Decision language models as affordable and rapid alternatives to LLM judges of clinical generative AI

LLM judges now score outputs against rubrics, in benchmarks and as training rewards. Decision models return probabilities over permitted answers with a confidence score but no free text. Two such models are Jev and an open reproduction, Perplexity's Decider. We compare each with three flash-tier LLM judges on nine panels from seven benchmarks with human judgments, giving every judge identical criterion texts. The LLM judges run in two setups, reading a whole rubric at once or one criterion at a time. Our findings suggest both decision models can often stand in for them. The LLM judges cost 16 to 357 times as much and take 5 to 350 times as long, yet in both setups each decision model trails them significantly in at most 6 of 27 comparisons. The two kinds of judge err alike, agreeing more with one another than with the human-annotated judgment labels on ordinal criteria. Over 85% of flash-tier LLM verdicts on either decision model's most confident errors repeat them, where independent errors would give about half. Each decision model's confidence ranks its errors on most ordinal panels, so each is a natural first stage for a cascade deferring uncertain verdicts to an LLM judge. Yet with flash-tier fallbacks, such cascades gained a mere 2.7 points at best over the strongest single judge, even with oracle thresholds, suggesting they mainly save cost. A cascade needs a fallback that is right where its first stage errs, but the LLM judges are mostly wrong in the same places as Jev, and the Decider is already the strongest single judge on most panels. Even each vendor's higher-tier model repeats those errors, and as a fallback it lifted no cascade more than 1.7 points above both tiers' strongest single judge. Holding across setups, effort levels, and tiers, these findings suggest designing future decision models afresh to get right what LLM judges get wrong, and vice versa.

LLM-as-a-judge scales evaluation, but reasoning judges are slow and costly. We study JEV-as-a-Judge: evaluation with JEV, a decision-only judge that returns label probabilities instead of text, and whose confidence decides whether to accept its verdict or escalate to a reasoning judge. Against sixteen generative and reward-model judges, with blinded human adjudication, JEV comes within three points of GPT-6 wherever a verdict can be read off the text, at 0.36% of its fee and a 0.15-second median latency, and falls behind where the verdict must be derived, as in math, code, and logic. Its confidence marks this boundary. With a threshold frozen in advance, accepting confident verdicts and escalating the rest is 0.9 points more accurate than GPT-6 on 1,610 held-out pairs at 41% of its fee, and in a pre-specified live test on two new workloads the cascade matches GPT-6's accuracy exactly. Confidence routing weakens on style-adversarial pairs and reference-free prose; we close with a simple recipe for validating thresholds locally.

Evaluating medical AI systems using expert clinician panels is costly and slow, motivating the use of large language models (LLMs) as alternative adjudicators. Here, we evaluate an LLM Jury, composed of three frontier AI models, for scoring 3334 diagnoses on 300 real-world low- and middle-income country (LMIC) hospital cases. Both LLM- and clinician-generated diagnoses are scored against expert panel diagnoses across four dimensions: diagnosis, differential diagnosis, clinical reasoning, and negative treatment risk. The LLM Jury scores are compared with expert and independent re-scoring panel scores to assess error metrics, inter-rater agreement, severe-risk errors, and the effect of post hoc calibration using isotonic regression. In our data, we find that: (i) the uncalibrated LLM Jury scores preserve ordinal agreement with the expert clinician panel scores, but are systematically lower; (ii) the probability of severe-risk errors is lower for the LLM Jury than the human expert re-score panels; (iii) the LLM Jury combined with LLM diagnoses can be used to identify diagnoses at high risk of error, enabling targeted expert review and improved panel efficiency; (iv) the calibrated LLM Jury scores and rankings of diagnosing agents show excellent agreement with those of the primary expert panels; (v) LLM Jury models show no self-preference bias, they did not score diagnoses generated by their own underlying model or models from the same vendor more (or less) favourably than those generated by other models. Together, these results provide evidence that a calibrated LLM Jury is a trustworthy and reliable proxy for expert clinician evaluation in medical AI benchmarking. Confirming these findings in other clinical settings is an important direction for future work.