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1
Knarfs Knewz / Re: Population Bottlenecks are Transient
« Last post by knarf on Today at 01:08:21 PM »
This is not a competition of symbols.

How about an "integration" of symbols?



Just kidding. I will not post any new symbols to my NEWZ. I will post them where they belong, in my subcategory "Hot Pursuit of T6thME Spread". I should of been doing this the whole time but I forgot....my bad.

Of course it is.  The position of the Diner (at least my position) is that a Near Term Human Extinction is not likely, just a Population Bottleneck.

You place up regularly Extinction Symbols, so I have to counteract them when you do it.  When you put up an Extinction Symbol, I will retaliate with a SUN☼ symbol.  :icon_sunny:

This is the Way of the Diner.

RE

Your position is of competition. I just want to show that "some" people are really concerned about what over 6,000 scientists have agreed on. I live in a monastery, for crying out load. Don't you think that is similar to what you are trying to get going with the SUN project?

Your life in a monastery is exemplary.  That has nothing to do with this.

By constantly pushing the Extinction Symbol here on the Diner, it makes it seem like the Diner is a facsimile of NBL, with a membership that buys the idea of NTHE.  You publish something often enough, people will believe it regardless of any evidence or discussion.  You have been shotgunning out this symbol for a few weeks now.

If you don't want a war of symbols with me, I suggest you refrain from dropping images of the Extinction Symbol across the Diner Pages and stick to arguing the topics with me.  :icon_sunny:

RE

I am pushing nothing. I am just showing that the symbol is being used more and in different ways. People can make up their own mind about it, and your SUN project.

"By constantly pushing the Extinction Symbol here on the Diner, it makes it seem like the Diner is a facsimile of NBL"

That is complete nonsense! Maybe you have some mental connections with NBL. I don't, and it doesn't represent what McSteinsen is yapping about. It IS about the predicament that the human race is facing at the present time. Why would you want to put together the Sun community if everything was peachy?

It's VOLUME Knarf.  You drop one of these Extinction Symbols on the Diner practically every day now.

RE

Not everyday, maybe once a week, and they are all different in different places. I thought this place was about DOOM. If the 6th mass extinction isn't about DOOM, then nothing is. Maybe if all people were aware that we are destroying more life everyday, and increasing the rate of extinction, they would do something about it, like start a community, and live simply without using so much ENERGY/OIL and PLASTICS. Pool their resources instead of competing in good ol' Merica's dog eat dog world, with money being it's "GOD".

I'm not going to try and go back to tally them up, just *I* get the impression every time I cruise through the forum, there is a new Extinction Symbol up.  I don't agree with this symbol or what it represents.  If you want to keep posting it, feel free.  However, I will respond to it with my own symbology as I see fit.

We can discuss this in detail if you like, or just exchange symbology.

RE
2
Economics / America's malls are rotting away
« Last post by RE on Today at 12:18:49 PM »
http://money.cnn.com/2017/12/12/news/companies/mall-closing/index.html

America's malls are rotting away
by Laura Sanicola   @laurasanicola December 12, 2017: 7:53 AM ET


Is the mall dead?
The worst is yet to come for American shopping malls.

As Macy's, JCPenney, Sears and other major department stores close their doors, the malls that housed those stores are facing a serious crisis.

That's because when so-called anchor tenants leave a mall, it opens the door for other stores to break their leases or negotiate much cheaper rent.
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As one big store closes, it can take several smaller stores along with it like a house of cards. Experts predict that a quarter of American malls will close in five years -- around 300 out of 1,100 that currently exist.

"When anchor stores close, it causes big problems for mall owners and other retailers in the mall," says Howard Davidowitz, chairman of New York-based retail consulting and investment banking firm Davidowitz & Associates. "And I'd say this problem is only in its second inning."

Retailers often sign co-tenancy agreements in their leases with malls, allowing them to reduce their rent or get out of a lease if a big store closes.

That's because the smaller retailers next to anchor stores no longer benefit from the foot traffic that the major retailers received, according to Garrick Brown, vice president of retail research for Cushman & Wakefield.

Related: Dollar General is opening 900 new stores next year

Brown said he expects the weakest malls to enter "death spirals."

Many former anchor tenants are closing hundreds of stores as Amazon (AMZN) eats their lunch.

Sears (SHLD), which had operated nearly 3,800 stores as recently as a decade ago is now down to 1,104 stores. Macy's (M) closed 68 stores this year, and JCPenney (JCP) was set to shutter 128.

It's not just department stores that have mall owners worried.

When Starbucks (SBUX) announced that it was closing its Teavana tea line and wanted to shutter all of its stores, mall operator Simon Property Group (SPG) countered with a lawsuit. Simon cited in part the effect the store closures might have on other mall tenants.

Earlier this month, a judge upheld Simons' suit, ordering Teavana to keep 77 of its stores open.

Some successful malls may be able to survive if they can convert department stores' spaces into better attractions for consumers.

Many big tenants were getting discounted rates on their leases, and malls may be able to charge higher rates to new tenants, according to Brown and Davidowitz.

Related: Another strong jobs report

"There will be a new push to get food halls and entertainment in malls, and make it more of an experience that will draw people in," Brown says.

However, even if new tenants can pay more for the space, smaller "specialty" stores can still break their leases if an anchor store leaves.

It's also unlikely that underperforming malls will be able to attract crowds anyway.

Experts classify malls into "A" "B" "C" and "D" grades characterized in part by sales per square footage of the malls. "B" malls and below are going to have a particularly hard time with the financial burden of the changing mall landscape, according to Brown.

The retail loan default rate is currently hovering around 5%, but Brown expects that number to triple.

And with defaults come bankruptcies -- lots an lots of bankruptcies. More than 300 retailers have already filed for bankruptcy this year.

"If that's not an apocalypse then I don't know what is," says Davidowitz.
3
10 Reasons The Republican Attacks On Clean Energy & Electric Vehicles Are So Smart  

December 11th, 2017 by Zachary Shahan

Republicans are interesting creatures. There are the voters, and then there are the politicians. The voters like things like clean air, jobs, Social Security, and ice cream. The politicians, on the other hand, like to let corporations pollute as much as they want, have been known to crash a global economy from time to time1, seem to always be looking for a way to “legitimately” cut holes in the social safety net (note: they’re working on a super clever attempt to do this right now), and like to melt ice cream via flamethrowers when the ice cream eater isn’t looking.

But hey, in the spirit of Monday, below are 10 reasons the latest Republican attacks on clean energy and electric vehicles might actually be a good thing.

1. The oil, coal, and natural gas industries simply haven’t had a fair enough head start via government subsidies. The trillions in subsidies they’ve received from the US government in the past several decades are not enough to put them on equal footing with renewable energy and electric vehicles today. Thus, it only makes sense to cut cleantech subsidies and give fossil fuels more subsidies for the time being.

2. While many people — the vast majority of them — don’t like pollution, some people prefer to breathe in potentially cancer-causing pollutants. It’s not fair that those people normally don’t get a say. It’s unfair that people who like pollution are always on the losing end of the conversation. They have a right to freedom of speech as well! Since the pollution lovers don’t get enough airtime, we should just cut any governmental support for clean technologies. That should balance things out.

3. Taking away subsidies prematurely hurts investor confidence in the government and crushes medium- and long-term investment plans. This is good since it’s the government’s role to indiscriminately attack and destabilize the investment community. Well, it’s good when it comes to renewable energy and electric vehicles. It’s not good when it comes to oil, gas, coal, and nuclear, all of which should continue to get subsidies.

4. Putting government money into young and quickly developing industries increases the chance or extent to which our society will benefit from 21st century technological and economic leadership. If the US supports such industries, that is not really fair to the Chinese. The Chinese are working hard and trying to be practical in order to become a bigger and bigger economic player, so why should we interfere? China deserves a massive economic win in the remainder of the century due to its foresight — and just because it’s China’s turn. Yeah?

5. Air pollution disproportionately hurts lower-income communities. The goal of any good government should be to hurt the lower-income and middle-income masses while giving more money to the super rich. That’s just good governance.

6. A livable climate is super overrated. We’re all going to be living on Mars soon anyway. Why waste time and money on trying to protect Earth and its human inhabitants.

7. Supporting clean energy and electric vehicles would improve our national security and our resilience in the face of various global fuel challenges. That’s just not much fun. It’s much more exciting to put lives at risk via more wars and dependence on foreign imports. (Also, those wars are great for our national debt. Just ask George W. Bush.)

8. Healthy citizens live longer, which means more services and support for those people over time. It’s cheaper and simpler if large numbers of American citizens die prematurely from high levels of pollution and more extreme natural disasters. Duh.


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9. Billionaires and big corporations in the oil, gas, and coal industries put millions of dollars into buying Republican politicians funding Republican campaigns. It would be a horrible message for the world and a breakdown in our democracy if it turned out billionaires and big corporations couldn’t shape the law of the land in a way that benefited them over others.




10. Come on — the whole world needs to come crashing down in order to instill a little humility. How will we put our collective ego into check if we don’t tank the economy, tank our health, and destroy our climate?

https://cleantechnica.com/2017/12/11/10-reasons-republican-attacks-clean-energy-electric-vehicles-smart/
4
GE Cutting 12,000 Jobs as Renewables and Energy Storage Upend Fossil Fuels

Motley Fool   
Travis Hoium, The Motley Fool
Motley FoolDecember 12, 2017

When an electric energy pioneer like General Electric (NYSE: GE) reconfigures its entire energy business, investors should take note. That's exactly what happened last week when GE Power announced it would cut 12,000 jobs, or 18% of the division's workforce, reducing the company's exposure to traditional power plants.

What wasn't affected was GE's staffing or investments in renewable energy and energy storage. In fact, these emerging energy assets are what's disrupting fossil fuels more broadly. GE has made the first step to reducing exposure to fossil fuels -- now the question may be "What's next?"

Coal power plant with smoke coming from smoke stacks. (picture at link)
Coal power plants like this one are being shut down by the hundreds, forcing GE to cut back on its power plant business. Image source: Getty Images.

What GE's layoffs tell us

As part of a plan to cut $1 billion in structural costs at GE Power, there will be about 12,000 positions eliminated up and down the business. Weak fundamentals in the power plant business overall were the drivers of the move, with the press release saying:

Traditional power markets including gas and coal have softened. Volumes are down significantly in products and services driven by overcapacity, lower utilization, fewer outages, an increase in steam plant retirements, and overall growth in renewables. GE Power is right-sizing the business for these realities and is focused on improving operational excellence and reducing its footprint and structure, which will help drive significant improvements in cash flows and margins.

Notice that growth in renewables was given as a reason for the reduction in GE's power business. As wind and solar energy have come down in cost, they've replaced traditional coal and natural gas power plants as the fuel of choice for new power plants around the world. And there's no reason that's going to change. What's unclear is if GE is going to transition from the dying fossil fuel business to the growing renewable energy business.

Is GE taking renewables seriously?

If GE is hoping to play a meaningful role in renewable energy in the future it's going to have to take the industry more seriously. GE sold its thin-film solar business to First Solar (NASDAQ: FSLR) in 2013, largely exiting the solar market. In wind, GE is a market leader in turbines, but pricing pressure has compressed margins for the industry as a whole. Energy storage is the third leg of renewable energy disruption, and GE hasn't made a meaningful play in the industry so far, ceding market share to AES (NYSE: AES), Siemens, and Tesla (NASDAQ: TSLA).

The only segment where GE seems to have taken renewable energy seriously is financing. The company has financed $5 billion of projects over the last three years. But that level of investment isn't going to drive earnings for a $153 billion company.

To take renewable energy seriously, I think GE needs to start putting its balance sheet to work, scooping up assets and developing projects around the world. Buying First Solar or SunPower (NASDAQ: SPWR) would make sense, although SunPower is majority owned by Total (NYSE: TOT) today. With SunPower, in particular, it could invest in the manufacturing scale necessary to become profitable and increase market share to become a top-3 manufacturer.

https://finance.yahoo.com/news/ge-cutting-12-000-jobs-153100975.html

5
http://www.businessinsider.com/coinbase-halts-ether-and-litecoin-trading-2017-12

Coinbase halts ether and litecoin trading as cryptocurrency market approaches $500 billion

    Frank Chaparro


Screen Shot 2017 12 12 at 12.09.40 PM MI

    Coinbase, the popular cryptocurrency trading platform, blocked users Tuesday from buying red-hot litecoin and ether.
    Investors poured into the two red-hot digital currencies Tuesday morning, pushing them both to new heights.
    Litecoin hit a record of $312 on Tuesday, while ether soared over to more than $600 for the first time.
    The cryptocurrency market is gunning for $500 billion.

 

Cryptomania has propelled two lesser-known cryptocurrencies to record highs Tuesday, forcing one exchange to halt trading.

Screen Shot 2017 12 12 at 1.01.59 PM Coinbase

Coinbase on Tuesday halted trading of red-hot litecoin and ether, according to cryptocurrency watcher CoinDesk. The publication tweeted a photo showing Coinbase "temporarily disabled" trades of the two digital coins on its platform.

Coinbase's status page showed ethereum and litecoin were experiencing major outages.

Both litecoin and ether hit all-time highs Tuesday morning.

Ether hit $600 a token, while litecoin gained more than 40% to $312.

Across the market for digital coins, new investors are pouring in. The 10 largest cryptocurrencies were all trading in the green Tuesday, according to data provider CoinMarketCap.

At the time of print, the entire market nearly reached $500 billion. Cryptocurrencies volumes approached record highs above $35 billion.

The launch of bitcoin futures by Cboe Global Markets, the Chicago exchange group, further pushed bitcoin and other cryptocurrencies into the spotlight. The new futures market, which went live Sunday, could pave the way for a bitcoin-linked exchange-traded fund and dampen bitcoin's spine-tingling volatility. Of course, the 1,000% plus returns across the market has also piqued the interest of Wall Street and Main Street investors.

Enthusiasts think the new found interest in the crypto-world will intensify in 2018.

"2018 will be the year of mass public awareness for bitcoin and cryptocurrency," Perry Woodin, CEO of Node40, said in preparded remarks sent to Business Insider. "It is going to be the year when every friend and relative will want to know how much you have and how to purchase it."

Still, many market watchers see a massive bubble in the crypto-market. Even Mike Novogratz, a famed hedge fund manager turned crypto-investor, called it "the biggest bubble of our lifetimes."

Litecoin's founder also chimed in on the frenzy. The former director of engineering at crypto exchange Coinbase tweeted a dire warning for potential litecoin holders Monday night:

"Sorry to spoil the party, but I need to reign in the excitement a bit…," he wrote. "Buying LTC is extremely risky. I expect us to have a multi-year bear market like the one we just had where LTC dropped 90% in value ($48 to $4). So if you can't handle LTC dropping to $20, don't buy!"

A spokeswoman for Coinbase told Business Insider, "The site is seeing high traffic volume at the moment and some users may be experiencing intermittent service outages."
6
Knarfs Knewz / Re: Post-apocalyptic life in American health care
« Last post by Eddie on Today at 05:57:53 AM »
    Much of my time for the past year has been spent navigating the medical maze on behalf of my mother, who has dementia.
    I observe that American health care organizations can no longer operate systematically, so participants are forced to act in the communal mode, as if in the pre-modern world.
    Health care is one leading edge of a general breakdown in systematicity—while, at the same time, employing sophisticated systematic technologies.
    Communal-mode interpersonal skills may become increasingly important to life success—not less, as techies hope.
    For complex health care problems, I recommend hiring a consultant to provide administrative (not medical!) guidance.

Epistemic status: impressionistic blogging during a dazed lull between an oncologist and an MRI. No attempt to validate with statistical data or knowledgeable sources.
No system

My mother’s mild dementia began accelerating rapidly a year ago. I’ve been picking up pieces of her life as she drops them. That has grown from a part-time job to a full-time job. In the past month, as she’s developed unrelated serious medical issues, it’s become a way-more-than-full-time job.

The most time-consuming aspect has been coordinating the dozens of different institutions involved in her care. I had read that the biggest failing of the American health care system is its fragmentation; I’ve now spent hundreds of hours observing that first-hand.

There is, in fact, no system. There are systems, but mostly they don’t talk to each other. I have to do that.

It’s been fascinating watching people working in hospitals and medical offices trying and failing to communicate with each other. I’ll tell one story, and then explain a pattern. This is the most dramatic instance I’ve encountered so far, but is typical in form.

The short version is that at least seven experts spent roughly ten full-time days trying to find out a basic fact about my mother’s insurance, and finally failed. Meanwhile, many thousands of dollars were wasted on unnecessary hospitalization.

This is a stark example of medical cost disease, but the post is not about that. It’s about how institutions fail to talk to each other—and what that implies about our future.

(If the story gets boring, you can skip ahead to my interpretation of the pattern.)

My mother went into the hospital a month ago with severe pain in her hip. (It’s still undiagnosed.) After two days, she was medically ready for discharge from the hospital: whatever the pain was, it wasn’t one they could help with. Instead, she should be sent to a “skilled nursing facility” (SNF) where she’d get “physical therapy,” i.e. leg exercises.

For a SNF to agree to take her, they had to get confirmation from an insurance company that insurance would cover her stay. She has two kinds of health insurance, Medicare plus coverage through a private insurer (Anthem). Which would cover her? Or both, or neither?

SNFs have admissions officers, whose full-time job is to answer this question. Two different SNFs started working on the problem. I talked with the admissions people every day. Both claimed to be working on it more-or-less full-time. The hospital wanted to free up my mother’s bed, so their insurance person was also working on it.

Days passed. The hospital doctor on rounds said “Well, this is typical, especially with Anthem. It’s costing them several thousand dollars a day to keep her here, versus a few hundred dollars a day in a SNF, but it might take a week for them to figure out which local SNF they cover. Don’t worry, they’ll sort it out eventually.”

Meanwhile, I learned that Anthem and Medicare were confused about their relationship. (As far as I can tell, this was a coincidence and not the underlying problem, although I’m still not sure.) Medicare believed that my mother (who retired in 1997) is employed and therefore ineligible. Her Anthem coverage is through her former employer.

I talked with her ex-employer’s benefits person (whose full-time job is understanding insurance, pretty much). She looked into it and said she couldn’t understand what was going on. She called the company’s outside insurance consultant. He couldn’t understand what was going on. He called people he knew at Medicare and Anthem. He said that they couldn’t understand it either, but that multiple people in both organizations were working on straightening it out.

A week later, I called Medicare to verify that it worked. The surprisingly competent customer service person looked up my mother’s info and said: “This is really weird… I don’t know what’s going on… there was a record that said Anthem is primary. And then on November 16th, there’s a note that said it’s deleted, and Medicare is primary. But then there’s an update on the 18th that says Anthem is primary. But obviously since your mother is 84 she’s not employed, so Medicare should be primary… I’ll delete the record again…”

After three days of trying, one of the SNFs gave up. I talked to the admissions dude there. I’ll call him Paul. He was smart and friendly, and he was willing to explain:

    My full-time job for ten years has been understanding how to get insurance to pay us, and I have no idea how the system works. Even if I somehow learned how it works, it changes completely every year, and I would have to start over. But at most of the insurance companies I know people who can sometimes make things happen, so I call them up, and then they try to figure out how it works. But Anthem… I spent hours and hours on hold, and in phone trees, getting transferred from one department to another, and eventually back to where I started. The most clueful-sounding person I could find sent me to a web site that just says ‘This program is not implemented yet.’ Does ‘program’ mean software, or does it mean some project they haven’t got going?

Hospitals are bad places that make you ill; you don’t want to spend any more time there than you have to. On day six, I said “if she doesn’t go to a SNF today, I’m taking her home—the risk of her dying there seems less now than the risk of her dying here.” That got results: the other SNF agreed to take her “on spec.” Their admissions person was reasonably confident that either Anthem or Medicare would pay, even though neither was willing to say either yes or no ahead of time.

The SNF called me to tell me they needed my mother’s records from the hospital. Well, what do you want me to do about that? We need you to call the hospital and ask them to fax us the records. “Fax”? Why not send clay tablets in wicker baskets on the back of a donkey?
No interface

To ship a package by FedEx, you don’t need to call someone who knows someone who knows someone. You go to a web site, put in some numbers, it gives you back some numbers, you put them on the envelope, drop it in a box, and it appears at a farmhouse on an island in Lapland the next day.

If Amazon sends you the wrong type of cable adapter, you don’t have to call them up and try to act pathetic and virtuous in order to convince someone that you need and deserve a refund because your poor mother is so ill. You go to a web site and push a button.

FedEx and Amazon have systematic interfaces. They are transparent on the outside, and black boxes on the inside. You don’t have to know anything about how they operate in order to use them.

Health care organizations are—at best—the opposite. They may run on systems internally, but the interface is opaque. There’s no defined way to get them to do something.

This is not their fault.
No fault

I was trying to get my mother into a SNF—but all I could do was talk to Paul, who couldn’t say yes or no. It wasn’t his fault. He was trying to talk to people at Anthem, who couldn’t say yes or no. Was that their fault?

Just speculating, I imagine they are supposed to apply 1600 pages of rules for what’s covered in what situation. And the rules are vague and conflicting and change constantly, and who can read 1600 pages of rules anyway? So eventually someone has to make up a yes-or-no answer on the basis of what seems more-or-less reasonable. Whoever it is could get blamed if someone higher up later decides that was “wrong” based on their interpretation of the rules, so it’s better to pass the buck.

Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to reconcile federal, state, and local legislation, plus the rules of three federal regulatory agencies, nine state agencies, and fifteen local agencies. All those are vague and conflicting and constantly changing, but Anthem’s rule-writing department does their best. They call the agencies to try to find out what the regulations are supposed to mean, and they spend hours on hold, are transferred from one official to another and back, and eventually get directed to a .gov web site that says “program not implemented yet.” Then they make something up, and hope that when the government sues Anthem, they don’t get blamed for it personally.

I imagine people working in legislative offices and regulatory agencies find themselves in a similar position.

In this maze, even competent people with good intentions cannot act systematically. Their work depends on coordinating with other institutions that have no systematic interface.
Traditional life in the ruins of systematicity

It’s like one those post-apocalyptic science fiction novels whose characters hunt wild boars with spears in the ruins of a modern city. Surrounded by machines no one understands any longer, they have reverted to primitive technology.

Except it’s in reverse. Hospitals can still operate modern material technologies (like an MRI) just fine. It’s social technologies that have broken down and reverted to a medieval level.

Systematic social relationships involve formally-defined roles and responsibilities. That is, “professionalism.” But across medical organizations, there are none. Who do you call at Anthem to find out if they’ll cover an out-of-state SNF stay? No one knows.

What do you do when systematicity breaks down? You revert to what I’ve described as the “communal mode” or “choiceless mode.” That is, “pre-modern,” or “traditional” ways of being.

Working in a medical office is like living in a pre-modern town. It’s all about knowing someone who knows someone who knows someone who can get something done. Several times, I’ve taken my mother to a doctor who said something like: “She needs lymphedema treatment, and the only lymphedema clinic around here is booked months in advance, but I know someone there, and I think I can get her in next week.” Or, “The pathology report on this biopsy is only one sentence, and it’s unsigned. The hospital that faxed it to me doesn’t know who did it. I need details, so I called all the pathologists I know, and none of them admit to writing it, so we are going to need to do a new biopsy.”

But at the same time, each clinic does have an electronic patient records management system, which does work some of the time. And there are professional relationships with defined roles that operate effectively within the building.

I suspect increasing “patchiness” of systems may be typical of our post-systematic atomized era. Understanding the medical case may help predict the texture of cultural and social life as atomization proceeds.

A central research topic in ethnomethodology is the relationship between formal rationality (such as an insurance company’s 1600 pages of unworkable rules) and “mere reasonableness,” which is what people mostly use to get a job done. The disjunction between electronic patient records and calling around town to try to find out who wrote a biopsy report that arrived by fax seems sufficiently extreme that it may produce a qualitatively new way of being.

I would like to ask:

    How does health care continue to function at all?
    Can it continue to function at all?
    How do people within the ex-system navigate a world that mashes up high-tech infrastructure that only sometimes works with pre-modern social relationships across organizations?
    How do they understand this contrast? How do they cope personally?1
    What can we do about it?

Maybe an ethnomethodological understanding of how health care organizations operate in practice could make the systems work incrementally better. Maybe an enlightened COO could incorporate the view that the systems and reality are only vaguely related. But… it may be impossible to improve individual organizations.
No local fix

It’s obvious how to fix health care. Just make everything run systematically, like FedEx or Amazon. There are no technical or business obstacles to this. Anyone who understands IT and/or business can see how to do it.2

Back-of-envelope calculations say a working health care system would deliver dramatically better quality at 10-20% of the current cost.

Health care is notionally a profit-driven free market. This looks like an easy opportunity to make trillions of dollars by making the world better for everyone. Why doesn’t someone do that?

It appears that 73% of the labor cost of a health care organization is spent on trying to communicate with other health care organizations that have no defined interface.3 Patrick Collison has suggested calling this pattern “Leibenstein’s Inefficiency Disease,” by analogy to Baumol’s Cost Disease. An organization can’t improve the 73% by much on its own; that inefficiency is forced on it by the environment it operates in.

Instead, organizations in sectors afflicted with inefficiency disease try to push their own administrative work outside. Both out into other organizations, and—more visibly—they force it onto you, the customer. It’s your job to fill out forms they could have done more efficiently themselves. When they screw up, you have to try to fix it. This negative externality could be called “paperwork pollution,” by analogy with negative externalities of smokestack industries.

Standardizing an interface between health care providers and insurance companies would be a huge win. No matter how badly designed, it would be better than the current mess, and save several percent of US GDP. That would need cooperation from most of the major players in the industry. Other industries manage that routinely: machine screws and futures contracts come in standard sizes, without which manufacturing and finance would be as inefficient as health care. The need for a standard insurer/provider interface is obvious. Since it’s lacking, I imagine some powerful group extracts enormous rents from the inefficiency. I know nothing about that, so I won’t speculate.
You will need village life skills

Perhaps American health care is a bellwether model for the future of other aspects of life in post-systemic world? A pattern that occurs in many other sectors: as systems fail, people fall back on innate communal logic. Politics and the media are obvious current examples.

The hope of the tech industry is that “software is eating the world,” as Marc Andreessen put it in 2011. That is, we’re FedEx-izing every aspect of the economy: making it radically more efficient and reliable, using well-designed IT-supported systematic business processes.

In that world, systematic-mode skills (especially programming and finance) will be ever more valuable. Hooray! We will create a utopia for all, in which (for once) those of us with high-functioning autism get properly rewarded.

In 2017, software is conspicuously not eating the cost-disease economic sectors: health care, education, housing, government. They are being eaten—by communal mode tribalism.

In 2017, tribalists are threatening to eat the tech industry.

There’s a possible future in which all systems fall to tribalism. Then everyone dies, because tribal signaling does not deliver electric power. In another possible future, we create a meta-systematic society that addresses the inherent defects of both tribalism and systematicity. (I discussed both these possibilities tangentially in “A bridge to meta-rationality vs. civilizational collapse.” I hope to write more soon.)

In the short run, more likely, current trends will continue. Additional aspects of life will increasingly revert to the communal mode, but some critical systems will fend off the barbarians and limp along well enough to keep us alive.

In that world, people skills will be ever more valuable. Surviving and thriving in 2037 may depend mainly on who you can charm, who you know, and whether they owe you favors.

Techies take note.

You might consider working in a medical office, to get some practice.
Hire a consultant

Some more-serious, practical advice:

If you find yourself in a situation like mine, hire an independent health care administration consultant. Their job is to know administrative people inside organizations who can get stuff done. They also know what can be gotten done, which is unknowable to the public. They can also deal with inscrutable paperwork and organizational screw-ups.

Hiring someone became imperative for me when coordinating my mother’s care got to be a way-more-than-full-time job. (In retrospect, I wish I had done that months earlier.)

It could also be worthwhile in less critical cases, if no one in the family can take enough time off from work, or in which you’d simply rather pay someone else to clean up after a hospital’s paperwork pollution.

This role has developed only recently, as systems have broken down. There’s not yet a standardized term; “health care advocate” is one among several.

Mine specializes in gerontology and dementia. Others specialize in other disease areas; or in other aspects of the administrative nightmare, such as sorting out bogus hospital bills, which frequently include fraudulent additions.

They are not inexpensive (mine charges $150/hour), so not an option for everyone.

There are good and not-so-good advocates. I spoke with several before hiring one. Some were clearly clueless; the one I hired last month has seemed consistently competent.

Since they recommend particular providers, there is an inherent principal-agent problem. Ask if they get any compensation from services they recommend. Take their recommendations with a grain of salt in any case.

    1.
    I imagine for many it’s awful. “Communal” sounds “nice,” but most are in medicine because they want to help others, and they can’t get their jobs done when the system breaks down.
    2.
    Step 1: Throw away the ubiquitous fax machines. Sink or swim. Hire donkeys if necessary.
    3.
    The number 73% is my dazed estimate based on informal observation and analysis conducted in doctors’ examination rooms.

    Much of my time for the past year has been spent navigating the medical maze on behalf of my mother, who has dementia.
    I observe that American health care organizations can no longer operate systematically, so participants are forced to act in the communal mode, as if in the pre-modern world.
    Health care is one leading edge of a general breakdown in systematicity—while, at the same time, employing sophisticated systematic technologies.
    Communal-mode interpersonal skills may become increasingly important to life success—not less, as techies hope.
    For complex health care problems, I recommend hiring a consultant to provide administrative (not medical!) guidance.

Epistemic status: impressionistic blogging during a dazed lull between an oncologist and an MRI. No attempt to validate with statistical data or knowledgeable sources.
No system

My mother’s mild dementia began accelerating rapidly a year ago. I’ve been picking up pieces of her life as she drops them. That has grown from a part-time job to a full-time job. In the past month, as she’s developed unrelated serious medical issues, it’s become a way-more-than-full-time job.

The most time-consuming aspect has been coordinating the dozens of different institutions involved in her care. I had read that the biggest failing of the American health care system is its fragmentation; I’ve now spent hundreds of hours observing that first-hand.

There is, in fact, no system. There are systems, but mostly they don’t talk to each other. I have to do that.

It’s been fascinating watching people working in hospitals and medical offices trying and failing to communicate with each other. I’ll tell one story, and then explain a pattern. This is the most dramatic instance I’ve encountered so far, but is typical in form.

The short version is that at least seven experts spent roughly ten full-time days trying to find out a basic fact about my mother’s insurance, and finally failed. Meanwhile, many thousands of dollars were wasted on unnecessary hospitalization.

This is a stark example of medical cost disease, but the post is not about that. It’s about how institutions fail to talk to each other—and what that implies about our future.

(If the story gets boring, you can skip ahead to my interpretation of the pattern.)

My mother went into the hospital a month ago with severe pain in her hip. (It’s still undiagnosed.) After two days, she was medically ready for discharge from the hospital: whatever the pain was, it wasn’t one they could help with. Instead, she should be sent to a “skilled nursing facility” (SNF) where she’d get “physical therapy,” i.e. leg exercises.

For a SNF to agree to take her, they had to get confirmation from an insurance company that insurance would cover her stay. She has two kinds of health insurance, Medicare plus coverage through a private insurer (Anthem). Which would cover her? Or both, or neither?

SNFs have admissions officers, whose full-time job is to answer this question. Two different SNFs started working on the problem. I talked with the admissions people every day. Both claimed to be working on it more-or-less full-time. The hospital wanted to free up my mother’s bed, so their insurance person was also working on it.

Days passed. The hospital doctor on rounds said “Well, this is typical, especially with Anthem. It’s costing them several thousand dollars a day to keep her here, versus a few hundred dollars a day in a SNF, but it might take a week for them to figure out which local SNF they cover. Don’t worry, they’ll sort it out eventually.”

Meanwhile, I learned that Anthem and Medicare were confused about their relationship. (As far as I can tell, this was a coincidence and not the underlying problem, although I’m still not sure.) Medicare believed that my mother (who retired in 1997) is employed and therefore ineligible. Her Anthem coverage is through her former employer.

I talked with her ex-employer’s benefits person (whose full-time job is understanding insurance, pretty much). She looked into it and said she couldn’t understand what was going on. She called the company’s outside insurance consultant. He couldn’t understand what was going on. He called people he knew at Medicare and Anthem. He said that they couldn’t understand it either, but that multiple people in both organizations were working on straightening it out.

A week later, I called Medicare to verify that it worked. The surprisingly competent customer service person looked up my mother’s info and said: “This is really weird… I don’t know what’s going on… there was a record that said Anthem is primary. And then on November 16th, there’s a note that said it’s deleted, and Medicare is primary. But then there’s an update on the 18th that says Anthem is primary. But obviously since your mother is 84 she’s not employed, so Medicare should be primary… I’ll delete the record again…”

After three days of trying, one of the SNFs gave up. I talked to the admissions dude there. I’ll call him Paul. He was smart and friendly, and he was willing to explain:

    My full-time job for ten years has been understanding how to get insurance to pay us, and I have no idea how the system works. Even if I somehow learned how it works, it changes completely every year, and I would have to start over. But at most of the insurance companies I know people who can sometimes make things happen, so I call them up, and then they try to figure out how it works. But Anthem… I spent hours and hours on hold, and in phone trees, getting transferred from one department to another, and eventually back to where I started. The most clueful-sounding person I could find sent me to a web site that just says ‘This program is not implemented yet.’ Does ‘program’ mean software, or does it mean some project they haven’t got going?

Hospitals are bad places that make you ill; you don’t want to spend any more time there than you have to. On day six, I said “if she doesn’t go to a SNF today, I’m taking her home—the risk of her dying there seems less now than the risk of her dying here.” That got results: the other SNF agreed to take her “on spec.” Their admissions person was reasonably confident that either Anthem or Medicare would pay, even though neither was willing to say either yes or no ahead of time.

The SNF called me to tell me they needed my mother’s records from the hospital. Well, what do you want me to do about that? We need you to call the hospital and ask them to fax us the records. “Fax”? Why not send clay tablets in wicker baskets on the back of a donkey?
No interface

To ship a package by FedEx, you don’t need to call someone who knows someone who knows someone. You go to a web site, put in some numbers, it gives you back some numbers, you put them on the envelope, drop it in a box, and it appears at a farmhouse on an island in Lapland the next day.

If Amazon sends you the wrong type of cable adapter, you don’t have to call them up and try to act pathetic and virtuous in order to convince someone that you need and deserve a refund because your poor mother is so ill. You go to a web site and push a button.

FedEx and Amazon have systematic interfaces. They are transparent on the outside, and black boxes on the inside. You don’t have to know anything about how they operate in order to use them.

Health care organizations are—at best—the opposite. They may run on systems internally, but the interface is opaque. There’s no defined way to get them to do something.

This is not their fault.
No fault

I was trying to get my mother into a SNF—but all I could do was talk to Paul, who couldn’t say yes or no. It wasn’t his fault. He was trying to talk to people at Anthem, who couldn’t say yes or no. Was that their fault?

Just speculating, I imagine they are supposed to apply 1600 pages of rules for what’s covered in what situation. And the rules are vague and conflicting and change constantly, and who can read 1600 pages of rules anyway? So eventually someone has to make up a yes-or-no answer on the basis of what seems more-or-less reasonable. Whoever it is could get blamed if someone higher up later decides that was “wrong” based on their interpretation of the rules, so it’s better to pass the buck.

Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to reconcile federal, state, and local legislation, plus the rules of three federal regulatory agencies, nine state agencies, and fifteen local agencies. All those are vague and conflicting and constantly changing, but Anthem’s rule-writing department does their best. They call the agencies to try to find out what the regulations are supposed to mean, and they spend hours on hold, are transferred from one official to another and back, and eventually get directed to a .gov web site that says “program not implemented yet.” Then they make something up, and hope that when the government sues Anthem, they don’t get blamed for it personally.

I imagine people working in legislative offices and regulatory agencies find themselves in a similar position.

In this maze, even competent people with good intentions cannot act systematically. Their work depends on coordinating with other institutions that have no systematic interface.
Traditional life in the ruins of systematicity

It’s like one those post-apocalyptic science fiction novels whose characters hunt wild boars with spears in the ruins of a modern city. Surrounded by machines no one understands any longer, they have reverted to primitive technology.

Except it’s in reverse. Hospitals can still operate modern material technologies (like an MRI) just fine. It’s social technologies that have broken down and reverted to a medieval level.

Systematic social relationships involve formally-defined roles and responsibilities. That is, “professionalism.” But across medical organizations, there are none. Who do you call at Anthem to find out if they’ll cover an out-of-state SNF stay? No one knows.

What do you do when systematicity breaks down? You revert to what I’ve described as the “communal mode” or “choiceless mode.” That is, “pre-modern,” or “traditional” ways of being.

Working in a medical office is like living in a pre-modern town. It’s all about knowing someone who knows someone who knows someone who can get something done. Several times, I’ve taken my mother to a doctor who said something like: “She needs lymphedema treatment, and the only lymphedema clinic around here is booked months in advance, but I know someone there, and I think I can get her in next week.” Or, “The pathology report on this biopsy is only one sentence, and it’s unsigned. The hospital that faxed it to me doesn’t know who did it. I need details, so I called all the pathologists I know, and none of them admit to writing it, so we are going to need to do a new biopsy.”

But at the same time, each clinic does have an electronic patient records management system, which does work some of the time. And there are professional relationships with defined roles that operate effectively within the building.

I suspect increasing “patchiness” of systems may be typical of our post-systematic atomized era. Understanding the medical case may help predict the texture of cultural and social life as atomization proceeds.

A central research topic in ethnomethodology is the relationship between formal rationality (such as an insurance company’s 1600 pages of unworkable rules) and “mere reasonableness,” which is what people mostly use to get a job done. The disjunction between electronic patient records and calling around town to try to find out who wrote a biopsy report that arrived by fax seems sufficiently extreme that it may produce a qualitatively new way of being.

I would like to ask:

    How does health care continue to function at all?
    Can it continue to function at all?
    How do people within the ex-system navigate a world that mashes up high-tech infrastructure that only sometimes works with pre-modern social relationships across organizations?
    How do they understand this contrast? How do they cope personally?1
    What can we do about it?

Maybe an ethnomethodological understanding of how health care organizations operate in practice could make the systems work incrementally better. Maybe an enlightened COO could incorporate the view that the systems and reality are only vaguely related. But… it may be impossible to improve individual organizations.
No local fix

It’s obvious how to fix health care. Just make everything run systematically, like FedEx or Amazon. There are no technical or business obstacles to this. Anyone who understands IT and/or business can see how to do it.2

Back-of-envelope calculations say a working health care system would deliver dramatically better quality at 10-20% of the current cost.

Health care is notionally a profit-driven free market. This looks like an easy opportunity to make trillions of dollars by making the world better for everyone. Why doesn’t someone do that?

It appears that 73% of the labor cost of a health care organization is spent on trying to communicate with other health care organizations that have no defined interface.3 Patrick Collison has suggested calling this pattern “Leibenstein’s Inefficiency Disease,” by analogy to Baumol’s Cost Disease. An organization can’t improve the 73% by much on its own; that inefficiency is forced on it by the environment it operates in.

Instead, organizations in sectors afflicted with inefficiency disease try to push their own administrative work outside. Both out into other organizations, and—more visibly—they force it onto you, the customer. It’s your job to fill out forms they could have done more efficiently themselves. When they screw up, you have to try to fix it. This negative externality could be called “paperwork pollution,” by analogy with negative externalities of smokestack industries.

Standardizing an interface between health care providers and insurance companies would be a huge win. No matter how badly designed, it would be better than the current mess, and save several percent of US GDP. That would need cooperation from most of the major players in the industry. Other industries manage that routinely: machine screws and futures contracts come in standard sizes, without which manufacturing and finance would be as inefficient as health care. The need for a standard insurer/provider interface is obvious. Since it’s lacking, I imagine some powerful group extracts enormous rents from the inefficiency. I know nothing about that, so I won’t speculate.
You will need village life skills

Perhaps American health care is a bellwether model for the future of other aspects of life in post-systemic world? A pattern that occurs in many other sectors: as systems fail, people fall back on innate communal logic. Politics and the media are obvious current examples.

The hope of the tech industry is that “software is eating the world,” as Marc Andreessen put it in 2011. That is, we’re FedEx-izing every aspect of the economy: making it radically more efficient and reliable, using well-designed IT-supported systematic business processes.

In that world, systematic-mode skills (especially programming and finance) will be ever more valuable. Hooray! We will create a utopia for all, in which (for once) those of us with high-functioning autism get properly rewarded.

In 2017, software is conspicuously not eating the cost-disease economic sectors: health care, education, housing, government. They are being eaten—by communal mode tribalism.

In 2017, tribalists are threatening to eat the tech industry.

There’s a possible future in which all systems fall to tribalism. Then everyone dies, because tribal signaling does not deliver electric power. In another possible future, we create a meta-systematic society that addresses the inherent defects of both tribalism and systematicity. (I discussed both these possibilities tangentially in “A bridge to meta-rationality vs. civilizational collapse.” I hope to write more soon.)

In the short run, more likely, current trends will continue. Additional aspects of life will increasingly revert to the communal mode, but some critical systems will fend off the barbarians and limp along well enough to keep us alive.

In that world, people skills will be ever more valuable. Surviving and thriving in 2037 may depend mainly on who you can charm, who you know, and whether they owe you favors.

Techies take note.

You might consider working in a medical office, to get some practice.
Hire a consultant

Some more-serious, practical advice:

If you find yourself in a situation like mine, hire an independent health care administration consultant. Their job is to know administrative people inside organizations who can get stuff done. They also know what can be gotten done, which is unknowable to the public. They can also deal with inscrutable paperwork and organizational screw-ups.

Hiring someone became imperative for me when coordinating my mother’s care got to be a way-more-than-full-time job. (In retrospect, I wish I had done that months earlier.)

It could also be worthwhile in less critical cases, if no one in the family can take enough time off from work, or in which you’d simply rather pay someone else to clean up after a hospital’s paperwork pollution.

This role has developed only recently, as systems have broken down. There’s not yet a standardized term; “health care advocate” is one among several.

Mine specializes in gerontology and dementia. Others specialize in other disease areas; or in other aspects of the administrative nightmare, such as sorting out bogus hospital bills, which frequently include fraudulent additions.

They are not inexpensive (mine charges $150/hour), so not an option for everyone.

There are good and not-so-good advocates. I spoke with several before hiring one. Some were clearly clueless; the one I hired last month has seemed consistently competent.

Since they recommend particular providers, there is an inherent principal-agent problem. Ask if they get any compensation from services they recommend. Take their recommendations with a grain of salt in any case.

    1.
    I imagine for many it’s awful. “Communal” sounds “nice,” but most are in medicine because they want to help others, and they can’t get their jobs done when the system breaks down.
    2.
    Step 1: Throw away the ubiquitous fax machines. Sink or swim. Hire donkeys if necessary.
    3.
    The number 73% is my dazed estimate based on informal observation and analysis conducted in doctors’ examination rooms.



Health care organizations are—at best—the opposite. They may run on systems internally, but the interface is opaque. There’s no defined way to get them to do something.

This is not their fault.


The hell it's not.

The confusion over who pays is a common ruse. It's all scripted. Welcome to my world. Insurance companies make money by not paying benefits. What's so hard to understand about that?  In order for healthcare to function, as many middlemen as possible need to be pruned from the income stream, and then maybe some of the premiums would get to the patients who paid for the coverage.

At first insurance companies forced us to use online claims submission. Once providers learned to do this it speeded up payment. When they figured out the system was more efficient, they changed back to a variety of arcane systems to slow things down. It's deliberate, and a lot of creative people are employed in the interest of figuring out new ways for insurance companies to get away with fucking their customers, and they come up with new ideas weekly.

7
Knarfs Knewz / Re: Population Bottlenecks are Transient
« Last post by RE on Today at 05:50:10 AM »
This is not a competition of symbols.

Of course it is.  The position of the Diner (at least my position) is that a Near Term Human Extinction is not likely, just a Population Bottleneck.

You place up regularly Extinction Symbols, so I have to counteract them when you do it.  When you put up an Extinction Symbol, I will retaliate with a SUN☼ symbol.  :icon_sunny:

This is the Way of the Diner.

RE

Your position is of competition. I just want to show that "some" people are really concerned about what over 6,000 scientists have agreed on. I live in a monastery, for crying out load. Don't you think that is similar to what you are trying to get going with the SUN project?

Your life in a monastery is exemplary.  That has nothing to do with this.

By constantly pushing the Extinction Symbol here on the Diner, it makes it seem like the Diner is a facsimile of NBL, with a membership that buys the idea of NTHE.  You publish something often enough, people will believe it regardless of any evidence or discussion.  You have been shotgunning out this symbol for a few weeks now.

If you don't want a war of symbols with me, I suggest you refrain from dropping images of the Extinction Symbol across the Diner Pages and stick to arguing the topics with me.  :icon_sunny:

RE

I am pushing nothing. I am just showing that the symbol is being used more and in different ways. People can make up their own mind about it, and your SUN project.

"By constantly pushing the Extinction Symbol here on the Diner, it makes it seem like the Diner is a facsimile of NBL"

That is complete nonsense! Maybe you have some mental connections with NBL. I don't, and it doesn't represent what McSteinsen is yapping about. It IS about the predicament that the human race is facing at the present time. Why would you want to put together the Sun community if everything was peachy?

It's VOLUME Knarf.  You drop one of these Extinction Symbols on the Diner practically every day now.

RE

Not everyday, maybe once a week, and they are all different in different places. I thought this place was about DOOM. If the 6th mass extinction isn't about DOOM, then nothing is. Maybe if all people were aware that we are destroying more life everyday, and increasing the rate of extinction, they would do something about it, like start a community, and live simply without using so much ENERGY/OIL and PLASTICS. Pool their resources instead of competing in good ol' Merica's dog eat dog world, with money being it's "GOD".

I'm not going to try and go back to tally them up, just *I* get the impression every time I cruise through the forum, there is a new Extinction Symbol up.  I don't agree with this symbol or what it represents.  If you want to keep posting it, feel free.  However, I will respond to it with my own symbology as I see fit.

We can discuss this in detail if you like, or just exchange symbology.

RE
8
Knarfs Knewz / Re: Population Bottlenecks are Transient
« Last post by knarf on Today at 05:40:37 AM »
This is not a competition of symbols.

Of course it is.  The position of the Diner (at least my position) is that a Near Term Human Extinction is not likely, just a Population Bottleneck.

You place up regularly Extinction Symbols, so I have to counteract them when you do it.  When you put up an Extinction Symbol, I will retaliate with a SUN☼ symbol.  :icon_sunny:

This is the Way of the Diner.

RE

Your position is of competition. I just want to show that "some" people are really concerned about what over 6,000 scientists have agreed on. I live in a monastery, for crying out load. Don't you think that is similar to what you are trying to get going with the SUN project?

Your life in a monastery is exemplary.  That has nothing to do with this.

By constantly pushing the Extinction Symbol here on the Diner, it makes it seem like the Diner is a facsimile of NBL, with a membership that buys the idea of NTHE.  You publish something often enough, people will believe it regardless of any evidence or discussion.  You have been shotgunning out this symbol for a few weeks now.

If you don't want a war of symbols with me, I suggest you refrain from dropping images of the Extinction Symbol across the Diner Pages and stick to arguing the topics with me.  :icon_sunny:

RE

I am pushing nothing. I am just showing that the symbol is being used more and in different ways. People can make up their own mind about it, and your SUN project.

"By constantly pushing the Extinction Symbol here on the Diner, it makes it seem like the Diner is a facsimile of NBL"

That is complete nonsense! Maybe you have some mental connections with NBL. I don't, and it doesn't represent what McSteinsen is yapping about. It IS about the predicament that the human race is facing at the present time. Why would you want to put together the Sun community if everything was peachy?

It's VOLUME Knarf.  You drop one of these Extinction Symbols on the Diner practically every day now.

RE

Not everyday, maybe once a week, and they are all different in different places. I thought this place was about DOOM. If the 6th mass extinction isn't about DOOM, then nothing is. Maybe if all people were aware that we are destroying more life everyday, and increasing the rate of extinction, they would do something about it, like start a community, and live simply without using so much ENERGY/OIL and PLASTICS. Pool their resources instead of competing in good ol' Merica's dog eat dog world, with money being it's "GOD".
9
Knarfs Knewz / Dying Ecosystems
« Last post by knarf on Today at 05:32:59 AM »


Earth’s ecosystems support all life, though collapsed ecosystems would be like stepping outside of the international space station not wearing a space suit. Pop! Bam! Gone!

A recent academic study about signals of ecosystem collapse throughout history fits the space suit analogy. Terrifying truth is exposed: The all-important biosphere is sending out warning signals of impending crises… worldwide. It does not seem possible that ecosystems collapse and life dies off. That’s too hard to believe… but, what if it does collapse?

“The Earth’s biodiversity is under attack. We would need to travel back over 65 million years to find rates of species loss as high as we are witnessing today.” (James Dyke, The Ecosystem Canaries, Which Act as Warning Signs of Collapse, The Guardian, Aug. 19, 2016).
“Biodiversity increases resilience: more species means each individual species is better able to withstand impacts. Think of decreasing biodiversity as popping out rivets from an aircraft. A few missing rivets here or there will not cause too much harm. But continuing to remove them threatens a collapse in ecosystem functioning. Forests give way to desert. Coral reefs bleach and then die,” Ibid.
It’s already happening! Imagine flying in an aircraft while watching the rivets pop, one by one. At some point in time screaming overrides thinking. But, thank heavens; we’re not quite there yet.
Scientists from University College London and the University of Maryland studied 2,378 archeological sites and discovered that every society for thousands of years gave early clues to its own demise. Of course, demise happened precisely because those early warnings were ignored, while thinking: “it’s impossible, can’t happen.”

The determinate signal of upcoming demise is referred to as “flickering,” which is a change in society’s responses to perturbations resulting in a society caught in a socio-ecological trap that reinforces negative behavior that started the issue in the first instance, thus, preventing adaption. (Source: Sean S. Downey, et al, European Neolithic Societies Showed Early Warning Signals of Population Collapse, Proceedings of the National Academy of Sciences, vol. 113, no. 35, March 2016.)

The formula: Every time a society flickers, losing rivets, it loses recovery time, thereby moving closer to collapse. In every case study, with nearly 100% accuracy, researchers found flickers precedent to eventual collapse All but 2 of 27 test cases showed statistically significant results. Every case experienced massive population growth as a result of the emergence of agriculture followed by technological advancements. Sound familiar?

Societal decline is empirically signaled by any number of drivers such as (1) changing climate, (2) declining environmental productivity, (3) disease, (4) warfare, or (5) combinations thereof. Today, we’ve got’em all.

Rivets are popping all across the globe, e.g., the Great Barrier Reef, the largest living structure in the world, is signaling its demise like there’s no tomorrow. “Many scientists are now saying it is almost too late to save it. Strong and immediate action is required to alleviate water pollution and stop the underlying cause: climate change.” (Source: Michael Slezak, The Great Barrier Reef: A Catastrophe Laid Bare, The Guardian, June 6, 2016.)
According to David Attenborough, the world’s most famous naturalist: “The Great Barrier Reef is in grave danger… The twin perils brought by climate change – an increase in the temperature of the ocean and in its acidity – threaten its very existence,” Ibid. In point of fact, Attenborough’s remarkable new film Blue Planet 2 details the damage wreaked in the seas by climate change, plastic pollution, and overfishing. This final episode of his series lays bare shocking damage.
Compared with what was happening before the 20th century, three-times as much sediment, twice as much fertilizer and 17,000 extra kilograms of herbicide wash over the reef each year. When the coral dies, the entire ecosystem gets hit. Fish that feed on the coral, use it as shelter, or nibble on the algae die or move away. The bigger fish that feed on those fish disappear. But the cascading effects don’t stop there. Birds that eat fish lose their energy source, and island plants that thrive on bird droppings are depleted. And, of course, people who rely on reefs for food, income or shelter from waves lose their vital resource, as the final rivets pop followed by high-pitched screaming.
The signal or flicker of the Great Coral Reef is not nature’s way. It is an anomaly. It is easy to read about it and dismiss it and go on with life, but, in large measure, that’s the problem haunting and overriding ecosystem disintegration. It’s easy to read but punishingly painful to fix. Unwavering commitment is simply not there but for a select few like David Attenborough or Sylvia Earle, the world famous marine biologist.
Alas, groundswell of public opinion is not extant for collapsing ecosystems. It’s just not there at all. Yet, one hundred million people will be glued to TVs watching Super Bowl LII on Sunday, February 4th 2018, whilst the fate of the world’s largest and most important ecosystem rest in the hands of Attenborough, Earle and a handful of dedicated naturalists/marine biologists. Singularly, as well as unfortunately, ecosystem collapse is warranted based upon mathematical calculations alone: One hundred million (100,000,000) watch football while a handful of scientists work at fixing the world’s seas. Football’s more immediate.
Ad interim, massive environmental degradation flickers around the world, including climate change-derived crop losses for which the Federal Crop Insurance Program pays out $17.3B.

Meanwhile, heavily sprayed agrichemical pesticides and fertilizers bring about the absolutely shocking discovery that parts of the ecosystem are dropping dead right before society’s eyes, seventy-five percent (75%) insect loss detected in a major 27-yr. German study. How in the world is it possible for a 75% insect die-off, if not for chemically infested environmental degradation?

As it happens, the list of collapsing/flickering ecosystems is a very long list indeed. Here’s only a smattering:

Oceans have lost 40% of plankton production over past 50 years, threatening loss of one of the major sources of oxygen for the planet. (Boris Worm, Dalhousie Univ.)

If the same amount of global heat that went into top 2000m of ocean from 1955-2010 went instead into atmosphere, temps would warm by 36 C and destroy all life (Grantham Institute).

“Ocean seasons are changing as a result of too much heat and CO2… The scale of ocean warming is truly staggering with numbers so large that it is difficult for most people to comprehend.” (D. Laffoley, IUCN Global Marine and Polar Programme).

The ocean’s acidification rate of growth is unprecedented in Earth’s known history. (Jane Lubchenco, NOAA).

Ocean acidification occurring at least 1oxs faster than 55 million years ago based upon paleoclimate record. (C.L. Dybas, Oxford)

Nearly all marine life that builds calcium carbonate show deterioration due to increasing levels of CO2 and acidification. (Richard Feely, NOAA).

A foreboding flicker haunts the Arctic Circle, as permafrost melts away as a result of anthropogenic (human-caused) global warming, awakening forgotten pathogens from the depths. A Russian team analyzed material from 125 feet below surface in permafrost. They found extremely abnormal viruses, e.g., Pithovirus Sibericum, which survived 30,000 years frozen in ice. All of which brings to mind John Carpenter’s spectacular film The Thing (1982), and likelihood that zombie pathogens are buried in super-charged-melting-like-crazy permafrost.

Seven thousand (7,000) pingos discovered in Siberia… new development in permafrost science, never reported before, there could be 100,000 explosive methane pingos extant. (Vladimir Romanovsky, geophysicist Univ. of Alaska)

The East Siberian Arctic Shelf has reached “thaw point,” the turning point from linear to exponential release of CH4 leading to runaway global warming. (Natalia Shakhova, Int’l Arctic Research Centre)

Methane emissions in East Siberian Ice Shelves are 100xs higher than normal. (Igor Semiletov, Int’l Arctic Research Centre)

Tibetan Plateau headwater glaciers for Lancang River (Danube of the East) down by 70%- similarly for Yellow River and Yangtze River- that flow into Mekong Delta, which feeds the entire SE Asia basin of countries. (Yang Yong- Senior Chinese Geologist)

According to YaleEnvironment360: “As Oceans Warm, the World’s Kelp Forests Begin to Disappear,” Nov. 20,2017: “Kelp forests – luxuriant coastal ecosystems that are home to a wide variety of marine biodiversity – are being wiped out from Tasmania to California, replaced by sea urchin barrens that are nearly devoid of life.” Tasmania’s kelp forests hit by a devastating loss of 95%. In northern California, magnificent bull kelp forests along hundreds of miles of coastline have collapsed into an ecological wasteland, ocean desert.

Venice, Italy risks going on the UN’s endangered heritage site list unless it bans humongous cruise ships from the city’s lagoon, which is rapidly deteriorating into a state of utter disrepair.

Greenland’s entire surface experienced melt for the first time in scientific history. (Jason Box – Geologic Survey of Denmark & Greenland)

Greenland 2012 melt of the entire island not expected by scientific models for decades ahead, but it hit in 2012. (Michael Mann)

The all-important Atlantic ocean conveyor belt circulation pattern, aka: Thermohaline, has already started to slow down way ahead of schedule as predicted by scientific models – a result of global warming. This has strong negative ramifications for Europe. Models claimed it wouldn’t start slowing until 22nd century. It’s already started slowing down and could be sudden, maybe within decades! (Michael Mann)

In 2017, the Gulf of Mexico’s Dead Zone, where oxygen is so weak that fish die, is the largest ever at 8,800 square miles. (NOAA)

Positive Climate Feedbacks just starting to influence the warming process, meaning the planet itself is now emitting one molecule of CO2 via positive feedback for every two molecules of CO2 emitted by human activity. (Scripps Institution of Oceanography)

The scientific journal Proceedings of the National Academy of Sciences has reported that the Earth is already in the stages of the sixth mass extinction, which will see the world’s wildlife and plants die out. The research found that species, including those, which are not endangered, had reduced in number due to habitation shrinkage, hunting, pollution and climate change.

The deadly trio, or fingerprints, of mass extinctions, including global warming, ocean acidification, and anoxia or lack of ocean oxygen at current rate of change are unprecedented in Earth’s known history. (Alex Rogers, Oxford, scientific director State of the Ocean)

According to YaleEnvironment360, d/d April 2017, a survey of 12,000 adults and children shows that people have lost a closeness or connection with nature. “It is increasingly normal to spend little time outside.”

In the face of people mindlessly staring at very small and/or super large screens, the planet’s ecosystems are flashing signals all the way from Patagonia to Burrow, Alaska with bells clanging, alarms blaring, sirens screeching, but not a word on Good Morning America. Ergo, people really do not know what’s going on, which in a strange, twisted macabre fashion may be a blessing in disguise, until the final rivets pop. Then, loud screaming will register all across the land: Off with their heads! But whose?

Postscript: For each of the past 5 mass extinctions the one common factor has been massive increase in CO2, but none of the mass extinctions in the past compare to the spike in CO2 today. (Jen Veron, Australian Institute of Marine Science)

https://www.counterpunch.org/2017/12/11/dying-ecosystems/
10
Knarfs Knewz / Post-apocalyptic life in American health care
« Last post by knarf on Today at 05:31:07 AM »
    Much of my time for the past year has been spent navigating the medical maze on behalf of my mother, who has dementia.
    I observe that American health care organizations can no longer operate systematically, so participants are forced to act in the communal mode, as if in the pre-modern world.
    Health care is one leading edge of a general breakdown in systematicity—while, at the same time, employing sophisticated systematic technologies.
    Communal-mode interpersonal skills may become increasingly important to life success—not less, as techies hope.
    For complex health care problems, I recommend hiring a consultant to provide administrative (not medical!) guidance.

Epistemic status: impressionistic blogging during a dazed lull between an oncologist and an MRI. No attempt to validate with statistical data or knowledgeable sources.
No system

My mother’s mild dementia began accelerating rapidly a year ago. I’ve been picking up pieces of her life as she drops them. That has grown from a part-time job to a full-time job. In the past month, as she’s developed unrelated serious medical issues, it’s become a way-more-than-full-time job.

The most time-consuming aspect has been coordinating the dozens of different institutions involved in her care. I had read that the biggest failing of the American health care system is its fragmentation; I’ve now spent hundreds of hours observing that first-hand.

There is, in fact, no system. There are systems, but mostly they don’t talk to each other. I have to do that.

It’s been fascinating watching people working in hospitals and medical offices trying and failing to communicate with each other. I’ll tell one story, and then explain a pattern. This is the most dramatic instance I’ve encountered so far, but is typical in form.

The short version is that at least seven experts spent roughly ten full-time days trying to find out a basic fact about my mother’s insurance, and finally failed. Meanwhile, many thousands of dollars were wasted on unnecessary hospitalization.

This is a stark example of medical cost disease, but the post is not about that. It’s about how institutions fail to talk to each other—and what that implies about our future.

(If the story gets boring, you can skip ahead to my interpretation of the pattern.)

My mother went into the hospital a month ago with severe pain in her hip. (It’s still undiagnosed.) After two days, she was medically ready for discharge from the hospital: whatever the pain was, it wasn’t one they could help with. Instead, she should be sent to a “skilled nursing facility” (SNF) where she’d get “physical therapy,” i.e. leg exercises.

For a SNF to agree to take her, they had to get confirmation from an insurance company that insurance would cover her stay. She has two kinds of health insurance, Medicare plus coverage through a private insurer (Anthem). Which would cover her? Or both, or neither?

SNFs have admissions officers, whose full-time job is to answer this question. Two different SNFs started working on the problem. I talked with the admissions people every day. Both claimed to be working on it more-or-less full-time. The hospital wanted to free up my mother’s bed, so their insurance person was also working on it.

Days passed. The hospital doctor on rounds said “Well, this is typical, especially with Anthem. It’s costing them several thousand dollars a day to keep her here, versus a few hundred dollars a day in a SNF, but it might take a week for them to figure out which local SNF they cover. Don’t worry, they’ll sort it out eventually.”

Meanwhile, I learned that Anthem and Medicare were confused about their relationship. (As far as I can tell, this was a coincidence and not the underlying problem, although I’m still not sure.) Medicare believed that my mother (who retired in 1997) is employed and therefore ineligible. Her Anthem coverage is through her former employer.

I talked with her ex-employer’s benefits person (whose full-time job is understanding insurance, pretty much). She looked into it and said she couldn’t understand what was going on. She called the company’s outside insurance consultant. He couldn’t understand what was going on. He called people he knew at Medicare and Anthem. He said that they couldn’t understand it either, but that multiple people in both organizations were working on straightening it out.

A week later, I called Medicare to verify that it worked. The surprisingly competent customer service person looked up my mother’s info and said: “This is really weird… I don’t know what’s going on… there was a record that said Anthem is primary. And then on November 16th, there’s a note that said it’s deleted, and Medicare is primary. But then there’s an update on the 18th that says Anthem is primary. But obviously since your mother is 84 she’s not employed, so Medicare should be primary… I’ll delete the record again…”

After three days of trying, one of the SNFs gave up. I talked to the admissions dude there. I’ll call him Paul. He was smart and friendly, and he was willing to explain:

    My full-time job for ten years has been understanding how to get insurance to pay us, and I have no idea how the system works. Even if I somehow learned how it works, it changes completely every year, and I would have to start over. But at most of the insurance companies I know people who can sometimes make things happen, so I call them up, and then they try to figure out how it works. But Anthem… I spent hours and hours on hold, and in phone trees, getting transferred from one department to another, and eventually back to where I started. The most clueful-sounding person I could find sent me to a web site that just says ‘This program is not implemented yet.’ Does ‘program’ mean software, or does it mean some project they haven’t got going?

Hospitals are bad places that make you ill; you don’t want to spend any more time there than you have to. On day six, I said “if she doesn’t go to a SNF today, I’m taking her home—the risk of her dying there seems less now than the risk of her dying here.” That got results: the other SNF agreed to take her “on spec.” Their admissions person was reasonably confident that either Anthem or Medicare would pay, even though neither was willing to say either yes or no ahead of time.

The SNF called me to tell me they needed my mother’s records from the hospital. Well, what do you want me to do about that? We need you to call the hospital and ask them to fax us the records. “Fax”? Why not send clay tablets in wicker baskets on the back of a donkey?
No interface

To ship a package by FedEx, you don’t need to call someone who knows someone who knows someone. You go to a web site, put in some numbers, it gives you back some numbers, you put them on the envelope, drop it in a box, and it appears at a farmhouse on an island in Lapland the next day.

If Amazon sends you the wrong type of cable adapter, you don’t have to call them up and try to act pathetic and virtuous in order to convince someone that you need and deserve a refund because your poor mother is so ill. You go to a web site and push a button.

FedEx and Amazon have systematic interfaces. They are transparent on the outside, and black boxes on the inside. You don’t have to know anything about how they operate in order to use them.

Health care organizations are—at best—the opposite. They may run on systems internally, but the interface is opaque. There’s no defined way to get them to do something.

This is not their fault.
No fault

I was trying to get my mother into a SNF—but all I could do was talk to Paul, who couldn’t say yes or no. It wasn’t his fault. He was trying to talk to people at Anthem, who couldn’t say yes or no. Was that their fault?

Just speculating, I imagine they are supposed to apply 1600 pages of rules for what’s covered in what situation. And the rules are vague and conflicting and change constantly, and who can read 1600 pages of rules anyway? So eventually someone has to make up a yes-or-no answer on the basis of what seems more-or-less reasonable. Whoever it is could get blamed if someone higher up later decides that was “wrong” based on their interpretation of the rules, so it’s better to pass the buck.

Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to reconcile federal, state, and local legislation, plus the rules of three federal regulatory agencies, nine state agencies, and fifteen local agencies. All those are vague and conflicting and constantly changing, but Anthem’s rule-writing department does their best. They call the agencies to try to find out what the regulations are supposed to mean, and they spend hours on hold, are transferred from one official to another and back, and eventually get directed to a .gov web site that says “program not implemented yet.” Then they make something up, and hope that when the government sues Anthem, they don’t get blamed for it personally.

I imagine people working in legislative offices and regulatory agencies find themselves in a similar position.

In this maze, even competent people with good intentions cannot act systematically. Their work depends on coordinating with other institutions that have no systematic interface.
Traditional life in the ruins of systematicity

It’s like one those post-apocalyptic science fiction novels whose characters hunt wild boars with spears in the ruins of a modern city. Surrounded by machines no one understands any longer, they have reverted to primitive technology.

Except it’s in reverse. Hospitals can still operate modern material technologies (like an MRI) just fine. It’s social technologies that have broken down and reverted to a medieval level.

Systematic social relationships involve formally-defined roles and responsibilities. That is, “professionalism.” But across medical organizations, there are none. Who do you call at Anthem to find out if they’ll cover an out-of-state SNF stay? No one knows.

What do you do when systematicity breaks down? You revert to what I’ve described as the “communal mode” or “choiceless mode.” That is, “pre-modern,” or “traditional” ways of being.

Working in a medical office is like living in a pre-modern town. It’s all about knowing someone who knows someone who knows someone who can get something done. Several times, I’ve taken my mother to a doctor who said something like: “She needs lymphedema treatment, and the only lymphedema clinic around here is booked months in advance, but I know someone there, and I think I can get her in next week.” Or, “The pathology report on this biopsy is only one sentence, and it’s unsigned. The hospital that faxed it to me doesn’t know who did it. I need details, so I called all the pathologists I know, and none of them admit to writing it, so we are going to need to do a new biopsy.”

But at the same time, each clinic does have an electronic patient records management system, which does work some of the time. And there are professional relationships with defined roles that operate effectively within the building.

I suspect increasing “patchiness” of systems may be typical of our post-systematic atomized era. Understanding the medical case may help predict the texture of cultural and social life as atomization proceeds.

A central research topic in ethnomethodology is the relationship between formal rationality (such as an insurance company’s 1600 pages of unworkable rules) and “mere reasonableness,” which is what people mostly use to get a job done. The disjunction between electronic patient records and calling around town to try to find out who wrote a biopsy report that arrived by fax seems sufficiently extreme that it may produce a qualitatively new way of being.

I would like to ask:

    How does health care continue to function at all?
    Can it continue to function at all?
    How do people within the ex-system navigate a world that mashes up high-tech infrastructure that only sometimes works with pre-modern social relationships across organizations?
    How do they understand this contrast? How do they cope personally?1
    What can we do about it?

Maybe an ethnomethodological understanding of how health care organizations operate in practice could make the systems work incrementally better. Maybe an enlightened COO could incorporate the view that the systems and reality are only vaguely related. But… it may be impossible to improve individual organizations.
No local fix

It’s obvious how to fix health care. Just make everything run systematically, like FedEx or Amazon. There are no technical or business obstacles to this. Anyone who understands IT and/or business can see how to do it.2

Back-of-envelope calculations say a working health care system would deliver dramatically better quality at 10-20% of the current cost.

Health care is notionally a profit-driven free market. This looks like an easy opportunity to make trillions of dollars by making the world better for everyone. Why doesn’t someone do that?

It appears that 73% of the labor cost of a health care organization is spent on trying to communicate with other health care organizations that have no defined interface.3 Patrick Collison has suggested calling this pattern “Leibenstein’s Inefficiency Disease,” by analogy to Baumol’s Cost Disease. An organization can’t improve the 73% by much on its own; that inefficiency is forced on it by the environment it operates in.

Instead, organizations in sectors afflicted with inefficiency disease try to push their own administrative work outside. Both out into other organizations, and—more visibly—they force it onto you, the customer. It’s your job to fill out forms they could have done more efficiently themselves. When they screw up, you have to try to fix it. This negative externality could be called “paperwork pollution,” by analogy with negative externalities of smokestack industries.

Standardizing an interface between health care providers and insurance companies would be a huge win. No matter how badly designed, it would be better than the current mess, and save several percent of US GDP. That would need cooperation from most of the major players in the industry. Other industries manage that routinely: machine screws and futures contracts come in standard sizes, without which manufacturing and finance would be as inefficient as health care. The need for a standard insurer/provider interface is obvious. Since it’s lacking, I imagine some powerful group extracts enormous rents from the inefficiency. I know nothing about that, so I won’t speculate.
You will need village life skills

Perhaps American health care is a bellwether model for the future of other aspects of life in post-systemic world? A pattern that occurs in many other sectors: as systems fail, people fall back on innate communal logic. Politics and the media are obvious current examples.

The hope of the tech industry is that “software is eating the world,” as Marc Andreessen put it in 2011. That is, we’re FedEx-izing every aspect of the economy: making it radically more efficient and reliable, using well-designed IT-supported systematic business processes.

In that world, systematic-mode skills (especially programming and finance) will be ever more valuable. Hooray! We will create a utopia for all, in which (for once) those of us with high-functioning autism get properly rewarded.

In 2017, software is conspicuously not eating the cost-disease economic sectors: health care, education, housing, government. They are being eaten—by communal mode tribalism.

In 2017, tribalists are threatening to eat the tech industry.

There’s a possible future in which all systems fall to tribalism. Then everyone dies, because tribal signaling does not deliver electric power. In another possible future, we create a meta-systematic society that addresses the inherent defects of both tribalism and systematicity. (I discussed both these possibilities tangentially in “A bridge to meta-rationality vs. civilizational collapse.” I hope to write more soon.)

In the short run, more likely, current trends will continue. Additional aspects of life will increasingly revert to the communal mode, but some critical systems will fend off the barbarians and limp along well enough to keep us alive.

In that world, people skills will be ever more valuable. Surviving and thriving in 2037 may depend mainly on who you can charm, who you know, and whether they owe you favors.

Techies take note.

You might consider working in a medical office, to get some practice.
Hire a consultant

Some more-serious, practical advice:

If you find yourself in a situation like mine, hire an independent health care administration consultant. Their job is to know administrative people inside organizations who can get stuff done. They also know what can be gotten done, which is unknowable to the public. They can also deal with inscrutable paperwork and organizational screw-ups.

Hiring someone became imperative for me when coordinating my mother’s care got to be a way-more-than-full-time job. (In retrospect, I wish I had done that months earlier.)

It could also be worthwhile in less critical cases, if no one in the family can take enough time off from work, or in which you’d simply rather pay someone else to clean up after a hospital’s paperwork pollution.

This role has developed only recently, as systems have broken down. There’s not yet a standardized term; “health care advocate” is one among several.

Mine specializes in gerontology and dementia. Others specialize in other disease areas; or in other aspects of the administrative nightmare, such as sorting out bogus hospital bills, which frequently include fraudulent additions.

They are not inexpensive (mine charges $150/hour), so not an option for everyone.

There are good and not-so-good advocates. I spoke with several before hiring one. Some were clearly clueless; the one I hired last month has seemed consistently competent.

Since they recommend particular providers, there is an inherent principal-agent problem. Ask if they get any compensation from services they recommend. Take their recommendations with a grain of salt in any case.

    1.
    I imagine for many it’s awful. “Communal” sounds “nice,” but most are in medicine because they want to help others, and they can’t get their jobs done when the system breaks down.
    2.
    Step 1: Throw away the ubiquitous fax machines. Sink or swim. Hire donkeys if necessary.
    3.
    The number 73% is my dazed estimate based on informal observation and analysis conducted in doctors’ examination rooms.

    Much of my time for the past year has been spent navigating the medical maze on behalf of my mother, who has dementia.
    I observe that American health care organizations can no longer operate systematically, so participants are forced to act in the communal mode, as if in the pre-modern world.
    Health care is one leading edge of a general breakdown in systematicity—while, at the same time, employing sophisticated systematic technologies.
    Communal-mode interpersonal skills may become increasingly important to life success—not less, as techies hope.
    For complex health care problems, I recommend hiring a consultant to provide administrative (not medical!) guidance.

Epistemic status: impressionistic blogging during a dazed lull between an oncologist and an MRI. No attempt to validate with statistical data or knowledgeable sources.
No system

My mother’s mild dementia began accelerating rapidly a year ago. I’ve been picking up pieces of her life as she drops them. That has grown from a part-time job to a full-time job. In the past month, as she’s developed unrelated serious medical issues, it’s become a way-more-than-full-time job.

The most time-consuming aspect has been coordinating the dozens of different institutions involved in her care. I had read that the biggest failing of the American health care system is its fragmentation; I’ve now spent hundreds of hours observing that first-hand.

There is, in fact, no system. There are systems, but mostly they don’t talk to each other. I have to do that.

It’s been fascinating watching people working in hospitals and medical offices trying and failing to communicate with each other. I’ll tell one story, and then explain a pattern. This is the most dramatic instance I’ve encountered so far, but is typical in form.

The short version is that at least seven experts spent roughly ten full-time days trying to find out a basic fact about my mother’s insurance, and finally failed. Meanwhile, many thousands of dollars were wasted on unnecessary hospitalization.

This is a stark example of medical cost disease, but the post is not about that. It’s about how institutions fail to talk to each other—and what that implies about our future.

(If the story gets boring, you can skip ahead to my interpretation of the pattern.)

My mother went into the hospital a month ago with severe pain in her hip. (It’s still undiagnosed.) After two days, she was medically ready for discharge from the hospital: whatever the pain was, it wasn’t one they could help with. Instead, she should be sent to a “skilled nursing facility” (SNF) where she’d get “physical therapy,” i.e. leg exercises.

For a SNF to agree to take her, they had to get confirmation from an insurance company that insurance would cover her stay. She has two kinds of health insurance, Medicare plus coverage through a private insurer (Anthem). Which would cover her? Or both, or neither?

SNFs have admissions officers, whose full-time job is to answer this question. Two different SNFs started working on the problem. I talked with the admissions people every day. Both claimed to be working on it more-or-less full-time. The hospital wanted to free up my mother’s bed, so their insurance person was also working on it.

Days passed. The hospital doctor on rounds said “Well, this is typical, especially with Anthem. It’s costing them several thousand dollars a day to keep her here, versus a few hundred dollars a day in a SNF, but it might take a week for them to figure out which local SNF they cover. Don’t worry, they’ll sort it out eventually.”

Meanwhile, I learned that Anthem and Medicare were confused about their relationship. (As far as I can tell, this was a coincidence and not the underlying problem, although I’m still not sure.) Medicare believed that my mother (who retired in 1997) is employed and therefore ineligible. Her Anthem coverage is through her former employer.

I talked with her ex-employer’s benefits person (whose full-time job is understanding insurance, pretty much). She looked into it and said she couldn’t understand what was going on. She called the company’s outside insurance consultant. He couldn’t understand what was going on. He called people he knew at Medicare and Anthem. He said that they couldn’t understand it either, but that multiple people in both organizations were working on straightening it out.

A week later, I called Medicare to verify that it worked. The surprisingly competent customer service person looked up my mother’s info and said: “This is really weird… I don’t know what’s going on… there was a record that said Anthem is primary. And then on November 16th, there’s a note that said it’s deleted, and Medicare is primary. But then there’s an update on the 18th that says Anthem is primary. But obviously since your mother is 84 she’s not employed, so Medicare should be primary… I’ll delete the record again…”

After three days of trying, one of the SNFs gave up. I talked to the admissions dude there. I’ll call him Paul. He was smart and friendly, and he was willing to explain:

    My full-time job for ten years has been understanding how to get insurance to pay us, and I have no idea how the system works. Even if I somehow learned how it works, it changes completely every year, and I would have to start over. But at most of the insurance companies I know people who can sometimes make things happen, so I call them up, and then they try to figure out how it works. But Anthem… I spent hours and hours on hold, and in phone trees, getting transferred from one department to another, and eventually back to where I started. The most clueful-sounding person I could find sent me to a web site that just says ‘This program is not implemented yet.’ Does ‘program’ mean software, or does it mean some project they haven’t got going?

Hospitals are bad places that make you ill; you don’t want to spend any more time there than you have to. On day six, I said “if she doesn’t go to a SNF today, I’m taking her home—the risk of her dying there seems less now than the risk of her dying here.” That got results: the other SNF agreed to take her “on spec.” Their admissions person was reasonably confident that either Anthem or Medicare would pay, even though neither was willing to say either yes or no ahead of time.

The SNF called me to tell me they needed my mother’s records from the hospital. Well, what do you want me to do about that? We need you to call the hospital and ask them to fax us the records. “Fax”? Why not send clay tablets in wicker baskets on the back of a donkey?
No interface

To ship a package by FedEx, you don’t need to call someone who knows someone who knows someone. You go to a web site, put in some numbers, it gives you back some numbers, you put them on the envelope, drop it in a box, and it appears at a farmhouse on an island in Lapland the next day.

If Amazon sends you the wrong type of cable adapter, you don’t have to call them up and try to act pathetic and virtuous in order to convince someone that you need and deserve a refund because your poor mother is so ill. You go to a web site and push a button.

FedEx and Amazon have systematic interfaces. They are transparent on the outside, and black boxes on the inside. You don’t have to know anything about how they operate in order to use them.

Health care organizations are—at best—the opposite. They may run on systems internally, but the interface is opaque. There’s no defined way to get them to do something.

This is not their fault.
No fault

I was trying to get my mother into a SNF—but all I could do was talk to Paul, who couldn’t say yes or no. It wasn’t his fault. He was trying to talk to people at Anthem, who couldn’t say yes or no. Was that their fault?

Just speculating, I imagine they are supposed to apply 1600 pages of rules for what’s covered in what situation. And the rules are vague and conflicting and change constantly, and who can read 1600 pages of rules anyway? So eventually someone has to make up a yes-or-no answer on the basis of what seems more-or-less reasonable. Whoever it is could get blamed if someone higher up later decides that was “wrong” based on their interpretation of the rules, so it’s better to pass the buck.

Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to reconcile federal, state, and local legislation, plus the rules of three federal regulatory agencies, nine state agencies, and fifteen local agencies. All those are vague and conflicting and constantly changing, but Anthem’s rule-writing department does their best. They call the agencies to try to find out what the regulations are supposed to mean, and they spend hours on hold, are transferred from one official to another and back, and eventually get directed to a .gov web site that says “program not implemented yet.” Then they make something up, and hope that when the government sues Anthem, they don’t get blamed for it personally.

I imagine people working in legislative offices and regulatory agencies find themselves in a similar position.

In this maze, even competent people with good intentions cannot act systematically. Their work depends on coordinating with other institutions that have no systematic interface.
Traditional life in the ruins of systematicity

It’s like one those post-apocalyptic science fiction novels whose characters hunt wild boars with spears in the ruins of a modern city. Surrounded by machines no one understands any longer, they have reverted to primitive technology.

Except it’s in reverse. Hospitals can still operate modern material technologies (like an MRI) just fine. It’s social technologies that have broken down and reverted to a medieval level.

Systematic social relationships involve formally-defined roles and responsibilities. That is, “professionalism.” But across medical organizations, there are none. Who do you call at Anthem to find out if they’ll cover an out-of-state SNF stay? No one knows.

What do you do when systematicity breaks down? You revert to what I’ve described as the “communal mode” or “choiceless mode.” That is, “pre-modern,” or “traditional” ways of being.

Working in a medical office is like living in a pre-modern town. It’s all about knowing someone who knows someone who knows someone who can get something done. Several times, I’ve taken my mother to a doctor who said something like: “She needs lymphedema treatment, and the only lymphedema clinic around here is booked months in advance, but I know someone there, and I think I can get her in next week.” Or, “The pathology report on this biopsy is only one sentence, and it’s unsigned. The hospital that faxed it to me doesn’t know who did it. I need details, so I called all the pathologists I know, and none of them admit to writing it, so we are going to need to do a new biopsy.”

But at the same time, each clinic does have an electronic patient records management system, which does work some of the time. And there are professional relationships with defined roles that operate effectively within the building.

I suspect increasing “patchiness” of systems may be typical of our post-systematic atomized era. Understanding the medical case may help predict the texture of cultural and social life as atomization proceeds.

A central research topic in ethnomethodology is the relationship between formal rationality (such as an insurance company’s 1600 pages of unworkable rules) and “mere reasonableness,” which is what people mostly use to get a job done. The disjunction between electronic patient records and calling around town to try to find out who wrote a biopsy report that arrived by fax seems sufficiently extreme that it may produce a qualitatively new way of being.

I would like to ask:

    How does health care continue to function at all?
    Can it continue to function at all?
    How do people within the ex-system navigate a world that mashes up high-tech infrastructure that only sometimes works with pre-modern social relationships across organizations?
    How do they understand this contrast? How do they cope personally?1
    What can we do about it?

Maybe an ethnomethodological understanding of how health care organizations operate in practice could make the systems work incrementally better. Maybe an enlightened COO could incorporate the view that the systems and reality are only vaguely related. But… it may be impossible to improve individual organizations.
No local fix

It’s obvious how to fix health care. Just make everything run systematically, like FedEx or Amazon. There are no technical or business obstacles to this. Anyone who understands IT and/or business can see how to do it.2

Back-of-envelope calculations say a working health care system would deliver dramatically better quality at 10-20% of the current cost.

Health care is notionally a profit-driven free market. This looks like an easy opportunity to make trillions of dollars by making the world better for everyone. Why doesn’t someone do that?

It appears that 73% of the labor cost of a health care organization is spent on trying to communicate with other health care organizations that have no defined interface.3 Patrick Collison has suggested calling this pattern “Leibenstein’s Inefficiency Disease,” by analogy to Baumol’s Cost Disease. An organization can’t improve the 73% by much on its own; that inefficiency is forced on it by the environment it operates in.

Instead, organizations in sectors afflicted with inefficiency disease try to push their own administrative work outside. Both out into other organizations, and—more visibly—they force it onto you, the customer. It’s your job to fill out forms they could have done more efficiently themselves. When they screw up, you have to try to fix it. This negative externality could be called “paperwork pollution,” by analogy with negative externalities of smokestack industries.

Standardizing an interface between health care providers and insurance companies would be a huge win. No matter how badly designed, it would be better than the current mess, and save several percent of US GDP. That would need cooperation from most of the major players in the industry. Other industries manage that routinely: machine screws and futures contracts come in standard sizes, without which manufacturing and finance would be as inefficient as health care. The need for a standard insurer/provider interface is obvious. Since it’s lacking, I imagine some powerful group extracts enormous rents from the inefficiency. I know nothing about that, so I won’t speculate.
You will need village life skills

Perhaps American health care is a bellwether model for the future of other aspects of life in post-systemic world? A pattern that occurs in many other sectors: as systems fail, people fall back on innate communal logic. Politics and the media are obvious current examples.

The hope of the tech industry is that “software is eating the world,” as Marc Andreessen put it in 2011. That is, we’re FedEx-izing every aspect of the economy: making it radically more efficient and reliable, using well-designed IT-supported systematic business processes.

In that world, systematic-mode skills (especially programming and finance) will be ever more valuable. Hooray! We will create a utopia for all, in which (for once) those of us with high-functioning autism get properly rewarded.

In 2017, software is conspicuously not eating the cost-disease economic sectors: health care, education, housing, government. They are being eaten—by communal mode tribalism.

In 2017, tribalists are threatening to eat the tech industry.

There’s a possible future in which all systems fall to tribalism. Then everyone dies, because tribal signaling does not deliver electric power. In another possible future, we create a meta-systematic society that addresses the inherent defects of both tribalism and systematicity. (I discussed both these possibilities tangentially in “A bridge to meta-rationality vs. civilizational collapse.” I hope to write more soon.)

In the short run, more likely, current trends will continue. Additional aspects of life will increasingly revert to the communal mode, but some critical systems will fend off the barbarians and limp along well enough to keep us alive.

In that world, people skills will be ever more valuable. Surviving and thriving in 2037 may depend mainly on who you can charm, who you know, and whether they owe you favors.

Techies take note.

You might consider working in a medical office, to get some practice.
Hire a consultant

Some more-serious, practical advice:

If you find yourself in a situation like mine, hire an independent health care administration consultant. Their job is to know administrative people inside organizations who can get stuff done. They also know what can be gotten done, which is unknowable to the public. They can also deal with inscrutable paperwork and organizational screw-ups.

Hiring someone became imperative for me when coordinating my mother’s care got to be a way-more-than-full-time job. (In retrospect, I wish I had done that months earlier.)

It could also be worthwhile in less critical cases, if no one in the family can take enough time off from work, or in which you’d simply rather pay someone else to clean up after a hospital’s paperwork pollution.

This role has developed only recently, as systems have broken down. There’s not yet a standardized term; “health care advocate” is one among several.

Mine specializes in gerontology and dementia. Others specialize in other disease areas; or in other aspects of the administrative nightmare, such as sorting out bogus hospital bills, which frequently include fraudulent additions.

They are not inexpensive (mine charges $150/hour), so not an option for everyone.

There are good and not-so-good advocates. I spoke with several before hiring one. Some were clearly clueless; the one I hired last month has seemed consistently competent.

Since they recommend particular providers, there is an inherent principal-agent problem. Ask if they get any compensation from services they recommend. Take their recommendations with a grain of salt in any case.

    1.
    I imagine for many it’s awful. “Communal” sounds “nice,” but most are in medicine because they want to help others, and they can’t get their jobs done when the system breaks down.
    2.
    Step 1: Throw away the ubiquitous fax machines. Sink or swim. Hire donkeys if necessary.
    3.
    The number 73% is my dazed estimate based on informal observation and analysis conducted in doctors’ examination rooms.
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