EPISODE 302

Do you want bots deciding what kind of health care you get? The Trump Administration is experimenting with using AI to determine whether patients in traditional Medicare can get the care they need. This is an attempt to make the traditional program more like Medicare Advantage — a glorified HMO that gets between you and your doctor. Our health policy expert, Anne Montgomery, explains why this is such a bad idea for Medicare beneficiaries. Plus: members of the Kennedy family join members of Congress in calling for the resignation of HHS Secretary Robert F. Kennedy, Jr.

TRANSCRIPT:

ANNOUNCER: It’s You Earned This, the Social Security and Medicare podcast, brought to you by the National Committee to Preserve Social Security and Medicare. And now, your host, Walter Gottlieb. 

WALTER: Hey there, well, on this podcast, we have talked about how Medicare Advantage (MA) plans sometimes demand pre-authorization for medical procedures and other types of care ordered by your doctor. 

Need skilled nursing care? That might need to be pre-authorized. Ditto with lab tests and hospital stays. And that’s because MA is like a giant HMO that can get between you and your doctor. 

Now, the Trump administration is amping up pre-authorizations in traditional Medicare, not Medicare Advantage, which is not supposed to be like an HMO. And they’ve started a new program to use artificial intelligence to decide what care you’ll get. Not human beings, but AI. But before we get started, here’s a word from our “sponsor.”

ANNOUNCER: Hello, friends. Are you tired of getting the medical care that you need? No need to fret any longer. Because the Trump administration is going to use AI bots to decide which services and procedures you can get. Isn’t that swell? Why trust your doctor when a bot knows better? Coming soon to a traditional Medicare program near you. This message has been brought to you by Donald Trump, who never met a health care program he couldn’t louse up. 

WALTER: In the studio today, we have none other than our very own health policy expert, Anne Montgomery. She’ll tell us how AI might just be infecting traditional Medicare, thanks to Donald Trump. Plus, calls from members of Congress for RFK Jr. to step down. Anne Montgomery, it is wonderful to see you. 

ANNE: Good afternoon. Good to see you. 

WALTER: Good afternoon. I don’t think I saw you all summer. What have you been up to? 

ANNE: What have I been up to? Well, I went to Montreal to see my daughter, and I’ve been at the flower farm where I live with my beautiful husband, having a good summer, a wonderful summer, actually. 

WALTER: And did you go to any of those exciting health policy conferences? 

ANNE: I did go to a couple. The Center for Innovation had a fantastic conference in St. Louis, and I love long-term care, so I talked endlessly about that and networked. It was great. 

WALTER: Well, that’s good. We appreciate all the good work you do for us and out there in the field. So, let’s talk about the Trump administration’s new pilot program, where they are going to test out the concept of having AI bots determine whether patients in traditional Medicare, or, as some people call it, original Medicare, should be allowed to have procedures that their doctor says they need. Anne, tell me if I summarized that properly. Like, I hope that isn’t what’s really going on, but let me know. 

ANNE: I think, unfortunately, you did summarize it correctly. Prior authorization is one of those utilization management tools that insurers use, particularly Medicare Advantage plans are well-known for using it. But, it is now coming to original Medicare, fee-for-service Medicare. Rather than having trained people, trained medical reviewers, look at whether a doctor-prescribed treatment or service is necessary, it’s going to be an artificial intelligence algorithm that apparently decides whether the payment will be made for a particular service. And that’s scary. It’s scary for beneficiaries, because if that payment is not made by Medicare, then they will be on the hook financially for paying for it out of pocket. 

WALTER: The Trump administration in general seems to be trying to turn Social Security and Medicare into some sort of high-tech operation, as if venture capitalists are about to buy them and destroy them and gut them. But be that as it may, why on earth would you want to use AI bots to determine whether people need healthcare?

ANNE: It’s not a good idea, and physicians and other providers are very doubtful that this will turn out well. For example, the American Medical Association (AMA) does periodic surveys of all kinds of things, including the use of AI, and physicians have been complaining really for years now that this gets in the way… that AI or any other kind of prior authorization review gets in the way of good medical care. So it’s an ongoing tension. Prior authorization is not new. It’s not new to Medicare. It’s been used in the context of a very few procedures here and there…. some hospital outpatient services, for example, and it’s been administered by Medicare administrative contractors or MACs. 

WALTER: People, human beings. 

ANNE: Actual human beings. But, this particular move by the Trump administration is to move, as you said, to an AI-administered screening in six states for six years over a broad range of procedures… a broader range of procedures than has been used before. The potential for negative impact on beneficiaries is going to be greater. 

WALTER: So, I’m eligible for Medicare soon, and I’m going to choose traditional Medicare because I don’t like anything that we know about Medicare Advantage. But now, if I do that and my doctor says I need this lab test, or my doctor says I should have this procedure to help whatever problem I’m having… now there’s a chance that an AI bot is going to decide what happens to me?

ANNE: That’s correct. The initial range of services will be fairly narrow. It won’t be inpatient hospital services, for example, but it could happen and you should be on the watch for it. If the payment is refused and you end up stuck with the bill, you should be aware of your rights to appeal formally, either through your Medicare Advantage plan or through original Medicare. 

WALTER: Yeah, this is like Grey’s Anatomy meets Blade Runner or something. I don’t know… it’s all sorts of work for me to do if I get denied care. 

The reason that we in the advocacy community consider Prior Authorization to be a little of a trigger or a hot button is because of Medicare Advantage plans, that’s the privatized version of traditional Medicare. These insurance companies are now using prior authorizations to deny care because it saves them money. Medicare Advantage is more like an HMO setting where you need approval for everything. 

ANNE: Correct. 

WALTER: Pretty much, right? So, it sounds like, am I wrong? The Trump administration is taking that idea and running with it a little bit and trying to impose that on traditional Medicare. 

ANNE: Yes, I would say that’s true. The problem with Prior Authorization in the context of Medicare Advantage or HMOs is that HMOs already have a powerful incentive since they get paid a certain amount of money per beneficiary per month and no more. 

WALTER: Right. 

ANNE: To arguably, you know, cut back on services or be careful with what services are provided so they can reap greater profits. The use of prior authorization can kind of spread and get more and more draconian in that kind of environment, which is a worry since it’s a black box. It’s a problem that could be solved legislatively if the regulations were codified in federal statute. And there is a bill out there in the Senate that’s bipartisan, and it would make a real difference if Congress could move on that. 

There still is the end of the year bill, of course, that Congress is working toward, which will extend various programs, you know, community health centers, hopefully, and others. And perhaps prior authorization curbs can be included in that bill. 

WALTER: When you take a look at what the Trump administration is doing at the Social Security Administration (SSA), they are using AI chatbots instead of live human beings to answer calls on the 1-800 number. And the results are not spectacular so far. I know that CNET called the chatbots “horrible.” Here are some of the things that the AI chatbots have been doing: They’ve been giving irrelevant and circular responses. They’ve been giving inaccurate information. Experts have tested A.I. systems on Social Security questions and received, quote “horribly” wrong answers. 

This results in worse customer service, which has compounded the effects of already low staffing and SSA and cutbacks that the Trump administration is doing. One report noted that an A.I. chatbot program delayed retirement claims by 25%. So, do we really want that in our health care decisions too? 

ANNE: We absolutely do not. And it is a concern. That kind of trend, when applied to the health care system, could be a disaster. There’s no substitute, obviously, for a human being who can listen, take notes, and provide detailed specifications based on your individual situation. AI chatbots really can’t do that. 

WALTER: Not yet anyway. Maybe in 100 years. Maybe less. I don’t know. But right now, it’s not a good time, that is all I’m saying. 

While we’re talking about Medicare Advantage… Healthcare Dive, the news site, had a headline saying, “Insurance Companies are Gaming Medicare Advantage Risk Adjustment,” according to a new analysis. Major insurers are gaming Medicare Advantage’s risk adjustment system to reap higher payments from the government, costing Medicare billions of dollars, according to a new analysis of CMS data. 

The worst offender was UnitedHealthcare, who cost Medicare more than $6 billion in excess payments, according to the Alliance of Community Health Plans. So this is rich, considering that Medicare Advantage was created to supposedly save taxpayers money versus traditional Medicare. And now, one company cost us in excess of $6 billion in a year. What is going on there? 

ANNE: Medicare Advantage plans are very good at creating a bid, which then allows them to be underneath a benchmark that’s set for each county in the U.S. And with that gap, with their bid being lower than the benchmark, they can offer additional supplemental benefits that aren’t covered by original Medicare. 

WALTER: Gym memberships, rides… 

ANNE: Hearing, vision, dental, and so on. That way, they can increase their enrollment because they market that very heavily. 

They then turn around and very carefully scrutinize all of their enrollees and code every single ailment, every single risk factor that they possibly can, and therefore end up with payments from the government for many more services than would be true if this same individual was in fee-for-service Medicare. They bill the government for more. 

WALTER: So, they’re inflating the cost of care, they’re exaggerating the patient’s condition so they can make more profits. 

ANNE: Exactly. 

WALTER: For them and their shareholders. 

ANNE: And that’s very costly. You know, for the Medicare program, it is a problem, an increasing problem. It’s going to shorten the life of the Medicare Part A hospital trust fund. It’s sending up Part B costs, which are physician services, and in general, it’s causing havoc. Now, there is legislation out there and calls to reduce those Medicare Advantage overpayments. I don’t know that Congress is going to be able to do that, but the pressure is growing and the momentum is growing to try to address this. It could be addressed in regulatory terms. You could figure out, if you were CMS and you were determined, how to address the gaming. Essentially, how to make it harder for Medicare Advantage plans to upcode. The efforts so far have been insufficient and this administration has not made much of an effort to really solve the problem. 

WALTER: You were alluding earlier to some of the staffing cuts at HHS, there are fewer people to do the really big job that that agency has. And of course, President Trump’s head of HHS—the HHS secretary—is Robert F. Kennedy, Jr. a choice that was “somewhat” controversial. He was grilled by Democrats on Capitol Hill last week after he fired the head of the CDC for no apparent reason, Centers for Disease Control. His own relatives are now calling for his resignation. I know former Congressman Joe Kennedy III called his uncle a “danger to the health of the American people.” And then, several Democratic members of the Senate Finance Committee, chaired by Ron Wyden of Oregon, signed a letter demanding RFK Jr.’s resignation. And what they say is pretty damning and worth paying attention to.

The letter says: “Robert Kennedy has failed to protect the health of the American people and endangers the lives of all Americans, particularly children, people with disabilities, and vulnerable Americans.” Which, I would include seniors in that group. They added: “Robert Kennedy must resign, and if he doesn’t, Trump should fire him.”

I guess both of those scenarios are unlikely right now. But what are people so exercised about concerning the reign of HHS Secretary Robert F. Kennedy Jr.? 

ANNE: I think the major concern is in the public health community and it’s around vaccines. RFK Jr. has a long history of being a skeptic, shall we say, of vaccination. 

WALTER: Yes, we shall say. 

ANNE: That is something that he insisted would not carry forward into his tenure when he was seeking to be HHS Secretary. And going through his nomination hearings, he said, “I will not lock vaccines, I will look at the science, I will follow protocols that have long been in place for vaccination, and I won’t oppose it.” It’s not turning out that way. He did fire a number of people on a very key FDA, Food and Drug Administration, vaccine advisory committee, and replaced some of those folks with people who are very skeptical, if not vaccine deniers. And, he seems to be listening to them. He is narrowing vaccination protocols for the COVID booster that’s coming out this fall. 

WALTER: That’s crazy. 

ANNE: Such that people over 65 will be able to get it, supposedly. I haven’t tried myself, but I’m going to shortly, and see if it really is possible and easy to get that vaccine. 

WALTER: But will you have to pay for it out of pocket now, or something? 

ANNE: I don’t think so. 

Walter: But anybody under 65? 

ANNE: Anybody under 65 is going to have a much harder time getting the vaccine. And their insurer may or may not pay for it. So it may end up, even if they can get it, being a cost burden for them, as the HHS advice will be not to prioritize those populations. And that’s pretty shocking. You know, when you think about all adults and all kids, this has been gospel for many decades. Vaccines prevent disease. We know this. And they are highly tested, highly regulated. So the idea of pulling back on that is pretty shocking. 

WALTER: And you see the resurgence of diseases like the measles, that we thought we had conquered. And this summer, this past summer, a lot of people I know got COVID. I mean, I got the booster, but COVID is not dead. It may be blunted somewhat. But to take away people’s ability to get the vaccine? That’s crazy. After we’ve made all this progress? 

ANNE: Correct. 

WALTER: Well, then I just have to ask you one more question. Do you believe in science? 

ANNE: I absolutely believe in science. It is the foundation of medicine. It’s the foundation of health policy. And it has to always continue and get better, because that’s how we get better. 

WALTER: Then you can never have a position in the Trump administration, Anne. 

ANNE: You are correct. 

WALTER: You’re doomed. Your political aspirations are doomed, at least till the next election, if we have one.

Anyway, hey, this has been a pleasure, Anne. We love having you on. You’ll be back again. Thanks for being our guest on just the second episode of Season 3. It’s so exciting. 

ANNE: Thank you, Walter. And thank you, Shahab, too. 

WALTER: Shahab, our engineer. Okay, Anne. Be well. Thank you. 

ANNE: All right. 

WALTER: And you can stay on top of everything that’s happening here in D.C. that affects you and your older loved ones by subscribing to our morning newsletter and our blog. You can sign up for both on our website, ncpssm.org. That’s ncpssm.org.

And gosh, if you like what you’re hearing, follow us and give us a review on your favorite podcasting platform. I’m Walter Gottlieb reminding you: “You Earned This!”