It is 28°C with 30% humidity and a cool breeze coming from the east. This is one of the many reasons we are again spending the summer in Serbia.
A few choice excerpts from a NYT investigation, Medicare Bleeds Billions on Pricey Bandages, and Doctors Get a Cut:
For one patient in Nevada, Medicare spent $14 million on skin substitutes over the course of a year, according to billing records reviewed by The Times. The wound of a patient in Washington State persisted after Medicare paid $6 million for the coverings. A man in Texas got $1.3 million of bandages despite having no wound at all.
Five years ago, the most expensive skin substitute cost $1,042 per square inch, while some were as cheap as $45. Today, the three most expensive products on the market each cost more than $21,000. (Samaritan Biologics, a company in Memphis that sells the three products, did not answer questions about why they cost so much.)
For the first six months of a new bandage product’s life, Medicare will set the reimbursement rate at whatever price a company chooses. After that, the agency adjusts the reimbursement to reflect the actual price paid by doctors after any discounts.
To circumvent the reimbursement drop, some companies simply roll out new products.
The doctor who earned the most for skin substitutes last year was Dr. Aaron Jeng of Southern California, according to Early Read’s analysis. Medicare paid him $117 million. (Dr. Jeng declined to comment.)
Another high earner, Dr. Stephen Dubin of Las Vegas, was paid $17 million by Medicare for skin substitutes in 2024. (He estimated that after expenses, he took home roughly $4 million.) Dr. Dubin retired at the end of last year, in part, he said, because of increased competition for wound patients. Sometimes he would show up at a patient’s home only to find that someone from a different clinic had placed a new skin substitute the day before.
The article is 3 months old but still relevant: a day after it came out the administration announced that it was indeed delaying implementation of the new reimbursement rules until 2026. Wouldn’t it be neat if there were a government department that deals with this kind of fraud, waste and abuse?
It is for the most part a reframing of what Schumacher has already written about the problems of extractive economies of scale and how intermediate technologies — to be rebranded “appropriate technologies” and, ultimately, “sustainable development” — can help remedy their dehumanizing effects. The difference is in the final chapter, “The making of Good Work”, written by one Peter N. Gillingham.
It starts with a — to the modern sensibilities rather offensive — comparison of people to different types of cattle. It quickly pivots to a discussion that is more relevant today than it was in the 1970s, about the pendulum swinging from institutions to individuals, and about the potential for a malignant entity to inhabit said crumbling institutions as a hermit crab would inhabit a dead shell. So it goes… There is much talk of people feeling the need to escape abstraction and get back to doing meaningful work in the “real world”. This was, let me remind you, written almost 50 years ago. And here I thought the Internet was to be blamed for everything.
There is next to no information about Peter Gillingham online. ChatGPT-o3 managed to dig up a few nuggets which ring true: this chapter would be his only publicly available work, the California-based Intermediate Technology Institute he led had folded within a decade of Schumacher’s death, and the 1970s oil crisis-inspired movement petered out, to be replaced by the 1980s Reagonomics, the 1990s end of history, the 2000s war on terror, and the 2010s social network boom. Of course, it is now the 2020s and the preceding four decades have all in their own way continued the hollowing out of the institutions. Americans continue to check out of capitalism, with mixed success. Everything old is new again.
So then, is this book a success or a failure? It declared the extraction party over 50 years too early and for the wrong reason: it wasn’t that the world ran out of oil, but rather that the consequences of its extraction became to dire (funnily enough, both Schumacher’s own Small is Beautiful and Donella Meadows’s Thinking in Systems hinted that this may end up happening). The book is out of print and for the most part out of the collective mind. The movements it promoted are either dead or so transformed as to be unrecognizable.
On the other hand, the themes keep being repeated: from Nassim Taleb’s promotion of localism and abhorrence of large scale, through John Vervaeke’s video essays on the meaning crisis, to Tim Harford writing about the corrosivness of commerce in the bastion of capitalism that is the Financial Times. There was, and still is, there there. Ignore it at your own peril.
It is 28°C with 30% humidity and a cool breeze coming from the east. This is one of the many reasons we are again spending the summer in Serbia.
Twelve years ago I made a single $50 payment for continued development of MailMate. This has been one of the best software purchases I have ever made, so I didn’t hesitate for a moment when the developer asked for continued support at $40 per year. I consider it an enshittification avoidance fee.
🍿 Heretic (2024) was a low-budget, high-suspense portrayal of a psychopathic Hugh Grant, and unlike his prior attempt it just flew by even at 110 minutes run time. The movie has four actors, a few set pieces and no highfalutin' special effects: kudos to A24 for still making them this way.
The FT and NYT both have stories about the dollar’s poor start to the year, which sounds alarming. But then NYT shows this graph to back up the claim and you know what, it really doesn’t seem to be all that dramatic. In fact, the very beginning of the year has been quite average, as have the last two months. It is only the period from March until mid-April that saw two unusual slumps, but does that count as “dollar having its worst start to a year since 1973”, as the NYT put it? It might, depending on your definition of “worst” and “start”, but hardly a foregone conclusion. I know that newspapers need to prepare for the slow news week with the holiday coming up, but come on. “Worst start to a year in more than 50 years” is a bit too dramatic for what the chart shows us.
What kind of data would deserve some drama? Well, again the NYT provides the perfect example with their front page news on April 2020 US unemployment data. The headline, in much deserved all-caps, says “U.S. UNEMPLOYMENT IS WORST SINCE DEPRESSION” and has the unemployed bard dip so far below anything in the past 50 years that it falls all the way down to the bottom of the front page. A true extreme value.
As an aside, if you thought you could call either “an outlier”, think again. Here is a 12-minute explainer on the difference from Pasquale Cirillo’s Log of Risk podcast but in short: outliers are impossible values, extreme values are, well, extreme but still in the realm of the possible. The dollar’s decline this year is neither but you wouldn’t know it if you just read the headlines.
Some good news to start the week:
Microsoft claims their new medical tool is “four times more successful than human doctors at diagnosing complex ailments”. Unsurprisingly, what they meant by “diagnosing a disease” was the thinking-hard part, not the inputs part:
To test its capabilities, “MAI-DxO” was fed 304 studies from the New England Journal of Medicine (NEJM) that describe how some of the most complicated cases were solved by doctors.
This allowed researchers to test if the programme could figure out the correct diagnosis and relay its decision-making process, using a new technique called “chain of debate”, which makes AI reasoning models give a step-by-step account of how they solve problems.
If and when deployed, how likely is it that these algorithms will get a query comparable to a New England Journal of Medicine case study? Most doctors don’t reach those levels of perception and synthesis, let alone the general public.
📚 Finished reading: A Thousand Brains by Jeff Hawkins, having no idea how it ended up in my Kindle library. I am glad to have opened it, as I now have some semblance of a framework for how this thing we call intelligence might work. Note that the newest developments in neuroscience are just a starting point, as most of the book deals with their implications for AI and the future of humanity. If that sounds like overreach, know that by the end of the book it is. Still, these wafer-thin speculations don’t detract from the book’s meatier parts.
Confirmation bias alert: the framework repeats almost word for word the thought I had a while back — and more recently — about AI, that true general intelligence needs to be able to interact with its environment. So I may be blind to some obvious deficiencies in the argument. But then again, great minds, etc.
I will have more to write about this soon (ha!), but until the stars align for an extended writing session here is a good opinion piece from FT’s John Thornhill about why LLMs may not be all that great for lay people dabbling in, for example, medicine:
When the test scenarios were entered directly into the AI models, the chatbots correctly identified the conditions in 94.9 per cent of cases. However, the participants did far worse: they provided incomplete information and the chatbots often misinterpreted their prompts, resulting in the success rate dropping to just 34.5 per cent. The technological capabilities of these models did not change but the human inputs did, leading to very different outputs.
The emphasis is mine, because it is a neat summarization of what I wrote 2 years ago. Humans are unique not because of what’s inside our heads but because of how we interact with the environment. There will be no artificial general intelligence until that problem is solved.