07/07/2025
CMS’s WISeR model claims to cut waste—but it’s targeting the wrong procedures, which will result in excess patient deaths if implemented. They are targeting several revolutionary procedures that actually work, which is why utilization is increasing. If the goal is truly to decrease unnecessary procedures, then we should look at lumbar surgery for axial back pain and DCS.
Some of the proposed targets:
—Vertebral augmentation, a procedure that actually saves lives, with absolute mortality reduction that is BETTER than percutaneous coronary interventions.
1. Reduces opioids, and costs less than $5,000 in outpatient settings.
2. With a cost per QALY of $2,700–$13,500, it's also more cost-effective than most cardiology PCI, which run from $18,000 to over $50,000.
—RFA and MILD procedure: cost $2,000–$9,000 with cost per QALY of less than $13,000.
Yet WISeR burdens these outpatient, evidence-based procedures with prior auth. If we want to fix unnecessary procedures, here are some suggestions that WISeR should ACTUALLY go after:
—Lumbar fusion for axial back pain? Decompression without instability or radiculopathy?
1. Cost: $40,000–$120,000+
2. Cost per QALY: $70,000–$120,000+
3. Minimal benefit over conservative care—and not even targeted.
4. Causes INCREASED opioid use and low return to work.
—Dorsal Column Stimulators
1. 5-year costs: $70,000–$100,000+
2. Cost per QALY: $60,000–$150,000+
3. Increased opioid use.
If WISeR’s true goal is to reduce inappropriate care, it should prioritize value—not claims growth. Seniors deserve access to treatments that actually work and save lives. Otherwise, we should call this Withholding Interventions Seniors Emergently Require.
