Tech "Doctors" Coming Soon

Let's ask AI if you need that medical procedure, OK?

In another subtle (so far) attack on Medicare, the Collins/Trump regime has implemented the Wasteful and Inappropriate Service Reduction (WISeR) model in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. This model uses artificial intelligence to review prior authorizations for certain services. It’s a 6-year pilot that the regime wants to ultimately take nationwide.

You know what they mean when they say “waste,” right? Remember DOGE? They mean slashing funding by any means possible, right or not, smart or not. Like DOGE, this project is being driven not by subject experts (you know, like doctors?) but by tech geeks. “Move fast and break things,” right?

As with all things Trump, the project has been a disaster. The rollout, already thrown together too fast, was delayed by two weeks due to technical glitches. According to the Medicare Policy Initiative, some providers reported problems with online portals, technical glitches, and poor communication with model participants. Each of the states has a different tech vendor, so each state is having a different experience.

There are many reports of longer wait times for patients, as found for instance by Senator Maria Cantwell (D-WA). For epidural steroid injections, she says, urgent authorizations used to be done in 1 day, but now it’s 15-20 days. Standard authorizations used to take 3 days, but now it’s 15-20 days. Authorizations for other procedures that used to be processed in 2 weeks are now taking 4-8 weeks.

Since like the steroid injections, many of the targeted services are intended to relieve pain (such as knee and hip replacements and shoulder arthroscopy), that means patients are enduring 2-6 weeks of unnecessary pain.

The participating states are also seeing extremely high rates of denials. The Washington Post reported (sorry, no link) that, in Texas, approximately 62% of prior authorization requests received initial approval. The approval rate increased to 84% after physician review following initial non-authorization.

What could be driving such high denial rates? Follow the money. The private tech companies running the AI analyses are paid based on how many claims they deny. This has been termed “pay-for-denial.” “The companies don’t receive a flat fee,” InsightHealth reports. “Instead, they earn a percentage of the savings generated by averted wasteful care. In other words, they get paid when services are denied or diverted — a structure that has immediately drawn scrutiny.”

The tech companies working on WISeR are Cohere Health, Inc. (Texas), Genzeon Corporation (New Jersey), Humata Health, Inc. (Oklahoma), Innovaccer Inc. (Ohio), Virtix (Washington), and Zyter Inc. (Arizona). I managed with some difficulty to find licensed healthcare providers at all of them, but they’re not driving the bus. The nerds are driving the bus.

Information on these companies and their WISeR involvement is hard to come by (all are privately held, and CMS doesn’t have much to say), but ProPublica did a deep dive on a publicly held tech company that does similar work for commercial insurance plans. They found that “EviCore markets itself to insurance companies by promising a 3-to-1 return on investment — that is, for every $1 spent on EviCore, the insurer would pay out $3 less on medical care and other costs.”

There’s a term for that: “perverse incentive.” ProPublica reported that “EviCore uses an algorithm backed by artificial intelligence, which some insiders call ‘the dial,’ that it can adjust to lead to higher denials. Some contracts ensure the company makes more money the more it cuts health spending. And it issues medical guidelines that doctors have said delay and deny care for patients.”

Read that again: they can calibrate the number of denials based on what, monthly quotas?

Fun fact: EviCore is owned by Cigna, the seventh largest health insurance company in the country. That would make it both the fox and the henhouse. We’re just the hens.

The WISeR intervention is also increasing stress on already stressed medical practices. InsightHealth says “For practice administrators managing call volume, referral pipelines, and front desk capacity, a model that flags 25% of covered service claims for prepayment review isn’t just a compliance issue. It means more inbound calls from patients asking what happened to their procedure, more staff time documenting medical necessity, and more operational pressure on teams that are already running thin.”

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Democrats in Congress have been galvanized by the project. They invoked the Congressional Review Act (CRA), which requires federal agencies to submit rules to Congress before they can take effect. Last December, Senators Ron Wyden (D-OR), Patty Murray (D-WA), Kirsten Gillibrand (D-NY), and Richard Blumenthal (D-CT) asked the Congressional Budget Office if the WISeR project met the definition of a “rule.” It did, so Democrats in both the House and Senate introduced “Joint Resolutions of Disapproval,” on which Congress must act within 60 days of a GAO ruling. If such resolutions pass in both houses and the president signs it, the program is dead.

The Senate voted on its resolution on July 16. Every Republican present, including Susan Collins, voted against it, so it failed. No House vote was taken because both chambers must approve it. Of course, Trump would never have signed it, so it was never going to happen. Who lobbied against it? The Collins/Trump regime, the tech companies, and of course nearly all members of That-Thing-That-Used-To-Be-The-Republican-Party^TM. Lobbying for it were organizations representing hospitals and physicians, a number of medical specialty groups, senior advocacy groups, and labor and education organizations.

At this point, the only way to stop this AI madness from invading our physician-patient relationships is to turn Congress blue this year and then turn the White House blue in 2028. Here’s the assignment: vote against every single Republican on every single ballot, from Congress to school board. Otherwise, faceless tech companies will determine whether or not you get that joint replacement, cardiac MRI, or joint MRI. And for-profit insurance and tech executives will continue to get richer.