The algorithms deciding when seniors get care, or don't

My colleagues Casey Ross and Bob Herman are out with a stunning investigation into the artificial intelligence-guided algorithms influencing when Medicare Advantage patients' care is covered and when it isn't. Medicare Advantage — offered by private companies, as opposed to traditional Medicare — covers about 31 million people.

Here's the big problem: These predictive algorithms — marketed as scientifically rigorous — are used with little independent oversight and have led to clashes between doctors and insurers about how much care patients really need. When payment for a patient's care is cut off, they're often forced to forgo treatment or fight through a lengthy appeals process.

"We take patients who are going to die of their diseases within a three-month period of time, and we force them into a denial and appeals process that lasts up to 2.5 years," said Chris Comfort, chief operating officer of Calvary Hospital, a palliative and hospice facility in the Bronx, N.Y.

While the businesses that sell and use these algorithms say they're only meant to make suggestions, "it ends up being a hard-and-fast rule that the plan or the care management firms really try to follow," David Lipschutz, associate director of the nonprofit Center for Medicare Advocacy, said. There's "no accounting for situations in which a person could use more care."

Read the full investigation into how the algorithms are impacting care here.

PROVIDERS

How one Medicare Advantage business backfired on its own investor

In reporting on those algorithms, Bob and Casey discovered another fascinating dust-up: This time between one of the companies hawking that technology and a large health system that was among its first funders.

NaviHealth, a startup that developed technology predicting post-acute care needs about a decade ago, got a $5 million check years ago from inpatient rehab and long-term care hospital chain Select Medical. Now, Select Medical is publicly bashing NaviHealth, which it says leads to improper denials of Medicare-covered care. Read more on Select Medical and NaviHealth's entanglement, and what it could mean for seniors, here.

data

Tweet of the week

finance

What SVB's collapse means for health and biotech

Silicon Valley Bank's collapse threw much of the startup world into turmoil last week, but the fallout may be especially significant for the health tech and biotech industries — as my colleague Allison DeAngelis reports, SVB did business with nearly half of tech and biotech companies in the U.S. She has a tick-tock on its implosion and the initial effects on biotech companies here.

As the impact on the digital health industry unfolds, a handful of tech leaders have spoken out about their response. Alison Greenberg, who heads maternal telehealth company Ruth Health, told CNN the company rapidly withdrew its money from the bank hours before it collapsed, for instance. The bank has said it was involved in almost half of venture-backed tech and health care IPOs last year, so we'll be tracking the after-effects in the coming weeks.

Give us a shout if you're impacted about how you're moving forward.

Big tech

On tap today: Google Health's annual status report

As technology giants ponder how best to break into the traditional health care market, Google has certainly seen some stumbles: The consolidated health care team was dissolved and redistributed throughout the company in 2021 when leader David Feinberg left for Cerner. And it faces fierce competition from behemoths like Amazon vying for health systems' cloud business.

Still, it's been quietly building out health-related functions for Cloud as well as for products like Fitbit, AI, YouTube — last year, for instance, it inked its first licensing deal with cancer detection company iCAD for an AI model aimed at improving breast cancer diagnosis. The company's health care leaders, including chief health officer Karen DeSalvo, are slated to offer updates on those projects today at 11 ET. Check out the livestream and let us know what stands out to you.

Washington

This week: Epic to testify about cybersecurity risks

As health care data breaches steadily increase, exposing tens of millions of records, Washington regulators are sounding the alarm: The White House recently issued a national cybersecurity strategy calling for, among other steps, more R&D for encryption technology and public-private partnerships defending "critical infrastructure, and the Senate's Homeland Security and Governmental Affairs committee is convening a hearing on health-related cyber risks on Thursday.

Stirling Martin, chief privacy and security officer at Epic, is slated to testify, as is Kate Pierce, senior virtual information security officer for Fortified Health Security; Scott Dresen, chief information security officer for Corewell Health; and Greg Garcia, a cybersecurity executive director at the Healthcare and Public Health Sector Coordinating Council.

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What we're reading

Q&A with the founder of maternal health tech company Poppy Seed Health, Ebony
Digital health investment trends for 2022's final quarter, Pitchbook
Why telehealth is at a crossroads, Boston Globe

Thanks for reading! More on Thursday - Mohana

Mohana Ravindranath is a Bay Area correspondent covering health tech at STAT and has made it her mission to separate out hype from reality in health care.