AI, Medicare and Denial

 

 The boys in DC have selected NJ as one of six states to trial an AI based pre-approval for Medicare payments. They plan to use AI companies. The NYT states:

The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims. Medicare plans to pay them a share of the savings generated from rejections. The government said the A.I. screening tool would focus narrowly on about a dozen procedures, which it has determined to be costly and of little to no benefit to patients. Those procedures include devices for incontinence control, cervical fusion, certain steroid injections for pain management, select nerve stimulators and the diagnosis and treatment of impotence. Abe Sutton, the director of the Center for Medicare and Medicaid Innovation, said that the government would not review emergency services or hospital stays.

Specifically they intend to review:

 

• Facet joint procedures for back pain

• Nerve and muscle tests (electrodiagnostic testing)

• TENS units and similar electrical stimulation devices

• Hyperbaric oxygen therapy

• Spinal cord stimulators

• Deep brain stimulation (commonly for Parkinson’s)

• Sacral neuromodulation (for urinary conditions)

• Transcatheter aortic valve replacement (TAVR)

• Arthroscopic knee cleaning or debridement

• Vertebroplasty/kyphoplasty for spine fractures

• Epidural steroid injections

• Non-emergency ambulance transport

• Botox injections for medical issues

• Negative pressure wound therapy pumps

• Hernia repairs

• Lumbar spinal fusion

• Skin graft substitutes for chronic wounds

 As my readers know I am a doubter in AI at this stage. Thus the application to millions of Medicare recipients is in my opinion grossly negligent. One should try at a lower level, not 15% of the US as a first bite. This is similar to the massive COVID vaccine program, just failing to test and just dumping on hundreds of millions.

One must ask who these "AI" companies are. What are their bona fides? Since we have no definition of what AI is it is likely that they will just be some friendly folks with the current Administration.  We should know these companies in detail. What is their technology, what is the basis for their decisions, what have they accomplished before? One suspects this will all be hidden behind some curtain of proprietary nonsense.

The test should be small, transparent and Congress should have a say as well as the Medicare recipients.

But alas, no one in DC gives a phenning! 

 

Swarming, Drones, and Warfare

 About 20+ years ago I wrote a paper on swarming warfare. As noted such warfare was characterized by:

Swarming has been characterized by Arqilla and Ronfelt as follows:

1. Autonomous or semi-autonomous units engaging in convergent assault on a common target

2. Amorphous but coordinated way to strike from all directions

3. “sustainable pulsing” of force or fire

4. Many small, dispersed, inter-netted maneuver units

5. Integrated surveillance, sensors, C4I for “topsight”

6. Stand-off and close-in capabilities

7. Attacks designed to disrupt cohesion of adversary

 Now with the use of drones and sophisticated netted multimedia communications one obtains a significant advance in this technique. 

DoD, now called War, should have been addressing this issue in detail. The PRC sure has been. Consider this as an attack by yellow jackets, before one knows it the swarm has in a coordinated manner attacked the poor victim.  

This is a new paradigm in warfare. Low costs attack platforms and counter persons destruction. Does the Russian forces have this? Not yet but the PRC may use this as a training opportunity. Beware!

One strategy for attack is the use of low yield neutron devices. A 5kT device can be tucked in a small drone, and such a device destroys living matter but leaves structures unharmed. It also can be readily accessed after deployment. This was a 1980s proposed strategy. However then there were no drones. Now the cost of deployment is low and the success ratio very high. Such a strategy can clear an enemy force in hours and allow re-entry the next day. Thus one asks; what is a counter-force strategy? 

March of the Turkeys

 

Fall is here and the turkeys are marching again.

Some say Larix some say Larch

 

The NY Times has an article about the larix, a tree indigenous to the White Mountains in New Hampshire and other similar locations. They note:

At least, it did. Since the late 2000s, about a quarter of Britain’s larch trees have been infected by Phytophthora (Greek for ‘plant-destroyer’) ramorum, a fungal-like pathogen that spreads via wind-blown spores and water in the soil. “Ramorum is so beautifully good at killing larch effectively,” Dr. Heather Dun, a scientist from Forest Research in Scotland who is studying the pathogen, told me. In the United States, it’s known as “sudden oak death,” targeting native trees like coast live oak and tanoak.

 The NH larix is a hardy tree if you grow it at 1,000 ft above sea level where the frost line in winter exceeds 1 foot! And the soil is very sandy. I tried one in New Jersey in clay soil and a frost line at best a few inches. No luck.

Trees need certain soil, certain moisture levels, and certain temperatures. My ginkgo loves clay soil in NJ but hates sandy soil in NH. My white pines are weeds in NH but struggle in NJ. 

Trees are very sensitive to location. White birch hate NJ but love NH. The list goes on.

Now for diseases, they all too often  result from some one bringing it into the region or country out of gross ignorance! Put it in their garden, wind blows and devastation occurs. 

Isolating the killing factors is complex but usually no single cause is present. 

 

JCP&L Is Collapsed Again!

 The local power distribution company has a long lasting record of failures and incompetence. It must, in my opinion and my experience, be run by a bunch of accountants who are clueless about electricity! Multiple times today power has been lost. The entire town seems to be down. 

They have bumped up the rates by 20% and reduced the service I fell by even more. Sounds like the local cable provider. It seems that any entity governed by a Utility Commission just does not give a damn.

Equipment fails, replacement parts are unavailable and repair crews are lost in translation. 

We are relying more and more on electricity. The companies are populated with less than average folks in an industry which will allegedly explode with AI. This will lead to total disasters! 

Pity!

AI in Medicine: GIGO?

 

The more I examine AI in medicine the more it appears to be very risky. In a Med City News piece they note:

Another healthcare executive — Jess Botros, vice president of IT strategy and operations at Ardent Health — noted that she wants the system’s clinicians to be able to spend as much time as possible with patients and have the right tools in hand. That said, there’s a lot of responsibility when it comes to deploying AI.

“In order to do this in the right way, you have to have your house in order from a data perspective, from a trust perspective,” she said. “You think about change management impacts and making sure that people are really along for the ride and really understand why we’re doing what we’re trying to do. It becomes super important.”

 My concerns are as follows:

1. Good medical practice is trying to understand the patient. Patients are often the main obstacle to good medical practice. They delay treatment, they often do not express all the symptoms, they try their own diagnosis thus adding noise to the process, and fundamentally they do not listen, often through fear, and the physician does not explain well enough.

2. Patient data is all too often in error. From time to time I examine my own data and see entries that make no sense and critical entries missing. For example I never have had GERD and my lipids are rock bottom. But both were listed otherwise on various reports. Thus if this data is entered into an AI system the AI doc will naturally come up with the wrong answer. Just try correcting these errors, impossible.

3. Does the AI doc need a license to practice? In what state? If I were to try practice in Georgia I would face a period in prison. But if the AI doc is in Montana can the patient in New York be diagnosed?

4. My best issue is who does a patient sue? The AI doc does not really exist.

5. The AI doc is really just a good and fast research librarian. Ask a question and get an answer based upon existing information. But what if this patient is a one off? Never seen this before. (98% of medicine is  rote, but the 2% is the challenge and most likely missing in the information fed to the AI system.

6. Patients are asked to fill out health forms. Many have no idea how to answer. Long lists of what a patient may have had get confusing answers. I am often reminded of Marty Samuels and his dizzy discussions. Trying to find out what type of dizzy and the cause may result in many unnecessary tests and may even miss a severe and immediate cause. 

Thus bad input data, unseen conditions, poor patient communications are just a few of the issues with AI docs. 

In a Bayesian world, and much of medicine is that way, diagnosis and treatment is often based upon pre-existing data. If that patient data is wrong, not current, then the results could be either unproductive or worse deadly!