This story is part of a Seattle Times focus on the affordability crisis in the Northwest. We explore the high cost of living and wealth disparities that shape our region; examine policies that impact prices for everything from housing to health care; and offer tips for making your money go further.\n<\/p>\n
In early February, Michael Edgerly\u2019s doctor recommended that he get an epidural steroid injection.<\/p>\n
Edgerly has degenerative disc disease and scoliosis, and suffers from low back pain. Over the past few months, the pain worsened to the point where he couldn\u2019t walk without a walking stick, and then a walker. Life contracted. Edgerly struggled to exercise, to do housework, to see friends.<\/p>\n
\u201cIt was depressing,\u201d he said in a phone call from his home in Cle Elum, Kittitas County, on Wednesday.<\/p>\n
An epidural steroid injection is a common first-line treatment for low back pain. But in early March, Edgerly discovered that he\u2019d been denied the procedure, despite it being covered by his traditional Medicare insurance.<\/p>\n
Across Washington, Medicare patients are facing denials and delays getting treatment for back pain just like Edgerly.<\/p>\n
In January, Medicare launched a pilot program that requires doctors to get approval from a third-party contractor using artificial intelligence technology before they can provide certain types of medical care. Epidural steroid injections are one of the procedures included in the pilot, which is being tested in Washington and five other states.<\/p>\n
The time needed to complete certain procedures is now up to four times longer compared with before the implementation of the pilot, according to a new report citing hospital data.<\/p>\n
Less than four months into the pilot\u2019s launch, lawmakers are demanding change.<\/p>\n
During a series of congressional hearings over the past two weeks, Washington lawmakers questioned Secretary of Health and Human Services Robert F. Kennedy Jr. about the program\u2019s unintended consequences.<\/p>\n
\u201cWhat\u2019s happening is AI is being used as a denial device,\u201d said Democratic Sen. Maria Cantwell at a Senate Finance Committee hearing on Wednesday, citing Seattle Times reporting<\/a> on the Medicare pilot program. \u201cWe have hospitals calling me about this, I have doctors calling me about this, I have patients calling me about this.\u201d<\/p>\n \u2018Not the hospitals\u2019 fault\u2019<\/p>\n The pilot program is called the \u201cWasteful and Inappropriate Service Reduction\u201d \u2014 or \u201cWISeR\u201d for short \u2014 and is intended to save Medicare money by limiting unproven or unnecessary medical procedures.<\/p>\n But doctors and patients in Washington say that WISeR is issuing wrongful denials, creating barriers to care and prolonging pain for those who need certain types of treatment.<\/p>\n Medicare patients across the state, from Edmonds to the Olympic Peninsula to Yakima have shared stories with The Seattle Times detailing WISeR denials that take time and effort to overturn.<\/p>\n Cantwell called on Kennedy to shore up program oversight, including by speeding up response times and mandating that all denials come with an explanation written by a human.<\/p>\n The Centers for Medicare and Medicaid Services, which administers Medicare, said that it would make changes to the pilot if necessary, including by taking corrective action in response to inappropriate barriers to access.<\/p>\n \u201cCMS is closely monitoring implementation in real time, including turnaround times, system performance, and denial patterns, and is actively addressing issues as they arise,\u201d a spokesperson wrote to The Seattle Times on Friday. \u201cCMS does not have evidence of inappropriate denials currently.\u201d<\/p>\n In its response, the agency also addressed epidural steroid injections specifically.<\/p>\n \u201cWISeR includes services such as epidural steroid injections because the clinical evidence shows that, while these procedures may offer short-term relief for certain patients, they also carry meaningful risks that can outweigh their benefits and are often overused in ways that do not improve long-term outcomes,\u201d the spokesperson wrote.<\/p>\n In Washington, the company contracted to administer the pilot program is a Phoenix-based tech firm called Virtix Health. Little information is publicly available about the company. Under WISeR, Virtix receives a portion of the money that it helps Medicare save.<\/p>\n Since the program launched, doctors\u2019 offices and patients have reported waiting through longer-than-standard response times from Virtix.<\/p>\n Virtix is supposed to either approve or deny a procedure within three days for standard requests, or within 24 hours for urgent requests.<\/p>\n In an email on Friday, Virtix acknowledged long turnaround times during the pilot\u2019s initial weeks, but disputed that the issue persists.<\/p>\n \u201cThat has improved significantly,\u201d the email read, adding that the company is currently meeting target turnaround times.<\/p>\n