As CMS gears up to implement its new Wasteful and Inappropriate Service Reduction model, one orthopedic surgeon is not too concerned about its day-to-day impact on the addition of prior authorization arthroscopy for knee osteoarthritis.
According to David Bernstein, MD, PhD, chief resident, Harvard Combined Orthopaedic Residency Program, the model should help reduce unnecessary and low-value care.
The implementation of artificial intelligence and machine learning through the model may be able to generate the blueprint of how AI and ML can be best implemented and utilized throughout the healthcare system.
Dr. Bernstein recently connected with Becker’s to share his view on the potential effects of the model.
Note: His response was lightly edited for clarity and length.
Question: What impact will the new CMS model have on traditional Medicare procedures, including arthroscopy for knee osteoarthritis?
Dr. David Bernstein: CMS’ WISeR Model demonstrates the government’s continued dedication to help “fix” American healthcare by designing and implementing care models that reduce wasteful, low-value care. This should be applauded, as Medicare is on a fiscally unsustainable path and innovative solutions are needed. Further, Americans deserve to know their tax dollars are being spent on high-quality, evidence-based care that improves the lives of their family members, friends, neighbors and fellow citizens.
Overall, the highest quality research shows that arthroscopy for knee osteoarthritis does not show clinically important and sustainable functional and pain benefits. However, as with all of healthcare, patients need to be treated as individuals. Thus, there may be rare instances where arthroscopy for knee osteoarthritis would be warranted clinically. The new CMS model allows for this to still occur, though – admittedly – with a hurdle to clear. Given how uncommon arthroscopy for knee osteoarthritis should be done, the daily impact on clinicians and their care teams will likely be quite limited, especially given the proposed streamlined prior authorization approach of this model.
One of the elements of the new model that I find most intriguing is the use of artificial intelligence (AI) and machine learning (ML). There has been a great deal of discussion about how best to use AI and ML to optimize care delivery, improve patient outcomes, reduce cost and streamline processes, such as prior authorization, that have often hindered care and increased administrative burden. Currently, we do not have a clear answer. By CMS introducing these enhanced technologies into the WISeR Model, my hope is that we gain invaluable insight into how AI and ML can best be used in healthcare.
It is important to remember that AI and ML are simply tools, not strategies to “fix” many of healthcare’s shortcomings. It is critical AI and ML are used appropriately to promote — and not obstruct — the patient-physician relationship. Specifically for the WISeR Model, it is also important that these enhanced technologies are supported by human clinical review (at least initially), which CMS notes will be the case.
Ultimately, I am cautiously optimistic about CMS’ WISeR Model. We must push the boundaries with AI and ML in healthcare if we are ever going to find the best way to utilize these enhanced technologies broadly to improve patient outcomes while decreasing cost. The use of AI and ML, with the support of human oversight, will hopefully streamline any prior authorization processes, reducing wasted time and continuing to ensure high quality musculoskeletal care for patients. Importantly, there should be continuous oversight and review of the WISeR model as it rolls out to make sure there are no unintended consequences that hurt patients or put undue burden on physicians.
