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.
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.
The OP is probably referring to the state legislature, the governor, and people appointed by the governor.
The state government is controlled by Republicans and though not all Republicans "hate" every aspect of the government, a large contingent of party could be accurately described as hating government involvement in areas they don't agree with--like welfare, disability, healthcare etc...
The leader of the party has explicitly advocated for allowing and encouraging the current healthcare system (the ACA) to implode, so that he can replace it with something else. He also placed people in charge of departments who explicitly stated that such departments shouldn't exist.
The consequences of which affect precisely nobody today.
In 2019, we are living in a world where one of the two parties made bad government a cornerstone of their party's policy, ~35 years ago. We are now reaping the wages of that decision.
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.
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.
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.
All of this stuff is happening at a high level. At the low level it’s all people responding to their incentives, it’s the high level that sets up the system.
People at the bottom can only change their own actions. So if 3/4 of them act well you still have a problem. However, if 3/4 at the top act directly they can change the rules.
Many of the incentives that act on higher levels are set in the Constitution or well-established law. The laws become a little bit worse from this perspective every year, as new forms of nest-feathering are introduced and entrenched. The system as it exists "incentivizes" this process. This will not be fixed by those whose own incentives lock them into this system, whatever level they inhabit.
The US is not in a steady downward spiral. Some years things improve and others they get worse, but it’s individuals that make the decisions shaping history.
Of course USA is not in a downward anything. USA government on the other hand is certainly circling the bowl. There is a difference between those! It may be that various states of America will eventually decide on a different way of organizing society. I'm hopeful, because when things change they often get better.
It's curious that you can see how incentives shape the behavior of some people, but not that of other people.
I am specifically saying the US government has been more and less corrupt in the past.
It’s not about people at the top responding differently it’s about the flow of influence. If 20% of the people at the bottom behave poorly the other people at the bottom have little influence. That changes at the top as it’s easyer to monitor a small group of people and their actions are more documented.
Ex: A cashier can fail to scan items for their friends at checkout and without any form of paper trail. The CFO can do more harm, but it’s harder for them to act in secret.
"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.
"
That's simply not true. Go to DC and you will meet a lot of dedicated and highly qualified people working at agencies. And they stay around. The real problem is Congress and some of the media that just scream "government bad" and "deep state" instead of doing their job which is to give the agencies guidance and fixing problems.
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.
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.
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.
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.
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
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.
"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."
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?
> 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%
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.
A couple of great articles for those who aren't aware that disability is the new welfare.
This is in no way meant to justify the absolutely insane process outlined in the Tennesseean article. I just see a lot of people questioning why disability claims would be up when unemployment is down. This is a decades-long trend.
The reason it is "the new welfare" is that states don't pay a share, it's a purely Federal program paid for out of payroll taxes. Certain states make it very difficult to get safety net benefits, and those who do can only get them for a limited period of time. SSDI is the last stop.
Administrative law judges make judgements based on individual and regional considerations. Someone who may not meet the standard in NYC for disability may qualify in Tennessee, due to the makeup of the employment environment.
The fact that the state is so aggressive about denials is interesting, as it is probably increasing costs to the state due to increased litigation.
Yes, it goes into detail about this in the npr article linked by GP.
There is even a consulting company whose job it is to recommend people who are on welfare that could be on disability, and then help them fill out the forms and get Dr. consent. This company gets paid 2k+ for each person they switch over..
Disability, Unemployment, Housing, and Medicaid are usually not included in a discussion about "welfare". Usually conservative types will lump everything except for unemployment together for their own purposes when talking about costs.
End of the day, the reality is that states that are aggressive about these costs for idealogical reasons are most aggressive about medicaid (cost is split with state), "temporary assistance" (cash payments to individuals and familyies, shared with state).
Usually states make money on disability, WIC, and food stamps. (The Feds fund administrative costs.) Opposing these things is weird, particularly since the alternatives to these programs (jail, ER visits) cost something like 5-10x more!
I'm of the opinion that some (not all) of this is driven by forces similar to why dollar stores are doing so well, especially as laid out in the NPR article.
> “Essentially what the dollar stores are betting on in a large way is that we are going to have a permanent underclass in America,” real estate analyst Garrick Brown told Bloomberg in 2017.
> Dollar General CEO Todd Vasos agreed, telling The Wall Street Journal, “The economy is continuing to create more of our core customers.” In other words, the more lower-income Americans struggle, the better dollar stores do.
Jobs Polarization is a fairly well researched and discussed topic in economics, but I'm yet to hear anything about it in the mainstream. Income inequality is a hot topic but I think this deserves more attention since it's part of that feedback loop and IMO what people feel directly.
People talk about robots stealing our jobs, but I think we've already kickstarted this process with things that produce similar effects like outsourcing. It's hard to say there's a causual relationship between the two, but disability benefit claims start rising around the same time as the recession in the early 90's.
There's an article from the National Bureau of Economic Research that suggests when firms are pressured they look to invest in automation or outsourcing. Then, when the economy recovers those jobs remain automated or outsourced, thus resulting in the 'Jobless Recoveries' we've been seeing in recent cycles.
If you're one of those people, then due to jobs polarization you're likely either looking at a lower paid job or training to find a higher paid one. Re-training has capital costs (not just money, but time and social capital to a point) that not everyone can afford.
Add in the hollowing out of many small towns and I think at least one cause of the rise in disability benefits starts to come into focus.
I don't think this is true for everyone by any means, but I do think it's a trend worth investigating. Right now, politically we're trying to tackle outsourcing, which IMO is kinda moot as automation is rising and produces similar effects.
People talk about automation as if it's something that's coming, but I think we're already seeing what that future looks like.
Related, there's a strong push to increase the minimum wage; while I agree that those on the bottom should have a higher quality of living I feel the effects of this first hand.
Increasing the minimum wage does nothing to increase the quality of life on the bottom, but does VERY WELL increase the cost of living (which rises to meet the new 'market will bear' level) and decrease everyone who pays rent rather than "earns" rent.
I feel that real world observation can confirm that raising the minimum wage mostly has the effects I describe above and that there are different approaches which should be tried (probably in combination).
* Actually tax the super-rich *1
* Tax passive income higher than "active" (work for living) income (maybe 2-3x rate?).
* Land Value based tax (re-development) on a trend (20 year median?) basis.
* Define "poverty" as 1.2 * (rent + healthy food + healthcare + other typical costs) per area.
* Supply side price controls.
* Anyone in poverty or out of work should instead be eligible for the New New Deal*.
* 1(taxes) High rates for those earning 10X the median income, and approaching 49% for those earning 20X.
Supply side price controls, a baseline offer in critical services for the private sector to (try to) beat, for ALL core public infrastructure: security (mil/'peace officers'), roads, water, sewer, education, healthcare, electricity, communications. Yes, this should focus on mostly covering natural monopolies and often provide a market framework for services on top of that infrastructure. Similar to how public roads enable many delivery services to compete.
New New Deal:
* free room/board/basic public food kitchen
* yearly aptitude assessment
* training for the job area of their choice out among aptitude matches/society needs
* arranged part time apprenticeship work with at least minimum wage per hour
Those linked articles hardly make the case for blanket assertions about 'disability being the new welfare'.
Every man made system has fraud and abuse and yet reasonable people do not use these instances to attempt to discredit the entire system, no sensible person points to evidence of bank and corporate fraud to discredit the concept of banking and corporations? Even the church has fraud.
This article goes into great depth with documented evidence of serious problems, what is the connection to fraud in other regions covered in 2 articles covered way back in 2013 and how is it useful to this discussion?
The centerpiece case for the story is an odd one to support the assertion.
The article vilifies the evil doctors who carelessly churn through disability claims, but it also notes that the doctor for the article's centerpiece was not provided any medical records indicating the patient's cancer was metastasized and inoperable. Absent that information, the determination may have been correct.
The doctor made $420k/yr for full time work processing claims. That puts him somewhere between dermatologists and urologists for doctor compensation, which is on the higher end of specialists. Is that too much? I have no idea, it seems like the job requires a great deal of breadth.
"In Chrisman’s case, Thrush failed to obtain one critical piece of evidence: a discharge paper from a hospital that stated Chrisman’s cancer was inoperable and had metastasized. The prognosis clearly qualified him for disability, even under the complex rules set by the Social Security Administration. The mistake was discovered only after Chrisman hired a lawyer."
That probably turns on "failed to obtain". The state collects and dumps case files onto the contract doctors. Is it the doctor's responsibility to search all sources of records for ones which were omitted and might be pertinent? Do privacy rules even allow this? I assume there is some waiver signed by the applicant to allow the state to request medical records, but is that then granted to the contract doctors?
It wouldn't have to be provided to the contract doctors, you'd just need a process where the doctor says "this paperwork is missing a discharge document, without that I can't make a determination" and the state/patient can get it. (I'm not a doctor so I don't know if a discharge document is something you would expect to see in a medical history)
You generally don’t get, or expect to get, every last file in a medical record. That said, a discharge summary is just that - a summary. For a cancer to be found inoperable, the record would usually include multiple imaging studies, pathology studies, reports analyzing the above, a specialist consult note, a primary internist note addressing the specialist consult note, etc. A lot would have to be missing for there to be no hint of this. Normal medical records tend to have a lot of redundance around cancer diagnosis and prognosis.
You would only know there was a discharge summary if there was a corresponding admission history and physical.
If no indication of an admission to a hospital was made, then you have no reason to expect a discharge summary. However, I would imagine the radiology reports would have included the metastases...
Not only did Thrush screw up, the article points out he was also a convicted felon. Given the preponderance of evidence marshaled by this article, you’d have to be ideologically blind to defend this systemic crime.
One problem is that physicians are being employed to make medical decisions affecting people who are not their patients. Another problem is that politics has demolished state welfare programs that would ordinarily serve to support those who cannot work, and the only reasonable alternative to those facing homelessness and starvation is to apply for federal benefits, of which the only benefit commonly available may be Social Security disability.
The politicians have already decided the people in question do not matter, and they would like to kill them off as quickly and quietly as possible, preferably in such a way that blame is not attachable to them. They have been temporarily frustrated by the fact that their targets have found some other means to acquire the means to survive. The physician that denies the disability claim by default is thus serving a political interest, not a medical or humanitarian one. They are not being paid to advance the health interests of the community, but to protect the coffers of the states from those who may have a lawful claim on the money in them, in a manner that is technically conformant with the letter of the law.
The people dying while their disability denials are reviewed? That stems directly from the same political assumptions that mandate work requirements for welfare recipients. "Why should we give them money, if they're just going to die soon anyway, and they will never be able to pay it back?" It's the same premise businesses use to fire workers that are temporarily unproductive. "If you aren't making me money continuously, and especially right now, I have no further interest in you, so get out."
So if you have stage IV metastatic cancer, and are unable to walk, stand, or sit, and may have enough pain and/or pain-management medication to make concentration difficult, then I guess you had better make sure you fill out your complex bureaucratic forms correctly, as just one of the many things you have to juggle now in order to not die. You also have to trust that everyone else involved, none of whom have any direct stake in your outcome, will also fill out their forms correctly.
You can temporarily alleviate the symptom, but you cannot cure the disease without addressing its root cause: people who lack empathy for the infirm and the insolvent have acquired a large amount of power over both the government bureaucracy and the healthcare business.
Thus I suspect that the only phrase the review physician really needed to make a disability determination--"diagnosis: inoperable stage IV metastatic cancer"--was intentionally omitted from the review materials, because it was the only way to plausibly deny the application. A vital missing record can plausibly be explained as accidental, if you intentionally make the bureaucratic process onerous enough. Absent that vital datum, the whole dossier of review materials was absolutely useless. There is no point in employing an impartial administrative physician at all, if the medical record is incomplete. In that light, paying someone $0.5M every year for "garbage in, garbage out" processing is a lot more than the healthcare value provided to the patients. But paying someone $0.5M to paint a veneer of respectability, professional expertise, and due process over a system that would otherwise be paying out many millions in disability benefits is a lot less than the political value provided to the system. It's a lot cheaper to pay out $0.5M and let those sick people die, than to pay out those millions to keep them all alive just a little longer, at $800 apiece, every month until they kick off.
So the corrupt physicians working admin jobs under contract to the state aren't really at fault. Vote for government representation that believes "provide for the general welfare" is more of a mandate than an introductory rationale. Pay more to buy products from companies whom you know to be honorable with respect to their treatment of their workers. Try to treat people that you encounter in your job like people, rather than tasks or obstacles. You can't meaningfully change the outcome until you change the culture that produced it.
> Thus I suspect that the only phrase the review physician really needed to make a disability determination--"diagnosis: inoperable stage IV metastatic cancer"--was intentionally omitted from the review materials, because it was the only way to plausibly deny the application. A vital missing record can plausibly be explained as accidental, if you intentionally make the bureaucratic process onerous enough. Absent that vital datum, the whole dossier of review materials was absolutely useless.
This is the key insight I took away as well. I have not applied for SSDI (nor made determinations for it); however, if the physician reviewing the records is not provided the information nor provided an opportunity to question to patient directly, you will of course have "garbage in, garbage out".
This is a systemic issue, and the system at fault is the local government.
"Those who are badly off must go there." "Many can't go there; and many would rather die." "If they would rather die," said Scrooge, "they had better do it, and decrease the surplus population."
I was a happy fully sighted software developer up until a few years ago an eye disease started all of a sudden. Now I am blind. I applied for disability and got denied. I appealed and was denied again. In the end I hired a lawyer and won the case. Judge told me he was surprised that I had to go this far as my case seemed so clear to him.
To make things fair, I wasn't fully blind at the time when I applied for disagbility. My doctor thought I was blind enough to be considered disabled. Social security's doctor didn't think so.
Maybe something you don't feel comfortable discussing, and feel free to disregard if it is. But I've often thought about what I would do if this, or a major injury to my hands, were to happen to me.
Programming is a big part of my life, and I don't know what I'd do if I suddenly couldn't do it anymore. You're able to read and write posts on HN, so it seems that you're able to edit text again, albeit at a (significantly) reduced rate? Have you picked up programming as a hobby again? Or have you moved on to other things now that you don't have to?
It took me a few years to adjust, but I'm back in the workforce. I am working in a big IT company now. Blind people can use screenreaders - assistive software - to write code and leave comments on hacker news. If something happens to your hands, I've heard of a software developer who is using dictation software to write code. There are ways you can work around your disabilities.
You can have your case re-reviewed. Urban legend is that after the third time they just magically approve it. There's a whole group of lawyers that specialize in getting people approved for disability benefits.
People on disability skyrocketed after the turn of the century. It's very easy for the overweight to qualify for heart/breathing problems.
At first glance you would assume that $804/month is a low enough amount to keep people from applying. It won't even cover rent in many places. Even a $10/hr job will pay double that in gross pay in a month.
Anecdata: My fiancee has lupus and a kidney transplant. There are days where they are completely bedbound and days where they can walk around just fine, depending on if they are in a lupus flare and what it is attacking. All of their doctors (rheumatologist, nephrologist, and internist) have urged her to apply for disability as they all consider them firmly in the permanently disabled camp.
> Urban legend is that after the third time they just magically approve it.
The state you are in seems to make a big difference. My fiance applied three times in the state of Florida and were denied all three times. They were approved on their first application in Wisconsin.
Your medical situation also seems to make a big difference. In Florida, my fiance's doctors were spread around, requiring several trips to get paperwork. In Wisconsin, they are all at a single hospital, so requesting records was simple, and the medical records department sent all of them at once from all of their doctors with a single request.
> There's a whole group of lawyers that specialize in getting people approved for disability benefits.
Many of them work on contingency, taking a cut of the back pay that you get when a previously rejected application is ultimately approved. I understand that lawyers need to be paid, but taking a cut of someone's disability benefits seems pretty low to me. (That said, there are firms that work on a pro-bono, sliding scale, or a fee-for-service basis where they do not take a cut of your back payment.)
> It's very easy for the overweight to qualify for heart/breathing problems.
I wish this myth would die. The morbidly obese very rarely qualify for disability.
> [Y]ou would assume that $804/month is a low enough amount to keep people from applying. It won't even cover rent in many places.
Many places have supplemental rent assistance and other benefits that you become eligible for once you are on disability, which mitigates some of that.
There are some counties in the US where 1 out of 5 people are on disability. I can't see how you get a rate that high unless it was easy to qualify for disability.
> I can't see how you get a rate that high unless it was easy to qualify for disability.
Poverty tends to be a very unhealthy situation - it leads to a poor diet, you skip medical treatment for initially small issues, jobs available are more likely to be of the sort that cause back and joint pain.
Now add in the fact that disabled folks need to live in cheaper, low cost-of-living areas, and you'll get big concentrations.
Poor people don't move because they lack funds to do so. It's one of the big problems in the US that hits the fixed income people who live in high expense areas. Access to healthcare for the poor is a lot better than in it was in 2005 because of Obamacare that expanded medicaid yet disability rate is at an all-time high. Indicators for health care access like high cholesterol levels and untreated cavities is at a 20 year low.
Most jobs hire for minimum wage in Mid-South with no benefits. They also try to give you part-time, not full-time. Think 12-16 hours for many people. There's enough desperate people that the employers are happy to ignore or fire anyone who wants more money or better schedule. That's easy because it's At-Will Employment.
So, that's the baseline to compare against for these welfare programs.
Does this allow the doctors to get compensated again for the additional review or does it simply reopen the existing case? Already frustrating enough to have to re-apply... can't imagine the frustration of putting more money in the pockets of the people carelessly rushing your review.
Thanks. Any implications for the initial reviewer(s) if further reviews reverse the initial decision? Doesn't seem like doctors should be compensated if their decision is found to be incorrect.
Only 5-10% in step two get reversed, but 50% of those who pursue to step three (the judge) get approved. I suspect it's intentionally like this as a weeding out sort of thing.
Step three is best done with a lawyer, but they'll eat up $6k or so of the back-pay you get if it's approved.
Anybody else find it ironic that there's such a barrier for people to get approval in the name of protecting taxpayer dollars, meanwhile huge amounts of taxpayer dollars are spent on paying these contract doctors?
That's the basic argument against all kinds of welfare gatekeeping, it costs more than it saves. People who insist on requiring drug tests to receive unemployment benefits, requiring seven life histories to receive SNAP, etc, often try and justify it as lowered spending, but it is mostly about making sure that Bad People don't get anything.
Per case, the contract doctors are paid ~$100 once (from both per-case and per-hour pay) rather than $800 every month to the applicants. That's still cost-effective. The only reason the numbers seem so large is because there are so few doctors, processing so many applications.
This is similar to the "New York marshals" involved in the debt-collections scheme articles that made the rounds on HN a short time ago. One person makes millions, solely because they have the bureaucratic rubber stamp that makes the grossly unethical business perfectly legal.
If you can put together a good racket, you can usually make a few hundred thousand dollars at it. That's just what sacrificing your own ethics is worth.
But now I wonder how much those docs pay for private security, to protect them from the terminally ill people, denied disability benefits, who may decide to go out with a suicidal attack on someone whom they could see as contributing to their doom.
> Urban legend is that after the third time they just magically approve it.
I can tell you that does not happen magically. I went through the entire process and still got denied.
You first apply for SSDI and they keep asking for records. Then they have some doctor look at you (at least in my case). The doctor actually got upset with me for taking too long to answer his questions. They also had a psychologist ask me some questions too. Finally they deny you the first time (which is actually to be expected).
You then have your case re-reviewed (your first appeal), and get to see the same exact doctor yet once again. They ask for the newest records from your doctor and you have to fill out some of the same forms again. After that I got denied again. Apparently this part differs from state to state, and some just skip this re-review and go straight to see a judge.
Finally you get to have the portion where you sit with a judge (your second appeal in many states). I even had a lawyer for this part (the law firm wouldn't even help me prior to my first denial). There is an expert in the room to say if you are able to work or not. The expert actually said everything in my favor, and told the judge I was unable to work at any job. This judge still denied me.
After this you can try to fight it in federal court essentially saying that the judge was wrong, but you only have a 1% chance of winning. At this point you just have to reapply and start the whole process over.
The problem is, when you have an actual chronic illness and are seeing one of the top doctors in the country for it with loads of evidence, it doesn't matter to social security. I would rather be able to work than go through this process. Trying to navigate the process of what to do and what not to do to please the social security gods is especially hard with little energy and high brain fog some days. I was so exhausted initially, I didn't do much research and just filled out everything the best I could, which apparently was not in my favor.
I am not an expert but from what I have read after a few years people drop off the unemployment numbers and aren't counted anymore. They pretty much cease to exist as far as the employment world goes. Either they have to go on welfare or disability.
If you look at disability rates by county you will find that people on disability tend to live in low cost of living counties. For instance, my daughter's county has 15% of the population with employment disability and an average income of $1330/mo. $804/mo isn't living like a king, but it will get you by there.
Sure there are a lot of places where $800/month won't cover rent, but there are also a lot of low cost of living places where you can get a crappy apartment for $3-400 and $800 is enough to scrape by on with no other income.
The obese often suffer from other medical conditions like a musculoskeletal system, cardiovascular, respiratory or endocrine systems like heart disease, diabetes, osteoarthritis which can qualify for benefits
Depending on how regressive the state taxes are and considering that the standard deduction doesn't apply to FICA, effective tax on minimum wage can be higher than you'd think.
Not to disclaim personal responsibility on consumption, but the government subsidizes unhealthy food for everyone, not just people who are fat or on disability.
It's very easy on SNAP to fill a month's worth of groceries with packaged, processed, subsidized shit. It's not very easy on SNAP to fill a month's worth of groceries with healthy foods.
I'd be more than happy to have the government pay people to exist. Paying them to exist is great. Paying them contingent on their maintaining an unhealthy lifestyle is not.
Did you read the article you posted? Long term starvation diets are still considered very dangerous even for overweight people. There have been multiple deaths from starvation diets for weight loss--your article even links to a study that examines one of them.
"While 'starvation' as a treatment enjoyed some popularity in the 1960s and '70s, doctors abandoned this strategy because it was likely to kill patients.
After a certain period of time the body burns through fat and muscle, eventually causing physical changes that drastically increase the chance of a fatal heart attack.
Even low-calorie diets that provide insufficient nutrition have killed, with autopsy reports showing the characteristic signs of starvation."
The starvation diet in the article was also medically managed. Doctors did regularly blood tests and proscribed necessary supplements when he needed them. We don't have exact records of everything he was given, but we know he was given magnesium, potassium, calcium, and phosphorus as well as yeast.
The point is, telling fat people to eat less isn't going to kill them. Even genuine starvation is not fatal for fat people, assuming they consume a few vitamins and essential nutrients that are very easily obtainable. I'm not advocating starvation diets, merely responding in kind to the ludicrous suggestion that not subsidizing obesity is tantamount to forced starvation.
Telling fat people to eat less is a bit different from cutting off disability to anyone who is obese, which was the suggestion.
>Even genuine starvation is not fatal for fat people, assuming they consume a few vitamins and essential nutrients that are very easily obtainable.
Starvation diets for weight loss are rare, but even among the few well documented, managed examples there have been multiple deaths. You're not correct here. A 27 year old in otherwise good health, supervised by doctors might be OK. A 55 year old with heart disease that's bad enough to qualify for disability probably won't be.
> I'm not advocating starvation diets, merely responding in kind to the ludicrous suggestion that not subsidizing obesity is tantamount to forced starvation.
How about you say what you mean then instead of arguing that starvation diets can't kill people?
Disability benefits are orthogonal to SNAP benefits - you can get SNAP without disability benefits and you can fail to qualify for SNAP because of disability benefits.
And if you live in a rural area where a car is required, you won't be able to get to the store to use those food stamps, or pay to have it delivered. There's also the issue of shelter being more important than food in most climates.
The most powerful word in the American justice system is:
LAWSUIT
If all of the patients who are being denied file one, then it will make denying these claims so expensive that no doctor will want to touch them with a 10 foot pole.
This word can be applied to all kinds of ills plaguing us in these times. I'm amazed that lawtech isn't right up there with biotech and fintech, but I'm guessing that as messed up as things are right now, law is ripe for disruption.
We're talking about people with sufficiently significant impairments that they are incapable of working. They are non-technical and likely do not have an emergency fund or usable credit. They do not have the bandwidth to file lawsuits.
I agree that this feels like a market misalignment that could be corrected and make someone a boatload of money in the process, but between the above issue and the general slowness of the legal market I'm not sure that that's actually the case.
>I agree that this feels like a market misalignment that could be corrected and make someone a boatload of money in the process
This is already done. There are law firms that specialize in disability cases on contingency - they take their payment as a cut of what your back pay would be if they win and nothing if they lose.
Issue is that most state and federal level organizations enjoy Sovereign Immunity. Makes them immune to most forms of lawsuits. They can do what they want without issue.
I'm not certain about this (maybe someone who knows for sure can chime in).
I'm pretty sure you can sue anyone for anything, and then the judge throws it out if the case doesn't have merit. But if enough people do it, somebody somewhere has to make a decision about whether to keep hearing cases or change the law to make filing illegal somehow. That's the point where people get seriously pissed off and protests form and somebody stands to lose an election.
I saw a documentary along similar lines where a town didn't want a pig farm (due to smell etc). The county wanted to force them to do it, so they said no and sued the county. Then the state said no so they sued the state. I think it went all the way to the supreme court. They worked their way up the ladder until finally the law was changed so that towns had their own say in whether they wanted to smell like a pig farm (which no town does).
This technique works well for environmental laws and when corporations poison neighborhoods with pollution, things of that nature.
Edit: I went to find the case but there are so many that I think the results stand on their own:
>I'm pretty sure you can sue anyone for anything, and then the judge throws it out if the case doesn't have merit.
You can file almost anything you want, but it costs money to do so, and in some cases you can be forced to pay the defendant's legal fees. Lawyers can also face disciplinary action for filing suit that they know will be dismissed.
Assuming you learn how to file on your own, and you continue filing meritless lawsuits, you can be declared a vexatious litigant, and the court will bar you from taking further legal action without prior approval by a judge.
Disability claims can be appealed to an administrative law judge without filing a lawsuit[1]. It helps to have a lawyer for this, but having a lawyer or filing an appeal does not guarantee approval.
The doctor denying the application incurs no cost when the case is challenged in court. The cost is incurred by the individual suing (paying legal fees) and the state (defending the suit).
When ever you concentrate a large enough wad of cash(i.e. the incentive) to a simple metric. Sooner or later that metric will be gamed. Metrics should be more nuanced and well studied and flexible to change and behavioral study needs to be incorporated into fraud detection and prevention.
Libor, No Child Left Behind policy that ties test scores to school funding are some of the other examples that have similar issues.
It seems they should just feed the reviewers some small percentage of redundant claims, and use statistics to direct oversight and scrutiny. The high-volume reviewers who statistically disagree with their peers would be easy to spot.
"Thrush’s productivity has paid off. He earned $420,000 for reviewing the applications of 9,088 Tennesseans applying for disability during the year ending June 30. He has made more than $2.2 million since 2013."
It's just gotta pass the Turing Test. The doctor in question could be represented by this pseudocode with no nesting:
claimstatus = rejected
randomvalue = GetRandomValue(1,100)
If (randomvalue <= 20), Then claimstatus = approved
return claimstatus
Doesn't even have to read the application. Well, maybe the name or app number just so it can reference it in the official response. That might be another application, though, with this one being the review application.
This is purely anecdotal, but I am from Tennessee, grew up near a poorer community...and it is seemingly normal for people to fraudulently claim disability as a supplement for welfare. People even brag about it. There are certainly perverse incentives for both doctors and people claiming disability claims to cheat the system.
The article seems to tie denying disability with receiving more pay...but that's not even how it works. It doesn't matter if you are denying or approving, what matters is speed of your review. So, while I do view this as a problem, the headline is highly misleading. They aren't getting "big money" for denying disability. They are getting big money from reviewing fast, period. Approval or denial.
Something mentioned in the article - the social security administration is required by law to double-check half of all approvals, but not denials. So the incentive is definitely to deny as quickly as possible - if you approve everyone you'll be caught, but if you deny everyone that's far less likely.
But it offers no data to support the general idea that this is the case (that denials are through the roof, even if TN is a higher rate than the national level, it is marginal. Also it leaves out the median which would be more interesting, since a few states could greatly bring down the average.) The approvals are reviewed because denials can be appealed. It's a safe guard against fraud. I'm not saying there aren't perverse incentives, but "doctors earn big money approving disability claims" has less of a moral outcry from the reverse.
If you are likely to make errors due to having to review too fast to properly evaluate claims, I'd expect you to lean toward denying claims so that your error would mostly be denying claims that should have been approved instead of approving claims that should have been denied.
That's because if your errors tend toward approving claims that should have been denied, your are going to have a higher than normal fraud rate among your approvals, which might raise suspicion that you are in cahoots with the fraudsters maybe taking bribes to approve them.
Denying claims that should have been approved, on the other hand, probably has little risk of getting you personally is trouble.
Hence, there is an incentive when rushed toward denial of claims.
And in reviewing quickly, they're making mistakes, denying a man dying of cancer the disability money he was entitled to under the law. Perhaps some people who don't meet the qualifications are being approved, but I think most people would view false positives as less of a problem than false negatives in this case, and the fact that the denial rate is higher in Tennessee suggests to me that it's faster to deny than approve anyway.
Same story with worker's compensation in Washington State. It's really not even worth applying without a lawyer and a few thousand dollars at least to gamble that you can prove that the pain is caused by work. The word of your actual doctors means nothing and only the five minute consultation by their hacks determines your fate, a consultation whose result is known ahead of time: denied. And this is a state run program allegedly ran for the benefits of the workers paying into it. Yeah right. A bunch of bullshit we wouldn't need to deal with if we had proper healthcare in this country. But instead, this is the way America treats its workers. Why would we expect anything better for disability?
Sure, a good doctor goes through more claims than a bad doctor... but if you take away the ultimately outcome goal of helping patients, you can go through a lot more a lot faster. "My goal is to close tickets... anything I can do to reject a claim gets me to a closed ticket and gets me a bonus."
Multi-dimensional KPIs can help, but any time you have a raw number metric you'll need to sanity check on them. When dealing with customers, including customer satisfaction scores is a no-brainer. A lot of companies, Amazon comes to mind, have a "how's my driving" link in their email signatures.
I wonder if putting a cap on the total annual payout, along with including “dummy claims” that need to be approved / rejected to test the doctors and keep them honest would be useful.
This also seems like a good job for machine learning eventually.
> This also seems like a good job for machine learning eventually.
I'm not sure what "this" you mean (testing the doctors or testing the patients), but I'd argue the opposite. ML is great at performing tests we understand, and is terrible at determining things we aren't sure how to determine.
In this case, either you are checking to see if someone is truly disabled (which we don't have a good test for other than doctors, and see how that's working out) or you are checking to see if a doctor is being wrong in their evaluation, and if you can't perform the evaluation, figuring out if the doctor is skimping won't be easier.
And of course, even if you develop a perfect test, because of the incentives people will find a way to abuse it, and machines aren't likely to notice that they are now being played.
Why is there a focus on one type of error? Is there some reason why doctors would be biased toward wrongly denying disability benefits, rather than wrongly allowing?
What are the economic incentives to bias the decision one way or another?
The article does not go into detail, but I expect a doctor with a high false positive rate to not get much applications his way in the future as it costs the state a lot of money.
This is a key point, and points to so many thing being broken at the same time it hurts my head. The real smoking gun would be to find some sort of defacto evidence that doctors got the hint that denial gets them more business. That would sit in the next layer up, the assignment of cases. Alternatively, could it just be a big pool e.g. the race to get through them is a cash grab, so the faster you go you'll get to drink more of the milkshake? In that case denial is more of a way to avoid scrutiny.
Cutting government staff doctors in favor or more expensive contractor doctors is a red flag. You can't fire a staff doctor for approving too many applications, but you can direct more contract business towards doctors with a proven track record of denials.
It is also possible that there is some form of administrative punishment that makes false positives more burdensome than false negatives. If you are fined $1 for each false positive, and $0 for each false negative, you deny by default. If approvals are flagged for automatic recheck by the computer, and denials are only rechecked if an appeal is filed, you deny by default and let the real work fall to the appeals doctor. If the system branches in any way based on the APPROVE/DENY bit, that may affect how the bit is evaluated in the first place.
It's broken all the way down to the foundations. The state government in Tennessee is controlled by the state politics. And the state politics is very far from liberal democratic socialism. This is the state that had to have a literal gun battle in order to fight local government corruption [0], and is is equally important to note that shooting live rounds at the bastards didn't even get them to behave for an entire year. The veterans' coalition assembled to vote out the corruption was itself co-opted and re-corrupted almost immediately.
I can't say for sure, but I assume they begin with a presumption of each claim being invalid, then looks for proof that the claim is valid. Faster review pays more, so there's incentive to go fast, but is more likely to miss relevant positive proof of the claim.
- Of the cases he reviewed since 2013, approximately 80% were denied. This would, as you note, be better phrased as "80 percent of the cases he reviewed were denied".
- Each year since 2013, he reviewed an unknown number of cases, and a certain percentage of those cases were denied. The arithmetic mean of those 6 yearly percentages is approximately 80%.
In the second case, the 80% figure is meaningless, but it's a calculation people often perform despite that fact.
Well, this should be defined as practicing medicine. (Ultimately, you are controlling whether and what treatment occurs.)
Correspondingly, their licenses should be on the line, as well as liability for malpractice.
Let regulation and tort law take a few of them out. See what happens, then. Maybe even criminal law, as inevitably some patients will die due to lack of proper care.
So.. if a MD has made a determination upon reviewing medical records submitted, that makes them a "patient", no?
So if they made a bad determination, I see no reason why the doctors can't be sued directly. Surely Social Security knows who reviewed it, so the records can be produced by FOIA.
Sure, these docs made .5M$ . But when these things are brought to light, have a way to make them much more painful and costly. Fraud by "rich people" usually isn't looked highly upon at jury trials.
Potentially true. However that's what medical malpractice insurance is usually for. And if they're found to be doing fraud according to a court, lets just say they are in for a very unpleasant time.
Unfortunately that will likely happen right after you are allowed to sue individual police officers for assaulting innocent people and illegal arrests.
Even if the doctors could be sued directly is that necessarily better than going after the flawed system with the additional hope that the individual is dismissed?
As an ambulance chaser I am confident most disability claims should be denied. These cases have exploded over the last decade as job opportunities for obese middle aged workers have been obliterated, dependence on opioids has surged, and the shame of not supporting yourself has largely gone away.
My wife is a physician and the stories you hear are unbelievably sad but most people don't fit the definition of disability by social security. Most people are able to perform another job, however, their training and personality limits them in being reintroduced to the labor markets.
The problem isn't a simple one but there are other solutions such as retraining
"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.