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Artificial intelligence leading to more nursing home coverage denials

Artificial intelligence is partly to blame for increasing Medicare Advantage denials, especially among beneficiaries in need of skilled nursing care, a new report finds.

An investigation published by STAT News Monday accused insurers of using “unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment.”

The report, based on court documents and extensive interviews, comes as the federal government tries to reduce the number of pre-authorization and other denials to address a spate of consumer complaints. It also follows a February study in the Journal of Applied Gerontology that showed ageism has been designed into some AI tools.

The increasing use of artificial intelligence to guide decision-making in healthcare may further fuel government regulators’ attempts to reign in MA plans. STAT outlined the cases of two nursing home residents whose skilled care coverage was denied after an AI tool recommended they should be better by a certain number of days. Both had their payment cut off at a time corresponding with an algorithm cut point, despite physicians’ orders and documentation indicating they needed ongoing skilled care.

While the article focused on the impact on post-acute patients going to nursing homes, AI is also keeping patients out of other settings, including rehab hospitals, STAT reported.

In response, one insurer told STAT that its AI tool is meant to be used as a guide to inform providers about the care patients may need, rather than a directive to discharge. But patient advocates objected to that characterization.

“While the firms say [the algorithm] is suggestive, it ends up being a hard-and-fast rule that the plan or the care management firms really try to follow,” David Lipschutz, associate director of the Center for Medicare Advocacy, told the website. “There’s no deviation from it, no accounting for changes in condition, no accounting for situations in which a person could use more care.”

Consumer groups and academics have previously warned that insurers’ use of artificial intelligence could further impede the relationship between patients and their healthcare providers. While the goal is to serve patients in the lowest-acuity setting and possibly make healthcare more efficient, it’s unclear whether or how much early discharges might influence rehospitalization or mortality rates. 

An Australian study examining what authors called the “underresearched intersections of ageism and AI technologies” last month warned that AI has the capacity to pick up on and integrate human stereotypes about aging and limitations. 

“This ageism is not just digital — it rests on a dynamic intersection of social and technical dimensions shaping the views of those who design and inscribe an end-user script into algorithms, and of those who have the power to implement AI through choices, practices, and applications,” the authors explained. They called for such services to be used in aging care only as a “part of a suite of care services and not as isolated solutions.”

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