Neither A nor B

Heads or tails?

It’s a choice, with the occasional ‘balance on edge’, or ‘simply fail to come down at all’, which applies well to tossed coins.

It may sometimes apply to other things. Stepping over a cliff for example. Humans very often apply it a lot more broadly. Democrat or Republican. Black or white. Male or female.

It is a core theme in many of my books, that patently in a lot of cases, this is bullshit. 1)Things are seldom simple and entirely and perfectly described by a narrow simple category. If you think they are… you probably are behaving like a sheep, and haven’t actually looked carefully. Pigeonholes may work well for pigeons. They are lousy for people, emotions, philosophies or political positions 2)There is almost always another possibility, if not a myriad of them. Yes, you may have chosen to vote for one or other party. It is massively unlikely, unless you are, in fact, a prion (and incapable of independent life, let alone thought) that, if you actually thought about a party manifesto you would agree with all of it. And, if you really thought about it, inevitably humans choices come down neither A nor B but a percentage of A, a percentage of B and percentage of options through to zz. DRAGON’S RING – a choice between A & B… and actually neither are good. 3)We may simply be looking at the whole damn thing bass ackwards. Take health insurance as a simple example. What is it intended to do? Make sure that when you get sick you can afford to be treated and get better? Or in other words, that you can stay in good health? Right? Does it? As far as I can work out, only incidentally, and in fact the principal beneficiaries are people who only benefit if you are sick (especially as inevitably the insurers themselves have ownership or part ownership of the facilities for treating you). The IDEA of making sure you are not sick simply because you can’t afford treatment is a very desirable one. I’ve yet to meet anyone who thought they deserved to die or be sick and miserable because they didn’t have the money for treatment. I’ve met a few people who didn’t mind if it happened to someone else, as it never seems to occur to them, that someone else could be them someday, or their child, lover, mother or friend. So: it’s a good goal. But yet… when you think about it, the way it has been applied has been as counter-productive as possible, making affordability more a case of ‘how much blood can we take in how many ways from the host before it actually dies?’. If I were to announce with convincing evidence that I had a cure for everything that might ail you, and that I was going to release it, free, next week, I would give Flinders Island about 3 days before being nuked, in the process killing several hundred highly paid assassins and hitmen from every part of the medical business. (I’m ugly but not that much of a fool. I’d be elsewhere.). Yes, indeed, there are some wonderful doctors, nurses, radiographers and research chemists who would love nothing more than to say ‘my years of training and experience are now worthless, I’m unemployed and have to find a new job, and I am so happy about it’. But these make a small fragment of a fairly desirable group of people, and Doctors, nurses etc, make up a valuable but a very, very small fraction of the group whose livelihood depend on people being sick. A lot of these are salesmen, administrators, accountants, managers, board members, lawyers, CEO’s – not medical people at all. In fact, if you did a careful look at where the money from that insurance goes… most of it will be into this group (who don’t fix you when you’re sick) and the smaller volume into the actual cost of things needed and the people needed. And really, there is no incentive (especially, yes Discovery Health, I am looking at you, where the hospital facility is owned by the insurer) to limit that wastage. In fact, big talk aside, there is no value in keeping the insured healthy. If the insured never need a doctor, high premiums will put them off (unless insurers get the state to play ball and make them have it by law. At which point you may as well give the medical industry your salary check.). To look at this more logically there need to be serious incentives to the medical industry… to stop people needing their treatments and to make those as affordable and effective as possible. And actually the only way to do that is to reward the right things and punish the wrong. So for example they get paid… if you aren’t sick. If you are sick your premium reduces. If you’re incapacitated or die… they pay out. If you over-live your expected span… they get a bonus. And work out ways to get rid of the dead weight which adds no value. If the state wanted to interfere, the right way would to punitively tax the non-medical (or in the case of pharmaceutical companies non-scientists) personnel. Or make those non-tax-deductable expenses. Costs that cannot easily be passed on to the public, either via directly charging more, or getting the public to pay more tax to cover for largely un-needed expenses.

And those are just some of the possibilities. If you don’t want to go that far, maybe an effective basic state health service that forces private medicine to be competitive and offer more.

What underlies much what I write are simple questions: what are we doing this for? and is how we deal with it an artifact or accident or history, or really best for the purpose? I’ve used medicine as an example, but you could apply it to anything from energy supply to governance. Of course my possible answers aren’t right. But they’re about providing the right motivation to solve the problem, rather than motivating the creation of groups/institutions/bureaucracies whose lifeblood is keeping the problem vaguely under control but there forever.

The answer is inevitably neither A nor B but a big mixture of that and other things, and sometimes something new.

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8 Comments

Filed under economics, philosophy, politics, Uncategorized, Writing

8 responses to “Neither A nor B

  1. Ian Clark

    WTF!

    I do not understand where you are coming from here, Dave.

    I ran computing for 22 hospitals from Port Macqaurie to Tweed Heads. Yeah, the non-medical staff cared mainly for their promotions within the NSW Public Service, yet 95% also cared very much about allocation of funding to patients.

    The medical staff I saw, and I met personally almost all 3,000+ o0f them, were dedicated to patient needs.

    If it wasn’t for the Australian Government health services, the two tablets I take every day would cost about $100 each, per week. Which I couldn’t possibly afford, and I would be dead instead of annoying you.

    There’s the Dave I used to correspond with.
    There’s the Dave that used to be on Baen’s Bar.
    There’s the Dave in Flinders Freer.
    Then there’s this Dave, who is very bad tempered and exhibits anger exceeding my actions of years ago for which I apologised to you. This Dave is mean and inconsistent.
    Whatever’s bugging you, get over it. Posts like this do not enhance your reputation nor help your book sales. You live in Australia now, act like an Australian.

    I remembered why I tried to talk to you by telephone last year. Eddie Funde was a regular visitor to my wife’s home in Wollongong when she was a teenager. She wanted a white SA’ns viewpoint of the ANC, as the attempted murder of Funde had come up in the press, and I suggested yourself as a wordsmith who could express an intelligible opinion.

    Your post above leaves me skeptical of my then evaluation.

    Disappointed and puzzled
    IanRC

    • Ian, I suggest you don’t follow this blog. It’s mostly complex Socio-politics, it doesn’t need anger, and you have problems in that regard. It does need a broad world view and an ability to think a long way out of the ordinary pattern. And it requires careful reading, which you don’t seem to be able to do. You’re confusing state health care with private health insurance, which was what I was writing about (I actually specifically state that a good state health care system would reduce costs). You’re also assuming that Australia is the universe, which, sadly, it isn’t. And Australia, like everywhere else, has seen the proportion of income that goes to people who neither see nor ever physically deal with patients, increase steadily. The pot is only so big. Even in state service: I have heard it from American, South African, Japanese, Australian, New Zealander even Cuban, Doctors and nurses- time (which is money) and money that should go for drugs or medical personnel is being devoured by admin. Admin from being tiny – is now dwarfing medical work, and administrators outnumber medical staff in places. If it hasn’t happened here yet, it will. The end result is not a vast improvement in patient care. It’s paper. There is fairly solid evidence that the pharmaceutical industry is not geared to cheap as possible cure, but to expensive as possible treatment. (I have recently read of an out-of-patent treatment for something nasty – no pharma company is even willing to test it (the Swedish govt came up with some funds, eventually). Sooner or later some administrator who has a _finite_ budget – not a Doctor – is going to have choose: having the money for administrators’ (like himself) wages, or $100 dollar pills (do you think those actually cost $100, in research and materials – or do you think some pharmaceutical company is making money hand over fist?) for you. Which will they choose, do you think? And THAT is my problem. 1)the pills shouldn’t cost $100. 2)the treatment of the patient, and medical staff and drugs should come first, long before admin.

      If I wrote purely to sell books to make money… I’d have done something else. I am a very capable person, and writing pays badly, generally. My fans (not my readers) tend to be deep thinkers. This is for them. I expect them to disagree. I also expect them to be polite and reasoned about it. You are being neither. If you can’t, please don’t follow, and don’t post.

  2. Ori Pomerantz

    The cost of medical research is so horrendously high for two reasons:

    1. Safety tests. The FDA, and its equivalents elsewhere, has inherent motivation to be careful. Nobody ever got fired for not approving a drug, AFAIK. Approving a drug that ends up being unsafe, OTOH, is a career killer.

    2. Failure rate. The one successful drug needs to pay the cost of the research that produced it. But it also needs to pay for about a thousand drugs that weren’t effective enough or weren’t safe enough.

    How do we reduce the cost of administration I don’t know, I suspect

    • Ori I must apologise! – these comments got overlooked. As usual you make good points.While yes, the cost of ongoing research is high, it’s also in theory recovered by the cost of the product… Which is how they justify sky high cost for a specific new product… except they also have products which have paid their own- and several hundred other successful projects and many failures costs… over and over (Ventolin springs to mind. Viagra too) which we are told has to be that way to pay for new research. My point is you can have it one way… or the other. Either the costs are paid off on that item post facto, OR provided for by previous products. Not both.

      • Unless the pharmaceuticals are deeply in debt, the costs are provided by previous products. However, the current generation of products still needs to be expensive to cover the research that will pay for the next generation of products.

        Looking at Pfizer, they have about 58 G$ in current assets (money on hand, etc.). They have about 108 G$ in liabilities. Out of that, 46 G$ is long term debt (including 4 G$ that comes due in 2012). I’d say this means that a large part of current research does get paid by products currently being researched.

  3. Ori Pomerantz

    Administrators tend to be very good at showing reasons why their job is vital. This is the safe effect that causes the US to have more generals now than in WWII. The only solution is to have very small hospitals, but there are huge economies of scale there we’d lose.

    • Economies of scale we SHOULD lose. The truth is the ratio of admin to patients has long since eaten any such benefits. There are probably (just as in small businesses) quanta in this -(it’s quantum, I tell you) where one person can not do one more patient, but employing one more person (who could handle 50 patients) is not worth while. You make a good point It’s useless having admin decide on their own jobs.

      • I disagree. The human body is incredibly complicated, and it makes sense for doctors to specialize – which means they need other doctors with all the other specialties nearby. Also, a lot of medical equipment is hideously expensive and it makes sense to amortize it over as many patients as possible.

        For an extreme example, see this hospital in India. Each surgeon specialized in just a few heart surgeries, with the result that they get really good at those operations, and can do them quickly (= cheaply).

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