But after your appendectomy, and after your angioplasty, and after your chemotherapy, this is when modern medicine, with this idea of coming in, fixing what’s broken, falls down. And what I learned at Laguna Honda is, when I used both models together, first fast and then slow medicine, the patients did the best. They did remarkably well. Many of them were actually able to go home, sort of unexpectedly.
And during the 20 years I practiced medicine, while I was practicing medicine at Laguna Honda, we eventually got discovered and our halcyon days of having enough time began to disappear. And, first by health care efficiency experts, who showed up one day, walking through the place and horrified to discover the aviary, and the greenhouse, and particularly the open wards. And the Department of Justice finally, eventually, showed up and told Laguna Honda that they were going to have to tear the place down and rebuild a new health care facility, that had private rooms for all of the patients, rather than keep the patients on the open wards.
And at that point, I decided to take some time off and write a book about what I’d seen there. That was my first book. And also to think about what I had seen so far in my life as a physician. It seemed to me, when I thought about, that in my life as a physician, the pendulum of health care had swung from the personal to the efficient. And I have been more and more impressed by what that leaves out.
So, for instance, the results of the kind of health care efficiency we’ve had over the last 20 years, as you can see, is that health care costs have kept rising no matter what health care economists have tried to do. They’ve tried to do all kinds of schemes for getting a hold of health care. And this is not true just in the United States, but across the world. Health care costs keep rising every year, despite DRGs and HMOs, and managed health care systems, everything we’ve tried.
Trying to understand what was going on in the system as a whole, I decided to look at Laguna Honda specifically and ask myself, what had gone on there in the last 20 years? So I figured out that in the last 20 years, as a cost-cutting measure, the patients we had, had gone from about 1,178 down to 780. This was as a cost-cutting measure. So we were taking care of a lot fewer patients.
Of course, correspondingly, the number of doctors we had went down, was cut, from 32, to nine. And, correspondingly also, the clinical staff, that’s the nurses, and the therapists, and the social workers, was also cut as a cost-cutting measure, from about 15,000, to 1,200. And yet, at Laguna Honda, every year the budget has increased.
So I asked myself, well, what counted for that? And I realized that even though the patients were fewer, and the doctors were considerably fewer, and the clinical staff had been cut, the total staff was actually the same. There were more and more administrators every year. What did all those administrators do, I asked myself? Well, what I realized was that, when I thought about it, that the one thing we had more of at Laguna Honda at the end of my time there, than at the beginning of the time, were forms. So when I first got there, we had paper charts. And we had two single-page forms in the chart.
And the day before I left Laguna Honda, I pulled out one of the paper charts just randomly. And I started looking through it. And I counted how many forms that were. There were 43 forms in that chart. And none of them were single-page forms. They were 10 page, 20 page. There were so many forms that the charts would explode from the forms. And medical records had to show up and thin out the doctors’ notes. And this, to sort of clarify things, because I do have somewhat of a mathematical mind, I created this chart at the time when I was figuring this out OK, now this is working.
So this is a chart I created at the time on a napkin, as Becca pointed out the other day. So these are the patients, going down, I was trying to understand this system. There are the doctors, going down. There’s the budget going up, the clinical staff, the total staff staying about the same. And this is the number of forms. And what I realized is, is that if current trends continued, by 2024 there would be no patients at Laguna Honda. There would be two doctors. There would be a staff of 1,400, a budget of $275 million, and an infinite number of forms. And I began to think of this as doing less with more.
And the thing that’s interesting about it is — and crucial about it — is exactly the same as the thing that’s been happening in the country as a whole. Let me show you what I mean. So this is the country as a whole. So if you look at the growth of its physicians and administrators, here’s what you find. So I’ll interpret this a little bit for you.
These are the number of docs, percentage growth. So it’s about doubled. So the docs have about doubled, in tandem with the population has about doubled. So there’s about the same number of docs per patient, and vice versa, as there always have been. The yellow is a number of administrators. There are 35 times as many administrators as there used to be. And as you can see, just like Laguna Honda, the budget has continued to go up every year. And what do all those docs do? What do all these administrators do, I should say? Well, this just is interesting. This is HHS paperwork. Really, they should say electronic computer work, in millions of hours, millions of hours.