Judge rules $400M algorithmic system illegally denied Medicaid benefits(gizmodo.com)
gizmodo.com
Judge rules $400M algorithmic system illegally denied Medicaid benefits
https://gizmodo.com/judge-rules-400-million-algorithmic-system-illegally-denied-thousands-of-peoples-medicaid-benefits-2000492529
125 comments
I don’t live in your country and so I’m not familiar, is a denial some potentially ‘fraudulent’ transaction, or something else?
You have to apply for the social benefits here, like you would apply for a job. It is when the state government says no, you don't get to benefit from social welfare programs. In this case, TennCare, a health insurance system for the poor and disabled.
This government denies those applications at around a 50% rate, iirc. With that decision taking around 4 months to a year Then an appeal is launched, with that decision generally taking 2+ years. A judge rules on that appeal eventually.
A panel is convened with a couple of lawyers, the judge, a vocational expert (job fitness person), a health care professional, and yourself. Who you are and what you are capable of is summed up and deliberated upon. If you are deemed indigent, you are given an insurance policy with TennCare.
This government denies those applications at around a 50% rate, iirc. With that decision taking around 4 months to a year Then an appeal is launched, with that decision generally taking 2+ years. A judge rules on that appeal eventually.
A panel is convened with a couple of lawyers, the judge, a vocational expert (job fitness person), a health care professional, and yourself. Who you are and what you are capable of is summed up and deliberated upon. If you are deemed indigent, you are given an insurance policy with TennCare.
This is well explained but its missing a key ingredient.
You are dealing with government. Its not a business like Instagram or a grocer like Costco. If IG crashes consistently or if Costco has long lines at chekout, you take your business elsewhere.
With Medicaid you dont have an option, and the govt program, unlike IG or Costco, will never go out of business due to poor business services
You are dealing with government. Its not a business like Instagram or a grocer like Costco. If IG crashes consistently or if Costco has long lines at chekout, you take your business elsewhere.
With Medicaid you dont have an option, and the govt program, unlike IG or Costco, will never go out of business due to poor business services
> You are dealing with government. Its not a business like Instagram or a grocer like Costco. If IG crashes consistently or if Costco has long lines at chekout, you take your business elsewhere.
In a democracy, when the government fails, you can vote it out and get a new one... and you get as many votes as a person with 100x your spending power. In the free market, a business that effectively serves a specific market can thrive despite absolutely abysmal performance for the rest of the market. It's not unusual for a business to be better off if they can get rid of certain customers, because they're a net cost to the business. So they have every incentive to be as hostile as possible to those "customers".
> With Medicaid you dont have an option, and the govt program, unlike IG or Costco, will never go out of business due to poor business services
It's not like the poor and indigent have a lot of influence over IG & Costco either. ;-)
You'll notice that Medicaid and Medicare have different levels of service. There's a reason for that (not a very pleasant one). There are different levels of service between Medicaid to discount private health insurance (particularly pre-ACA private health insurance), and the comparison makes Medicaid look pretty good. Go compare this case to the cases against private health insurers, and then tell me that private health insurance works out better.
In a democracy, when the government fails, you can vote it out and get a new one... and you get as many votes as a person with 100x your spending power. In the free market, a business that effectively serves a specific market can thrive despite absolutely abysmal performance for the rest of the market. It's not unusual for a business to be better off if they can get rid of certain customers, because they're a net cost to the business. So they have every incentive to be as hostile as possible to those "customers".
> With Medicaid you dont have an option, and the govt program, unlike IG or Costco, will never go out of business due to poor business services
It's not like the poor and indigent have a lot of influence over IG & Costco either. ;-)
You'll notice that Medicaid and Medicare have different levels of service. There's a reason for that (not a very pleasant one). There are different levels of service between Medicaid to discount private health insurance (particularly pre-ACA private health insurance), and the comparison makes Medicaid look pretty good. Go compare this case to the cases against private health insurers, and then tell me that private health insurance works out better.
>In a democracy, when the government fails, you can vote it out and get a new one.
When's balloting for HHS principal deputy administrator? I keep missing those elections. :-)
When's balloting for HHS principal deputy administrator? I keep missing those elections. :-)
Americans have time and again voted against social welfare.
"Social welfare" hasn't been on the ballot for well over a century.
That's a fine point. If you can't vote for each individual position in the government, then really you don't have the same influence you have over a multinational conglomerate's insurance division.
If this is supposed to be some argument for how the free market actually provides accountability, I would love if you could cite the last health insurance company that died because of their poor business service.
And some people want everyone to have to use this system. Our private insurance system in the USA is far from perfect but it's a lot better than the government system. I have never once had an issue with my employer provided insurance covering any care that a doctor feels is necessary.
I dread the day I have to move to Medicare.
I dread the day I have to move to Medicare.
The application process parent is talking about is Medicaid, not Medicare.
Medicare is pretty ironclad, because the recipients are elderly and vote. Medicaid recipients tend to be marginalized and high need, so they’re used as a punching bag by local governments in states where that’s a good way to score political points.
Medicare is pretty ironclad, because the recipients are elderly and vote. Medicaid recipients tend to be marginalized and high need, so they’re used as a punching bag by local governments in states where that’s a good way to score political points.
This particular system wasn't nationwide, it was a system that the state of Tennesee paid 400 million dollars to Deloitte for. Conveniently, Tennesee is one of those states filled with people who think "Government bad" and gets tons of tax dollars from states like California and New York at the end of the day.
My experience so far on Medicare (a couple years) has been that it is equivalent to the private insurance I had before. No surprises.
You don't have to move to Medicare if you do not want to - you can continue with all the private insurance your employer offers or you can afford, or you can 'self insure'.
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Not everyone qualifies for government assistance. The software Deloitte built was supposed to automatically determine if someone was eligible. It is now being alleged that the software did not function correctly and was denying people because of bugs and issues with the software, not because the person was ineligible.
I’ve commented a similar story about australia in the root of the comment stream, if you’re interested.
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Wonder if there's an up-and-coming AI based version of the system in development already? ;)
In australia, we have a recent ‘robodebt’ where Centrelink (welfare) payments were evaluated by a debt recovery system, deeming (MANY) incorrect bills of thousands of tens of thousands.
Suicides happened.
As a result of a royal commission into the legality of the debt recovery scheme, it was deemed illegal, and I think all debts were rescinded. Many people in charge were recommended to be prosecuted by the anti corruption commission within the royal commission, the recommendations were made by (afaik) a Supreme Court judge. The anti corruption commission chose not to prosecute.
Suicides happened.
As a result of a royal commission into the legality of the debt recovery scheme, it was deemed illegal, and I think all debts were rescinded. Many people in charge were recommended to be prosecuted by the anti corruption commission within the royal commission, the recommendations were made by (afaik) a Supreme Court judge. The anti corruption commission chose not to prosecute.
Out of all forms of accountability, do you think that would have been the best form if they did prosecute?
Unfortunately i could probably bet that no other form of accountability was pursued
Unfortunately i could probably bet that no other form of accountability was pursued
Yes, they absolutely should have been prosecuted.
These people are still around to this day, likely making similarly consequential decisions that affect others with zero accountability.
These people are still around to this day, likely making similarly consequential decisions that affect others with zero accountability.
You may be interested to earmark this for future watching. I think the more mud these people are dragged through the better, given justice has failed the country.
https://www.themandarin.com.au/253449-robodebt-tv-drama-and-...
https://www.themandarin.com.au/253449-robodebt-tv-drama-and-...
They had legal advice that what they were doing was not lawful and they did it anyway.
So at scale fraud and gross negligence, for a start. And jail is a perfectly suitable punishment for knowingly sending fraudulent invoices to the most vulnerable people in our country, driving several to suicide.
Instead, they got cushy jobs.
So at scale fraud and gross negligence, for a start. And jail is a perfectly suitable punishment for knowingly sending fraudulent invoices to the most vulnerable people in our country, driving several to suicide.
Instead, they got cushy jobs.
I doubt Deloitte did this without direct guidance and approval from state governments.
The unemployment system here in FL was also built to spec to be incredibly hard to use and that was the goal of the administration. I have no love lost for consultancies, but if no government agents are penalized for this and they take the fall alone it will happen again with some other consultancy.
The unemployment system here in FL was also built to spec to be incredibly hard to use and that was the goal of the administration. I have no love lost for consultancies, but if no government agents are penalized for this and they take the fall alone it will happen again with some other consultancy.
To some extent, the reason business consultancies get paid so much is to be the fall guys when what the client wanted to do all along turns out badly.
However, they're still businesses. If the fall is big enough, or it starts happening reliably enough, they will stop volunteering for certain types of falls.
We need to make "business practices that kill vulnerable people who they're supposed to be helping" a category of fall that is reliably unprofitable.
However, they're still businesses. If the fall is big enough, or it starts happening reliably enough, they will stop volunteering for certain types of falls.
We need to make "business practices that kill vulnerable people who they're supposed to be helping" a category of fall that is reliably unprofitable.
I recommend the book "Automating Inequality" by Virginia Eubanks for a deeper dive here.
https://virginia-eubanks.com/automating-inequality/
> In Automating Inequality, Virginia Eubanks systematically investigates the impacts of data mining, policy algorithms, and predictive risk models on poor and working-class people in America. The book is full of heart-wrenching and eye-opening stories, from a woman in Indiana whose benefits are literally cut off as she lays dying to a family in Pennsylvania in daily fear of losing their daughter because they fit a certain statistical profile. Deeply researched and passionately written, Automating Inequality could not be more timely.
https://www.youtube.com/watch?v=Avxm7JYjk8M
> In Automating Inequality, Virginia Eubanks systematically investigates the impacts of data mining, policy algorithms, and predictive risk models on poor and working-class people in America. The book is full of heart-wrenching and eye-opening stories, from a woman in Indiana whose benefits are literally cut off as she lays dying to a family in Pennsylvania in daily fear of losing their daughter because they fit a certain statistical profile. Deeply researched and passionately written, Automating Inequality could not be more timely.
https://www.youtube.com/watch?v=Avxm7JYjk8M
More likely, they lacked incentive to get it right
These states salivate at every opportunity to cut themselves off at the knees with tax cuts. They tend to receive a disproportionate amount of federal funding but that isn't enough to maintain high quality services and you get these sort of death panels meant to restrict spending so that the top earners can pretend they're going to trickle down their wealth. Tennessee is a tax haven state. They are the worst offenders at this.
Very cynical
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> When an enrollee is entitled to state-administered Medicaid, it should not require luck, perseverance, and zealous lawyering for him or her to receive that healthcare coverage
That's such a powerful statement. If they are entitled, they are entitled. Simple as that. And anything that systematically prevents that is absolutely wrong.
What's more important is the approval process. Deloitte might have build this, but the State approved it's use. People signed off on this.
Further, this isn't an easy fix. Loosing coverage like this is not something you can just fix. This has affected people's entire life going forward, and not in a good way.
Yes, mistakes happen, but this isn't a simple one-of mistake. This is something rotten, and while Deloitte wrote it, they wrote it for a client who asked for it and put it out there. And that's who is ultimately responsible.
That's such a powerful statement. If they are entitled, they are entitled. Simple as that. And anything that systematically prevents that is absolutely wrong.
What's more important is the approval process. Deloitte might have build this, but the State approved it's use. People signed off on this.
Further, this isn't an easy fix. Loosing coverage like this is not something you can just fix. This has affected people's entire life going forward, and not in a good way.
Yes, mistakes happen, but this isn't a simple one-of mistake. This is something rotten, and while Deloitte wrote it, they wrote it for a client who asked for it and put it out there. And that's who is ultimately responsible.
> The TennCare Connect system—built by Deloitte and other contractors for more than $400 million
There you have the reason. The government software should be open source because
- People need to be able to make public officers accountable (Article XV – The society has the right of requesting an account from any public agent of its administration. https://en.m.wikipedia.org/wiki/Declaration_of_the_Rights_of...)
- You should be able to fire incompetent contractors, and replace them with someone else, for which open source code base makes it much more practical and the contractor cannot use any trade secrets clauses to make this impossible
> Deloitte was a major beneficiary of the nationwide modernization effort, winning contracts to build automated eligibility systems in more than 20 states, including Tennessee and Texas.
So much tax payers money wasted.
There you have the reason. The government software should be open source because
- People need to be able to make public officers accountable (Article XV – The society has the right of requesting an account from any public agent of its administration. https://en.m.wikipedia.org/wiki/Declaration_of_the_Rights_of...)
- You should be able to fire incompetent contractors, and replace them with someone else, for which open source code base makes it much more practical and the contractor cannot use any trade secrets clauses to make this impossible
> Deloitte was a major beneficiary of the nationwide modernization effort, winning contracts to build automated eligibility systems in more than 20 states, including Tennessee and Texas.
So much tax payers money wasted.
Maybe it should be open source. It is using our tax dollars after all. But I think this failure isn't a failure of the software. But a failure of using software. And of have complex laws/criteria of who can be helped. We should craft laws and programs that are uncomplex. 400 million dollars on admin software to ultimately deny people care they want. That just shouldn't be a thing. We should have spent that money on helping people, and using it to 'eat' the cost of accepting too many people.
Our justice system acknowledges that it's flawed and it's flawed with the idea of letting guilty people go, in order to make sure we aren't charging innocent people.(granted we are failing at that). But we should be crafting care with the intention of accidentally helping people who may have no qualified so that all qualified people would get care.
Our justice system acknowledges that it's flawed and it's flawed with the idea of letting guilty people go, in order to make sure we aren't charging innocent people.(granted we are failing at that). But we should be crafting care with the intention of accidentally helping people who may have no qualified so that all qualified people would get care.
I'll do you one better:
We should just have a publicly-funded health insurance plan that applies to every American at a basic level. Then you don't have to have a massive bureaucracy to figure out who's eligible, who's not, how long they are eligible, etc.
We've successfully spent more money trying to deny people public benefits than we probably would have just providing a basic level of public benefits to everyone.
We should just have a publicly-funded health insurance plan that applies to every American at a basic level. Then you don't have to have a massive bureaucracy to figure out who's eligible, who's not, how long they are eligible, etc.
We've successfully spent more money trying to deny people public benefits than we probably would have just providing a basic level of public benefits to everyone.
I cannot fathom that it's nothing more than a strange coincidence that we have spent more money making sure as few people access any benefits as possible than it would cost to simply provide things, and that those circumstances directly benefit some of the largest corporate donors in the USA. Like, every business that has employees on welfare is receiving a subsidy. The fact that Walmart and other large employers (I think maybe Amazon got caught out doing this?) pass out literature on how to apply for welfare tells you everything you need to know. If those people received a basic income, public insurance, etc. etc. that would provide a baseline, okay existence, with the option to then get a job to buy luxuries and such, not a fucking soul would work for Walmart. Because why the fuck would you have a job that doesn't pay you enough to have a good life unless the alternative is starvation?
Think of every single employer in this country that employs people who, despite working full time, still qualify for welfare. All of those companies have a direct financial incentive to pour shit tons of cash into ensuring our social safety net is as shitty as possible.
Think of every single employer in this country that employs people who, despite working full time, still qualify for welfare. All of those companies have a direct financial incentive to pour shit tons of cash into ensuring our social safety net is as shitty as possible.
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>every business that has employees on welfare is receiving a subsidy.
Apparently, that subsidy can happen whether or not you are even offered a job. This was found on a recent job application:
"We are asking you for the following information to determine if we, your potential employer, could be entitled to tax credit benefits. These tax credits were created to help people that have historically faced barriers to employment. We may be able to obtain valuable tax credits based on your answers to the upcoming questions."
Apparently, that subsidy can happen whether or not you are even offered a job. This was found on a recent job application:
"We are asking you for the following information to determine if we, your potential employer, could be entitled to tax credit benefits. These tax credits were created to help people that have historically faced barriers to employment. We may be able to obtain valuable tax credits based on your answers to the upcoming questions."
I would think the wording is just not very well chosen, and the tax credits will only be unlocked when the potential employee becomes an actual employee.
>> People need to be able to make public officers accountable (Article XV – The society has the right of requesting an account from any public agent of its administration. https://en.m.wikipedia.org/wiki/Declaration_of_the_Rights_of...)
I agree with this sentiment, but what is the relationship between the linked French Declaration and American law? Why not try to build the argument based on FOIA: https://en.wikipedia.org/wiki/Freedom_of_Information_Act_(Un...
I agree with this sentiment, but what is the relationship between the linked French Declaration and American law? Why not try to build the argument based on FOIA: https://en.wikipedia.org/wiki/Freedom_of_Information_Act_(Un...
Four hundred million dollars is unfathomable.
Has Deloitte ever built any software that is good? I certainly have a super strongly negative bias against their work. But hey maybe someone here has worked with them and was impressed…
Has Deloitte ever built any software that is good? I certainly have a super strongly negative bias against their work. But hey maybe someone here has worked with them and was impressed…
Their skill is in winning huge government contracts, which is not easy.
I’d be comfortable betting my house that they’ve never produced even mediocre software. Why would they if the government is willing to pay for garbage-tier work?
I’d be comfortable betting my house that they’ve never produced even mediocre software. Why would they if the government is willing to pay for garbage-tier work?
One thing to remember is that governments often cannot hire qualified people to work on these projects, which means it’s less “willing to pay” than “forced to accept the only option”. If they aren’t allow to pay market rates for tech workers, they won’t have the skills to even properly evaluate proposals or validate the work being done until it’s too late – and by that point if there’s a dispute, the contract business analysts and project managers will likely be able to point to some documents they wrote as proof that “the government” required whatever problematic decision was made even when that was some non-technical civil servant picking an option they suggested without fully understanding the implications.
The single best way to save government money on infrastructure projects (software and real) would be to hire a bunch of engineers at competitive salaries so there’d be in-house expertise without conflicts of interest, but since that involves spending money up front and trusting people to be professional it’s politically unlikely.
The single best way to save government money on infrastructure projects (software and real) would be to hire a bunch of engineers at competitive salaries so there’d be in-house expertise without conflicts of interest, but since that involves spending money up front and trusting people to be professional it’s politically unlikely.
Deloitte has really once built software that good, it is a AI / strategy / tactic type multitool AI used for the purpose of winning government contracts
The contract is likely structured into "Scope of Work" and "Ongoing Maintenance and Support" to help justify this cost.
> Has Deloitte ever built any software that is good?
Not in my experience.
Not in my experience.
There is no competent government contractor. The only companies which survive RFP operate in a way to maximize cost and minimize value.
There is a subset pushing the change that. Typically people connected in some way to USDS or GSA TTS who then go into private business. It shows up in surprising places.
The United Stated Digital Service is pushing for more government software to be open source[1]. I have no idea how effective it is, but it made me happy to see
[1] https://playbook.usds.gov/ ctrl+f "Default to open"
[1] https://playbook.usds.gov/ ctrl+f "Default to open"
Not just the USDS (as the USDS is a small part of a larger effort), the GSA as a whole is pushing for this. They maintain a lot of open source software for the federal and state governments and they try to do open by default and FOSS COTS where they can.
Just the main GSA github org has over 1000 repos in it.
https://github.com/GSA/
https://open.gsa.gov/
Just the main GSA github org has over 1000 repos in it.
https://github.com/GSA/
https://open.gsa.gov/
Deloitte hates this
It's extremely effective. Not just USDS either, but also 18F (now GSA TTS). Also, much of the UK government.
The people win when the sun can shine.
The people win when the sun can shine.
I would go further and say that not only the software but also the execution of the software should also be open, akin on a non-financial blockchain database, with the rules, execution, and decision recorded permanently (under an anonymous ID, of course). Anyone should be able to easily replay the execution. This would allow for citizen monitoring of government actions. If not for this, at least a weekly export of all anonymized processed claims, plus the corresponding logic rules, should be made available on the web, similarly facilitating a local replay.
The problem with a scheduled export is that a corrupt state government will gladly change your records for you (in their favor) when you go to court. This is more difficult to do with a blockchain.
The problem with a scheduled export is that a corrupt state government will gladly change your records for you (in their favor) when you go to court. This is more difficult to do with a blockchain.
> blockchain [...] replay
That's burning down your house to kill a spider. Even in a closed system infinite replay-ability is a big headache, and adding "blockchain" adds a hundred new problems. There's already legal system which is a direct dependency, and it is more efficient and manageable. (Yes, that's right, the US legal system actually looks sane by comparison.)
Instead, make a legal requirement that patients (and sometimes other stakeholders) can demand the data/logic behind the company decisions.
If you still want very tamper-proof write-only records, that can be done way more easily/quickly/cheaply with an old-school distributed database with fixed trusted nodes, run by multiple institutions that are not likely to conspire together.
That's burning down your house to kill a spider. Even in a closed system infinite replay-ability is a big headache, and adding "blockchain" adds a hundred new problems. There's already legal system which is a direct dependency, and it is more efficient and manageable. (Yes, that's right, the US legal system actually looks sane by comparison.)
Instead, make a legal requirement that patients (and sometimes other stakeholders) can demand the data/logic behind the company decisions.
If you still want very tamper-proof write-only records, that can be done way more easily/quickly/cheaply with an old-school distributed database with fixed trusted nodes, run by multiple institutions that are not likely to conspire together.
> make a legal requirement that patients (and sometimes other stakeholders) can demand the data/logic behind the company decisions.
Huh. This is already available, and it never works in the interest of the patient. Unless one has expensive attorneys, no individual has the time and patience to jump through all the hoops needed to get it to work. The point is to eliminate friction completely.
I do reiterate that scheduled data+logic exports from the government would alternatively also help, allowing the execution to similarly be replayed. A problem with a scheduled export, however, is that a corrupt state government will gladly change your records for you (in their favor) when you go to court. This is more difficult to do with a blockchain.
Huh. This is already available, and it never works in the interest of the patient. Unless one has expensive attorneys, no individual has the time and patience to jump through all the hoops needed to get it to work. The point is to eliminate friction completely.
I do reiterate that scheduled data+logic exports from the government would alternatively also help, allowing the execution to similarly be replayed. A problem with a scheduled export, however, is that a corrupt state government will gladly change your records for you (in their favor) when you go to court. This is more difficult to do with a blockchain.
Ah yes, because blockchain is the 100% true source of ultimate truth.
Despite the little overlooked fact that data in it will be input by external systems and people.
Despite the little overlooked fact that data in it will be input by external systems and people.
If someone receives a letter in the mail with a claim rejection that contradicts what the blockchain says, that then is a very easy win in court.
The problem is not people’s denials being lies, but that they actually were denied illegally.
We're now going in circles. This has already been covered. Jump to parent comment #2 in the hierarchy.
If someone receives a letter in the mail with a claim rejection that never contradicts whatever blockchain says, they will not win in court.
Somehow you assume that data on blockchain was entered correctly and truthfully just because it's blockchain. Somehow you assume that no one will need expensive attorneys and expertise to sift through data just because it's on blockchain. Somehow you assume that there's some magic "execution" on blockchain that you can somehow easily "replay".
Somehow you assume that data on blockchain was entered correctly and truthfully just because it's blockchain. Somehow you assume that no one will need expensive attorneys and expertise to sift through data just because it's on blockchain. Somehow you assume that there's some magic "execution" on blockchain that you can somehow easily "replay".
You obviously don't know much about how a blockchain works, haven't spent a minute thinking about the answers to your questions, and think no one else has either. Your concerns are unoriginal as far as blockchain technology is concerned, and solutions easily exist to each issue.
I know how blockchain works. For the purposes of this discussion it's an append-only distributed log.
However, blockchain proponents en masse have no idea how blockchain works or how real world works. That's why they always assign these magical properties to it: that all information added to blockchain is true and correct. That it's trivially easy for anyone to "replay" any number of any complex events containing any arbitrarily complex data to do something or reach some conclusion.
When challenged on this assumptions the answer is, inevitably, "you don't know how blockchains work" (everyone does) and "solutions to these challenges exist" (they don't).
Literally nothing in blockchain can prevent entry of bad/incorrect/falsified data. Literally nothing in blockchains makes it easy to navigate complex medical decisions without the help of experts (and in the US, lawyers) to untangle and understand the data and decisions.
However, blockchain proponents en masse have no idea how blockchain works or how real world works. That's why they always assign these magical properties to it: that all information added to blockchain is true and correct. That it's trivially easy for anyone to "replay" any number of any complex events containing any arbitrarily complex data to do something or reach some conclusion.
When challenged on this assumptions the answer is, inevitably, "you don't know how blockchains work" (everyone does) and "solutions to these challenges exist" (they don't).
Literally nothing in blockchain can prevent entry of bad/incorrect/falsified data. Literally nothing in blockchains makes it easy to navigate complex medical decisions without the help of experts (and in the US, lawyers) to untangle and understand the data and decisions.
I am sick and tired of the inept comment, but let's take your points, one at a time:
> Somehow you assume that data on blockchain was entered correctly and truthfully just because it's blockchain.
If the information on the blockchain contradicts a denial communication e/mailed to the patient, it will be an easy win in court. And if it's a simple data entry error, it will be fixed when reported.
Somehow you assume that no one will need expensive attorneys and expertise to sift through data just because it's on blockchain.
> There are numerous blockchain explorer websites that catalog the data and conveniently query+format it for display. These days even LLMs can write queries.
> Somehow you assume that there's some magic "execution" on blockchain that you can somehow easily "replay".
Yes, that's how it works, and there is no magic in it. The rules and claims and diagnosis codes both go on the blockchain. The client software executes the rules against the claims and diagnosis. Again, even a website can assist in it.
It is obvious that you're operating 100% in bad faith. Also, your experience of having to deal with experts and attorneys has ruined you from seeing beyond it.
> Somehow you assume that data on blockchain was entered correctly and truthfully just because it's blockchain.
If the information on the blockchain contradicts a denial communication e/mailed to the patient, it will be an easy win in court. And if it's a simple data entry error, it will be fixed when reported.
Somehow you assume that no one will need expensive attorneys and expertise to sift through data just because it's on blockchain.
> There are numerous blockchain explorer websites that catalog the data and conveniently query+format it for display. These days even LLMs can write queries.
> Somehow you assume that there's some magic "execution" on blockchain that you can somehow easily "replay".
Yes, that's how it works, and there is no magic in it. The rules and claims and diagnosis codes both go on the blockchain. The client software executes the rules against the claims and diagnosis. Again, even a website can assist in it.
It is obvious that you're operating 100% in bad faith. Also, your experience of having to deal with experts and attorneys has ruined you from seeing beyond it.
An "easy" win in court can cost thousands of dollars needed up front, and may take years to achieve. For someone on Medicaid that is not easy.
> If the information on the blockchain contradicts a denial communication e/mailed to the patient, it will be an easy win in court.
And you will understand that how? As a person who is no an expert in medicine.
> There are numerous blockchain explorer websites that catalog the data and conveniently query+format it for display.
So you've got yourself hundreds of pages of medical data and decisions. Now what?
> The rules and claims and diagnosis codes both go on the blockchain. The client software executes the rules
Ah yes. The magical rules that exists just because there's blockchain. And there's magical software that can easily execute those rules just because blockchain. Because as we all know, all medical data and decisions are input into systems in easily digestible machine-readable formats and all the machine-executable rules are there.
Funny how none of that exists now, but will somehow magically appear the moment you say "blockchain".
> It is obvious that you're operating 100% in bad faith.
The only thing that's obvious is that the vast majority of blockchain proponents assume their opponents operates in bad faith the moment their opponents ask questions rooted in reality, and not in wishful thinking.
> your experience of having to deal with experts and attorneys has ruined you from seeing beyond it.
I've never dealt with experts or attorneys when it comes to medicine.
I've read enough of simple non-complicated descriptions of such simple things done to me like routine dental checkups and removal of a non-malignant tumor to see through any of the fairy tales you're trying to sell.
--- Edit ---
> https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585683/
> More than half of the physicians in this study reported engaging in some questionable hospital chart documentation practices. Many of the physicians reported using charting practices that would be considered unacceptable (e.g. charting prior to seeing the patient or without seeing the patient on the day of charting).
> The pressures that may influence physicians to engage in questionable documentation practices are numerous, including reimbursement regulations, time-constraints, fear of litigation, and quality audits.
> ... fear of litigation and the threat of malpractice liability have been cited as reasons why physicians alter their clinical behavior and practice defensive medicine
lol good luck with your "blockchain is the source of all truth and it's easy to run the rules on some client software"
I'm definitely not interested to continue this conversation, as it devolves into a well know pattern of blockchain-related delusions.
Adieu.
And you will understand that how? As a person who is no an expert in medicine.
> There are numerous blockchain explorer websites that catalog the data and conveniently query+format it for display.
So you've got yourself hundreds of pages of medical data and decisions. Now what?
> The rules and claims and diagnosis codes both go on the blockchain. The client software executes the rules
Ah yes. The magical rules that exists just because there's blockchain. And there's magical software that can easily execute those rules just because blockchain. Because as we all know, all medical data and decisions are input into systems in easily digestible machine-readable formats and all the machine-executable rules are there.
Funny how none of that exists now, but will somehow magically appear the moment you say "blockchain".
> It is obvious that you're operating 100% in bad faith.
The only thing that's obvious is that the vast majority of blockchain proponents assume their opponents operates in bad faith the moment their opponents ask questions rooted in reality, and not in wishful thinking.
> your experience of having to deal with experts and attorneys has ruined you from seeing beyond it.
I've never dealt with experts or attorneys when it comes to medicine.
I've read enough of simple non-complicated descriptions of such simple things done to me like routine dental checkups and removal of a non-malignant tumor to see through any of the fairy tales you're trying to sell.
--- Edit ---
> https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585683/
> More than half of the physicians in this study reported engaging in some questionable hospital chart documentation practices. Many of the physicians reported using charting practices that would be considered unacceptable (e.g. charting prior to seeing the patient or without seeing the patient on the day of charting).
> The pressures that may influence physicians to engage in questionable documentation practices are numerous, including reimbursement regulations, time-constraints, fear of litigation, and quality audits.
> ... fear of litigation and the threat of malpractice liability have been cited as reasons why physicians alter their clinical behavior and practice defensive medicine
lol good luck with your "blockchain is the source of all truth and it's easy to run the rules on some client software"
I'm definitely not interested to continue this conversation, as it devolves into a well know pattern of blockchain-related delusions.
Adieu.
It is clear when someone is spreading FUD such as in your comment. As for blockchain, it is demonstrably used millions if not billions of times daily to do all the things I noted. Your limited mind can hardly comprehend the rule-based contracts that execute on Ethereum.
If left to you, civilization would never have progressed out of the stone age, and I mean the stone-throwing age, not the stone-tooling age.
If left to you, civilization would never have progressed out of the stone age, and I mean the stone-throwing age, not the stone-tooling age.
Nnnnnnah, I don't want claims to be public. There's no real way to anonymize claims. e.g. someone getting specialized immune therapy in west virginia is pretty damn identifiable. Or someone being paid out in a claim of 300k+ for some highly specific antiviral.
> I don't want claims to be public.
I don't think you realize this already happens. It is already available to hundreds of organizations, both domestic and foreign. Any organization can license it really at a price. What I said would only democratize it, also mandating an appropriate level of anonymization which is currently inconsistent or missing. Also, think of the bigger picture, of the clues such data will yield for advances in healthcare.
> someone getting specialized immune therapy in west virginia is pretty damn identifiable.
Yes, despite the best anonymization, some can still be identified, but it will take significant effort, and be limited to a very small number of people, like the one in WV. Overall though, the ratio of benefits to harms from transparency would exceed 999:1.
I don't think you realize this already happens. It is already available to hundreds of organizations, both domestic and foreign. Any organization can license it really at a price. What I said would only democratize it, also mandating an appropriate level of anonymization which is currently inconsistent or missing. Also, think of the bigger picture, of the clues such data will yield for advances in healthcare.
> someone getting specialized immune therapy in west virginia is pretty damn identifiable.
Yes, despite the best anonymization, some can still be identified, but it will take significant effort, and be limited to a very small number of people, like the one in WV. Overall though, the ratio of benefits to harms from transparency would exceed 999:1.
It shouldn't be auditable by anyone. There should be an audit trail though, and it should be available to the subject of that process on request.
That would be something, but the issue is that most people don't have the time or capacity to audit their own records, or to hire an attorney to escalate it. Journalists on the other hand specialize in this; they can audit everyone's records and expose wrongdoing at a state level.
A simple request for the audit record is absolutely something that consumers should be able to do. There's no guarantee that journalist is going to look at your record to get you help. It won't help in edge cases and those people will still be screwed.
> There's no guarantee that journalist is going to look at your record
The journalists look at aggregates first, and then individuals help tell the story. The point is that both individual-audit-records and full data+logic exports serve their unique purpose. Anyone should be able to use the data+logic to replay the execution, whether for oneself or for the entire community.
The journalists look at aggregates first, and then individuals help tell the story. The point is that both individual-audit-records and full data+logic exports serve their unique purpose. Anyone should be able to use the data+logic to replay the execution, whether for oneself or for the entire community.
"Anyone should be able to use the data+logic to replay the execution, whether for oneself or for the entire community."
No. You can't guarantee anonymity. If you want to have someone audit them, use the GAO or similar.
No. You can't guarantee anonymity. If you want to have someone audit them, use the GAO or similar.
I would really prefer my health information not be exposed in any way, "anonymized" or otherwise, thanks.
I don't think you realize this already happens. It is already available to hundreds of organizations, both domestic and foreign. Any organization can license it really at a price. What I said would only democratize it, also mandating an appropriate level of anonymization which is currently inconsistent or missing. Also, think of the bigger picture, of the clues such data will yield for advances in healthcare.
I think this is plainly untrue in any of the situations relevant to what we're discussing.
Some "de-identified" health information can be used or disclosed without restriction under HIPAA, but it needs to genuinely not be possible to correlate back to an individual, which I don't think is something that's possible with what you're describing (at least if prior medical history and decisions factor into the execution of the program). Some health information can be released in the public interest (like for research) or for bettering healthcare operations, but that's not this either.
It might be worth taking a look at https://www.hhs.gov/hipaa/for-professionals/privacy/laws-reg....
This is excluding stuff like 23AndMe genome sharing / Ancestry.com law enforcement collaboration, which might be what you're alluding to, but I believe it to be irrelevant in this case.
Some "de-identified" health information can be used or disclosed without restriction under HIPAA, but it needs to genuinely not be possible to correlate back to an individual, which I don't think is something that's possible with what you're describing (at least if prior medical history and decisions factor into the execution of the program). Some health information can be released in the public interest (like for research) or for bettering healthcare operations, but that's not this either.
It might be worth taking a look at https://www.hhs.gov/hipaa/for-professionals/privacy/laws-reg....
This is excluding stuff like 23AndMe genome sharing / Ancestry.com law enforcement collaboration, which might be what you're alluding to, but I believe it to be irrelevant in this case.
Yet somehow data brokers know every medical condition you've ever had and they sell it to anyone who will pay them.
See also: https://www.nytimes.com/2019/11/11/business/google-ascension...
https://www.scientificamerican.com/article/how-data-brokers-...
https://arstechnica.com/science/2019/11/would-you-trust-goog...
https://slate.com/technology/2022/06/health-data-brokers-pri...
See also: https://www.nytimes.com/2019/11/11/business/google-ascension...
https://www.scientificamerican.com/article/how-data-brokers-...
https://arstechnica.com/science/2019/11/would-you-trust-goog...
https://slate.com/technology/2022/06/health-data-brokers-pri...
If this is supposed to be some sort of "own", you're missing my point. I do not want my HIPAA-protected information going any further than it needs to, I do not want these practices to be encouraged. I understand HIPAA etc. are leaky, that people are inventing new ways to leak my information to people who want to buy it, and so on.
That is different from taking the pipeline of information directly from my insurance provider and firing it off into the public eye in a way that prevents it from being deleted or forgotten, even if it may be anonymized to some extent.
I understand the situation is not good. I want it to not be made worse. I'm not sure if you ignored the sibling thread where I felt I made myself clear.
That is different from taking the pipeline of information directly from my insurance provider and firing it off into the public eye in a way that prevents it from being deleted or forgotten, even if it may be anonymized to some extent.
I understand the situation is not good. I want it to not be made worse. I'm not sure if you ignored the sibling thread where I felt I made myself clear.
I promise that I wasn't attacking you. More just commiserating over the sad state of the situation we find ourselves in as of right now.
I don't know what the solution to this problem will look like, but (like so many other solutions) I'm also pretty sure that it won't involve a blockchain.
I don't know what the solution to this problem will look like, but (like so many other solutions) I'm also pretty sure that it won't involve a blockchain.
> it needs to genuinely not be possible to correlate back to an individual
What you say is a theoretical goal. In practice, despite good efforts, there is no hard rule imposed by reality that 100% of records will totally remain anonymized.
What you say is a theoretical goal. In practice, despite good efforts, there is no hard rule imposed by reality that 100% of records will totally remain anonymized.
Maybe it's unclear why I've brought this up. I understand it's not possible to keep everything locked down in a way that prevents my information from leaking.
And as unfortunate as that is, that's not my concern with your original comment.
I do not want that problem made worse. I don't care if it's already kind of bad. I have no idea why the problem already being bad would justify making it worse.
And as unfortunate as that is, that's not my concern with your original comment.
I do not want that problem made worse. I don't care if it's already kind of bad. I have no idea why the problem already being bad would justify making it worse.
I guess you forgot the part where you're a mortal human, and where biomedical data helps discover patterns to solve problems. Just you wait until you get old. Also forgot the part about exposing statewide corruption wrt claims.
I'm not interested in your snark. I'm aware of my mortality and of statewide corruption. Those are not good reasons to publish my health data publicly even in an anonymized form. The people who might be able to fix my mortality are already allowed to have my data (whether I'm happy or not about that is moot as you've made clear yourself). That does not change my belief that the scheme you propose for "exposing statewide corruption" is a bad idea.
> are already allowed to have my data
You mean the ones that license it commercially? Their interest is not in fixing you; it is in exploiting you and your wallet, so please remember the distinction.
To really fix it (you), access to that data needs to be democratized. But since people (you) don't want that to happen, I guess mortality will remain in the cards. In the end, people (you) get what you deserve.
You mean the ones that license it commercially? Their interest is not in fixing you; it is in exploiting you and your wallet, so please remember the distinction.
To really fix it (you), access to that data needs to be democratized. But since people (you) don't want that to happen, I guess mortality will remain in the cards. In the end, people (you) get what you deserve.
Can you link where I can license this information?
If you offer to give $10+ million to any health insurance company or hospital IT company, they will gladly give it to you, plus more fees for updated batches. In practice it will cost much less if you negotiate well. There also are commercial data aggregators that specialize in it, that GPT can probably name for you. (I don't want to name names here.) At multiple employers, I have worked with this data from various vendors.
Which specific vendors?
Not sure if you can license it, but its possible to tap into HIEs for a lot of patient information. Or, if you have a deal with a PBM, you could literally see 100% of all prescriptions issues to americans using the PBM.
Again, i don't think you can license it, but its a data feed that is accesible incident-to providing other services.
You can build on top of that, of course, anyway you want.
Again, i don't think you can license it, but its a data feed that is accesible incident-to providing other services.
You can build on top of that, of course, anyway you want.
I think way he meant a hashed chain: one where the history is tamper proof. The important part is that the data and logic used to process claim is digitally documented and sealed by hash. You get a copy of the hash in your claims. The hash chain is public or has to be given to an independent third-party. If you get into a kicking contest in court, the company they have to reproduce documentation with the hash. The hashing prevents forging the original documents in the process.
[deleted]
A plug for everyone in this thread to read `Recoding America` by Jennifer Pahlka, founder of Code For America. Extremely good book which goes into detail about why software is such a crapshow in government... there are many more reasons than "bad software engineers", and they're all fascinating.
Her Substack is pretty good too:
https://www.eatingpolicy.com/
https://www.eatingpolicy.com/
> by Deloitte and other contractors for more than $400 million—is supposed to analyze income and health information to automatically determine eligibility for benefits program applicants.
Ultimately this needs to be weighed against 1. How accurately, corruption free, and expediently would $400M of humans performed compared to the software, and 2. How much better software could have been delivered by Code for America had they been given the $400M in resources.
My gut suspicions are 1. Much worse, and 2. Much better
Ultimately this needs to be weighed against 1. How accurately, corruption free, and expediently would $400M of humans performed compared to the software, and 2. How much better software could have been delivered by Code for America had they been given the $400M in resources.
My gut suspicions are 1. Much worse, and 2. Much better
It should only be weighed against the harms it's caused right now and any company responsible for those harms should face meaningful consequences as a result. It doesn't matter if humans would have done worse in the same situation (something you can't easily prove anyway) the same way we don't weigh the actions of a murderer based on how much more horrifically some other murderer might have killed the victims. We just punish the murderer we have for what they've actually done.
Maybe generally software is a good idea, but this software was a total nightmare and it clearly has no place making these decisions.
Maybe generally software is a good idea, but this software was a total nightmare and it clearly has no place making these decisions.
The point is that humans doing the work was the baseline control. If we invested $400M and got something for our money, then it's a good iteration.
I mean what would it have cost to just greenlight every applicant?
That is also a fantastic comparison point. The same ideal is part of the idea behind UBI replacing the social welfare bureaucracy.
I found this documentary "Freedom to choose" to be really interesting: https://www.youtube.com/watch?v=dngqR9gcDDw&list=PLt27lKoC5L...
I found this documentary "Freedom to choose" to be really interesting: https://www.youtube.com/watch?v=dngqR9gcDDw&list=PLt27lKoC5L...
> The TennCare Connect system—built by Deloitte and other contractors for more than $400 million—is supposed to analyze income and health information to automatically determine eligibility for benefits program applicants. But in practice, the system often doesn’t load the appropriate data, assigns beneficiaries to the wrong households, and makes incorrect eligibility determinations, according to the decision from Middle District of Tennessee Judge Waverly Crenshaw Jr.
Not at all surprised to see the name of a big consulting firm like Deloitte in something like this. How much money and productivity is lost to these leeches across our entire economy?
Leaving aside this particular case: how can potential recipients of benefits even know how or why they were denied to bring such lawsuits in the first place? Especially if they are forced into arbitration? For example I feel like private health insurance companies, particularly Aetna, deny many claims falsely as a typical approach to avoid having to pay out as much. And patients are then subjected to a long drawn out process with hours of wait times, hours of calls, and constant vigilance. This method of avoiding payouts by creating expenses for patients should be illegal. But how can anyone see what’s happening and be in a position to challenge it without even a basic level of transparency?
Not at all surprised to see the name of a big consulting firm like Deloitte in something like this. How much money and productivity is lost to these leeches across our entire economy?
Leaving aside this particular case: how can potential recipients of benefits even know how or why they were denied to bring such lawsuits in the first place? Especially if they are forced into arbitration? For example I feel like private health insurance companies, particularly Aetna, deny many claims falsely as a typical approach to avoid having to pay out as much. And patients are then subjected to a long drawn out process with hours of wait times, hours of calls, and constant vigilance. This method of avoiding payouts by creating expenses for patients should be illegal. But how can anyone see what’s happening and be in a position to challenge it without even a basic level of transparency?
> how can potential recipients of benefits even know how or why they were denied to bring such lawsuits in the first place? Especially if they are forced into arbitration?
You get a letter in the mail, with a review of the decision they made. There is a section where they have to explain why they denied you. It is a direct, "We don't think you meet this criteria" statement.
Awful letters, imo.
You get a letter in the mail, with a review of the decision they made. There is a section where they have to explain why they denied you. It is a direct, "We don't think you meet this criteria" statement.
Awful letters, imo.
IMHO, the state should be the one to approve/deny claims (except if they're duplicate claims within a time-period specific to the code). Leaving it to the insurance company to process the claim is akin to letting robbers play cops.
Imagine you get together a team of really good developers, who really want to help government work better for people, pay them semi-competitively [*], and just task them with building and deploying the software aspects of this system.
Maybe the software is fully delivered within a year, at a cost of $10M? (Excluding non-software costs of this project.)
Then those team members can move on to the next project(s).
[*] I'm thinking: don't pay as much as FAANG, but maybe 50% FAANG-TC, as straight salary. Meaning FAANG mercenary types motivated only by money filter out themselves for you, but it's still doable for top-tier people who want to do beneficial work, with enough income and job stability that they shouldn't be distracted from work by those stresses. You'd really need to keep the hiring bar up, though, carefully hand-picking small teams, and not compromising if your formula is successful. (And be able to say no to agencies want to scale to too many projects in parallel, or to some politician wants to make it a jobs program, or stuff it with patronage/nepo hires.)
Maybe the software is fully delivered within a year, at a cost of $10M? (Excluding non-software costs of this project.)
Then those team members can move on to the next project(s).
[*] I'm thinking: don't pay as much as FAANG, but maybe 50% FAANG-TC, as straight salary. Meaning FAANG mercenary types motivated only by money filter out themselves for you, but it's still doable for top-tier people who want to do beneficial work, with enough income and job stability that they shouldn't be distracted from work by those stresses. You'd really need to keep the hiring bar up, though, carefully hand-picking small teams, and not compromising if your formula is successful. (And be able to say no to agencies want to scale to too many projects in parallel, or to some politician wants to make it a jobs program, or stuff it with patronage/nepo hires.)
I have run consulting before and was thinking of getting back into with a similar arrangement. Having been involved tangentially in government procurement for small software projects, you get first had visibility into how the normal predatory ISVs operate. Their single site licensing cost is from my experience 20-30% below what it would cost to build it yourself. But then you don't own the software and have to pay for ongoing maintenance. It looks cheaper but ends up costing more for worse software.
This whole sector is ripe for getting flipped because every actor in it operates using the same set of greedy rules.
This whole sector is ripe for getting flipped because every actor in it operates using the same set of greedy rules.
I wouldn't want to have to be playing bidding games against one of the big consulting firms that sometimes bill massively to create disasters.
I'd rather just have more information systems be recognized as necessarily a government core competency, to in-house. And to pay well enough, to hire the best teams for that (without leaning on their altruism/patriotism so hard that they have to worry about money).
I'd rather just have more information systems be recognized as necessarily a government core competency, to in-house. And to pay well enough, to hire the best teams for that (without leaning on their altruism/patriotism so hard that they have to worry about money).
I agree, but they often don't have the skills. I do think many states could benefit from something like digital service, where a state level dev shop could supply services to towns and counties.
I’m with you but much in-house work relies upon consultants anyway. “Doing things” isn’t a core competency of most modern governments.
That was the healthcare.gov rescue team. patio11 was on it.
But the government guys usually aren't looking to do that. They're not trying to build the software. They're trying to make their friends who got them elected rich. And then maybe when they're out after some time, their other friends can run the law team that extracts something from the government which they're no longer part of.
POSIWID baby. You think this is accidental. But it's the way it is on purpose.
But the government guys usually aren't looking to do that. They're not trying to build the software. They're trying to make their friends who got them elected rich. And then maybe when they're out after some time, their other friends can run the law team that extracts something from the government which they're no longer part of.
POSIWID baby. You think this is accidental. But it's the way it is on purpose.
(I was not on the healthcare.gov rescue mission.)
This is roughly the Code For America model... there are many other roadblocks other than "ability to build a system" though, for example the pointlessly strict and bloated regulation which is mandatory to follow. Unfortunately it's not quite enough to have good engineers.
It's hard to ignore the fact that the prior governor of Florida was convicted of medicare fraud. There is something to that.
*prior Governor, promoted to current US Senator. You would think stealing from billions of dollars from taxpayers, and this is billions in the 1990s, would disqualify you from attaining one of the highest government positions.
The last eight or so years has proven that the vast majority of the American system of governance is based on the idea that people have basic amounts of shame and are willing to not do something if they can't do it in good faith, and that such things would be enough to deter malignant parties from being involved in government without the need for explicit laws.
Now you have a bunch of sociopaths realizing that, oh, wait, there isn't any reason, legally or technically speaking, that I cannot be involved in government.
Now you have a bunch of sociopaths realizing that, oh, wait, there isn't any reason, legally or technically speaking, that I cannot be involved in government.
If it was an algorithmic system, why did denials take months?
If that's the way the system works then perhaps assume the malice is part of the design? If it takes months to deny, maybe the person will be dead by then and you won't have to pay out anything, plus you keep whatever money they had put in before. It's brilliant.
This makes a great case for UBI.
Years to get a benefit that should be dispersed in days or even minutes. Shame.
Years to get a benefit that should be dispersed in days or even minutes. Shame.
How many of the software engineers, project managers, and sparkle-shoe consultants from Deloitte are on Medicaid?
In banking it is mandated that a group validates any model that is used and reports the results to the FED. I wonder if something similar should exist for public institutions.
Probably another case of technology blamed by politicians who behind closed doors ordered to deny the claims
That's justice served. Big algorithm deserves Medicaid benefits too
Private healthcare/medical services should be illegal. Nationalise it. So broken to be in 2024 and people still have to pay for Healthcare. Thank God I don't live in the US. Our healthcare ain't great but it shits on theirs (Aus).
There are zero arguments that private Healthcare should exist.
There are zero arguments that private Healthcare should exist.
With many of those decisions as incorrect as they were, with people as poor as they are here... This is a tragedy that has had people hiding the cause of their suicides for an insurance payout to their families.
I am guessing that the healthcare costs for those denied are generally larger now than they would have been had they been accepted; that the hospital system is still paying the price tag, not the destitute. - A layered tragedy in that the finances are worse for everyone but Deloitte.