HL 6 Incentives

6 Incentives
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The Prime Minister and the paramedic: The pitfalls of imposing tidy targets on a messy world

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Ttttttttttttttttt

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Tony Blair was eager to improve the performance of the National Health Service.
Note:MEROTOCRAZIA

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introduced a system of targets to hold NHS providers accountable.
Note:TRASPARENZA E INCENTIVI

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when patients called their NHS doctor, they would be given an appointment within forty-eight hours.
Note:ESEMPIO...MEDICI DI FAMIGLIA

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doctor refused to book a follow-up appointment in a week’s time.
Note:IL PROB DEL FOLLOW UP....TELEFONARE X OGNI APPUNTAMENTO

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A doctor could maximise her chances of hitting the forty-eight-hour waiting target by keeping her appointment book clear.
Note:IL TRUCCO

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Every advance booking was a potential obstacle
Note:L AGENDA ORDINATA É UN OSTACOLO

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patient had to call the clinic, wait on hold and hope to get through – on a day-by-day basis.
Note:L BINCUBO DELLE CHIAMATE COME MEZZO X HIT THE TARGET

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the quality of service was falling
Note:OBBIETTIVO CENTRATO A SCAPITO DELLA QUALITÀ....MERITOCRAZIA E QUALITÀ

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1763,
Note:ALTRA STORIA

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Johann Gottlieb Beckmann assembled a team of workers.
Note:IL PROTAGONISTA...MAPPATORE DI FORESTE

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The men were trying to count and assess every tree they passed.
Note:MAPPARE LA FORESTA

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Forests are messy.
Note:INTRICO

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It’s difficult to count trees, or compare one tree to another as a potential source of wood,
Note:PROIBITIVO

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the better they comprehend the world, the better they will be able to control
Note:L IDEA CHIAVE

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The trouble is that when we start quantifying and measuring everything, we soon begin to change the world to fit the way we measure it.
Note:IL GUAIO...PIÙ MISURI PIÙ MODIFICHI X RENDERE TUTO PIÙ MISURABILE

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The foresters lined up the rows to make the forests easier to survey,
Note:LA DEGENERAZIONE SUCCESSIVA

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The forests eventually came to resemble the neat abstractions
Note:LA MAPPA È IL TERRITORIO

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the local peasants lost out – they were no longer able to access fallen trees for firewood, saps for glue, medicines and firelighters,
Note:IL CAPRO

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since these resources had never been registered in the first place, whatever the peasants lost did not officially count.
Note:IN BILANCIO

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top-down affair,
Note:DUE STORIE TOP DOWN

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simply having a way to count things can be enough to trigger an arms race.
Note:ALTRO DIFETTO DELLA CONTA

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Apgar score.
Note:ALTRA STORIA

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after a baby is born a nurse or obstetrician can, at a glance, give it marks out of ten for whether it seems to be thriving.
Note:UN OCCHIATA X STABILIRE LO STATOK DI SALUTE

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two points for being pink, two points for crying, two points for a brisk pulse
Note:APGAR SCOR

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Virginia Apgar,
Note:SCOPRITRICE NEL 1950

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quick and convenient,
Note:CARATTERISTICHE

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Apgar score ‘turned an intangible and impressionistic clinical concept – the condition of a newly born baby – into a number
Note:NUMERIFICAZIONE DELLA SALUTE

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Doctors, a competitive bunch, wanted to improve their scores.
Note:ARM RACE

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‘They both want solutions that will lift the results
Note:TEACHING TO THE TEST

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Demanding procedures such as the use of forceps gave way to the more predictable use of the caesarean section,
Note:IL CESAREO SQUARTA MA È MENO IMPEGNATIVO

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Done well, the forceps delivery can spare the mother a major piece of surgery.
Note:Cccccccccc

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tidy, one-size-fits-all approach,
Note:CESAREO

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C-sections are now used in almost a third of all deliveries in the United States,
Note:RISULTATO

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medical experts believing that only 10–15 per cent of deliveries require such operations.
Note:EPPURED...33 vs 10

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once a simple score becomes available to the factory managers.
Note:I GUAI

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Nudging doctors into performing C-sections was surely not what Virginia Apgar intended.
Note:UNINTENDED

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1990s,
Note:ALTRO CASO...QUANDO

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New York and Pennsylvania
Note:DOVE

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a system of ‘report cards’, publicly disclosing how patients were faring at the hands of particular surgeons and hospitals.
Note:COSA INTRODUSSERO...DARE UN VOTO AI TRATTAMENTI

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designed to inform patients
Note:SCOPO

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assumption that patients will choose the physicians they prefer,
Note:ASSUNTO...SCELTA INFORMATA

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reward the skilled, punish the incompetent
Note:SCOPO ULTIMO...MERITOCRAZIA

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there are many ways to win a game
Note:PURTROPPO

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David Dranove, Daniel Kessler, Mark McClellan and Mark Satterthwaite,
Note:GLI ECONOMISTO CHE STUDIARONO L IMPATTO

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Surgeons were avoiding operations on seriously ill patients, preferring to operate on patients who did not need surgery at all.
Note:IL VERO EFFETTO

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who wants to operate on a very sick patient who may die
Note:LOGICA FERREA

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pushed surgeons into performing more expensive treatments, but patients were sicker as a result.
Note:CONCLUSIONI

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healthcare is usually heavily regulated, and offers apparently clear outcomes (How long must I wait? Will I die?)
Note:XCHÈ MOLTI ESEMPI VENGONO DALLA SANITÀ?....POCA CONCORRENZA E ILLUSIONE MISURABILITÀ

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U.S. News & World Report website ranks the best colleges in America.

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ALTRO CASO

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how selective a college is
Note:UN PARAMETRO

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Northeastern University in Boston,
Note:GAMING

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increase the number of applications it received.
Note:PIÙ ACCESSI X AVERE PIÙ BOCCIATURE

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the Research Excellence Framework, which is designed to measure the quality of academic research
Note:ALTRO ENTE IN UK

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department could get credit for research conducted by an academic on a part-time contract that demanded only 20 per cent of full-time hours.
Note:PARAMETRO

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in just two years, UK universities had increased their recruitment of staff on 20 per cent hours by nearly two thirds.
Note:OVVIAMENTE

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international development,
Note:LTRO SETTORE

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Millennium Development Goals
Note:WISH LIST

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to halve the extreme poverty rate in every country around the world.
Note:OBBIETTIVO

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country such as Bulgaria or Mexico,
Note:FACILE....LA PIVERTÀ ESTREMA ERA SOLO IL 2%...BASTAVA SCENDERE DI UN PUNTO

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in a destitute country
Note:PAESI A POVERTÀ ESTREMA DEL 20%....BISOGNAVA SCENDERE DI 10 PUNTI

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an incentive to funnel money away from the countries with the most serious problems.
Note:EFFETTO XVERSO DEL TARGET

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On the Folly of Rewarding A, While Hoping for B’.
Note:ARTICOLO SEMINALE DEL 1975 CHE AFFRONTA QS PROBLEMI

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Why not simply set the right target?
Note:DOMANDA INGENUOTTA

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In 1995, Peter Smith,
Note:ELENCO DEI MODI IN CUI LE COSE VANNO MALE

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targets tend to be simple, while the world is complicated.
Note:PRIMA DIFFICOLTÀ

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bus driver who is rewarded for sticking to the timetable, and who keeps on time by driving past lines of passengers without stopping.
Note:ENNESIMO ESEMPIO

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This results in short-termism, where long-term investment is sacrificed in order to hit a short-term target.
Note:DUE...SHORT TERMUSM

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a manager can skimp on training or maintenance, or just squeeze pay. In the short term, profits will rise; in the long term, the company will suffer.
Note:ESEMPIO CANONICO

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Sometimes a target reflects yesterday’s problems, not today’s.
Note:TERZO

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world tends to change faster than bureaucracies can keep
Note:PURTROPPO

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Imagine a company with a target for resolving queries from customers who phone the call centre, but no target for dealing with a problem using the web.
Note:ESEMPIO

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lying and cheating.
Note:4…I TSRGEY SONO AGGIRABILI

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The family doctors who refused to take advance appointments were gaming Tony Blair’s target;

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ESEMPIO

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designed to improve how ambulance services responded to emergency calls.
Note:UN TARGET MEMORABILE

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ambulance service had eight minutes to get to the scene.
Note:SE UN CASO URBANO È IN CODICE ROSSO

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The most obvious was the outright lie.
Note:PRIMO ESPEDIENTE...E CHI TI CONTRADDICE?

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graph starts to rise sharply at 7 minutes and 50 seconds, reaching implausibly high levels at 7 minutes and 59 seconds,
Note:GRAFICI TUTTI DA RIDERE

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8 minutes and 1 second.
Note:A PICCO

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‘within eight minutes’ turns out to be a poor substitute for ‘as soon as possible’.
Note:IL PROBLEMA

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The logic of the target dictates that the ambulance should now be rerouted to a patient who has not yet breached;
Note:SE DURANTE IL TRAGITTO SFORO MEGLIO RINUNCIARE PROPRIO

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Another serious piece of gaming involved the definition of ‘life-threatening’
Note:ALTRO PROB

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The target gave services an incentive to say that a call wasn’t urgent
Note:TUTTI CODICI BIANCHI

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Two paramedics in a single ambulance could be split and put on to motorbikes or even bicycles. That makes it more likely that a paramedic will arrive within eight minutes,
Note:TRUCCHI...VIAGGIARE SEPARATI SU PIÙ MEZZI

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Ambulance crews complained that rather than being based at the hospital, they were being sent out in their vehicles to face an uncomfortable
Note:CONSEGUENZE DI SHORTERMISM

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Patient care in the short term may have improved, but the crews’ morale suffered.
Note:Ccccccccccc

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managers relocated ambulances to urban areas, where the targets were tough to hit, from rural areas, where the targets operated differently. The target wasn’t designed to favour cities over the countryside,
Note:ALTRA XVERSIONE

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to lie about the stopwatch, to reclassify urgent cases, to put ambulance crews in vehicles that weren’t ambulances, to pull staff out of rural areas, to risk the health and morale of their paramedics, and to celebrate all of this as having hit their target.
Note:SOMMARIO

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to make the targets more sophisticated,
Note:UNA POSSIBILE SOLUZIONE

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financial regulations
Note:ESEMPIO

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Basel I.
Note:1988…PRIMO ACCORDO

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setting a minimum threshold for how much capital the bank should have.
Note:CAP REQ

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it did not do justice to the fact that different banks take very different risks.
Note:IN TEORIA DOVREBBE FARLO IL MERCATO

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a bank that lends $100 million to a Silicon Valley start-up is taking much more risk than a bank that lends $100 million to the US government.
Note:PRIMO PROB

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five different categories of risk,
Note:PRIMO INTERVENTO...DIVIDERE I SETTORI

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five categories of risk weren’t enough;
Note:MA IL REGOLATORE COMPRENDE L I SUFF

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Banks would seek out investments that the rules defined as boring and safe, but which banks themselves knew were exciting,
Note:I MODELLI DELLE BANCHE SONO SOFISTICATISSIMI RISPETTO AI ROZZISSIMI MODELLU DEL REGOLATORE

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a series of regulatory upgrades were published in 2004,
Note:X TAMPONARE...NASCE BII

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While Basel I had been just 30 pages long, Basel II was 347 pages
Note:LA COSA SI COMPLICA

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The most complicated financial stability agreement in history was promptly followed by the most complicated financial crisis in history.
Note:IRONIA?

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what kind of asset had zero risk on paper, yet paid a fat return to investors? The answer: Greek government bonds.
Note:L ACCORDO GOVERNATIVO PRIVILEGIA I GOVERNI

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European Union banks were allowed to lend money to European Union governments
Note:Ccccccccc

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So, catastrophically, banks could borrow huge sums and lend that money to Greece, which was risk-free on paper but (curiously) paid a hefty return.
Note:Cccccccccccccc

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Basel rules encouraged banks to seek out all the places where the rules seemed to be wrong
Note:CFR TASSI ELEVATI E RISCHI DI CARTA BASSI

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safe-on-paper assets encouraged complex financial engineering, producing theoretically safe investments on the back of highly risky subprime mortgage lending.
Note:CONSEGUENZE DEL RISCHIO DI CARTA

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Rather than competing in a natural way, investing in real projects all over the world, banks tended to try to squeeze through the same loopholes – lending money to Greece, buying subprime derivatives
Note:ADDIO DIVERSITÀ...UNA REGOLA UNA STRATEGIA PER TUTTI...CONCENTRAZIONE DEL RISCHIO

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the post-crisis Basel III
Note:SI È RIMEDIATO AI PROBLEMI

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twice as long as Basel II,
Note:SEMPRE PIÙ CASINO

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Dodd-Frank Act in the United States)
Note:ANCORA PIÙ INCASINATO

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making targets more complex doesn’t stop them being gamed
Note:LA LEZIONE DI BII

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gamed in more complex and unpredictable ways.
Note:Cccccccc

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what if these ever more refined attempts to quantify risk were useless – or worse?
Note:LA DOMANDA DI ANDY HALDANE

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every single way you sliced the data, the highly rational, hyper-quantified risk management methods were less effective than a crude rule of thumb: ‘Beware indebted banks.’
Note:LE CONCLUSIONI DI H

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Rules of thumb like Haldane’s have proved surprisingly effective
Note:MEGLIO I PRINCIPI...ANCHE SE GENERICI

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simple heuristics
Note:OPPOSIZIONE DI 1…

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complex decision rules
Note:…2

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Avalanches
Note:ESEMPI...PREVEDERE LE VALANGHE

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snowfall, temperature, slope shape and other factors.
Note:FATTORI RILEVANTI

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‘obvious clues’ checklist,
Note:METODO A SPANNE...FACILE DA MEMO

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have avalanches been reported in the area in the past forty-eight hours?
Note:PRIMA DOMANDA

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Does the surface of the snow show signs of melting?
Note:2

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Has there been a new snowfall or rain shower in the past forty-eight hours?
Note:3

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how much it relied on borrowed money rather than its own capital.

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UNICA DOMANDA X LA CRISI BANCARIA

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If the patient is in the early stages of a heart attack, they need to go straight to a specialist coronary care unit. But that is expensive, possibly dangerous – since hospitals are a breeding ground for drug-resistant infections
Note:ALTRO E...COME GIUDICARE UN FORTE DOLORE AL TORACE?

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researchers responded by putting together a complex diagnostic guide: a table of probabilities,
Note:IL CONSIGLIO DEI RICERCATORI X GIUDICARE UN CASO

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run some tests, consult the table, tap the numbers into the calculator and thus produce an estimate
Note:CASINO..

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the guide was too complex
Note:IL PROBLEMA...I DOTTORI TRASCURANO

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Lee Green
Note:L ALTERNATIVA

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tree asks three yes/no questions:
Note:DI COSA PARLIAMO

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does the patient display a particular anomaly on a heart monitor?
Note:1...SE SÌ AL CORONARICO DI CORSA

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is the patient’s main complaint about chest pain?
Note:2 SE NO A CASA

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if so, then a third question tells the doctor to look for one of five obvious clues – any one of them is enough to send the patient to coronary care.
Note:SE SÌ...

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it seems to work better
Note:CONTROLLO

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generating fewer false positives than the diagnostic. More important, it saves time and effort in an urgent situation
Note:I PREGI

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it gets used.*
Note:MA SOPRATTUTTO

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when we set aside money for a pension.
Note:ALTRO PROB

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Harry Markowitz, worked out a sophisticated method for selecting the optimal financial portfolio,
Note:NEL 1952

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you buy shares in an umbrella company and a maker of sunglasses, you will be fine in all weathers.
Note:IL SEMPLICE PRINCIPIO....X I DETTAGLI VINSE IL NOBEL

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put half of his money in stocks and half in bonds.
Note:....E IL PORTAFOGLIO DI MARKO?

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economic theory is far too sophisticated
Note:LA LEZIONE TRATTA DA MOLTI

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Markowitz the small investor was right all along; it was Markowitz the Nobel-Prize-winning theorist who was wrong.
Note:IRONIA NELL IRONIA

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while history is some guide, it’s not perfect – especially not when estimating the likelihood of rare events.
Note:IL METODO SOFISTICATO...TUTTO CENTRATO SULLE SERIE

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Markowitz’s rule of thumb
Note:MIGLIORE IN ASSENZA DI DATI

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anything less than five hundred years’ worth is probably limited enough to tip the balance in favour of the simple rule
Note:COSA INTENDIAMO X DATI LIMITATI?

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The problem here is known as ‘overfitting’ – what happens when a detailed statistical analysis slavishly follows historical data.
Note:IL PROB DI MARKO COME DI BASEL...SEGUIRE PEDESTREMENTE IL PASSATO

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‘How many patients can get an appointment in forty-eight hours?’ is probably a good rule of thumb for judging the overall quality of doctor surgeries that don’t know they’re being judged on it.
Note:TARGET SCONOSCIUTO

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But as soon as we formalise a rule of thumb into a target, it becomes a source of distortion.

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LA MELEDIZIONE DELL UFFICIALITÀ

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You study for months, or years, knowing that only a tiny fraction of the knowledge you’re accumulating will come in handy
Note:LA SOLUZIONE È BEN NOTA AGLI STUDENTI

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impossibilizing the knowledge’ of how to game the examination.
Note:LA VAGHEZZA DELL ARGOMENTO DELL ESAME

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The answer is neither the weighty rulebook of Basel nor one simple rule of thumb. Instead, we should be defining many rules of thumb and deliberately leaving it ambiguous as to which will be used in any given situation.
Note:CONCLUSIONE

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for each assessment, the regulator would choose a few measures at random
Note:RANDOM

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‘stress test’.
Note:ALTRO ESEMPIO DI ESAME NOTO A PRIORI

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These tests are too predictable, however,
Note:Ccccccccccccc

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the stress test has to be unpredictable.
Note:RIFORMA

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if the timing of the test is deliberately vague, so is the punishment.
Note:VAGHEZZA A TUTTO CAMPO

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Andy Haldane isn’t the only person to argue for randomness in targets.
Note:ANCORA HALDANE

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Gwyn Bevan, has made much the same case
Note:IN AMBITO SANITARIO

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embrace the constructive ambiguity of randomly timed tests of arbitrarily chosen areas,
Note:INVOCAZIONE

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One possible concern is that ambiguous regulation could give too much discretionary power to the regulator.
Note:PRFOB UNO

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A more cynical explanation is that regulators themselves often have a conflict of interest that gives them the perverse incentive to create a system that can be gamed.
Note:PROB 2

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Perhaps the simplest reason, though, is our general fear of messy ambiguity.
Note:PROB 3

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In September 2015, Volkswagen,
Note:BECCATA AD IMBROGLIARE

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The tests are tough and the standards are high. But the tests are also absurdly predictable
Note:COME È STATO POSSIBILE?

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But the real scandal is not that VW found a way to cheat a predictable test. It is that the regulators kept the test so predictable
Note:UN TEST CHIARO E CONOSCIUTO....TI DICO GIÀ COSA TI CHIEDO

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VW was not caught because the EPA introduced yet more predictable rules. It was exposed when a non-profit group, the International Council on Clean Transportation, looked into the emissions of VW cars.
CHI HA BECCATO VW?