New Medicare model will increase prior authorizations, not decrease them, House Democrats say

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Democratic lawmakers say a planned program in Medicare will increase prior authorizations (PAs) in health care, not decrease them, despite the claims of the administration of President Donald J. Trump.

Meanwhile, America’s Physician Groups (APG) “is gravely concerned” about Health and Human Services Secretary Robert F. Kennedy, Jr., possibly dissolving or appointing new members to the U.S. Preventive Services Task Force (USPSTF).

The latest developments involved two issues that could have affects across U.S. health care.

More prior authorizations, or fewer?

House Democrats said the new Wasteful and Inappropriate Service Reduction (WISeR) Medicare model will increase the use of prior authorization by introducing PA to traditional Medicare. Rep. Ami Bera, MD (D-California) and Rep. Suzan DelBene (D-Washington) led the effort, detailing their concerns and asking questions about the program in a letter to Mehmet Oz, MD, MBA, administrator of the U.S. Centers for Medicare & Medicaid Services (CMS).

The WISeR model is scheduled to run five years starting Jan. 1, 2026, in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, and will contract with private companies to use artificial intelligence (AI) to automate prior authorizations. The Dems say it will require PA for skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.

“While prior authorization is often described as a cost-containment strategy, in practice it increases provider burden, takes time away from patients, limits patients’ access to life-saving care, and creates unnecessary administrative burden,” the letter said. “Many patients choose Traditional Medicare because they know their care will be determined by their doctors and not by insurance companies.”

Health and Human Services Secretary Robert F. Kennedy, Jr., and his top aides have committed to reforming the use of PA across health care, the legislators said.

The WISeR model will run its demonstration by contracting with Medicare Advantage insurers — “the very entities that have abused prior authorization for Medicare patients enrolled in private plans,” the House Democrats said.

“The model is described as voluntary, but it is only voluntary for the model participants,” they wrote. “Medicare providers in WISeR model states will be required to either submit a prior authorization claim or be subject to review prior to payment, making this an involuntary burden on providers and Medicare beneficiaries.”

The lawmakers asked a series of questions about the selection process for the participating states, the prior authorization reviewers, and performance measures for the program. They asked for answers by Sept. 1.

Additional signers were Democratic Representatives Eleanor Holmes Norton of Washington, D.C., Linda Sánchez of California, Brad Schneider of Illinoi, Danny Davis of Illinois, Don Beyer of Virginia, Nikki Budzinski of Illiniois, Jimmy Panetta of California, Jonathan Jackson of Illinios, Marilyn Strickland of Washington, Terri Sewell of Alabama, Marc Veasey of Texas, Judy Chu of California, Emily Randall of Washington, Raja Krishnamoorthi of Illinois, and Marcy Kaptur of Ohio.

USPSTF under review

APG has become the latest organization to voice its concern about firing or replacing the USPSTF.

The Affordable Care Act requires health insurers to cover, at no cost to patients, any preventive services that receive “A” or “B” ratings by USPSTF. That provision is helping patients, according to APG.

“Having robust evidence behind preventive screenings is especially important, for example, at a time when high-cost screenings of indeterminate value for cancers and other conditions are proliferating,” APG said in a statement late Aug. 7.

Preventive services also are crucial to value-based care models that APG participate in and believe in due to accountability in care, the APG statement said.

“APG is troubled by the lack of transparency about why the potential dismantling of the task force may be warranted; who may be considered for future appointments to the task force; and whether future task force members will have the academic, clinical, and policy expertise to evaluate the scientific evidence behind preventive interventions and understand how to provide them well in the clinical setting,” the organization’s statement said. “APG stands ready to work with the secretary to achieve the goal of providing accountable, high quality health care and to ensure the stable provision and coverage of the most effective evidence-based preventive services.”

In late July, The Wall Street Journal first reported Kennedy planned to fire the 16 members of the panel “because he views them as too ‘woke,’” according to “people familiar with the matter.”