AI Meets Medicare: Inside CMS’s WISeR Model With Sanjay Doddamani, MD, MBA, Part 2

On June 27, CMS announced plans for its Wasteful and Inappropriate Service Reduction (WISeR) Model, which will see the Center for Medicare and Medicaid Innovation (CMMI) add artificial intelligence (AI)–powered prior authorization processes—while preserving physician judgment through human oversight—to services it deems of low value and prone to fraud abuse.^1,2 These services include skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.² WISeR will target these services delivered to patients with traditional Medicare coverage, but even then, the model is only being tested in 6 states to start: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.¹

This latest initiative to overhaul a process that has become a nightmare for many patients and providers alike comes on the heels of a joint announcement from HHS and CMS of a voluntary pledge for prior authorization reforms from more than 50 major health insurers.³

To revisit part 1 of Doddamani's interview:

AI Meets Medicare: Inside CMS’s WISeR Model With Sanjay Doddamani, MD, MBA

In this second part of his interview with The American Journal of Managed Care^® (AJMC^®), Sanjay Doddamani, MD, MBA, a former senior advisor to CMMI and founder and CEO of Guidehealth, continues a dialogue on the future of value-based care and the promise—and limits—of AI-enabled innovation. Reflecting on challenges like rising Medicare costs and patients’ growing financial burdens, he emphasizes the need for affordability and the human element of care. In this discussion about how models like WISeR can test the balance between automation and oversight while restoring trust in a system often criticized for opacity, he also stresses that new technology must support—not replace—clinical wisdom and patient connection.

Doddamani: Not yet, but I think once the model gets operationalized, there will be updates in terms of listening sessions and feedback with CMMI and with the model team to ensure there’s no new problem or new harm potential. Also, if there’s any need for evolution of the model, whether it’s additional reporting or it’s close monitoring, or even what’s included in some of the prerequisite human clinical reviews that don’t suffer from attrition, essentially. I think that’s where we need this model turned to gain trust and have that clinical escalation pathway built into it.

AJMC: The WISeR model also promises faster approval decisions and fewer unnecessary procedures, but some worry about delays or denials for borderline cases. How should those involved weigh the potential benefits—such as lower costs and reduced harm—against concerns about access to care if a provider’s requests face stricter scrutiny?

Doddamani: Clinical medicine is all about trust, and this is no different in terms of ensuring that these nuanced cases get clinical reviews that are human-led and don’t suffer from any kind of rigidity in these rules. I think we have all seen how speed can be drawn in, in terms of the promise of faster approvals when applying AI, and how by creating a transparent process, including an appeals process that is swift and tied and connected and grounded in clinical evidence—not just having some algorithm make thresholds—there’s an opportunity to manage the denials process more efficiently. That’s one.

This also is a test that’s going to withstand the rigor of all CMS Innovation Center models, and that’s where there is a strong history of having a tailored and monitoring and evaluations approach that is both concurrent and able to answer the question, “Can we apply a best practice around fraud, waste, and abuse to reduce low-value care that’s avoidable and manage to reduce avoidable costs and harm to patients by introducing AI-enabled prior authorizations?" That’s essentially the question.

AJMC: On your LinkedIn profile it says you are “on a quest to create the best value for patients and communities combining advanced data science and business intelligence, high-touch care, enhanced experience, and two-sided financial risk for physicians to maximize impact.” Given the recent upheaval in US health care policy—such as debates over Medicare funding, drug pricing, and value-based care—how do you see this mission statement aligning with or challenging the current direction of the system?

Doddamani: One of the biggest things that we face today in our nation is an affordability crisis. Yes, we face an access crisis, and we face a crisis of trust as well, but I think the biggest thing we face is the mounting costs, especially to the Medicare system. It is bringing into question the solvency of the Medicare trust funds at the macro level. However, even at the individual level, the out-of-pocket costs have become exorbitant for patients, who have to choose between food and paying some of their co-pays. The medication costs have also skyrocketed. Where inflation used to be 3% and 5% a decade ago, we’re now talking about 12% and 13%. This is unsustainable. We need to harness technology to impact the overall costs. That’s why, from our vision [Guidehealth’s], from our standpoint, we want to ensure that great health care is also affordable for all.

At the moment, we have been patchy, as a nation, in terms of the use of smart technology, as well as accountability in terms of the payment model. Although payment reform is underway in terms of moving more care into value and value-based agreements, including some form of accountability, we need to ensure that whatever we’re doing is going to be able to reduce the burden on both the patients and the taxpayer, on the overall cost of care delivery in this country. Our work is leading that human connection and wisdom, coupling it with AI in terms of reducing operating costs and creating scalability so that we are all on this path to value. I love the idea of having a WISeR model, or a model that can bring in a level of transparency in the Medicare system that has gone largely unchecked for all these decades. But as a test, it’s also proving ground for what’s possible, especially when we strike the right balance.

AJMC: How do you balance the need for technology and innovation in value-based care with the very personal, human aspect of health care?

Doddamani: I think several of us who have aging family members want the best care. We don’t want machines and robots telling us what care our family is eligible for or not. But at the same time, we want the technology in place to protect our families, to make access more readily available, and to have labs at the forefront of our fingertips and on our smartphones. We would be shortchanging ourselves to not harness the technology to also ensure that we’re managing total costs and we’re managing the quality of care delivered—and we have some oversight. There has been no oversight thus far, or very little oversight thus far, on essentially what has been a $1.8-trillion government spend in health care.

This is, I think, the start of a very broad and long, hopefully, commitment for us as physicians to embrace this opportunity and use this opportunity to essentially remind ourselves that there are evidence-based and best practices and that we do need technology guiding us in our clinical decision-making—at least weighing in as one component in our overall armamentarium for helping to advance care for patients. I hope that will be seen. At the same time, we need to all keep our eyes wide open to ensure there are no pitfalls or that we are at least watching out for them so that we can make the process smooth and reduce and eliminate any harm from introducing any new process change in health care.

I think for all of us, that’s what this is. Health care is very personal, and so there has to be that drive in all of our actions. We’ll see who are going to be the early adopters of innovation and not shy away from it, and that’s why you can't be faint-hearted. For us who want to be these change agents in health care, I think these opportunities lay bare conversations that are difficult to have, but they’re very needed. They’re very, really vital.

AI Meets Medicare: Inside CMS’s WISeR Model With Sanjay Doddamani, MD, MBA, Part 2

To revisit part 1 of Doddamani's interview:

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