WHEREAS:
Earlier this year, the Centers for Medicare & Medicaid Services (CMS) launched a pilot program named the Wasteful and Inappropriate Service Reduction (WISeR) model in six states, introducing prior authorization requirements for certain services within the traditional Medicare program; and
WHEREAS:
The WISeR model relies on outside, for-profit vendors who are expected to test the use of artificial intelligence (AI) tools to manage the prior authorization process; and
WHEREAS:
These vendors have an apparent financial incentive to identify instances to deny approval of care; and
WHEREAS:
Prior authorization requirements often interfere with access to necessary, appropriate care, and Medicare has other tools to address the provision of unnecessary care. For example, for one of these high-profile items and procedures covered by the WISeR model, skin substitutes, CMS has already acted by significantly reducing reimbursement. It has also signaled heightened scrutiny towards the bad actors providing wasteful and fraudulent services; and
WHEREAS:
The pilot has gotten off to a rocky start, with providers reporting widespread confusion and technical glitches that can delay and interrupt needed medical care; and
WHEREAS:
Many U.S. Senators have repeatedly called for an end to the WISeR pilot, noting that the program imports the worst abuses of the private insurance market into Medicare; and
WHEREAS:
Many retirees expressly choose traditional Medicare coverage because it typically does not impose limits on accessing care such as prior authorization requirements or restrictive provider networks usually found in private Medicare Advantage plans.
THEREFORE BE IT RESOLVED:
That AFSCME calls for the WISeR model pilot program to be terminated; and
BE IT FURTHER RESOLVED:
That AFSCME opposes arrangements between the Medicare program and private, for-profit entities that explicitly incentivize the denial of prior authorization for medical care, such as by giving those private vendors a share of the “savings” from denying coverage; and
BE IT FINALLY RESOLVED:
That AFSCME opposes the denial of access to care by automated decision-making systems or otherwise using AI without meaningful human oversight in the Medicare program or anywhere else in the health care system.
SUBMITTED BY:
Steven Tully, Executive Director and Delegate
Ronald McMullen, President and Delegate
AFSCME Council 63
New Jersey