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> 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 o

> 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_Man_and_of_the_Citizen 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.

OutOfHere 2y ago
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.
- striking 2y ago
  I would really prefer my health information not be exposed in any way, "anonymized" or otherwise, thanks.
  - OutOfHere 2y ago
    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.
    - KittenInABox 2y ago
      Can you link where I can license this information?
      - OutOfHere 2y ago
        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.
        Larrikin 2y ago
        Which specific vendors?
      - IG_Semmelweiss 2y ago
        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.
    - striking 2y ago
      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-regulations/index.html 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.
  - cdumler 2y ago
    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 2y ago
  [deleted]
- KittenInABox 2y ago
  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.
  - OutOfHere 2y ago
    > 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.
- Terr_ 2y ago
  > 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.
  - OutOfHere 2y ago
    > 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.
    - troupo 2y ago
      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.
      - OutOfHere 2y ago
        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.
- giantg2 2y ago
  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.
  - OutOfHere 2y ago
    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.
    - giantg2 2y ago
      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.
      - OutOfHere 2y ago
        > 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.
        giantg2 2y ago
        "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.
abduhl 2y ago
>> 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 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_(United_States) https://en.wikipedia.org/wiki/Freedom_of_Information_Act_(Un...
forrestthewoods 2y ago
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…
- akira2501 2y ago
  The contract is likely structured into "Scope of Work" and "Ongoing Maintenance and Support" to help justify this cost.
- tomrod 2y ago
  > Has Deloitte ever built any software that is good? Not in my experience.
- ungreased0675 2y ago
  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?
  - acdha 2y ago
    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.
amonon 2y ago
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/ https://playbook.usds.gov/ ctrl+f "Default to open"
- CuriousCosmic 2y ago
  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://github.com/GSA/ https://open.gsa.gov/ https://open.gsa.gov/
  - miohtama 2y ago
    Deloitte hates this
- tomrod 2y ago
  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.
geraldwhen 2y ago
There is no competent government contractor. The only companies which survive RFP operate in a way to maximize cost and minimize value.
- tomrod 2y ago
  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.
Flozzin 2y ago
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.
- lenerdenator 2y ago
  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.
  - ToucanLoucan 2y ago
    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.

OutOfHere 2y ago

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.

striking 2y ago
I would really prefer my health information not be exposed in any way, "anonymized" or otherwise, thanks.
- OutOfHere 2y ago
  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.
  - KittenInABox 2y ago
    Can you link where I can license this information?
    - OutOfHere 2y ago
      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.
      - Larrikin 2y ago
        Which specific vendors?
    - IG_Semmelweiss 2y ago
      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.
  - striking 2y ago
    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-regulations/index.html 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.
- cdumler 2y ago
  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 2y ago
[deleted]
KittenInABox 2y ago
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.
- OutOfHere 2y ago
  > 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.
Terr_ 2y ago
> 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.
- OutOfHere 2y ago
  > 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.
  - troupo 2y ago
    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.
    - OutOfHere 2y ago
      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.
giantg2 2y ago
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.
- OutOfHere 2y ago
  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.
  - giantg2 2y ago
    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.
    - OutOfHere 2y ago
      > 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.
      - giantg2 2y ago
        "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.

abduhl 2y ago

>> 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 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_(United_States) https://en.wikipedia.org/wiki/Freedom_of_Information_Act_(Un...

forrestthewoods 2y ago

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…

akira2501 2y ago
The contract is likely structured into "Scope of Work" and "Ongoing Maintenance and Support" to help justify this cost.
tomrod 2y ago
> Has Deloitte ever built any software that is good? Not in my experience.
ungreased0675 2y ago
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?
- acdha 2y ago
  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.

amonon 2y ago

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/ https://playbook.usds.gov/ ctrl+f "Default to open"

CuriousCosmic 2y ago
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://github.com/GSA/ https://open.gsa.gov/ https://open.gsa.gov/
- miohtama 2y ago
  Deloitte hates this
tomrod 2y ago
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.

geraldwhen 2y ago

There is no competent government contractor. The only companies which survive RFP operate in a way to maximize cost and minimize value.

tomrod 2y ago
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.

Flozzin 2y ago

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.

lenerdenator 2y ago
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.
- ToucanLoucan 2y ago
  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.