Friday, October 26, 2007

Efficiencies of Scale

I just got off the phone from a survey about my healthcare insurer/provider, and it left me thinking hard about what we today call “efficiency”. Over and over again, I hear that it saves money and time to gather services into large, “efficient” units, to “standardize procedures and outcomes” and generally impose more rules and details into everyone’s lives. Now, that might have been true at the start, but shall we look at it more closely? To start with the healthcare provider: someone (from somewhere among the multi-levels of “management”) had to decide to give this survey, someone(s) else had to create it, another to test it for accuracy, and then a sub-contractor has to give it to hundreds of patients… to find out how they are doing, because the actual product has now become so far removed from those deciding what to produce that they can’t even see it with a telescope.

Instead of going to your local doctor, whom you knew because he/she lived in your town and had the office in his/her house (no, that is not a myth - I grew up that way and I’m only just going gray), you stand on line in a clinic the size of Macy’s and put your little plastic card in some holder for some clerk to scan and find your record in some computer system that has taken several years to create and takes several fulltime programmers to maintain. Before: 1 doctor, maybe one part-time clerk; Now: a staff of hundreds, a parking lot the size of Rhode Island, more paperwork than would fit in the New York Public Library -- and still there’s not enough staff to actually give you a decent answer.

Or another example: it is more “efficient” to have hog farms the size of the Woodstock Festival (I wonder why that came to mind?), trucking in thousands of pounds of feed every month (week?), generating enough toxic (though mostly organic) waste to fill Lake Mead (no joke: “In 1995 an eight-acre hog-waste lagoon in North Carolina burst, spilling 25 million gallons of manure into the New River. The spill killed about 10 million fish and closed 364,000 acres of coastal wetlands to shellfishing“ -National Resources Defense Council), fouling the air around the farms such that the poor victims - er, neighbors -- have to get air filters, or seal themselves into their houses, or move… (more disturbing facts from the NRDC: “Large hog farms emit hydrogen sulfide, a gas that most often causes flu-like symptoms in humans, but at high concentrations can lead to brain damage. In 1998, the National Institute of Health reported that 19 people died as a result of hydrogen sulfide emissions from manure pits)…. than to have a hundred hogs that require about 140 lbs of soybean meal each for their whole lifespan (my best guess from highly technical online jargon), generate just enough waste to manure the local fields (thus making it a benefit rather than a toxin), do not require antibiotics because they’re not crammed in like NYC subway riders, and need only a moderate size truck (versus a convoy) to take to slaughter… where’s the savings, exactly? Okay, you have to come up with 99 fewer hog farm names, but otherwise…

I think when they talk “efficiencies of scale” they are not at all taking into effect the several added layers of supervision, organization & planning, survey-taking, rule making and printing, network maintaining and just plain getting-lost-in-the-systeming that the modern behemoth system takes these days. How can it possibly be more efficient to spend half of every work day just filling out papers saying what you’ve not had time to do?? (And trust me, in the mental health system, that’s where it’s gotten to). This is barely touching the surface, but since I’m not striving for efficiency, this will have to do for today. By tomorrow I'll figure out why healthcare and hog farms seem linked in my mental train of thought...

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