We start by delving into the rich trove of man's perfidy as manifest in 'Law & Order' with the episode 'Mega' wherein Annette O'Toole frames husband Michael McKean for murder. They play a pair of self-help/created religion grifters (aka, Scientology/EST). McKean's character is convicted of the murder, but post-trial the DAs realize that he's likely been set up, and the most likely candidate for that is O'Toole's character. The DAs meet with her to attempt to figure out the problem. She parrys their questions, but does tell them her motive (if she did it!):
There was never enough, enough power, money, attention, women, enough control.
(Why did you speak up in his defense and let him live?)
So he would have to sit very quietly for a very, very long time, and know that now I had it all.
I wanted him to know that, for him, there wasn't going to be any more.
If you see the video, note that O'Toole drags out that last as 'moooooooore', with lips deeply curled. Which brings us to three situations where 'more' is something of an issue.
First, my adventures with medical care on Block Island. We decided to do an additional week this year, Memorial Day week. Normally we visit in spring and fall when the number of Mainlanders isn't much more than the 900 Islanders, so this would be a visit closest (for us) to High Season. Would we like all those crowds? On the whole, the weekend was tolerable and the rest of the week much better as most Mainlanders had been sent back to where they came from. On Memorial Day afternoon, I managed to drive a huge splinter into my foot, which meant medical intervention. Fortunately, the Island has a Medical Center, and I found it staffed. In the end, I was able to get around well enough for the rest of the week. My doctors here found yet more stuff in my foot, so recovery took longer than it might have.
What made the whole situation interesting is that we had come over on the Point Judith ferry on Memorial Saturday, and, as usual, read the latest issue of 'The Block Island Times'. This is a weekly tabloid, and the huge headline read 'Dr. Clark Resigns'. At the time, on the ferry, the drama was amusing, but of no concern to us. Boy howdy, was I wrong about that!! Since then there have been many twists and turns in the saga of Dr. Clark, the Medical Center, and the controlling Block Island Health Services (BIHS). You can follow it on the site, if you wish. Which, of course, I have since I've got some skin in the game. So to speak.
In short order, the clear dysfunction led me to send a letter-to-the-Editor at the Times. He replied asking for some additional information, but I had by then concluded that a Mainlander's view of the issue might not be welcome, so asked him to spike it. But, of course, as more reporting (news, editorials, letters) appeared in yet later issues, I took to the keyboard and composed a longer and more specific missive (more than one draft, as more news poured out). No response from the Editor this time. Didn't surprise me. So, here is the bit relevant to this missive:
None of the reporting since Memorial Saturday has spoken to the principle issue: health care for a community of the size and isolation of Block Island will only work if it's run as a community service. Based on reporting, some number of Islanders consider the Board to be the problem. Others say that the Medical Center should prioritize PCP services. Well,
"We don't physically have enough bodies on the island to make up for the deficit," said Miller. "If you only have 800 to 1,000 people on-island, you will only see them once a year if they're not sick. You can't bring them in for nothing."
-- Times 2/2/14
So, clearly, at one time the conflict between serving Islanders and getting revenue from Fumbling Mainlanders was understood.
The conflict boils down to: who should control? Clearly, the town government provides substantial funds, but, once again based on reporting, has little to no say in the running of BIHS/Medical Center. Why? Islanders must know how the arrangement was consummated in 1989 ceding control. Reading the latest financial report, I didn't see any numbers delineating the split in revenue between Islanders and Fumbling Mainlanders over the year. But I think it fair to guess that we Fumbling Mainlanders manage to get into all sorts of predicaments both at a higher rate and simple count, given the widely asserted number of 20,000 of us per day during High Season. Naturally, this last visit was the only one even near High Season; way too many Fumbling Mainlanders. (Yes, I get the irony.)
Health economics has been a sub-specialty of the field for some time. According to the wiki: "A seminal 1963 article by Kenneth Arrow, often credited with giving rise to health economics as a discipline, drew conceptual distinctions between health and other goods." One of the differences between health and other kinds of production is that is largely fixed cost. In the case of my injury, the direct costs were:
- a disposable scalpel
- some gauze
- some lidocaine
- some latex gloves
- a tetanus booster
- and, eventually, some antibiotic (turned out that more splinter was left in)
So, of course, as I was polishing and editing the fourth iteration of this missive, The Editor publishes the story about the 'slipup' with the multiple Stovers. Which, of course, led me to look up as much history of Mr. Stover as the innterTubes provided. Of particular interest was his later rebuttal of financial shenanigans. As you can see from the latest (calendar 2016, in innterTube territory) BIHS financial report, direct costs of service are a minuscule part of the income statement at $37,249.34 (line 5650-30 Medical Supplies) from a total expenses of $907,309.75; given the number of patients times the consumables in my case, that number is well within the ballpark. The rest, or vastly most, of expense is fixed cost. Note also the %39.000 in depreciation, which is a non-cash item, or should be. With a patient load of 5,126 (page 1), direct cost of service works out to $7.27 per patient. It is likely that fully 5,000 of those visits were Fumbling Mainlanders. As you can see, it's an overwhelmingly fixed cost operation. With such a structure, the only way to reduce *total average cost* per patient is to run as many patients through the system as possible, spreading all those fixed costs as thinly as possible. There aren't enough Islanders to pull that off. Fumbling Mainlanders to the rescue!! You're welcome. If this back of the envelope analysis, dependent as it is on sparse innterTubes available data, comes as a surprise to anyone, well...
In all, likely less direct cost than the co-pay for my insurance. I don't know, and may never, how much my insurance paid the Medical Center, but nearly all of that reimbursement went to pay down the fixed costs of the Medical Center. Unless the staff are paid on a piece work basis ($X per patient, scaled by severity of condition) even labor costs are fixed. Well, until someone gets canned? :) The point, of course, is that Fumbling Mainlanders have to be the largest source of revenue, or second behind the town contribution/memberships. Yet neither Fumbling Mainlanders nor the town have any control over the Medical Center.
Here on the mainland, within some limits, folks can change providers if they become dissatisfied. I suppose (and was likely true before the current regime existed?) Islanders could hop a plane to Westerly in an emergency or take the ferry for scheduled appointments. Having a PCP practice on-Island is clearly of benefit to Islanders. But it can't be funded just by Islanders on an out of pocket fee-for-service model. Early this year I asked my PCP (he has a few others working for him), just for yucks, how many patients he carried. He said 2,000. An HMO just for Block Island?
In sum, health services on the Island is a public good, not like a tee shirt concession. It is a monopoly that is currently unregulated. Staffing is at the whim of, by all reporting, one person. It is funded largely, if not almost entirely, by the town and Fumbling Mainlanders such as myself. Does this make any sense to anyone?
So, how does fixed cost dominant production survive? And the answer is: make it up on volume. The three days of Memorial weekend demonstrated how stupid Fumbling Mainlanders are on the narrow pavements, crossing in front of vehicles and riding bikes and mopeds into traffic. It's a wonder that there's not a death every day during High Season. Or is there...? There can't be 'more' health care for Block Islanders without more Fumbling Mainlanders' insurance coverage being billed. Or just go all socialist by having the Town government take over the Medical Center and BIHS. Or less stringently, putting BIHS under closer regulation. Which seems to be ignored by Islanders. Some times 'more' requires changes.
Which brings us to Second: 5G smartphones. Will there ever be 'more' than 4G/LTE? Not likely, most places. First off, what does 5G mean? The telecoms are baiting and switching like mad over the very definition. 'Real 5G' is in the microwave bands and higher, while 'Fake 5G' just uses an extension to LTE bands. mmWave transmission goes almost no where. Even humidity deflects it. Will there be 'real 5G' outside a few metro areas? Nope. And even in metro areas, inside use will work only with some expensive tweeks. As Barnum said about suckers.
And now, hot off the press, Third: Netflix going all marginal cost in India.
Netflix customers in India watch a higher percentage of videos on their phones than anywhere else in the world, and a greater proportion of Indian customers sign up to the platform via mobile than any other country, Ajay Arora, Netflix's director of product innovation, said Wednesday.
"We want to really broaden the audience for Netflix, want to make it more accessible, and we knew just how mobile-centric India has been," he told reporters in New Delhi.
The push to widen its audience in India, which now has more smartphone users than the entire population of the United States, comes a week after Netflix reported lower-than-expected subscriber growth.
This is exactly the behavior of a producer with high fixed costs: do anything to attract revenue that's greater than the marginal/variable cost of the next widget, thus amortizing a bit more of that fixed cost burden. For the likes of Netflix, that variable cost is indistinguishable from zero.
It's not nice to fool Mother Nature.
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