I just got back from vacation and didn’t have to think about this for a whole week. But there’s no place like home. For a whole week, I didn’t have to worry about chores, obligations, or how Medicare Advantage is taking unfair advantage of 54% of seniors who qualify for Medicare.
My only concern was wondering why Mardi Gras starts so early in New Orleans.
As providers in skilled nursing facilities and home care, we know the disadvantages of Medicare Advantage (MA). We know the disingenuous traps that snare people with low premiums (sometimes considered “no premiums” because they don’t get a bill.) We know that the care these plans provide sometimes amounts to neglect. We have lost respect for the celebrities hawking these plans during the afternoon judge shows.
However, a recent class action lawsuit against Humana alleges that artificial intelligence is making clinical decisions and denying doctors’ recommendations to cut costs.
No advantage to these algorithms
It’s not news that Medicare Advantage is not Medicare. MA plans are for-profit HMO plans that frequently incentivize brokers to steer clients in order to maximize their profits and bonuses. They’re not the government plans they promise, and they’re not Medicare. The lawsuit alleges that the AI model that Humana uses is highly inaccurate and that Humana knows it but doesn’t alter it.
AI has a place in healthcare. It has been shown that when radiology and other tests are run through an AI model, the interpretation of the results is often optimized and more accurate. In order for AI to be ethical and useful in clinical practice, it must be approved by regulators, integrated with EHR, and taught to clinicians. But as a tool to determine how to maximize profit for a private insurer, ethics take a back seat.
The algorithm used by Humana, and let’s face it, the other MA plans, has been deemed as a “fraudulent scheme” to deny care. The AI algorithm used, called nH Predict, is considered a strategy to “reap a windfall by systematically denying claims to desperately ill people.”
United Healthcare appears to have the same problem. The AI model used by this MA plan has been shown to have a 90% error rate. Ninety percent. Another lawsuit brought by the estates of two deceased clients who were denied coverage opens the door to not only more lawsuits but more illnesses and deaths as well.
Look past Medicare Advantage’s ‘perks‘
I have spent too much of my time on appeals to Medicare Advantage plans. Time that could have been spent on patient care was devoted to protesting, appealing, Peer-to-Peer calls, and more.
However, the hours spent on all the steps to regain coverage and control over the care of the patients frequently resulted in a successful extension of their coverage. Once you speak to a clinician who understands individual medical complexity and expected outcomes, logic, experience, and compassion prevail. Explaining to a human person that sending Mr. Smith home too early and knowing that he’s going right back to the hospital at a higher cost than staying for three more days in your SNF makes sense to a human clinician.
Redeeming Medicare Advantage may not be possible. With all the hospital systems, physicians and other providers canceling their contracts and getting out of the plans, fewer clients have providers “in-network” and may end up canceling their MA programs on their own. Aside from the “delay, deny and don’t pay” model, the allegations of fraud have reputable hospitals and providers running scared. Who can blame them?
For several years, Congress has been trying (with little success) to crack down on the alleged fraud and abuse inflicted by Medicare Advantage programs. With the current lawsuits, current allegations of fraud, and current trends of network exclusions, it may only be a matter of time before MA is either reformed or eliminated.
But in the meantime, as your clients, patients and loved ones begin their search for the best options for themselves and others, educate them and steer them to the decision that will enhance and prolong their lives. It’s easy to be misled by lower premiums and little perks like gift cards, but not at the expense of our health.
We are in the business of healthcare, but healthcare is more than a business.
Jean Wendland Porter, PT, CCI, WCC, CKTP, CDP, TWD, is the regional director of therapy operations at Diversified Health Partners in Ohio.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
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