6 ms·

Medicare's new payment model is built for AI. Most of the tech world has no idea

86 points by brandonb 5mo ago

AndrewKemendo 5mo ago
>The company's premise was that you can't improve health outcomes without addressing the full context of someone's life They are absolutely correct about this mathematically, you can’t solve problems you don’t have data for The question is what organization would I trust with the full context of my life. None. Zero. **future headline: Consumer warning: The panopticon(tm) product is embedded into your care plan, insurance is only available for panopticon subscribers.
- w10-1 5mo ago
  > what organization would I trust with the full context of my life. None. Zero Wouldn't this mean you'd rather interact with an AI, if it meant whatever you said was provably shown that it could never leak (though the medical conclusions would be documented in your HIPAA-protected record)?
  - AndrewKemendo 5mo ago
    Provided I own the infrastructure and can smash SSDs if needed then yes. But if it’s in someone else’s computer? thats gonna be a no from me dawg.
spwa4 5mo ago
> The first call that shifted his thinking was with a 67-year-old woman living out of her car, managing PTSD and congestive heart failure. She spoke with Flora for over an hour. "It was both incredible and depressing," Batlivala told me. "Flora was probably the only 'person' she'd talked to in weeks about her situation." Now, hourlong conversations with Flora are routine. "That's the companionship piece," he said. "And it turns out that is truly an intervention." People don't seem to realize that this is both coming and that before long people will be defending AI "persons" because of this reason (OpenAI is already complaining about people doing this). Nobody's going to deliver this level of care using humans. It's not going to happen. A lot of people needing care are deeply isolated and will be of the opinion that AI changes that.
- esseph 5mo ago
  Every psychologist and therapist I have talked to about using LLMs in place of personal interactions (just discussion about this topic) have all said roughly the same thing: Any attempt to use LLMs as a substitute for personal interaction is playing an incredibly dangerous game that will probably make them a lot of money, while hurting a lot of people.
  - spwa4 5mo ago
    You might want to read again who the patient was. Because: obviously not going to happen, no matter how bad the AI is ... Oh and taking sycophancy out of a model is easy. Just finetune out that they (have to) agree with everything. Plus every new model has less of it, or at least masks it better.
- vjvjvjvjghv 5mo ago
  I feel the same about caretaking. Having an AI talk to people with dementia will be a godsend for families. Before he died, my dad had the same thought every 5 minutes and it slowly drove my mom crazy. A super patient AI would have helped a lot and freed up the rest of the family for other tasks. One step further would be robots that take people to the bathroom, clean them and other stuff. Having this done by humans is either extremely expensive or it will not be done properly. Some people are horrified by the loss of human touch but for most old people human touch is a luxury they can't afford.
  - saltcured 5mo ago
    I don't think it will be helpful when it is slopped together and doesn't have a real mental model to keep the dementia patient on a healthy track. Look at all the "AI psychosis" problems with people going into a conversation loop that amplifies their worst thought patterns. Now consider the same where the person in this loop is already having delusions and other cognitive decline. It seems to me that it could spiral in the wrong direction quite easily. It's quite difficult for human caretakers to navigate this space too. That is part of why it is so exhausting. You're constantly trying to make judgement calls and implicitly predict the unreliable response of the dementia sufferer. I think there is a large uncanny valley between having some facsimile of human interaction in a short session and having some kind of trustworthy caretaker that can consistently respond in a way that promotes health and safety. I think it involves a lot of subjunctive interpretation and reasoning to navigate all the mixed up layers of fact, fantasy, and simply aphasic expression that come from dementia.
bonsai_spool 5mo ago
It seems that TechCrunch, not a strong source of news since around 2014/15, is now just sending out AI text: First the title: "Medicare's new payment model is built for AI. Most of the tech world has no idea", classic AI tell. The by-line is by the editor-in-chief. Em-dashes everywhere, including in this quote, somewhat unusually: “The best solution wins, which, in regulated industries like healthcare — that’s not been the case.” Oddly-short paragraphs: "That payment structure is the real news." Rule of threes: "Pair Team launched in 2019 with a specific kind of patient in mind: people managing chronic conditions who were also dealing with unstable housing, too little food, or lack of transportation" This whole paragraph: "There are real risks. Participants are feeding extraordinarily sensitive patient data — intimate conversations about housing and diseases and mental illness — into a federal infrastructure with a documented history of breaches, including exposed Social Security numbers. For the vulnerable populations ACCESS is designed to serve, that's not an impractical concern." --- I haven't opened a TC article in years and I think I'll return to that practice. I think there's an ongoing conversation about whether we should accept all LLM-generated text without commentary. I write this comment because I have some sympathy for a Show HN with AI-assisted writing, but I will not spend time enriching TechCrunch's use of machine-generated text anymore than I would scroll through an ad block at the end of any other article. (Just for the sake of comparison, here's something by the same writer from a few years ago - https://techcrunch.com/2022/11/16/boompop-gains-traction-by-designing-high-end-off-sites-for-our-now-remote-first-world/ https://techcrunch.com/2022/11/16/boompop-gains-traction-by-... You can see more examples here, too https://techcrunch.com/author/connie-loizos/page/16/ https://techcrunch.com/author/connie-loizos/page/16/ )
- brandonb 5mo ago
  Isn't the first em dash taken from an interview that the writer did with the subject over Zoom? I think using an em dash to punctuate a broken or partial sentence like that is pretty standard journalistic practice when you don't want to modify the original quotation (e.g, denote a paraphrase with brackets), and definitely not an AI tell. The other uses are honestly pretty standard rhetorical patterns; they do not seem especially AI-flavored to me.
- ineedasername 5mo ago
brandonb 5mo ago
I run a YC startup that was accepted to Medicare ACCESS. Historically, insurance has paid for activity: time spent in visits, RVUs generated, and minutes logged. This was a reasonable starting point, but the flaw is that there's no strong incentives to be efficient. ACCESS is explicitly a "deflationary" approach. Medicare has set the payment rates high enough to be viable for startups, but low enough that you have to use software (including AI) to deliver a large part of your program. So Medicare has basically created economic incentives to reward software without prescribing the exact shape of the programs. I thought it was a really interesting approach and builds on 15 years of lessons from CMMI (Medicare's innovation group).
- caycep 5mo ago
  I would maybe modify this to say - there is a strong incentive to be efficient - you only make so much money per encounter, DRG visit to the hospital, etc. So the pressure from "management" on a lot of us clinicians is to see more people per day, make each hospital visit as short as possible, etc. Medicaid providers now see something like 50-60 patients a day because the per-patient visit is relatively low. But there isn't as much incentive for outcomes. I think CMS has tried it in the past, but with varying success. Whether this new mousetrap will work, who knows.
  - brandonb 5mo ago
    The existing CPT codes (roughly) pay proportionately to physician time (RVUs). So I wouldn't say there's an an incentive toward delivering care efficiently, but rather hospital management wants to maximize billable hours.
    - caycep 5mo ago
      Oh no, there's both. At least for consultations, there's only 3 inpatient / 5 outpatient levels of CPT codes which work for both complexity and/or time. And patients tend to be pretty complex, so it'd not hard to justify a level 4 or 5 CPT code; any less than that and the patient usually has absolutely nothing wrong with them. And at best, max complexity, Medicare pays, something like $227 per CPT code. So to keep the lights on, you'd better figure out a way to see 14, 16, 20 patients a day...a practice cannot stay afloat if you take 45 mins to an hour to see a level 5 CPT code. For hospital stays, I may be outdated in this, but Medicare pays a lump sum DRG which doesn't tend to go up much, so the longer the patient is in the hospital, the less money the hospital makes. Short story is the biggest pressures from the higher-ups is for us to see more volume outpatient, and cut duration of stays inpatient....
swe_dima 5mo ago
Is it basically about giving as much data as possible to insurance companies?
- brandonb 5mo ago
  Medicare is a government-run insurance program, so this is one of the few cases where a private insurance company wouldn't receive data. (There is such a thing as Medicare advantage, where a patient can choose to put their Medicare dollars toward private insurance, but it's not part of the initial launch of this program.)
ineedasername 5mo ago
>rewards health outcomes rather than required activities… earn the full amount only when patients meet measurable health goals, like lower blood pressure or reduced pain They’ll just start cherry picking their patients, finding ways to squeeze out the people just that little bit lower on the prognosis curve. Or at least that will be the risk in a setup like that.
- throwway120385 5mo ago
  One might argue that that's the goal. There's the approach we've taken of trying to help people, and then there's the approach some people want, which is to treat every problem as if it is an entirely individual problem and treatment has to be earned by trying to will yourself out of the problem.
  - euroderf 5mo ago
    > One might argue that that's the goal. If they can cure 80% of the entire caseload with 20% of the total estimated cost of the entire caseload, you'll want to be in that 80%.
- deleted 5mo ago
  [deleted]
- derbOac 5mo ago
  That's the biggest risk. I can also imagine it encouraging a certain kind of fraud. The program sounds reasonable until you become aware that the patients most in need are often the ones least likely to improve. It also ignores the reality that sometimes even the most rigorous, well reasoned treatment plans fail for unpredictable reasons. Do you punish providers and patients for that?
- estearum 5mo ago
  You see upcoding in risk-based programs already too (like Medicare Advantage). It's trivial to say a patient is sicker than they are and then let them "miraculously improve". Real bummer.
- 5mo ago
myhf 5mo ago
Billing Medicare for services that never get performed is a particularly offensive kind of fraud. I hope these criminals get a harsh sentence.
- gowld 5mo ago
  The worst one in history was elected to the Senate. https://en.wikipedia.org/wiki/Rick_Scott https://en.wikipedia.org/wiki/Rick_Scott
  - shimman 5mo ago
    Yeah but that's the point, you need to display to the serfs that you're above the law and you will do nothing about it. You need one every generation or else the workers might rise up.
- lazyasciiart 5mo ago
  I think this is less offensive than the kind of scheme where a hospital billed for doing actual heart surgery on patients who didn’t have heart problems. https://www.sfgate.com/health/article/REDDING-Settlement-in-heart-surgery-fraud-case-2594884.php https://www.sfgate.com/health/article/REDDING-Settlement-in-...
d0liver 5mo ago
Gross .
w10-1 5mo ago
The payment model is not "built for AI"; it's incentivized to drive costs down for chronically ill patients (and likely other high utilizers), which matters because a small number of patients (and end-of-life care) represents the bulk of costs. That means automation, ideal for SaaS. Remember: this is just v1. In theory Medicare Access will learn to weed out the bad actors and get better at focusing on progress that matters and can't be faked, and the AI companies will get better at reaching more people. This kind of work is profoundly unrewarding: hand-holding chronic patients and sorting out medical and personal logistics is no one's calling. Right now Pair Team has 3 engineering positions (~170K), but 14 for case workers that get to work from home for ~$50K (outside the bay area). I could see them pivoting to social services, with health care being just one aspect. (As a reminder, the homeless problem is driven by mental health issues blocking people from adapting economically, for which social services cannot keep up. I'd love to see a program offering free phones for daily AI discussions that surface some cheap partial solutions.)
- throwawayqqq11 5mo ago
  Isnt "bad actor" just a set of parameters, with cost at the center of it? And AI a neat tool to deflect responsibility and to bury one in verbose but good sounding bs? When you throw such a tool into the existing incentive structure, that already produces inhumane atrocities, i wouldnt be that optimistic.
sj1135 5mo ago
Recent podcast episode with CMS explains how ACCESS works in practice https://open.spotify.com/episode/720DvvkFd73BwXiXlOOte1?si=bffb4f8dfdd047ca&nd=1&dlsi=443026144bb043c9 https://open.spotify.com/episode/720DvvkFd73BwXiXlOOte1?si=b...

86 points by brandonb 5mo ago

>The company's premise was that you can't improve health outcomes without addressing the full context of someone's life They are absolutely correct about this mathematically, you can’t solve problems you don’t have data for The question is what organization would I trust with the full context of my life. None. Zero. **future headline: Consumer warning: The panopticon(tm) product is embedded into your care plan, insurance is only available for panopticon subscribers.

w10-1 5mo ago
> what organization would I trust with the full context of my life. None. Zero Wouldn't this mean you'd rather interact with an AI, if it meant whatever you said was provably shown that it could never leak (though the medical conclusions would be documented in your HIPAA-protected record)?
- AndrewKemendo 5mo ago
  Provided I own the infrastructure and can smash SSDs if needed then yes. But if it’s in someone else’s computer? thats gonna be a no from me dawg.

spwa4 5mo ago

> The first call that shifted his thinking was with a 67-year-old woman living out of her car, managing PTSD and congestive heart failure. She spoke with Flora for over an hour. "It was both incredible and depressing," Batlivala told me. "Flora was probably the only 'person' she'd talked to in weeks about her situation." Now, hourlong conversations with Flora are routine. "That's the companionship piece," he said. "And it turns out that is truly an intervention." People don't seem to realize that this is both coming and that before long people will be defending AI "persons" because of this reason (OpenAI is already complaining about people doing this). Nobody's going to deliver this level of care using humans. It's not going to happen. A lot of people needing care are deeply isolated and will be of the opinion that AI changes that.

esseph 5mo ago
Every psychologist and therapist I have talked to about using LLMs in place of personal interactions (just discussion about this topic) have all said roughly the same thing: Any attempt to use LLMs as a substitute for personal interaction is playing an incredibly dangerous game that will probably make them a lot of money, while hurting a lot of people.
- spwa4 5mo ago
  You might want to read again who the patient was. Because: obviously not going to happen, no matter how bad the AI is ... Oh and taking sycophancy out of a model is easy. Just finetune out that they (have to) agree with everything. Plus every new model has less of it, or at least masks it better.
vjvjvjvjghv 5mo ago
I feel the same about caretaking. Having an AI talk to people with dementia will be a godsend for families. Before he died, my dad had the same thought every 5 minutes and it slowly drove my mom crazy. A super patient AI would have helped a lot and freed up the rest of the family for other tasks. One step further would be robots that take people to the bathroom, clean them and other stuff. Having this done by humans is either extremely expensive or it will not be done properly. Some people are horrified by the loss of human touch but for most old people human touch is a luxury they can't afford.
- saltcured 5mo ago
  I don't think it will be helpful when it is slopped together and doesn't have a real mental model to keep the dementia patient on a healthy track. Look at all the "AI psychosis" problems with people going into a conversation loop that amplifies their worst thought patterns. Now consider the same where the person in this loop is already having delusions and other cognitive decline. It seems to me that it could spiral in the wrong direction quite easily. It's quite difficult for human caretakers to navigate this space too. That is part of why it is so exhausting. You're constantly trying to make judgement calls and implicitly predict the unreliable response of the dementia sufferer. I think there is a large uncanny valley between having some facsimile of human interaction in a short session and having some kind of trustworthy caretaker that can consistently respond in a way that promotes health and safety. I think it involves a lot of subjunctive interpretation and reasoning to navigate all the mixed up layers of fact, fantasy, and simply aphasic expression that come from dementia.

bonsai_spool 5mo ago

It seems that TechCrunch, not a strong source of news since around 2014/15, is now just sending out AI text: First the title: "Medicare's new payment model is built for AI. Most of the tech world has no idea", classic AI tell. The by-line is by the editor-in-chief. Em-dashes everywhere, including in this quote, somewhat unusually: “The best solution wins, which, in regulated industries like healthcare — that’s not been the case.” Oddly-short paragraphs: "That payment structure is the real news." Rule of threes: "Pair Team launched in 2019 with a specific kind of patient in mind: people managing chronic conditions who were also dealing with unstable housing, too little food, or lack of transportation" This whole paragraph: "There are real risks. Participants are feeding extraordinarily sensitive patient data — intimate conversations about housing and diseases and mental illness — into a federal infrastructure with a documented history of breaches, including exposed Social Security numbers. For the vulnerable populations ACCESS is designed to serve, that's not an impractical concern." --- I haven't opened a TC article in years and I think I'll return to that practice. I think there's an ongoing conversation about whether we should accept all LLM-generated text without commentary. I write this comment because I have some sympathy for a Show HN with AI-assisted writing, but I will not spend time enriching TechCrunch's use of machine-generated text anymore than I would scroll through an ad block at the end of any other article. (Just for the sake of comparison, here's something by the same writer from a few years ago - https://techcrunch.com/2022/11/16/boompop-gains-traction-by-designing-high-end-off-sites-for-our-now-remote-first-world/ https://techcrunch.com/2022/11/16/boompop-gains-traction-by-... You can see more examples here, too https://techcrunch.com/author/connie-loizos/page/16/ https://techcrunch.com/author/connie-loizos/page/16/ )

brandonb 5mo ago
Isn't the first em dash taken from an interview that the writer did with the subject over Zoom? I think using an em dash to punctuate a broken or partial sentence like that is pretty standard journalistic practice when you don't want to modify the original quotation (e.g, denote a paraphrase with brackets), and definitely not an AI tell. The other uses are honestly pretty standard rhetorical patterns; they do not seem especially AI-flavored to me.
ineedasername 5mo ago

brandonb 5mo ago

I run a YC startup that was accepted to Medicare ACCESS. Historically, insurance has paid for activity: time spent in visits, RVUs generated, and minutes logged. This was a reasonable starting point, but the flaw is that there's no strong incentives to be efficient. ACCESS is explicitly a "deflationary" approach. Medicare has set the payment rates high enough to be viable for startups, but low enough that you have to use software (including AI) to deliver a large part of your program. So Medicare has basically created economic incentives to reward software without prescribing the exact shape of the programs. I thought it was a really interesting approach and builds on 15 years of lessons from CMMI (Medicare's innovation group).

caycep 5mo ago
I would maybe modify this to say - there is a strong incentive to be efficient - you only make so much money per encounter, DRG visit to the hospital, etc. So the pressure from "management" on a lot of us clinicians is to see more people per day, make each hospital visit as short as possible, etc. Medicaid providers now see something like 50-60 patients a day because the per-patient visit is relatively low. But there isn't as much incentive for outcomes. I think CMS has tried it in the past, but with varying success. Whether this new mousetrap will work, who knows.
- brandonb 5mo ago
  The existing CPT codes (roughly) pay proportionately to physician time (RVUs). So I wouldn't say there's an an incentive toward delivering care efficiently, but rather hospital management wants to maximize billable hours.
  - caycep 5mo ago
    Oh no, there's both. At least for consultations, there's only 3 inpatient / 5 outpatient levels of CPT codes which work for both complexity and/or time. And patients tend to be pretty complex, so it'd not hard to justify a level 4 or 5 CPT code; any less than that and the patient usually has absolutely nothing wrong with them. And at best, max complexity, Medicare pays, something like $227 per CPT code. So to keep the lights on, you'd better figure out a way to see 14, 16, 20 patients a day...a practice cannot stay afloat if you take 45 mins to an hour to see a level 5 CPT code. For hospital stays, I may be outdated in this, but Medicare pays a lump sum DRG which doesn't tend to go up much, so the longer the patient is in the hospital, the less money the hospital makes. Short story is the biggest pressures from the higher-ups is for us to see more volume outpatient, and cut duration of stays inpatient....

swe_dima 5mo ago

Is it basically about giving as much data as possible to insurance companies?

brandonb 5mo ago
Medicare is a government-run insurance program, so this is one of the few cases where a private insurance company wouldn't receive data. (There is such a thing as Medicare advantage, where a patient can choose to put their Medicare dollars toward private insurance, but it's not part of the initial launch of this program.)

ineedasername 5mo ago

>rewards health outcomes rather than required activities… earn the full amount only when patients meet measurable health goals, like lower blood pressure or reduced pain They’ll just start cherry picking their patients, finding ways to squeeze out the people just that little bit lower on the prognosis curve. Or at least that will be the risk in a setup like that.

throwway120385 5mo ago
One might argue that that's the goal. There's the approach we've taken of trying to help people, and then there's the approach some people want, which is to treat every problem as if it is an entirely individual problem and treatment has to be earned by trying to will yourself out of the problem.
- euroderf 5mo ago
  > One might argue that that's the goal. If they can cure 80% of the entire caseload with 20% of the total estimated cost of the entire caseload, you'll want to be in that 80%.
deleted 5mo ago
[deleted]
derbOac 5mo ago
That's the biggest risk. I can also imagine it encouraging a certain kind of fraud. The program sounds reasonable until you become aware that the patients most in need are often the ones least likely to improve. It also ignores the reality that sometimes even the most rigorous, well reasoned treatment plans fail for unpredictable reasons. Do you punish providers and patients for that?
estearum 5mo ago
You see upcoding in risk-based programs already too (like Medicare Advantage). It's trivial to say a patient is sicker than they are and then let them "miraculously improve". Real bummer.
5mo ago

myhf 5mo ago

Billing Medicare for services that never get performed is a particularly offensive kind of fraud. I hope these criminals get a harsh sentence.

gowld 5mo ago
The worst one in history was elected to the Senate. https://en.wikipedia.org/wiki/Rick_Scott https://en.wikipedia.org/wiki/Rick_Scott
- shimman 5mo ago
  Yeah but that's the point, you need to display to the serfs that you're above the law and you will do nothing about it. You need one every generation or else the workers might rise up.
lazyasciiart 5mo ago
I think this is less offensive than the kind of scheme where a hospital billed for doing actual heart surgery on patients who didn’t have heart problems. https://www.sfgate.com/health/article/REDDING-Settlement-in-heart-surgery-fraud-case-2594884.php https://www.sfgate.com/health/article/REDDING-Settlement-in-...

d0liver 5mo ago

Gross .

w10-1 5mo ago

The payment model is not "built for AI"; it's incentivized to drive costs down for chronically ill patients (and likely other high utilizers), which matters because a small number of patients (and end-of-life care) represents the bulk of costs. That means automation, ideal for SaaS. Remember: this is just v1. In theory Medicare Access will learn to weed out the bad actors and get better at focusing on progress that matters and can't be faked, and the AI companies will get better at reaching more people. This kind of work is profoundly unrewarding: hand-holding chronic patients and sorting out medical and personal logistics is no one's calling. Right now Pair Team has 3 engineering positions (~170K), but 14 for case workers that get to work from home for ~$50K (outside the bay area). I could see them pivoting to social services, with health care being just one aspect. (As a reminder, the homeless problem is driven by mental health issues blocking people from adapting economically, for which social services cannot keep up. I'd love to see a program offering free phones for daily AI discussions that surface some cheap partial solutions.)

throwawayqqq11 5mo ago
Isnt "bad actor" just a set of parameters, with cost at the center of it? And AI a neat tool to deflect responsibility and to bury one in verbose but good sounding bs? When you throw such a tool into the existing incentive structure, that already produces inhumane atrocities, i wouldnt be that optimistic.

sj1135 5mo ago

Recent podcast episode with CMS explains how ACCESS works in practice https://open.spotify.com/episode/720DvvkFd73BwXiXlOOte1?si=bffb4f8dfdd047ca&nd=1&dlsi=443026144bb043c9 https://open.spotify.com/episode/720DvvkFd73BwXiXlOOte1?si=b...