Trump admin using AI to deny medical care for seniors in disastrous experiment

特朗普政府利用人工智能在灾难性的实验中拒绝为老年人提供医疗护理

In January, the Trump administration rolled out a pilot program that uses artificial intelligence to authorize or deny certain types of care for patients with Medicare—a federal healthcare program for seniors that previously hasn’t required doctors to get any such pre-approval, called prior authorization. 今年1月，特朗普政府推出了一项试点计划，利用人工智能来批准或拒绝联邦医疗保险（Medicare）患者的某些护理服务。联邦医疗保险是一项针对老年人的联邦医疗保健计划，此前并不要求医生进行此类预先批准（即“事先授权”）。

Not long after, media outlets began relaying the disastrous outcomes: technical difficulties, long delays in decisions and care, puzzling denials, frustrated doctors, and patients suffering in pain. Those reports were largely confirmed earlier this month when the Electronic Frontier Foundation released a tranche of federal documents about the program, called WISeR, that the group obtained amid litigation. 不久之后，媒体开始报道该计划带来的灾难性后果：技术故障、决策和护理严重延误、令人费解的拒绝申请、医生感到沮丧，以及患者在痛苦中煎熬。本月早些时候，电子前沿基金会（EFF）在诉讼过程中获得了一批关于该计划（名为WISeR）的联邦文件，这些报道在很大程度上得到了证实。

The documents included feedback from healthcare providers, including one who called the program “a disgrace to the human race” and reported seeing patients crying in pain as they waited for care. Amid the worrying reports, lawmakers have been trying to get answers and shut the program down. Meanwhile, the Government Accountability Office determined in May that Trump officials did not follow proper procedure in setting up the program, calling its legality into question. 这些文件包含了来自医疗服务提供者的反馈，其中一人称该计划是“人类的耻辱”，并报告说看到患者在等待护理时因痛苦而哭泣。在这些令人担忧的报道中，立法者一直试图寻求答案并关闭该计划。与此同时，美国政府问责局（GAO）在5月份认定，特朗普政府官员在设立该计划时未遵循正当程序，对其合法性提出了质疑。

Still, it appears to be moving ahead unabated, with plans to expand in the years to come. Last week, Rep. Suzan DelBene (D-Wash.) called a committee vote to try to get the Trump administration to release more documents about WISeR, but Republicans voted the effort down. “It’s clear why the administration is doing everything they can to conceal these documents,” DelBene said in a statement. “The more that Americans learn about WISeR, the more outraged they get at the Trump administration for jeopardizing their care and trying to privatize Medicare.” 尽管如此，该计划似乎仍在继续推进，并计划在未来几年内扩大规模。上周，众议员苏珊·德尔贝内（华盛顿州民主党人）要求进行委员会投票，试图促使特朗普政府公布更多关于WISeR的文件，但共和党人投票否决了这一努力。“很明显，政府为什么要竭尽全力隐瞒这些文件，”德尔贝内在声明中表示，“美国人对WISeR了解得越多，就越会对特朗普政府危及他们的护理并试图将联邦医疗保险私有化的行为感到愤怒。”

Technical fumbles

技术失误

WISeR, which stands for Wasteful and Inappropriate Service Reduction, aims to use AI and machine learning to ensure “appropriate Medicare payment” for select services while benefiting taxpayers “by decreasing fraud, waste and abuse.” It was rolled out in January in six states—New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington—and intends to run until the end of 2031. WISeR（意为“减少浪费和不当服务”）旨在利用人工智能和机器学习，在确保特定服务的“适当医疗保险支付”的同时，通过“减少欺诈、浪费和滥用”来造福纳税人。该计划于1月在新泽西州、俄亥俄州、俄克拉荷马州、得克萨斯州、亚利桑那州和华盛顿州这六个州推出，计划持续到2031年底。

So far, the program requires prior authorization for around a dozen medical services, including nerve stimulation, epidural steroid injections for pain, cervical fusions (permanently connecting bones in the neck), skin substitutes for wounds, and treatments for incontinence and impotence. 到目前为止，该计划要求对大约十二种医疗服务进行事先授权，包括神经刺激、用于疼痛的硬膜外类固醇注射、颈椎融合术（永久性连接颈部骨骼）、伤口皮肤替代物，以及针对失禁和阳痿的治疗。

According to the documents released by the EFF, the program’s implementation was rushed, and the technology wasn’t ready. One vendor, Innovaccer, was so unprepared that it asked the government to delay the rollout, and when it didn’t, the vendor set up its program to automatically approve all requests temporarily. “[A]uto-affirming is the only path available that avoids creating a backlog of unprocessed prior authorizations and claims while we finalize, validate, and deploy the full rules-based solution,” Innovaccer wrote, according to a letter it sent to government officials. 根据EFF发布的文件，该计划的实施过于仓促，技术尚未准备就绪。其中一家供应商Innovaccer准备不足，曾要求政府推迟推出，在政府拒绝后，该供应商将其程序设置为暂时自动批准所有请求。根据Innovaccer发给政府官员的一封信，该公司写道：“在我们最终确定、验证并部署完整的基于规则的解决方案时，‘自动确认’是避免造成未处理的事先授权和索赔积压的唯一途径。”

But others carried on. One vendor, Zyter, had data discrepancies for months because it apparently didn’t understand the difference between Medicare Part A, which covers inpatient/hospital care, and Part B, which covers outpatient services. Zyter’s CEO, Sundar Subramanian, told Ars Technica in a written statement that the company is now “fully functional across Medicare Part A and Part B claims.” The company is working closely with federal partners and the healthcare providers to “enhance the experience,” Subramanian said. 但其他供应商仍在继续。供应商Zyter出现了数月的各种数据差异，因为它显然不了解涵盖住院/医院护理的联邦医疗保险A部分与涵盖门诊服务的B部分之间的区别。Zyter首席执行官桑达尔·苏布拉马尼安（Sundar Subramanian）在给Ars Technica的书面声明中表示，该公司现在“在联邦医疗保险A部分和B部分的索赔处理上已完全正常运作”。苏布拉马尼安说，公司正在与联邦合作伙伴和医疗服务提供者密切合作，以“改善体验”。

More denials than approvals

拒绝多于批准

Another vendor, Virtix, was found to be denying more prior authorization requests than it was approving. According to a weekly report on March 30, Virtix had reviewed 6,096 pre-authorization requests. It approved 2,863 of them, denying 3,233 (53 percent). In addition to a questionable number of denials, decisions from the various contracted companies often took too long. 另一家供应商Virtix被发现拒绝的事先授权请求多于批准的请求。根据3月30日的一份周报，Virtix审查了6,096份预授权请求。其中批准了2,863份，拒绝了3,233份（占53%）。除了拒绝数量令人质疑外，各签约公司的决策往往耗时过长。

WISeR is intended to provide authorization decisions within 72 hours, but many have taken weeks, some even months. The documents from EFF reveal at least one request was still pending after 83 days. In a survey, one healthcare provider said it “had a surgery pushed back almost two months due to zero communication.” WISeR旨在72小时内提供授权决定，但许多决定耗时数周，甚至数月。EFF的文件显示，至少有一项请求在83天后仍处于待处理状态。在一项调查中，一位医疗服务提供者表示，由于“零沟通”，他们的一台手术被推迟了近两个月。

It was revealed in June that Virtix was put on a Corrective Action Plan (CAP) by the Centers for Medicare & Medicaid Services (CMS) for “noncompliance” with the 72-hour window. In a statement to Ars Technica, Virtix confirmed it was on a CAP but said it has since “reduced its average turnaround time for prior authorization to 1.18 days and prepayment review determinations to 1.17 days, well within the WISeR Model’s 3-day requirement.” Virtix said the CAP ended on August 14. 6月份有消息称，由于“不符合”72小时窗口要求，Virtix被美国联邦医疗保险和医疗补助服务中心（CMS）列入纠正行动计划（CAP）。在给Ars Technica的一份声明中，Virtix证实其曾处于CAP之下，但表示此后已“将事先授权的平均周转时间缩短至1.18天，将预付款审查决定的平均时间缩短至1.17天，完全符合WISeR模型3天的要求。”Virtix表示，CAP已于8月14日结束。

It’s unclear if any other vendors have been put on a CAP. The CMS and the Department of Health and Human Services did not immediately respond to Ars Technica’s request for comment and a list of questions related to WISeR in time for publication. 目前尚不清楚是否有其他供应商被列入CAP。CMS和美国卫生与公众服务部未能在截稿前及时回应Ars Technica的置评请求及有关WISeR的一系列问题。

In its comment to Ars, Virtix said that it “understand[s] that any delay in care is difficult for patients, and we do not take lightly the impact that the prior authorization process can have on people who are in pain and seeking relief.” That said,” the company continued, “the WISeR program uses long-established [National Coverage Determinations] and [Local Coverage Determinations] set by CMS, not by Virtix Health, to evaluate the medical appropriateness of each requested procedure.” Virtix encouraged providers to consider resubmitting authorization requests and ask for peer-to-peer discussion about denials. 在给Ars的评论中，Virtix表示，他们“理解任何护理延误对患者来说都是困难的，我们不会轻视事先授权流程对那些处于痛苦中并寻求缓解的人们所产生的影响。”该公司继续说道：“话虽如此，WISeR计划使用的是由CMS而非Virtix Health设定的长期确立的‘国家覆盖范围确定’（NCD）和‘地方覆盖范围确定’（LCD），来评估每项请求程序的医疗适当性。”Virtix鼓励医疗服务提供者考虑重新提交授权请求，并就拒绝决定要求进行同行评审讨论。

“A disgrace to the human race”

“人类的耻辱”

The suggestion to reach out for support is unlikely to assuage many providers who have experience with WISeR. From their perspective, technical snags, delays, and unexpected denials have led to real misery, and many provider 这种寻求支持的建议不太可能安抚许多有WISeR使用经验的医疗服务提供者。在他们看来，技术故障、延误和意想不到的拒绝已经导致了真正的痛苦，许多医疗服务提供者……