60 comments

  • brandonb a day ago ago

    I run a YC startup that was accepted to Medicare ACCESS.

    Historically, insurance has paid for activity: time spent in visits, RVUs generated, and minutes logged. This was a reasonable starting point, but the flaw is that there's no strong incentives to be efficient.

    ACCESS is explicitly a "deflationary" approach. Medicare has set the payment rates high enough to be viable for startups, but low enough that you have to use software (including AI) to deliver a large part of your program.

    So Medicare has basically created economic incentives to reward software without prescribing the exact shape of the programs. I thought it was a really interesting approach and builds on 15 years of lessons from CMMI (Medicare's innovation group).

    • caycep a day ago ago

      I would maybe modify this to say - there is a strong incentive to be efficient - you only make so much money per encounter, DRG visit to the hospital, etc. So the pressure from "management" on a lot of us clinicians is to see more people per day, make each hospital visit as short as possible, etc. Medicaid providers now see something like 50-60 patients a day because the per-patient visit is relatively low. But there isn't as much incentive for outcomes. I think CMS has tried it in the past, but with varying success. Whether this new mousetrap will work, who knows.

      • brandonb a day ago ago

        The existing CPT codes (roughly) pay proportionately to physician time (RVUs). So I wouldn't say there's an an incentive toward delivering care efficiently, but rather hospital management wants to maximize billable hours.

        • caycep a day ago ago

          Oh no, there's both. At least for consultations, there's only 3 inpatient / 5 outpatient levels of CPT codes which work for both complexity and/or time. And patients tend to be pretty complex, so it'd not hard to justify a level 4 or 5 CPT code; any less than that and the patient usually has absolutely nothing wrong with them. And at best, max complexity, Medicare pays, something like $227 per CPT code. So to keep the lights on, you'd better figure out a way to see 14, 16, 20 patients a day...a practice cannot stay afloat if you take 45 mins to an hour to see a level 5 CPT code.

          For hospital stays, I may be outdated in this, but Medicare pays a lump sum DRG which doesn't tend to go up much, so the longer the patient is in the hospital, the less money the hospital makes.

          Short story is the biggest pressures from the higher-ups is for us to see more volume outpatient, and cut duration of stays inpatient....

      • jart a day ago ago

        There are a million doctors in the U.S. so if they're each seeing 60 patients per day that would mean that 17% of the population needs to be seen by a doctor daily.

        That would put hospitals somewhere between churches and offices in terms of the impact they have attracting attendance.

        • 7bees 18 hours ago ago

          That's not what the post you're replying to said, at all.

          I'm not in a position to evaluate whether they were right, but you've presented this as if it proves them wrong when it's barely related to what they said.

          • 7 hours ago ago
            [deleted]
          • jart 8 hours ago ago

            I'm not sure you understand how the Internet works. I'm here to share thoughts, not to prove I'm smarter than people.

        • 7 hours ago ago
          [deleted]
    • lesuorac a day ago ago

      Why isn't this vulnerable to the upcoding problem that plagues medicare advantage plans?

      • clearstack 13 hours ago ago

        MA upcoding survives because insurers profit from risk-coding patients sicker. if this breaks that link, watch how insurer Medical Loss Ratios shift in 10-K filings over the next 2-3 years

  • w10-1 a day ago ago

    The payment model is not "built for AI"; it's incentivized to drive costs down for chronically ill patients (and likely other high utilizers), which matters because a small number of patients (and end-of-life care) represents the bulk of costs. That means automation, ideal for SaaS.

    Remember: this is just v1. In theory Medicare Access will learn to weed out the bad actors and get better at focusing on progress that matters and can't be faked, and the AI companies will get better at reaching more people.

    This kind of work is profoundly unrewarding: hand-holding chronic patients and sorting out medical and personal logistics is no one's calling.

    Right now Pair Team has 3 engineering positions (~170K), but 14 for case workers that get to work from home for ~$50K (outside the bay area).

    I could see them pivoting to social services, with health care being just one aspect.

    (As a reminder, the homeless problem is driven by mental health issues blocking people from adapting economically, for which social services cannot keep up. I'd love to see a program offering free phones for daily AI discussions that surface some cheap partial solutions.)

    • throwawayqqq11 20 hours ago ago

      Isnt "bad actor" just a set of parameters, with cost at the center of it? And AI a neat tool to deflect responsibility and to bury one in verbose but good sounding bs?

      When you throw such a tool into the existing incentive structure, that already produces inhumane atrocities, i wouldnt be that optimistic.

  • ineedasername a day ago ago

    >rewards health outcomes rather than required activities… earn the full amount only when patients meet measurable health goals, like lower blood pressure or reduced pain

    They’ll just start cherry picking their patients, finding ways to squeeze out the people just that little bit lower on the prognosis curve. Or at least that will be the risk in a setup like that.

    • derbOac a day ago ago

      That's the biggest risk. I can also imagine it encouraging a certain kind of fraud.

      The program sounds reasonable until you become aware that the patients most in need are often the ones least likely to improve. It also ignores the reality that sometimes even the most rigorous, well reasoned treatment plans fail for unpredictable reasons. Do you punish providers and patients for that?

    • throwway120385 a day ago ago

      One might argue that that's the goal. There's the approach we've taken of trying to help people, and then there's the approach some people want, which is to treat every problem as if it is an entirely individual problem and treatment has to be earned by trying to will yourself out of the problem.

      • euroderf 19 hours ago ago

        > One might argue that that's the goal.

        If they can cure 80% of the entire caseload with 20% of the total estimated cost of the entire caseload, you'll want to be in that 80%.

    • estearum a day ago ago

      You see upcoding in risk-based programs already too (like Medicare Advantage). It's trivial to say a patient is sicker than they are and then let them "miraculously improve".

      Real bummer.

    • a day ago ago
      [deleted]
    • sj1135 a day ago ago

      This recent article about Outcome Aligned Payments in the Journal of the American Medical Association (JAMA) explains how they mitigate cherry-picking: https://jamanetwork.com/journals/jama/fullarticle/2848799?gu...

  • myhf a day ago ago

    Billing Medicare for services that never get performed is a particularly offensive kind of fraud. I hope these criminals get a harsh sentence.

  • sj1135 a day ago ago

    Recent podcast episode with CMS explains how ACCESS works in practice https://open.spotify.com/episode/720DvvkFd73BwXiXlOOte1?si=b...

  • swe_dima a day ago ago

    Is it basically about giving as much data as possible to insurance companies?

    • brandonb a day ago ago

      Medicare is a government-run insurance program, so this is one of the few cases where a private insurance company wouldn't receive data.

      (There is such a thing as Medicare advantage, where a patient can choose to put their Medicare dollars toward private insurance, but it's not part of the initial launch of this program.)

  • AndrewKemendo a day ago ago

    >The company's premise was that you can't improve health outcomes without addressing the full context of someone's life

    They are absolutely correct about this mathematically, you can’t solve problems you don’t have data for

    The question is what organization would I trust with the full context of my life. None. Zero.

    **future headline: Consumer warning: The panopticon(tm) product is embedded into your care plan, insurance is only available for panopticon subscribers.

    • w10-1 a day ago ago

      > what organization would I trust with the full context of my life. None. Zero

      Wouldn't this mean you'd rather interact with an AI, if it meant whatever you said was provably shown that it could never leak (though the medical conclusions would be documented in your HIPAA-protected record)?

      • AndrewKemendo a day ago ago

        Provided I own the infrastructure and can smash SSDs if needed then yes.

        But if it’s in someone else’s computer? thats gonna be a no from me dawg.

  • bonsai_spool a day ago ago

    It seems that TechCrunch, not a strong source of news since around 2014/15, is now just sending out AI text:

    First the title: "Medicare's new payment model is built for AI. Most of the tech world has no idea", classic AI tell. The by-line is by the editor-in-chief.

    Em-dashes everywhere, including in this quote, somewhat unusually: “The best solution wins, which, in regulated industries like healthcare — that’s not been the case.”

    Oddly-short paragraphs: "That payment structure is the real news."

    Rule of threes: "Pair Team launched in 2019 with a specific kind of patient in mind: people managing chronic conditions who were also dealing with unstable housing, too little food, or lack of transportation"

    This whole paragraph: "There are real risks. Participants are feeding extraordinarily sensitive patient data — intimate conversations about housing and diseases and mental illness — into a federal infrastructure with a documented history of breaches, including exposed Social Security numbers. For the vulnerable populations ACCESS is designed to serve, that's not an impractical concern."

    ---

    I haven't opened a TC article in years and I think I'll return to that practice.

    I think there's an ongoing conversation about whether we should accept all LLM-generated text without commentary.

    I write this comment because I have some sympathy for a Show HN with AI-assisted writing, but I will not spend time enriching TechCrunch's use of machine-generated text anymore than I would scroll through an ad block at the end of any other article.

    (Just for the sake of comparison, here's something by the same writer from a few years ago - https://techcrunch.com/2022/11/16/boompop-gains-traction-by-...

    You can see more examples here, too https://techcrunch.com/author/connie-loizos/page/16/ )

    • hathawsh a day ago ago

      These are also the markers of human journalists who write daily. Journalism is the reason AI acquired these habits. Gemini says this article is probably not generated by AI, particularly because it has original quotes.

      https://gemini.google.com/share/ba48849a15a9

      • ameliaquining a day ago ago

        Personally I wouldn't cite Gemini for this because I have no idea if it has any kind of track record of accurately distinguishing human from AI writing.

        That said, Pangram agrees and its track record is pretty good.

      • bonsai_spool a day ago ago

        > particularly because it has original quotes.

        I'm not saying the quotes are fake, that would be horrific. I'm saying the rest of the article appears to have had minimal human intervention.

        • jvanderbot a day ago ago

          At some point, however distasteful to the naturalists, do we accept that writing with AI is still writing? There will be an arms race the way there was moving from banner ads -> whatever hellscape we have today ...

        • ameliaquining a day ago ago

          Then why did you point to the em-dash in the quote as evidence of AI authorship?

      • yen223 a day ago ago

        LLMs did not invent clickbaity headlines. Kinda odd that people think it did

    • brandonb a day ago ago

      Isn't the first em dash taken from an interview that the writer did with the subject over Zoom? I think using an em dash to punctuate a broken or partial sentence like that is pretty standard journalistic practice when you don't want to modify the original quotation (e.g, denote a paraphrase with brackets), and definitely not an AI tell.

      The other uses are honestly pretty standard rhetorical patterns; they do not seem especially AI-flavored to me.

    • section_me a day ago ago

      I got an LLM to analyse all of my messages and e-mails from the launch of gmail to work out my writing style, it says I heavily favour em-dash's. I used to work in the industry of type settings and press and publishing. I even use — in HTML when I have to write it nowadays. em-dash is not a LLM thing. It's just most people don't know how to use it. It also said I'm wry. Go figure.

    • ineedasername a day ago ago

      Language is leaky, it gets just about everywhere. Some LLM goes and spills a bunch of emdashes and subordinate clauses all over a billion folks’ browsers and a bunch of them— especially those that may come into contact with a lot of language for a living— writers, for example— and they soak up a bit of it themselves and smear it all around.

      Put another way, search out the great vowel shift. That happened over more time but then again the contact with different speakers wasn’t as constant as every day on the internet. It’s just what happens, how things spread. No different and maybe to a further degree than typical memes.

      • ameliaquining a day ago ago

        My suspicion is that the causation mostly goes the other way—LLMs write like that for the same reason that many humans do, namely, that it's a cheap trick for sounding smart with limited effort and cognitive capacity. (My guess would be that em-dash usage among human writers is down in the LLM era because people don't want to be accused of being LLMs, though I don't have any data on this.)

        Coincidentally I just read a blog post today that explained this in a way I always struggled to: https://www.astralcodexten.com/p/nostalgebraists-hydrogen-ju...

    • polynomial a day ago ago

      Very obviously LLM written to anyone who's spent any time using them.

    • scared_together a day ago ago

      Pangram considers this text human written.

      • bonsai_spool a day ago ago

        Do you consider it human written? We can't let machines take over our thought.

        And if we're using machines to assess this, the appropriate action is to look at the author's writing from before the time of LLMs and compare it to now.

        • ameliaquining a day ago ago

          On the contrary, when a machine has been shown to outperform human judgment at a specific task, you should trust it over your own gut feeling, especially if you have no particular training or track record at the task.

          There've been third-party evaluations of Pangram, e.g., https://bfi.uchicago.edu/wp-content/uploads/2025/09/BFI_WP_2.... I personally do not think I could achieve that rate of accuracy, if you made me read a bunch of text samples and guess whether humans or AIs wrote them. Do you think you could?

          • bonsai_spool 13 hours ago ago

            One needs to be careful of citing papers - Pangram was not tested on the most recent models; the most recent one in that report is Claude Opus 4. Notably, Pangram does worse on news reports than on other types of textual detection tasks, and its failure depends on the model used in a way that suggests Pangram detection is very sensitive to whatever sources it was used for training.

            > Do you think you could?

            Not the right question. I am saying that this particular article based on its tendencies and the historical writings of this author are LLM-assisted if not wholly generated.

        • scared_together a day ago ago

          You're asking me to actually read the article instead of responding to the comment section? Oh the humanity! ;)

          The author's name in the article is linked to a list of articles attributed to her, and it's easy to advance through the list by editing the URL, like so: [0]. As other commenters point out she's the editor-in-chief so maybe she could put her name on an AI article. But I'm assuming she would not put her name on another human's work.

          This lead me to [1], an article from 2018. And when comparing the old article to the OP ... I'm stumped.

          They both rely on quotes from a company founder. This is a bit intentional, I wanted to pick similar articles.

          They are both somewhat .. dry? They have a sincere tone, devoid of hyperactive meme-speak or jokes (presumably the hyperactivity is reserved for the advertising). The older article has one oddly casual line: "What has changed since then is, well, not much, argues Sims." The newer article has an extremely short paragraph that sticks out visually: "That payment structure is the real news." But otherwise I don't see any super-obvious difference.

          They both used em-dashes.

          To be honest, I could be convinced that the OP is written by the same human who wrote [1], some humans just write like LLMs after all. My intuition isn't really helping me out here, if I wanted to go further "manually" I'd have to break out Wikipedia's list of AI tells or something like that.

          (EDIT: and just to be clear, Pangram also thinks the old article is human-written, which I guess is our control case).

          (EDIT: in your earlier comment, you mentioned the rule of three as a sign of AI writing, but it's a pretty common pattern in human writing as well and appears in the older article: "A second offering is Codecademy Pro Intensive, which is designed to immerse learners from six to 10 weeks (depending on the coursework) in either website development, programming or data science.").

          [0] https://techcrunch.com/author/connie-loizos/page/45/

          [1] https://techcrunch.com/2018/10/04/as-some-pricey-coding-camp...

      • estearum a day ago ago

        Pangram is fraudulent lol

        • scared_together 21 hours ago ago

          I only started using it a couple of days ago, so I have no loyalty to it.

          Do you have any suggestions for identifying AI writing, other than relying on intuition or going through the points of Wikipedia's list [0]?

          [0]: https://en.wikipedia.org/wiki/Wikipedia:Signs_of_AI_writing

          • estearum 11 hours ago ago

            No, it's a fool's errand. The only way to trust anything from here on out is to trust the source.

    • bitwize a day ago ago

      Also "X is the real Y" is another tell. Surprised it didn't double down with "X—that's the real Y."

  • spwa4 a day ago ago

    > The first call that shifted his thinking was with a 67-year-old woman living out of her car, managing PTSD and congestive heart failure. She spoke with Flora for over an hour. "It was both incredible and depressing," Batlivala told me. "Flora was probably the only 'person' she'd talked to in weeks about her situation." Now, hourlong conversations with Flora are routine. "That's the companionship piece," he said. "And it turns out that is truly an intervention."

    People don't seem to realize that this is both coming and that before long people will be defending AI "persons" because of this reason (OpenAI is already complaining about people doing this). Nobody's going to deliver this level of care using humans. It's not going to happen.

    A lot of people needing care are deeply isolated and will be of the opinion that AI changes that.

    • vjvjvjvjghv a day ago ago

      I feel the same about caretaking. Having an AI talk to people with dementia will be a godsend for families. Before he died, my dad had the same thought every 5 minutes and it slowly drove my mom crazy. A super patient AI would have helped a lot and freed up the rest of the family for other tasks.

      One step further would be robots that take people to the bathroom, clean them and other stuff. Having this done by humans is either extremely expensive or it will not be done properly.

      Some people are horrified by the loss of human touch but for most old people human touch is a luxury they can't afford.

      • saltcured a day ago ago

        I don't think it will be helpful when it is slopped together and doesn't have a real mental model to keep the dementia patient on a healthy track.

        Look at all the "AI psychosis" problems with people going into a conversation loop that amplifies their worst thought patterns. Now consider the same where the person in this loop is already having delusions and other cognitive decline. It seems to me that it could spiral in the wrong direction quite easily.

        It's quite difficult for human caretakers to navigate this space too. That is part of why it is so exhausting. You're constantly trying to make judgement calls and implicitly predict the unreliable response of the dementia sufferer.

        I think there is a large uncanny valley between having some facsimile of human interaction in a short session and having some kind of trustworthy caretaker that can consistently respond in a way that promotes health and safety. I think it involves a lot of subjunctive interpretation and reasoning to navigate all the mixed up layers of fact, fantasy, and simply aphasic expression that come from dementia.

        • vjvjvjvjghv 11 hours ago ago

          What's the alternative? Adequate human care is out of reach for a lot of people due to cost so the alternative is either nothing or bringing families to a breaking point which often can lead to abusive behavior. AI is not perfect but I assume it can be improved.

        • spwa4 12 hours ago ago

          > Look at all the "AI psychosis" problems ...

          First: of course this is fixable.

          Second: As opposed to the damage of no attention at all? Because you act as if the alternative is that a professional therapist will be helping the homeless, walking around in the cold. I've never once seen that happen.

    • esseph a day ago ago

      Every psychologist and therapist I have talked to about using LLMs in place of personal interactions (just discussion about this topic) have all said roughly the same thing:

      Any attempt to use LLMs as a substitute for personal interaction is playing an incredibly dangerous game that will probably make them a lot of money, while hurting a lot of people.

      • spwa4 a day ago ago

        You might want to read again who the patient was. Because: obviously not going to happen, no matter how bad the AI is ...

        Oh and taking sycophancy out of a model is easy. Just finetune out that they (have to) agree with everything. Plus every new model has less of it, or at least masks it better.

    • polynomial a day ago ago

      A 67 year old woman living out of her car? JFC.

  • d0liver a day ago ago

    Gross .