Trump Administration's AI-Driven Prior Authorization Pilot Raises Patient Access Concerns

The Centers for Medicare and Medicaid Services is piloting an AI-driven model called WISeR in six states, aiming to reduce wasteful spending in original Medicare. The program uses machine learning alongside human review to evaluate services deemed vulnerable to overuse or fraud, such as certain implants and knee procedures.

The push comes amid widespread frustration with prior authorization, a process that requires insurers to approve treatments beforehand. While intended to control costs, it's often criticized for delaying care. A recent Commonwealth Fund survey found that over 40% of people denied through this process experienced delayed treatment, with more than a quarter reporting their health worsened as a result.

Doctors are particularly wary. An American Medical Association survey showed 61% of physicians worry AI will lead to more denials of necessary treatments. Critics argue the technology could be used to make inappropriate denials easier, not to simplify access to appropriate care. Early reports from the WISeR pilot suggest it has already caused care delays and denials in some cases.

The administration and private insurers have pledged to streamline the system, including setting faster decision timelines and reducing the number of services requiring approval. However, the introduction of AI into this contentious process raises a central question: will it fix a burdensome system, or create new barriers to care for vulnerable patients?