lucky enough to last past 65, you should be able to afford to go to a doctor and get care.

Eyes glazing over yet? Wait — now we’re going to get into Medicare Advantage and its algorithms.

You might be able to see that traditional Medicare isn’t a favorite of health insurance companies. While they can handle Medicare B, and other aspects for-pay of the program they have limited responsibilities. by governmental regulations and rules as to how much they can charge for services and how much power they have over doctors’ recommendations for care. Medicare Advantage was also known by Medicare Part C in 1997.

Medicare Advantage is a type of private insurance that allows you to get Medicare benefits. is handed control of all parts of your Medicare benefits — the hospital part, the doctor part, the drug part, and all the other parts. Advantage has, well, advantages, at least at first — it costs less to you than the government programs, is easier to deal with (because it’s a single entity), and there are all those really cool advertisements showing active, carefree gray-haired people golfing, vacationing, hugging their grandkids — oh so happy that they handed over the responsibility for their healthcare Big Health Insurance, Inc.

However, because an insurance company running your Medicare Advantage program has more control over payments, it can demand that you — and your doctors — get advance approval for pretty much anything short of a checkup. And since the fewer procedures it has to pay for, the more profit it can keep, there’s a strong incentive to deny as many procedures as possible.

What care do you really need?

A recent survey by a report by the medical journal Stat, insurance companies have been using these algorithmic tools — rather than doctors or other medically trained people — to determine whether patients who all Medicare Advantage program enrolled are entitled to care. According to the report, these tools are being utilized. “to pinpoint the precise moment when they can shut off payment for a patient’s treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying treatment of seriously ill patients who are neither aware of the algorithms, nor able to question their calculations.” Appealing against those denials may take several months, or even years. This can mean that some appeals will last for longer than the time it takes to get through all the steps. This saves you money.

The advertisements for these products are very clear in describing what they can do. A pamphlet for nH PredictThis is one reason why, one of the products that was used, says, “Using the nH Predict tool, case managers now determine first if lower levels of care can meet patients’ clinical needs, and then recommend higher levels of care on an individual basis when medically necessary.” 

It now appears that those case managers mentioned in the quote may be saving their time. by Pass on the “individual basis” part and taking the tool’s recommendations at face value. Center for Medicare Advocates was established last year. issued a special report This is what we said. “Although most AI-powered decision-making tools claim to offer only recommendations that are not intended to substitute for clinical or medical judgment or for Medicare law, in the Center’s experience, users often implement the tools’ recommendations without any critical examination of their impact on patients.”

In other words, if your doctor feels you need a procedure to, say, prevent you from having a stroke, and your insurance company’s algorithmic tool pops up saying that you don’t need that procedure (and so the insurance company can deny payment for it), you have a couple of choices. There are two options. You could pay the entire procedure and then go into debt to try and convince your doctor. Or if you can’t afford to pay on your own, you can wait and hope that your appeals will come through before you have that stroke.

Or there’s always GoFundMe.

It’s not easy to be the caretaker for an older adult or parent. It’s going to get a lot worse if, when my mother needs medical care in the future, I (and her doctor) will have to battle an algorithm as to whether she deserves the prescribed care. I’m not looking forward to it. And I’m not the only one dealing with this issue. Many, many parents who are part of Advantage plans are involved. who may one day be informed that, according to the judgment of an unnamed statistical tool, the treatment that their parents’ doctor says is necessary — is not.