Tweak the Algorithm is not a feisty battle cry, but it befits this age of AI, of cyberspace, of computerized masses of data.
The familiar enemy is the Bigs: Big Pharma, Big Insurance, Big Pharmacies. The corporatization of healthcare has left us with bureaucrats-in-charge. In the battle of patients versus the Bigs, no David vanquishes Goliath, because Goliath is a protean mass, with a thousand faces, with no clear lines of control.
Behind the Bigs, though, is an algorithm.
By now “Prior Authorization” is standard: before the insurer will pay for a treatment, the insurer must authorize it in advance. Frequently — more frequently than patients expect — the answer to treatment has been ”no.” We patients, along with our physicians, have gotten worn down with the “no”responses. When an insurer denies payment for a treatment that your physician prescribes, whom do you call? Whom can the office call? How many attempts to connect with anybody, let alone anybody empowered to make that decision? Who decides the “no“? Who can reverse it? Is the power in the hands of a “compliance officer?” A physician? A nurse? A clerical data-person?
The Bigs will point to the mighty Algorithm. The Bigs will assure us that the decisions are rooted in scientific evidence, in data, in sound judgment. We are assured that race, income, class, education ethnicity — the traits that might sway a person’s judgment — don’t sway the evidence.
The Algorithm amasses data, including patient records, evidence of treatment efficacy, a review of alternative treatment options and costs. To be effective, the “prior authorization” process must be rapid.
At last we know — though we might have suspected — that the data behind the algorithm’s decisions are rooted more in financial legerdemain than scientific data. The people who deny you treatment, or force your physicians to jump through multiple procedural hoops for a “yes” are not thinking of your wellbeing, but of their employer’s bottom line.
At last there is action afoot. The families of two deceased patients filed a suit in federal court, alleging that United used an algorithm with a 90% rejection rate to deny coverage to their relatives, insured under a Medicare Advantage plan. Egregiously, the lawsuit argues that United denied coverage to those patients whom it predicted would not object. Indeed, fewer than 2% do object.
United Health is not alone in using algorithms. The algorithms are an ostensibly data-driven, ostensibly impartial screen for the millions of medical decisions that demand action. Algorithms are a more palatable decision-making hoop than the staff who rely on who-knows-what to say “no.” And the algorithms allow for timely decisions. So it is no surprise that insurers have looked to mathematical models to rule on patients’ care. Today from 50 to 75 percent of the manual work in gathering information and checking patient records is automated.
It is the data behind the algorithm that is the concern. We know that the slot machines in Las Vegas enrich the casinos. We haven’t known that the insurers’ algorithms are similarly rigged against the patient.
Now that we do know, though, we patients are empowered to object to every “no,” “later,” “maybe,” we need more information” that the algorithms spew forth. When patients protest, often that protest in and of itself nudges the needle from “no” to “yes.” So protest. Protest. Protest. If your physician prescribes a treatment or medication, argue for it. Your opponent is a mathematical tool geared to bolster the insurers’ profits.
And after the protests, force the insurers to make their algorithms fair.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email joan.retsinas@gmail.com.
From The Progressive Populist, February 15, 2024
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