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This is everything that is wrong with health care in the US. From the article: "Staff doctors take more time. The state employed a small number of staff doctor

This is everything that is wrong with health care in the US. From the article: "Staff doctors take more time. The state employed a small number of staff doctors whose compensation is not tied to the number of cases they review. These doctors reviewed cases at a rate that is in line with federal recommendations. They typically earned less than $150,000 annually, according to the state’s salary database. Beginning this year, however, the state is terminating all doctors on salary and relying only on contract physicians." So essentially, salaried state doctors took their time to review cases, perhaps realizing that these are real people on the other end of the paper work. The state doctors were paid less than the private doctors and the state is going to lay them off to go full private despite the fact that some of the private doctors are clearly just plowing through the reviews to boost their income. A whistle blower then called this out and was let go. Seems like corporate lobbying is alive and well in TN. Don't worry about the individuals, there's money to be made.

onetimemanytime 8y ago
If all the papers are submitted and checked by other staff, I don't think 40 minutes or so is not enough to decide. The doctor is simply checking what is submitted. I'm only commenting on the time aspect.
- wonderwonder 8y ago
  From the article: "Like Thrush, some of these doctors work very fast. Dr. Kanika Chaudhuri, a pediatrician, evaluated 3,872 cases last fiscal year, averaging more than four cases per hour when she worked. She earned $192,000 in fiscal 2018 and $1.1 million since 2013. Out of all the cases Chaudhuri reviewed over the five years, 78 percent were denied, according to data provided by the state."
  - briandear 8y ago
    Is it possible that 78% should have been denied? What rate is acceptable? If the doctor approved 78% wouldn’t that also be concerning? One of the biggest areas of fraud is in disability claims. I am not saying that 78% denial is accurate, but what evidence do we have that it isn’t?
    - lsiebert 8y ago
      The national average is 66%, and presumably living in TN doesn't make one more likely to be fraudulent.
      - darkpuma 8y ago
        > and presumably living in TN doesn't make one more likely to be fraudulent. Is it really a safe assumption that all states have identical rates of fraud? Different states have very different economic and social situations that could pressure somebody into committing fraud. Some states are suffering more than others with prescription drug abuse. Some states have industries that result in more disabilities than other states \cough{coal mines...} In West Virginia 8.9% of the working age population receives disability, while in Hawaii only 2.8% do. In Tennessee, 6.5% of the working age population is on disability. The national average is 4.6%
        kjs3 8y ago
        You cannot homogenize disability rates across all states. For example, they don't mine coal in Hawaii and they do in West Virginia.
      - deleted 8y ago
        [deleted]
- sobrevivendo 8y ago
  I trust the recommendations by a panel of professionals much more than my gut feeling in this. Specially given the complexity, the stake and this broken appeal system.
sharemywin 8y ago
Seems like a simple 10X fine for screwing up would fix the problem. But the government has run by people that hate government will never fix the problem.
- dsfyu404ed 8y ago
  Very very few people who don't believe in the mission of whatever their organization does make it very long in government. Government organizations are such a political and bureaucratic nightmare that you need to believe in what they do to be able to see past all that. The guy who's shooting dogs for the ATF might thing the DEA is scum and the guy who's shooting dogs for the DEA might think the ATF is a waste but they both believe in the mission of their organization (or at least to the extent needed to do their jobs). They don't care or even realize that shooting dogs isn't their mission, it's just what the incentive structure tells them to do.
  - DFHippie 8y ago
    I think you misunderstood the comment. The guy who's shooting dogs for the ATF isn't who's meant by "person running the government". It's the elected/appointed officials who hate government. These don't have to last very long to cause a lot of damage. Look at Scott Pruitt and Ryan Zinke.
    - dsfyu404ed 8y ago
      I see where you're coming from but none of the stuff related to the article is happening on that level. It isn't top down intentional negligence that's causing these sorts of incentive misalignment. It seems to be good old fashioned incompetence. These doctors are shooting all the dogs (metaphorically speaking of course) but they're shooting all the dogs because the organization they work within has incentivized that behavior. It's not a top down policy to shoot (metaphorical) dogs. It just so happens that if your top down policy is to suck at everything then there's no motivation to stop the people at the leafs of the organizational tree from shooting dogs (denying disability wrongly as a matter of standard) practice. I think this is incompetence, not malice. The people actually misbehaving are too far removed from policy for this to be malice.
vonmoltke 8y ago
> Seems like corporate lobbying is alive and well in TN. Where is the corporate lobbying in this case? There are no corporations mentioned in connection with this story.
- vernie 8y ago
  Maybe parent is referring to Marsha Blackburn.
- Spooky23 8y ago
  Follow the money. Start with the principals associated with the contractors awarded the work.
  - vonmoltke 8y ago
    These are independent contractors. The doctors doing the work are the principals, and they get all the payout from the contract.
    - Spooky23 8y ago
      Government procurement doesn't work that way. Disability determination is a program funded by the US Social Security Administration, and comes with lots of compliance requirements that would be too expensive to implement for hundreds of contractors. Even if Tennessee allows you to give cash to random individuals, the Feds do not. There is almost certainly a prime contractor who owns the relationship, who then hires independent contractors as subs. They probably collect a percentage or fixed fee for each piecework task completed.
mtgx 8y ago
And yet another case warning whistleblowers against "going through the proper channels". That almost never works out for the whistleblower.
- ABCLAW 8y ago
  In my line of work, whistleblower complaints often result in very concrete investigations and mitigative action being taken. One key similarity between these issues is that the problem is dealt with internally as discretely as possible. Some organizations are looking for a paper trail to indicate they've done something - anything - to remedy the issue. Others try to get the full story and fix the rot. I think we just don't hear about situations where the whistleblowers do a tremendous amount of good, because those are situations in which the problem has successfully been contained and thus aren't newsworthy.
nickthemagicman 8y ago
Is this considered privatization?
async-await 8y ago
Please remind me not to move my tech firm to TN.
nostrebored 8y ago
A consultant with zero incentive to solve cases quickly being slower isn't necessarily a good thing or surprising
- longerthoughts 8y ago
  I wouldn't say zero incentive - I'd imagine they're still being evaluated according to established standards for close rates, which would explain why their close rates are described as in line with guidelines. The problem is having people take more time to close cases doesn't necessarily mean they're being more thorough - they could simply be waiting longer to start an equally superficial review because they know that they're supposed to be hitting a given close rate and don't want to appear to rush. Basically, time with eyes on application isn't necessarily equal to time elapsed from receipt to close.
  - nostrebored 8y ago
    Exactly. If 45 minutes is the established lower bar for determining disability qualification by (non medical?) professionals, I would expect to see some meaningful difference in the average time and the lower bar. To me, having a standard close rate is zero incentive for each qualified individual
stefan_ 8y ago
I'm cynical, so I think you missed the punch line. Presumably those previously salaried doctors will be hired back as consultants, bringing their productivity in line.

onetimemanytime 8y ago

If all the papers are submitted and checked by other staff, I don't think 40 minutes or so is not enough to decide. The doctor is simply checking what is submitted. I'm only commenting on the time aspect.

wonderwonder 8y ago
From the article: "Like Thrush, some of these doctors work very fast. Dr. Kanika Chaudhuri, a pediatrician, evaluated 3,872 cases last fiscal year, averaging more than four cases per hour when she worked. She earned $192,000 in fiscal 2018 and $1.1 million since 2013. Out of all the cases Chaudhuri reviewed over the five years, 78 percent were denied, according to data provided by the state."
- briandear 8y ago
  Is it possible that 78% should have been denied? What rate is acceptable? If the doctor approved 78% wouldn’t that also be concerning? One of the biggest areas of fraud is in disability claims. I am not saying that 78% denial is accurate, but what evidence do we have that it isn’t?
  - lsiebert 8y ago
    The national average is 66%, and presumably living in TN doesn't make one more likely to be fraudulent.
    - darkpuma 8y ago
      > and presumably living in TN doesn't make one more likely to be fraudulent. Is it really a safe assumption that all states have identical rates of fraud? Different states have very different economic and social situations that could pressure somebody into committing fraud. Some states are suffering more than others with prescription drug abuse. Some states have industries that result in more disabilities than other states \cough{coal mines...} In West Virginia 8.9% of the working age population receives disability, while in Hawaii only 2.8% do. In Tennessee, 6.5% of the working age population is on disability. The national average is 4.6%
      - kjs3 8y ago
        You cannot homogenize disability rates across all states. For example, they don't mine coal in Hawaii and they do in West Virginia.
    - deleted 8y ago
      [deleted]
sobrevivendo 8y ago
I trust the recommendations by a panel of professionals much more than my gut feeling in this. Specially given the complexity, the stake and this broken appeal system.

sharemywin 8y ago

Seems like a simple 10X fine for screwing up would fix the problem. But the government has run by people that hate government will never fix the problem.

dsfyu404ed 8y ago
Very very few people who don't believe in the mission of whatever their organization does make it very long in government. Government organizations are such a political and bureaucratic nightmare that you need to believe in what they do to be able to see past all that. The guy who's shooting dogs for the ATF might thing the DEA is scum and the guy who's shooting dogs for the DEA might think the ATF is a waste but they both believe in the mission of their organization (or at least to the extent needed to do their jobs). They don't care or even realize that shooting dogs isn't their mission, it's just what the incentive structure tells them to do.
- DFHippie 8y ago
  I think you misunderstood the comment. The guy who's shooting dogs for the ATF isn't who's meant by "person running the government". It's the elected/appointed officials who hate government. These don't have to last very long to cause a lot of damage. Look at Scott Pruitt and Ryan Zinke.
  - dsfyu404ed 8y ago
    I see where you're coming from but none of the stuff related to the article is happening on that level. It isn't top down intentional negligence that's causing these sorts of incentive misalignment. It seems to be good old fashioned incompetence. These doctors are shooting all the dogs (metaphorically speaking of course) but they're shooting all the dogs because the organization they work within has incentivized that behavior. It's not a top down policy to shoot (metaphorical) dogs. It just so happens that if your top down policy is to suck at everything then there's no motivation to stop the people at the leafs of the organizational tree from shooting dogs (denying disability wrongly as a matter of standard) practice. I think this is incompetence, not malice. The people actually misbehaving are too far removed from policy for this to be malice.

vonmoltke 8y ago

> Seems like corporate lobbying is alive and well in TN. Where is the corporate lobbying in this case? There are no corporations mentioned in connection with this story.

vernie 8y ago
Maybe parent is referring to Marsha Blackburn.
Spooky23 8y ago
Follow the money. Start with the principals associated with the contractors awarded the work.
- vonmoltke 8y ago
  These are independent contractors. The doctors doing the work are the principals, and they get all the payout from the contract.
  - Spooky23 8y ago
    Government procurement doesn't work that way. Disability determination is a program funded by the US Social Security Administration, and comes with lots of compliance requirements that would be too expensive to implement for hundreds of contractors. Even if Tennessee allows you to give cash to random individuals, the Feds do not. There is almost certainly a prime contractor who owns the relationship, who then hires independent contractors as subs. They probably collect a percentage or fixed fee for each piecework task completed.

mtgx 8y ago

And yet another case warning whistleblowers against "going through the proper channels". That almost never works out for the whistleblower.

ABCLAW 8y ago
In my line of work, whistleblower complaints often result in very concrete investigations and mitigative action being taken. One key similarity between these issues is that the problem is dealt with internally as discretely as possible. Some organizations are looking for a paper trail to indicate they've done something - anything - to remedy the issue. Others try to get the full story and fix the rot. I think we just don't hear about situations where the whistleblowers do a tremendous amount of good, because those are situations in which the problem has successfully been contained and thus aren't newsworthy.

nickthemagicman 8y ago

Is this considered privatization?

async-await 8y ago

Please remind me not to move my tech firm to TN.

nostrebored 8y ago

A consultant with zero incentive to solve cases quickly being slower isn't necessarily a good thing or surprising

longerthoughts 8y ago
I wouldn't say zero incentive - I'd imagine they're still being evaluated according to established standards for close rates, which would explain why their close rates are described as in line with guidelines. The problem is having people take more time to close cases doesn't necessarily mean they're being more thorough - they could simply be waiting longer to start an equally superficial review because they know that they're supposed to be hitting a given close rate and don't want to appear to rush. Basically, time with eyes on application isn't necessarily equal to time elapsed from receipt to close.
- nostrebored 8y ago
  Exactly. If 45 minutes is the established lower bar for determining disability qualification by (non medical?) professionals, I would expect to see some meaningful difference in the average time and the lower bar. To me, having a standard close rate is zero incentive for each qualified individual

stefan_ 8y ago

I'm cynical, so I think you missed the punch line. Presumably those previously salaried doctors will be hired back as consultants, bringing their productivity in line.