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Medicare has launched a six-year pilot program that could eventually transform access to healthcare for some of the millions of people across the U.S. who rely on it for their health insurance coverage. Traditional Medicare is a government-administered insurance plan for people over 65 or with disabilities. About half of the 67 million Americans insured through Medicare have this coverage. The rest have Medicare Advantage plans administered by private companies. The pilot program, dubbed the Wasteful and Inappropriate Service Reduction Model, is an experimental program that began to affect people enrolled in traditional Medicare from six states in January 2026. During this pilot, medical providers must apply for permission, or prior authorization, before giving 14 kinds of health procedures and devices. The program uses artificial intelligence software to identify treatment requests it deems unnecessary or harmful and denies them. This is similar to the way many Medicare Advantage plans work. As health economists who have studied Medicare and the use of AI in prior authorization, we believe this pilot could save Medicare money, but it should be closely monitored to ensure that it does not harm the health of patients enrolled in the traditional Medicare program. Prior authorization The pilot marks a dramatic change. Unlike other types of health insurance, including Medicare Advantage, traditional Medicare generally does not require healthcare providers to submit requests for Medicare to authorize the treatments they recommend to patients. Requiring prior authorization for these procedures and devices could reduce wasteful spending and help patients by steering them away from unnecessary treatments. However, there is a risk that it could also delay or interfere with some necessary care and add to the paperwork providers must contend with. Prior authorization is widely used by Medicare Advantage plans. Many insurance companies hire technology firms to make prior authorization decisions for their Medicare Advantage plans. Pilots are a key way that Medicare improves its services. Medicare tests changes on a small number of people or providers to see whether they should be implemented more broadly. The six states participating are Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The 14 services that require prior authorization during this pilot include steroid injections for pain management and incontinence-control devices. The pilot ends December 2031. If the Centers for Medicare & Medicaid Services, which administers Medicare, deems the pilot successful, the Department of Health and Human Services could expand the program to include more procedures and more states. Introducing a hurdle This pilot isnt changing the rules for what traditional Medicare covers. Instead, it adds an extra hurdle for medical providers before they can administer, for example, arthroscopic treatment for an osteoarthritic knee. If Medicare issues a denial rather than authorizing the service, the patient goes without that treatment unless their provider files an appeal and prevails. Medicare has hired tech companies to do the work of denying or approving prior authorization requests, with the aid of artificial intelligence. Many of these are the same companies that do prior authorizations for Medicare Advantage plans. The government pays the companies a percentage of what Medicare would have spent on the denied treatments. This means companies are paid more when they deny more prior authorization requests. Medicare monitors the pilot program for inappropriate denials. What to watch for Past research has shown that when insurers require prior authorization, the people they cover get fewer services. This pilot is likely to reduce treatments and Medicare spending, though how much remains unknown. The Centers for Medicare & Medicaid Services chose the services targeted by the pilot because there is evidence they are given excessively in many cases. If the program denies cases where a health service is inappropriate, or of low value for a patients health, people enrolled in traditional Medicare could benefit. But for each treatment targeted by the pilot, there are some cases where that kind of healthcare is necessary. If the programs AI-based decision method has trouble identifying these necessary cases and denies them, eople could lose access to care they need. The pilot also adds to the paperwork that medical providers must do. Paperwork is already a major burden for providers and contributes to burnout. AIs role No matter how the government evaluates prior authorizations, we think this pilot is likely to reduce the use of the targeted treatments. The impact of using AI to evaluate these prior authorizations is unclear. AI could allow tech companies to automatically approve more cases, which could speed up decisions. However, companies could use the time saved by AI to put more effort into having people review cases flagged by AI, which could increase denials. Many private insurers already use AI for Medicare Advantage prior authorization decisions, although there has been limited research on these models, and little is known about how accurate AI is for this purpose. What evidence there is suggests that AI-aided prior authorization leads to higher denial rates and larger reductions in healthcare use than when insurers make prior authorization decisions without using AI. The bottom line Any money the government saves during the pilot will depend on whether and how frequently these treatments are used inappropriately and how aggressively tech companies deny care. In our view, this pilot will likely create winners and losers. Tech companies may benefit financially, though how much will depend on how big the treatment reductions are. But medical providers will have more paperwork to deal with and will get paid less if some of their Medicare requests are denied. The impact on patients will depend on how well tech companies identify care that probably would be unnecessary and avoid denying care that is essential. Taxpayers, who pay into Medicare during their working years, stand to benefit if the pilot can cut long-term Medicare costsan important goal, given Medicares growing budget crisis. Like in Medicare Advantage, savings from prior authorization requirements in this pilot are split with private companies. Unlike in Medicare Advantage, however, this split is based on a fixed, observable percentage so that payments to private companies cannot exceed total savings, and the benefits of the program are easier for Medicare to quantify. In our view, given the potential trade-offs, Medicare will need to evaluate the results of this pilot carefully before expanding it to more statesespecially if it also expands the program to include services where unnecessary care is less common. Grace Mackleby is a research scientist of health policy and economics at the University of Southern California. Jeff Marr is an assistant professor of health services, policy, and practice at Brown University. This article is republished from The Conversation under a Creative Commons license. Read the original article.
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E-Commerce
Nikolai Tesla was a revolutionary thinker with bold, transformative ideas. Yet it was George Westinghouse and Thomas Edison who shaped how electricity was brought to the world. The personal computer was invented at Xerox PARC (Palo Alto Research Center), but it was Apple that brought the Macintosh to market. William Coley pioneered cancer immunotherapy, but James Allison made it a reality. We grow up believing that if an idea is good, it will naturally rise to the top. Yet thats rarely, if ever, true. To make an impact, you need to understand power and influence. It isnt about titles, authority, or formal position. Its about understanding how decisions actually get made, how people get mobilized, and how systems really change. To do that, you need to master three forms of power: hard power, soft power, and network power. Hard power compels. Soft power persuades. Network power amplifies. Real influence comes from knowing how to combine all three. Thats the difference between having a good idea and building the traction you need to bring about the impact you want to see. How a Group of Kids Harnessed Institutional Hard Power to Bring Down a Dictator In 1998, five young activists met in a café in Belgrade. Still in their twenties, they were, to all outward appearances, nothing special. They werent rich, or powerful. They didnt hold important positions or have access to significant resources. Nevertheless, that day they conceived a plan to overthrow their countrys brutal Milo¹evię regime. The next day six friends joined them, and together they became the 11 founders of the activist group Otpor. They had some experience with activism, taking part in the protests against the war in Bosnia in 1992 and then in the Zajedno movement in 1996. But those efforts had fallen short, and Milo¹evię continued to rule with an iron hand. Yet they had learned from the experience, and an activist introduced them to the Albert Einstein Institution as well as the ideas of Gene Sharp. They found that there are sources of power that support the status quo and these have an institutional basis. As long as these remain in place, nothing will ever change. But if you can shift them, anything becomes possible. Even a seemingly all-powerful dictator needs to control or influence institutions to carry out their will. So Otpor set out to influence key institutions, such as the media, local businesses, and international organizations, and had a particularly innovative strategy for influencing the police. When Milo¹evię tried to steal the election, people took to the streets, in what is now known as the Bulldozer Revolution. Those institutional shifts proved decisive in bringing down his government. The Serbian strongman would die in his prison cell in The Hague in 2006. Everyone with an idea is, in some way, like those five kids in the café in Belgrade. If youre ever going to get anywhere, you need access to hard power. And that means unless you already control institutions that can make decisions, youre going to have to learn how to influence them. Thats the essence of hard power strategy: shaping decisions by shaping institutions. The Pervasive Soft Power of Ramanujan As the story of Otpor shows, influencing the hard power of institutional authority is critical for driving through transformational change. Otherssuch as the Occupy movement, Black Lives Matter, and the Gezi Park protests in Turkeywere able to mobilize massive numbers of people, but without institutional influence they were unable to achieve significant progress. Still, you cant just use institutional heft to overpower. You also need to attract people to your cause, and thats where soft power comes in. Consider the story of Ramanujan, a destitute Indian with little formal education. In 1913, he sent his work to G.H. Hardy, a prominent mathematician working at one of the worlds most prestigious institutions, Cambridge University. It feels almost strange to ask why Ramanujan reached out to Hardy and not the other way around. As a leading professor at a major center of learning, Hardy carried a lot of institutional clout, while Ramanujan had none. But in the end, it was Hardy who did Ramanujans bidding and, in fact, considered it to be one of the greatest privileges of his life to do so. How did that happen? Ramanujan was able to harness the three foundational elements of soft power: ethos, pathos, and logoscredibility, emotion, and logic. Ramanujan was, by any measure, one of the greatest mathematical minds the world has ever produced. His story as a poverty-stricken man doing complex mathematical proofs in his spare time was emotionally compelling, and the logic of bringing him to Cambridge was clear and undeniable. In other words, for a variety of reasons Hardy found Ramanujan attractive, and thats at the core of the concept of soft powerit is the power to influence without coercion. Hard power might get people to do what you want, but that can create resentment and backfire. Soft power is how you get people to want what you want, and that can sometimes be more valuable. The Power of Tony Sopranos Networks As a Mafia boss, Tony Soprano clearly understood hard power and strictly enforced his will. He was also no stranger to soft power, joking and cajoling with his associates. But at the root of Tonys power were his networks. He was, in gangland parlance, connected, not only to other criminals, but to government officials, religious leaders, and legitimate businesspeople. Yet it isnt only mob bosses who nee to be connected. One of the best examples is the Medici Family in Renaissance Florence. The Medici weren’t kings. They didn’t hold official power, but they became one of the most powerful families in Europe. How? Because they sat at the center of multiple overlapping networks. Through their bank, they were connected to merchants, princes, and even popes. They built alliances through strategic marriages. They funded artists, scientists, and thinkers. And they acted as bridgesconnecting powerful people who wouldn’t otherwise talk to one another. That made them extraordinarily influential. That’s network power. The same pattern shows up again and again. Bill Gates used network power to weaken IBM and dominate the tech industry for over a decade. Microsoft didn’t own the hardware. It didn’t control distribution. But everyone needed its software. That’s what made the company dominant. That’s network power. In the 1980s, when home video recorders were just coming to market, Betamax built a better product, but VHS built a better network and came to dominate the market. Next time you make a purchase, think about what you use to pay. Visa, Mastercard, American Expressthat’s also network power at work. While soft power can persuade and hard power can compel, it is network power that can help you gain scale, expanding access to information and providing the connectivity needed to communicate ideas and actions widely. Setting Your Ideas Up for Success Most of us grow up believing in merit. Were raised to think that the truth will win out and the best idea will always win in the end. Unfortunately, thats not really true. As much as we might like to believe that our ideas can stand on their own, the truth is that we need power and influence to put them into action. Stanford professor Jeffrey Pfeffer, who teaches the incredibly popular course Building Power to Lead, defines power as the ability to get things done your way in contested situations, and that gets to the meat of it. People dont encounter our ideas in a vacuum, but in a sea of other ideas, ambitions, prerogatives, and priorities. For people to adopt an idea, it needs to cross their thresholds of resistance, points at which joining in no longer feels risky or costly. To get them over that hump, we need to access power and influence, which comes in three forms: hard power, soft power, and network power. Hard power lowers thresholds by changing incentives. Soft power lowers them by making adoption desirable. Network power builds momentum and propagates the idea forward. These dont work in isolation, but in combination. Hard power can force a decision, but risks resentment. Soft power can win buy-in, but without connection to authority, it cant deliver results. Network power can get you access, but not action. When you use all three in tandem, however, you dont just push ideas forward, you pull people in, motivate them to make your cause their own, and encourage others to do so as well. So dont just ask whether your idea is good enough. Think about how youre going to access the power and influence you need to set it up for success. That, more than anything, will determine whether you succeed or fail.
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E-Commerce
Ah, brainstorming. The corporate rite of passage where creativity goes to die. It usually involves a room full of well-intentioned people offering ideas that feel familiar but not fresh. Why does this happen? Because most people stick to the safe zone, avoiding anything that might make waves, or worse, ruffle feathers. But heres the problem: safe ideas dont change the game. If you want ideas that truly shake things up, youve got to do something radical. You have to give your team permission not just to think differently but to think outrageously. And to do that, you need to encourage them to come up with ideas so bold, they might just get them fired. How to Generate ‘Firing-Worthy’ Ideas Heres how it works: start your brainstorming session as usual, letting your team throw out the predictable, respectable suggestions. Once those are on the table, and everyones energy is thoroughly underwhelming, its time to shake things up completely. Tell your team: Now I want you to pitch ideas so outrageous, so audacious, they could theoretically get you fired. Thats when the magic happens. Pretty quickly, the energy in the room goes up dramatically, people start laughing, and ideas start to fly. Without the usual guardrails, the brain feels unrestrained. Instead of staying within the confines of reasonable, your team starts coming up with wild, bold, and totally unfiltered ideas: What if we launched this product in zero gravity? What if we eliminated this process entirely? What if we let customers design their own versions and just sold that? When you mandate that people let the irrational, crazy, or uncomfortable act as their guide, fear dissipates, and creative thinking better takes hold. Permission to Dream Big By removing the fear of judgment, you unlock your teams ability to think without limits. People stop worrying about how their ideas will be perceived or whether theyll sound ridiculous. Instead, they focus on possibility. When we realized our brainstorm sessions were resulting in lackluster innovations and leaned towards incremental improvements versus transformational ideation, we knew we had to remove the shackles that were surrounding peoples brains,” says Victoria Platt, Vice President, Airline Strategy & Transformation, SITA. “So, in our next session, we told participants to imagine that privacy laws dont exist, there are no state or federal regulations, industry standards dont matter, the budget is boundless, resources are boundless, and it doesnt matter if the technology for an idea doesnt yet exist. The idea was to just think BIG and pull back to reality later.” In that next session,” Platt says, “40 strong ideas were generated . . . four of which are currently being developed for radical cost savings and provocative revenue generation. We took a bold chance and got bold results. And no, youre not actually going to act on ideas that would get anyone fired (obviously, no ones suggesting a new policy involving legal loopholes or ethically questionable practices). However, what you will get are new hunting grounds you never thought to explore. Often, these firing-worthy concepts arent as impractical as they seem; theyre just bold enough to challenge the norm. Apples modern designs didnt come from playing it safe. The company dared to envision products that were invisible to the eyesleek, minimalist, and without the clutter of traditional gadgets or overwritten marketing copy. At the time, those ideas sounded ridiculous. Today, theyre the gold standard of design. From Crazy to Commercially Viable Heres the best part of the exercise: outrageous ideas are what unlock brilliance. Once you weed out irrelevant concepts and focus on ones with actual potential, your team can start refining them into actionable concepts: Killing a process? It could lead to improved customer-service support that no one thought possible. Letting customers design their own versions of your products? Perhaps it evolves into a customizable product line you can charge much higher prices for next year. The point is to remove the handcuffs on ideas that hold us back. Risk often leads to reward when youre willing to take that first leap. Pushing Boundaries as a Practice Entrepreneur Jim Rohn said: If youre not willing to risk the unusual, youll have to settle for the ordinary. Too many teams stick to the sensible and safe, producing ideas that are fine but forgettable. But extraordinary results come from taking chances and from daring to color outside the lines. Encouraging your team to pitch ideas that would get them fired isnt just about shaking up a meeting: its about shifting the entire culture. It signals that boldness is valued, creativity is celebrated, and innovation is required. Stop having mediocre brainstorms. Give your team the freedom (and the challenge) to pitch the kind of concepts that just might get them fired. Youll get lots of laughs and some truly wild suggestions. But youll also get something even better: the kind of thinking that redefines the game.
Category:
E-Commerce
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