Summary
CMS Innovation Center leader Abe Sutton and Chief of Staff Gita Deo recently outlined the center’s new strategy in a Health Affairs Forefront article, and I thought their discussion of the WISeR model as an example of prioritizing high value care was instructive. Take skin substitutes for example:
One chief medical officer reported that improper use of skin substitutes on her system’s patients caused “devastating outcomes” including infection-induced “sepsis, amputation, and death.” CMS OIG reported that in the third quarter of 2024, Medicare Part B spending on these items was $2.9 billion (at a cost of $1,470 per unit) compared to $192 million in Medicare Advantage (at a cost of $730 per unit). Medicare Part B spending on skin substitutes exploded from $256 million in 2019 to more than $10 billion in 2024.
These examples of low-value (unnecessary, duplicative) care are far too common in our health care system and put patients at both clinical and financial risk. The Medicare Payment Advisory Commission estimated that Original Medicare spent up to $5.8 billion in 2022 on services with minimal clinical value.
This seems like a huge and obvious problem that urgently needs to be solved. But when CMMI first announced WISeR, there was backlash and concern from traditional Medicare participants and advocates. Although it’s long been a utilization management strategy for Medicare Advantage, prior authorization has only been used in traditional, fee-for-service Medicare in a very limited way. This represents a significant departure from how things have been done in the past.
Now that CMS has selected its participating companies and the first performance year is only a few weeks away, we enjoyed chatting with Dr. Jeremy Friese, CEO of Humata Health, for a discussion of the WISeR model, how he thinks about prior authorization philosophically, and what the proper role of technology is in these sorts of decisions.
Check out the conversation below!
Connect & learn more
What we covered:
00:00 Introduction and overview
01:07 The problem that WISeR is solving
03:24 What's covered by the program
05:02 Two paths for providers in the regions
08:08 Criticisms of the program
12:05 The WISeR shared savings model
15:00 Gold carding philosophy
18:09 Provider and payer conflicts and managing trust
21:09 Solving the many to many problem of prior authorization
24:15 The technical challenges of promoting transparency
26:30 The AI arms race in prior auth
29:07 How can we follow along with the program