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STAT investigation: How Medicare Advantage plans use AI to deny coverage, costs of weight loss drugs, & ripples from a bank's failure

March 13, 2023
Reporter, Morning Rounds Writer
Good morning. Be sure to read how AI tools intended to improve and personalize health care are being used to deny it.

a stat investigation

Medicare Advantage plans increasingly use AI to deny care to seniors

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Mike Reddy for STAT

The Medicare Advantage plan's algorithm said Frances Walter, 85, was ready to go home. But after 16.6 days in the hospital being treated for a shattered left shoulder, she was far from able to care for herself. While she fought the insurer's decision, she spent down her life savings and enrolled in Medicaid. Health insurance companies have rejected medical claims for as long as they've been around, STAT's Casey Ross and Bob Herman note. But their investigation found artificial intelligence — which promises better, personalized care — is driving denials to new heights.

"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," Calvary Hospital COO Chris Comfort said of Medicare Advantage. "The appeal outlasts the beneficiary." Read Bob and Casey's investigation here, plus a related story of how an algorithm developer is being publicly bashed by a health care chain that once backed it.


Biotech

How we could feel the failure of biotech's top bank 

If bank failures bring to mind black-and-white photos of soup lines from the last century or memories of the more recent 2008 crash, Friday's news about Silicon Valley Bank's abrupt closure might furrow some brows outside the sectors it serves. The bank's customers include half of the nation's tech and biotech companies, including cash-burning startups that could be forced to change their plans and possibly delay the development of new medicines, STAT's Adam Feuerstein, Damian Garde, and Allison DeAngelis report.

"Our risk is in our drugs. The money we put in a bank, we want to be safe," Alexis Borisy, a serial entrepreneur who runs a venture fund called Curie.Bio, told STAT. The FDIC has taken control of SVB, presiding over an asset sale to cover clients' deposits. Meanwhile, companies of all sizes face an uncertain future if the capital they need to run clinical trials, pay rent, and make payroll is unavailable. And biotech may lose a banker of choice. Read more


Health

Most men can delay treatment for prostate cancer, study says

It's sometimes called "watchful waiting" and a new long-term clinical trial says it works in prostate cancer. The study directly compared the three approaches to the cancer, which in most patients develops slowly over many years: surgery to remove tumors, radiation treatment, and monitoring. After 15 years, there was no statistical difference among the three groups in the 97% survival rate, even though after 10 years the cancer had spread at different rates. 

The results are encouraging for men who want to avoid treatment-related sexual and incontinence problems, Stacy Loeb, a prostate cancer specialist at NYU Langone Health who was not involved in the research, told the Associated Press. Men with high-risk or more advanced disease do need urgent treatments, but in the U.S., about 60% of low-risk patients choose monitoring, now called "active surveillance." Read more.



Closer Look

What covering the new weight loss drugs could mean for Medicare — and patients

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While highly effective and wildly popular weight loss drugs are changing the narrative on obesity, they're also raising concerns about how — and whether — Medicare should pay for older adults to get them. Researchers wrote in a new NEJM perspective piece that if only a small fraction of Americans over 60 who are obese take one of the new drugs, it could cost Medicare anywhere from $14 billion to $27 billion a year. If this sounds familiar from debates about the polarizing Alzheimer's drug Aduhelm, that's because similarly stratospheric estimates were made ($34 billion at its initial price, a STAT analysis found). 

The researchers also say these weight loss drugs may have fewer benefits and more risks for older people. It may be too late, for example, to prevent diabetes or heart disease. And if lean muscle mass as well as fat mass melts away in older people, that's a recipe for frailty. STAT's Elaine Chen has more.


health inequities

Infant deaths are down, but disparities are up

At first the news sounds good: Overall, infant mortality in the U.S. continued to fall through 2020. Then there's this puzzling statistic: The rate of sudden unexplained infant deaths (including accidental suffocation and strangulation in bed as well as sudden infant death syndrome) did not decline, rising the most for non-Hispanic Black babies. SIDS climbed by 15% from 2019 to 2020 but the researchers say in their Pediatrics study that the increase was probably related to changes in diagnostic criteria used on death certificates because the overall SUID rate did not go up.

Under that umbrella term of SUID, racial disparities widened. Infants born to non-Hispanic Black families now have a nearly threefold higher death rate than infants born to non-Hispanic white families. The study authors can't prove cause and effect, but point to the disproportionate disruption Covid-19 caused communities, including access to health care, crowded housing, and other social determinants of health.


health

Insurance can modify inequities in cervical cancer, study says

Insurance works, and so does diagnosing cervical cancer at an earlier stage, thanks to Pap tests and other screening tools. A new study in JAMA Network Open looked at disparities in who in the U.S. is diagnosed with and who dies from cervical cancer. Black and Hispanic women are more likely than white women in both cases, but health insurance coverage was linked to diagnosis earlier in the disease. 

To reach their conclusion, the researchers analyzed records of nearly 24,000 women under age 65. They found that insurance mattered for more than half of them over the study's span, from 2007 through 2016. Patients with private insurance or Medicare were more likely to be diagnosed with an early, localized cancer than those with Medicaid or no insurance. Lack of access to screening and barriers to follow-up care could explain diagnosis at a later stage, the authors say. 


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What we're reading

  • Exclusive: Biogen's Samantha Budd Haeberlein, an architect of Aduhelm, leaves company, STAT
  • Judge in abortion-pill lawsuit schedules hearing but delays announcing it, Washington Post
  • FDA approves first treatment for Rett syndrome, a genetic neurological disease, STAT
  • Opinion: What if the next pandemic hit tomorrow? New York Times
  • Opinion: The second age of psychedelic therapies for mental health, STAT

Thanks for reading! More tomorrow,


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