[FRIAM] money is a delusion

Thu Apr 17 17:33:47 EDT 2025

Totally agree.  

In one of the long-time collaborative groups I have attended, the two main cohorts are agriculture-related (practice, research, policy) and the corresponding medical-related.  Everything you point to here is core to their complaints.

Where are the drivers, and is it appropriate to try to reduce to a modest number of main actors (or would that just be the human desire for comprehensibility making a projection)?  I am willing to suppose there are two drivers.  The most-visibly-different recent one is private equity.  My reading says this is the major driver behind the extinction of hospitals in low-density areas, driving medical-service deserts.  (I have deliberately not used the word “care”, which to me is part of the manipulative jargon, even though sometimes it applies.)  I guess the insurance companies aren’t exactly private equity, but if I look at business practices like those of which UHC was (presumably still is) one of the worse offenders, and the way their lobbying severely limited what Obama and Pelosi could do to trim around the edges of health-service improvement in the US, the business model isn’t far at all from the one driven by private equity.  But PE, specifically, looks to me like a symptom of when near-singularity levels of wealth-concentration become possible from the network-way in which the current capitalist economies are set up.  Money concentrated from one area (crypto-mining companies and their VCs?) suddenly gets to purchase hospitals, veterinary clinics, residential buildings, and god-knows what else, and carve them all up and sell them off, or pimp out the doctors until service degrades enough to close them.  If money accumulation beyond operating expenses were less easy, requiring that the quality of “risk” it supports be improved, and if regulation against predatory practices added a little dimensionality to the pure-money valuations of things, we could probably cut that problem down considerably.

My understanding, too, has been that the Scandinavians have managed to hold this off longer than most of the West, but that they are by no means secure.  One of my long-term group is a Danish cardiologist, and he complains and worries that what starts in the US doesn’t stay in the US, and Europe gets dragged in similar directions, with Scandinavia getting drafted in eventually even if less-so.  So they somehow haven’t managed to hold off the forces of institutional Darwinism that seem to homogenize every domain.

But the one that really stumps me is the one for which I have held off blaming universities and funding agencies as well, which is what you term bureaucracy.  From my days with Shubik, I stopped regarding bureaucracy as an inherently negative term (which is the normal social usage), and tried to understand in how far it is driven into existence by coordination problems that people collectively commit themselves to, whether wittingly or piecemeal through local things they accept or even want.  One of our friends (as I have mentioned before) tried to start a 401C3 organization for people to do scientific research out of the house, but have legal access to agency funding etc.  They survived for about 10 years, but eventually collapsed under the workload of the accounting and legal, which they hadn’t committed to hiring (and charging for) a significant paid and trained staff to handle.  A lot of that regulatory and reporting load was adopted “with good intentions (?)”, either to forestall cheating, or at least to give legal cover against getting sued or congressional-witch-trialed out of existence for.  I don’t like the result, but had I been the decision maker piece by piece, I don’t have good (and plausible) ideas for what I would have proposed in its place as a defensive measure.  I think that overhead creeps, and would have significantly impaired medicine and research in any publicly-accountable sector, even without the problems created by singular wealth concentration.

Now would be a great time to see high-quality professional comparative analysis of alternative models, how they work and to what extent that depends on other aspects of their circumstances.  I have been very very impressed with medical services in Japan, as a quite complex institution that is not publicly run, per se (so not “socialized” in the strict sense), but is a quite tight coordination at all levels from the national government down to the training and staffing of local functions like accountants and techs.  Very clearly, these are all ordinary human beings, of a range of talents and sharpnesses etc., and yet the system they are in gets _so_ much more benefit from their efforts than in the US, as to be shocking.

Eric

> On Apr 17, 2025, at 22:50, glen <gepropella at gmail.com> wrote:
> 
> I guess we could make the same argument with physicians: "act like a physician, not a business".
> 
> https://linkprotect.cudasvc.com/url?a=https%3a%2f%2fwww.statnews.com%2f2025%2f04%2f15%2fai-scribes-artificial-intelligence-medicine-note-writing-physician-patient-relationship%2f&c=E,1,3gRfDNHkk13o310iM0_6Fs5EyrSEX6kI2z4AlJI9DhLGsUitet_kuxYKHltOpfoQxMpF6PKKY-Ww3t0zxto0GYV5WGgaQRiDu6UngCRtSekff1A,&typo=1
> 
> I guess I'd prefer "act like a witch, not a doctor". My GP back in Oregon was a great example of a *general* practitioner. Granted, I had insurance. But he rarely recommended specialists. He'd cut pieces off me right there in his office, tolerated my rants against acupuncture pamphlets, etc. But! He was originally trained in India. I only have a couple of experiences. But it wouldn't surprise me if Global South doctors act more like physicians than US trained doctors, in general. Actually, I've seen studies that show the average visit with a physician in Scandinavia is ~1 hour, whereas the average in the US is more like ~15 min. So, maybe it's not the Global South, but the rest of the world versus the US?
> 
> And it's not quite fair to blame the humans. The hospital and clinic systems, coerced by insurance/payers, captures them in their ion traps. Even the less-than-greedy ones are subliminally encouraged to escape into a specialty. If we think university accreditation is resource hungry, take a look at the firey hoops hospitals jump through: https://linkprotect.cudasvc.com/url?a=https%3a%2f%2fpmc.ncbi.nlm.nih.gov%2farticles%2fPMC8011742%2f&c=E,1,taSSkOtyvDln2I-WXAWBr6OoE-KAaYP9hqnPUWgSPrVxYCmCZgASDhQUvZLRQ1BZK4Pk7Y0VBEsIvc5aVl7K6Hxe-P876x4UQeLO9bCXLr9F0qmhAEw4wg,,&typo=1
> 
> Stupid bureaucracy.
> 
> On 4/15/25 1:11 PM, Santafe wrote:
>> Turns out Masha Gessen wrote a kind of nice piece in the NYT a few days ago, which came to me on a different list.
>> 14gessen-videoSixteenByNineJumbo1600-v2.jpg
>> Opinion | This Is How Universities Can Escape Trump’s Trap, if They Dare <https://www.nytimes.com/2025/04/14/opinion/trump-higher-education.html>
>> nytimes.com <https://www.nytimes.com/2025/04/14/opinion/trump-higher-education.html>
>> <https://www.nytimes.com/2025/04/14/opinion/trump-higher-education.html>
>> To the extent that it has been done, it’s proper to say it is a strategy.  I think the resulting education will end up being rather more restrictive than what I had hoped for from a full educational program, and probably focused heavily on civics.  Math could be possible, in the sense that that can be taught “behind the hedges”.  Medical research, not so much.  But, one does what one can do.
>> It’s an interesting question what is the proper balance of criticism and understanding to give the businessmen who run universities, and who have Darwin-wise managed to eliminate almost any other model from the ecosystem.  It’s not total criticism, in the sense that there is sheer mechanics that they do contribute to solving, without which the broad set of functions I want don’t get done.  But the sense that they don’t take seriously what it means to live under a fascist regime where dissidence is the _only_ alternative to collaboration — there is no more neutrality — does seem to be a deserved criticism of their responses so far.
> 
> 
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