The WiSER program to erode your Medicare coverage: Not WISE for you!

While much about American health insurance is infuriating, starting with it treating the healthcare system as a vehicle for making money rather than providing healthcare, “prior authorization” (PA) is one of its most infuriating, and dangerous, practices. It means that before you can get the treatment your physician has recommended, indeed often before you can see the physician you want, the insurance company must authorize it. This practice is ubiquitous in commercial health insurance, including “Medicare Advantage” (MA), a program that allow an insurance company to collect the money allocated for you by Medicare. This means that if you receive a terrible diagnosis, such as lung cancer and your oncologist recommends a specific treatment, it is entirely possible that they will deny coverage for it, especially if your cancer is rare, or requires an expensive drug. You can file an appeal, but even if it is eventually granted, the process takes time, and meanwhile you are sick and your cancer is advancing.

But if you have Traditional Medicare (TM), this has not been a problem. TM covers virtually all doctors and hospitals in the country, covers most treatments, and does not subject the individual to PA, or decide that another (usually cheaper and possibly less effective) treatment, or even no treatment might be better for you. Or that a different doctor or hospital that is “in network” (for them) would be a better choice even if their track record is inferior. The absence of PA is a major reason why many health experts recommend TM over MA. 

Back in January, 2023 I wrote about the proposed ACO/REACH program at CMS (Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!), which would allow companies (many owned by private equity) to purchase primary care practices, and voilà!, all those doctors’ patients were now in the company’s ACO and subject to restrictions on their care, including PA, without having to do anything at all and thinking they were safe because they were in TM! The REACH name was dropped but the program still continues; a friend in northern NJ was just informed he is now part of an ACO because they have acquired his doctor’s practice!

And other assaults on TM and the patients it covers continue. If you live in Arizona, as I do, or in 5 other states (New Jersey, Ohio, Oklahoma, Texas, Washington), even if you have TM you will suffer the indignity and damage of PA as Medicare implements a 6-year “pilot program” called WiSER (Wasteful and Inappropriate Services Reduction). No longer will you be able to get any Medicare-approved procedure from any Medicare-accepting doctor at any Medicare-accepting hospital (ie, virtually all doctors and hospitals). Medicare will contract with private companies that will utilize artificial intelligence (AI) algorithms to decide whether you can get the treatment. As with ACO/REACH, you have no choice, as participation is “voluntary” by state, but not by individual Medicare recipient. Actually, then it is worse than ACO/REACH, which you could get out of by changing your primary care physician (provided you could find another one!); WiSER will require you to move out of state!

Maybe the AI algorithms know better than you or your doctor. After all, isn’t reducing wasteful and inappropriate services a good thing? If you believe that the high cost of health care is the result of your using inappropriate and wasteful services, you might want to consider that the companies Medicare contracts with to do the PA will be paid “based on a share of averted expenditures.” That is, they will be paid on commission, receiving a percentage of the money saved by denying your care! But that won’t affect their decisions at all, right?

In reality, the use of “inappropriate and wasteful services” by you and your family and friends is not the reason for the high cost of health care. The reason is the enormous administrative costs of the US healthcare system, including the huge amounts made by for-profit insurance companies and pharmaceutical companies (and the eight-figure salaries of their CEOs and other executives), as well as health care providers (hospitals and health systems and the physicians, usually employed by them). This is a system found nowhere else among wealthy countries, every single other one of which comprehensively covers the care of all their people at much lower per-capita cost.

Bringing PA into Medicare is not “wiser”. It is the exactly wrong way to go. What we need is the expansion of Medicare to include everyone in the US, birth to death, and the improvement of that system by covering all health needs, including mental, dental, hearing, vision, and eliminating the 20% hospital co-pay Medicare recipients now are responsible for (and must buy Medigap insurance to cover). The “administrative costs” now being taken out of the “healthcare” system by companies would more than pay for it.

We would then have a system designed to provide health care for the American people, not profit for corporations. Imagine that!

 

adapted from a piece originally written to be a guest essay in the Arizona Star, but not published 

Drink more? Do more prostate cancer screening? I don't think so. But be careful about falls!

If the malignant lies and disinformation coming from HHS Secretary Robert F. Kennedy, Jr. (RFKJr) and his minions, whom he regularly replaces if they are too inclined to make decisions based on truth and science (see Susan Monarez, head of CDC for less than a month) were not enough, his psycho – but totally dangerous -- baloney regarding vaccines and other health issues provides cover for the re-emergence of other potentially dangerous “health” recommendations. This is par for the course for this administration, which is entirely focused on distracting us from important issues by focusing our attention on other things, brush fires (or sometimes major conflagrations). Trump is quite willing to arrest, brutalize, imprison, and deport people, to start wars across the globe, or whatever it takes to keep the Epstein files – which must contain truly damning information about him – from being made public. 

In the area of health this re-emergence has not been of the major blaze type, certainly nothing compared to the evil of RFKJr’s opposition to, discouragement of, and even blocking vaccines, but more of “well, we have an axe to grind and let’s bring it back out now that we have cover”. Who, after all will worry so much about the issues I address below when they can worry about the return of polio, measles, mumps, whooping cough, H. influenza, Covid, etc. And maybe even smallpox! But there have been several recent articles covering health issues which should be already settled. But, heck, if vaccines are not settled, why should these be?

On Sept 2, 2025, the NY Times Roni Caryn Rabin reports that Reduced Screening May Have Led to Rise in Advanced Prostate Cancer Diagnoses,  and follows that with the subhead “Changes in screening recommendations over a decade ago may have inadvertently resulted in later diagnosis of the most common cancer in men, a new study has found.” It sounds pretty scary, as it goes on to report that Black men are the least likely to be screened for prostate cancer and the most likely to die from it. Prostate cancer is being diagnosed at a later stage and the implication – no, the direct assertion in the article – is that it is because of a recommendation from the US Preventive Services Task Force (USPSTF) which in 2012 began discouraging the use of routine screening with PSA (Prostate-Specific Antigen). The Times article, and the article it is based on, from CA: A cancer journal for Clinicians, and the comments of the chief scientific officer of the American Cancer Society and one of the article’s authors, Bill Dahut, say “The pendulum may have swung too far in one direction, where we were afraid of overtreatment, and now we’re not finding these cancers early on, when they can be treated and are more curable, and we’re more likely to find metastatic disease that is not curable.” 

This conflates diagnosis of cancer at later stages with (implicitly) increase in death from prostate cancer. Well, doesn’t that make sense? Except that what makes sense is not always true. There is no data in the article that says more men are dying from prostate cancer, only that they are being diagnosed with further advanced cancer. Dr. Dahut says that finding the prostate cancer earlier would make it more curable, but if this were true, the decrease in screening would not only have led to cancers being diagnosed at a later stage, but in an increase in deaths from prostate cancer. How come it didn’t? There are basically two types of prostate cancer: the kind that kills you and the kind you die with, but not from. Medicine has yet to be able to find a test that can identify which kind you have. If diagnosing the kind that kills you earlier can make it curable, that’s great – but then we would see more deaths from prostate cancer as a result of not screening, and we don’t. What has historically happened is that the other, more indolent, kind has been treated and physicians have claimed “cures” – even though men don’t die from it without treatment. But they do suffer the morbidity of treatment (i.e., impotence, incontinence, radiation cystitis, etc.) This, along with the poor performance of PSA as a screening test for prostate cancer, is what led the USPSTF to recommend against screening. This issue has been addressed a number of times over the years on this blog (PSA Screening: What is the value?, March 21, 2009, PSA Screening: “One of Medicine's Great Success Stories"?, Oct 27, 2009,  PSA redux: The USPSTF finally recommends NOT getting it!, Oct 14, 2011, Prostate Screening and the Public’s Health, July 12, 2015, as well as other posts on the benefits – or not – of cancer screening), and essentially, nothing has changed. It is terrible that Black men die from prostate cancer. It is terrible that anyone dies from prostate cancer. If screening saved lives we should do it. But this article presents no new evidence that lives are being lost that could be saved.

A few days later (Sept 5, 2025) the Times had an article by the same reporter titled Federal Report on Drinking Is Withdrawn with the subhead “The upcoming U.S. Dietary Guidelines will instead be influenced by a competing study, favored by industry, which found that moderate alcohol consumption was healthy.” Yup. Favored by industry. Not only were the guidelines withdrawn by HHS and thus not, as planned, presented to Congress, but HHS promotes a “competing report” by a panel of the National Academies of Sciences, Engineering and Medicine that “came to a conclusion long supported by the industry: that moderate drinking is healthier than not drinking”. Yay for the alcohol industry! Of course, “Some panelists came under criticism for financial ties to alcohol makers,” but what the heck. It is perhaps surprising, as the article points out, that RFKJr’s MAHA (“Make America Healthy Again”) campaign does not include anything about the use of alcohol – or, even more amazingly, tobacco! When we don’t like the message, we kill the message (and sometimes the messenger), especially in the current administration. But despite the fact that “Science Over Bias, an industry-supported advocacy group, faulted the alcohol intake study for bias: “The Dietary Guidelines should be guided by a preponderance of sound science, not the personal ideologies of a handful of researchers,” it is the industry’s position that is based on bias rather than on evidence. With regard to physical health (not short-term mental health), there is no amount of alcohol that is good for you, and any amount is a little bad. No alcohol is better than moderate alcohol, except for the financial interests of the industry and the scientists on their payroll.

On a somewhat different issue regarding health, not about controversy (screen or do not screen for prostate cancer? Drink alcohol in moderation or not at all?), is the Times article from Sept 7 by Paula Span titled Why Are More Older People Dying After Falls? It doesn’t provide a definitive answer, but strongly implicates prescription drug use (“Some researchers suspect that rising prescription drug use may explain a disturbing trend.”) It’s important. Falls are a major cause of morbidity and mortality in older people. You can break your hip or your head, you can get a concussion or a brain bleed or die. No joke. The association with prescription medication is legitimate, especially certain ones, called FRIDs, or “fall risk increasing drugs”, that are more likely to cause falls though inducing drowsiness, dizziness, drops in blood pressure, etc. Older people are more likely to have more diseases and be on more medications to treat them, and they are also more sensitive to the side effects of these drugs. (Note that drugs do not know which of their effects are “side effects”; we define them as the ones we don’t like!) And they are more likely to suffer serious injuries from a fall. The take-away message is that physicians should carefully review the medications that their older patients (actually all patients) are on, make sure that there is a need for them, and that there is not another less risky (less FRID) drug that could be substituted. Psychoactive drugs “like benzodiazepines, opioids, antidepressants and gabapentin — that act on the central nervous system” should be especially assessed for need, with particular emphasis on the use of more than one drug with similar side effects that can lead to greater risk. The message should not be “stop taking my drugs because the pharmaceutical industry is greedy and trying to drug us all”. Sure, they ARE greedy, and we shouldn’t have to pay so much to them, but that is another issue. They also make drugs that are effective and in standardized doses (unlike “natural” herbs). And often it is the drugs that people like most (because they relieve pain and/or make them feel better) that are most likely to be FRIDs. Exercises to increase strength and balance are important. And, if the risks still cannot be significantly reduced, people may have to modify their lifestyles. For example, it may be necessary to stop walking a big dog.

These are 3 different issues. I included the first two, prostate cancer screening and alcohol use, because they represent efforts to peel back science-based policies that may have been deleterious to the profits of industry, which is like many of the policy changes across the administration over the last 8+ months. The falls issue is a little different; here the concern is to address the risks to the extent possible without overreacting and stopping all your medications!

Medicine and science are complex. But findings can be skewed to fit an agenda, and when that agenda is corporations making more money, a little skepticism is wise.