medicare

The AI ‘modernization’ project at CMS

In the not-too-distant future, the entire process of finding Medicare coverage may be influenced by artificial intelligence — a development that would allow this technology to guide one of the most important decisions that older adults and people with disabilities make.  

The Centers for Medicare and Medicaid Services is actively looking for AI companies “that are capable of enhancing the Medicare experience” for the country’s 70 million Medicare beneficiaries, according to a new notice from the agency. This would include, and go well beyond, AI chatbots and automating call centers.

CMS wants AI tools that help Medicare enrollees “make informed plan choices and maximize their coverage.” The technology would create “personalized, claims-informed plan recommendations based on individual health needs, medications, provider preferences, and actual utilization patterns,” CMS said in the notice. This implies AI companies would have access to Medicare patients’ medical data.

Here’s the rub: More than half (55%) of all Medicare beneficiaries are enrolled in Medicare Advantage. Ten years ago, just a third of Medicare enrollees were in Medicare Advantage plans, which offer more benefits and coverage than the traditional Medicare program but costs taxpayers significantly more money and restrict the care people can get. 

I have a lot of questions about how this AI would work, and how it would be regulated. What would stop AI from nudging more people into Medicare Advantage? If an older adult is healthier and doesn’t have many medical claims — the type of person every Medicare Advantage plan wants — would AI suggest a Medicare Advantage plan because it’s cheaper? Would sicker people be guided into traditional Medicare? Will tradeoffs and restrictions be fully explained? 

CMS said it would account for potential conflicts of interest. Interested AI companies “must not be affiliated with or owned by … any entity with a financial incentive to steer beneficiaries toward specific plans or carriers,” the agency said. That includes health insurers, brokerages, and third-party marketing organizations. 

The entire American economy is whipped up on fantastical visions of what AI can do, so it was only a matter of time before the nation’s bedrock social insurance program was roped into it. CMS is accepting responses until March 31, and plans on issuing formal requests for bids after — although future contracts could be smaller in scope.

hospitals

OhioHealth in the antitrust crosshairs

The Department of Justice and Ohio’s attorney general have sued OhioHealth, a Columbus-based hospital goliath, for allegedly forcing anticompetitive terms on health insurers, my colleague Tara Bannow reports.

The DOJ complaint is somewhat vague on specific contracting details, but antitrust officials alleged OhioHealth used anti-steering and all-or-nothing contracts with insurers. The end result would be insurers having to include OhioHealth’s hospitals in all their plans, which would give OhioHealth the power to name its price. 

“If OhioHealth is a must-have, especially if you needed it for network adequacy, then they would have you over a barrel,” Leemore Dafny, a Harvard professor and former federal antitrust regulator, told Tara. Read more.

technology

Ask for a directory and thou shalt receive

A national directory that lists up-to-date information for doctors and hospitals is finally going to launch in a beta phase later this year. 

It’s unclear what has been built so far, which technology companies remain involved, and which providers and insurers are participating in the initial launch. Four companies — Palantir, Availity, the Council for Affordable Quality Healthcare, and Gainwell Technologies — had “proof of concept” contracts to build out a prototype, but those contracts expired in January. 

CMS, which is overseeing the national provider directory, stayed mum. Read more from me.