NATIONAL LIBRARY OF MEDICINE


                         REGIONAL MEDICAL PROGRAMS
                               Bethesda, MD
                             December 6, 1991

                                Session III

                               [Video shown]

Lindberg:  My friend Charles Flagle uses the metaphor of John Le
Carr 's novel The Looking Glass War.  For those of you who know
it, it's about a bunch of old warriors who reassemble to set off
on a picturesque mission.  I hope we don't fall in that category,
but Charlie tweaks us every once in a while with that thought.    
   I won't delay further.  I've said enough about Vern Wilson
already.  He is going to head the next panel.  The panel will be
focused on, but doesn't have to limit its attention to, the
question, "How did RMPs get terminated?"  Dr. Wilson.

Wilson:  I don't know whether I should introduce this as the
Missouri Mafia Programs, since we have the director of the
library, but I think I won't.  [General laughter]  I have
thoroughly enjoyed the opportunity to both see all of these folks
and to relive some parts of the RMP program, kind of like a
flashback in time, or maybe more appropriately it's sort of a
computerized window in which we're examining one part of
something that is at least officially completed.  
     Our task in this panel, if we can accomplish it, is to
provide a post mortem analysis of the body, and we won't bother
to eulogize the program.  We could take all the time in the
afternoon and probably not accomplish much by that.  
     Karl Yordy, of course, will draw the conclusions.  He's the
pathologist.  So we don't have to interpret what we find.  We'll
simply restrict ourselves to looking at some of the causes.  The
film was excellent, and I'm not sure that we can make major
contributions beyond that, but we'll at least share what we know. 
      Dr. C.H. William Ruhe and I go back more years than I like
to think.  During the time that he was involved with RMP, he was
secretary to the Council on Medical Education and he was chairman
of the Review Committee of RMP.  My guess is that if anyone could
give us the history of RMP, both in its rise and fall, Bill's
probably it.  I threatened him by giving him the whole time and
the rest of us would just sit still, but I guess I can't quite
take that much latitude.  
     Dr. William McBeath I have not really had the opportunity to
meet, who was coordinator of the Ohio Valley Regional Medical
Program and represents the trenches.      Herb Pahl, who will be
doing some of the questioning, was a fine commissioned officer,
served with distinction.  He took over the program from '73 to
'75 and got the task of being the funeral director, or whatever,
as the program kind of winded into oblivion.
     Gordon Barrow, who is also going to comment, was coordinator
of the Georgia program.      My comments, I think, will be
restricted to only one or two.  The Missouri program has been
described, so I'll not describe that further.  Buck has covered
that.  HSMA, I think we need to spend just a couple of minutes on
because it's been loosely addressed, usually with epithets.  It
was a short-lived government program that was produced as a
result, really, of the decision by HEW to have no surgeon
general.  In that process they developed the tactic of producing
what was called HSMA.  Mental Health Administration chose to be
joined with HSMA instead of with NIH, and that's another story. 
But there were seventeen programs, each of which were in place
when I replaced Joe English as head of the agency.  That was the
second step from Bob Marston.  Those seventeen programs each had
a categorical responsibility and categorical appropriations.  All
of them were underfunded and, of course, the scene was set for
real competition for funds.        If one looks at the government
money spent on health, as I recall it, 85 percent of that
government money went into entitlement programs.  That's
Medicare, Medicaid, programs in which the money was spent and
Congress didn't have to act upon it.  That left roughly 15
percent of the health money for the rest of us to scramble for. 
In that setting, RMP did not have friends enough to politically
persist.        I'll drop my comments there.  I hope somebody
else disagrees, and I'm sure they will, but it seems to me that
one can encapsulate the problems of RMP rather simply into Cap
[Caspar] Weinberger and unfriendliness and the fact that there
was so much competition for funds. 
Ruhe:  First of all, I want to tell everybody how nice it is to
be here and see so many of you again.  If we haven't accomplished
anything else, it's probably been worth it for that.  I am
pleased to be here.  I think Vernon has moved me up in at least
one respect.  I was never chairman of the Review Committee in the
RMP.  I was a member of that committee from the beginning, I
think, to the end, and spent a great deal of time in activities
related to it.
     I don't know that I have any greater insight into the
problems than anybody else has.  In a sense, I was a token AMA
person on the Review Committee and in the discussions.  It was
always viewed wise to have somebody from AMA there, and I usually
got asked.  I'm not quite sure why.  Perhaps I was considered the
least noxious of the people.  But my first relationship came when
I was asked to work with the representative of our legislative
department to analyze the proposed legislation and, Vern, that
same time also the proposed legislation for CHP.  It was a
dreadful task.  It was almost impossible to tell what was being
proposed from the proposed legislation.  Knowing, of course, that
the basis for it was the report of the DeBakey Commission, we
went back and reread that and studied it again, yet we found in
some cases it was rather difficult to trace the commission report
to the legislation and connect the two.        But the point in
referring to this is to emphasize something I think has not been
emphasized enough.  I think it has been alluded to once or twice,
but I want to strengthen that by saying that the RMP program was
many things to many different people, and it was easy to find a
whole variety of views on what it was supposed to do.  This was
not only true out in the field before the planning grants were
organized extensively and the operational grants came on board,
but it was true in the staff as well.  There was, in fact, as was
related earlier, a feeling of excitement among those who were
working for the Regional Medical Programs, and many people moved
into that staff group from other areas in HEW.  I found in the
meetings frequently the attitudes of persons who had moved into
the program would differ from person to person.        On the
Review Committee, when we were reviewing both planning grant
applications and operational grants applications, it became clear
that in looking at what a given region was proposing to do, the
reactions to it were quite various on the part of both committee
members and staff members.  That was always puzzling because it
meant that there was not a single unified direction for the
forward movement of the total program.  That was partly
deliberate, as has been pointed out repeatedly, because the
intent was to allow the regions to initiate their own ideas and
to present them so that there would be a varied and diversified
program.  That's a good thing in some ways, but when it comes
time to call for unified support of a program like this, it's
difficult to marshal constituents unless they're all facing in
the same direction and to get behind a program.      I think that
the very variety and disparate nature of the individual programs
in the individual regions made it difficult to have a concerted
support posture.  I believe that if one wants to reduce this to
its simplest terms, I think you can say that the reason for the
demise was pretty much the reason for the establishment.  Both
were political in nature.  I don't mean this in a disparaging
way.  I'm not saying it in terms of the narrow sense of political
parties or even of individual political goals of individuals, but
rather in the broader sense of what was going on in society, what
was going on in the country at the time RMP was established. 
It's been mentioned that the RMP could be viewed as having been
the health part of the Great Society program of President
Johnson, and this, of course, was one reason for the great speed
with which it was launched.  As Mike [DeBakey] said earlier, the
president told him, "You can't take so long.  We have to get it
going and get it started sooner."  I think that gave it a
projectile force when it began, impelled it, and I believe that
the reception in Congress was partly favorable because of that,
because it was regarded as being urgent, and that was a good
thing.  But on the other hand, you always lose something when you
take that kind of position and that kind of approach, because,
again, you do not have everybody facing in the same direction,
everybody understanding what is being done, and having a chance
to sift and sort out the best parts of it from the less good and,
consequently, to get the kind of really community support from
the health workers that have them completely involved with it.    
 The program was imaginative in the sense that it was viewed as a
bright, new, exciting overture, a change in the way things had
been done, and an opportunity to strike a major blow at the major
killer diseases.  I think personally that it was oversold, but
that's the way political positions are often established and
programs are often oversold.  But it's always bothered me, Mike,
I'm sure I never mentioned it to you, but the commission report,
when it was issued, announced that it was to conquer heart
disease, cancer, and stroke.  I don't really think that many
people thought that this approach was going to conquer any of
these diseases, and as a previous speaker has pointed out, they
are still the leading killer diseases today, just as they were in
those days, although the numbers are somewhat improved.  
     So the program reaped some of the success of early
initiation of strong impetus, strong leadership from the
administration, supported pretty strongly by the Congress, and
yet at the same time there was no assurance that these forces
would endure for very long.  What happens with any bright new
shining program, I think happened here, in that the luster wears
off a little bit.  When an administration changes, obviously
there isn't much enthusiasm for improving funding of a program
that was started by a previous administration, and so it could
have just been allowed to die for that reason alone.  But I think
there was also a changing emphasis, as you recall, a major push
in the new administration toward cancer, to the point where it
was separated out in the government halls.  Consequently, that
was putting a different image on the major federal programs.     
The concept that this would eventually lead to demise of RMP, I
have no idea whether that was a target from the beginning or
whether it was simply a matter of trying to save money and this
was a natural target which had been established by previous
administration.  It was already beginning to lose its excitement. 
When one attempted to evaluate it, it was very difficult.  There
were two things that could be done.  You could count the number
of programs you had in the number of regions, and if you
evaluated it that way, inevitably it was going to get a very high
rating because eventually every region had a program.  If you
evaluated it on the basis of whether it conquered heart disease,
cancer, and stroke, it was going to get a very poor rating
because that was not going to happen.  
     In between, there were hosts of things that could have been
done and might have been done better.  I also had the opportunity
to serve on the committee which helped the surgeon general with
his design of the report to the Congress in 1967, I believe it
was.  The committee wrestled very hard with this thing, how to
evaluate something so disparate, so different in different
regions and in terms that the public was going to be able to
understand and in terms that the Congress would understand as far
as getting additional support was concerned.  This was before
anybody really thought that things were going to be phased out. 
The committee waxed fairly enthusiastic in its report, perhaps
more so than I would have personally, and it recommended
extension for five years, which was not done.  Support was
extended for three years.  Not unusual for that kind of thing to
happen.  But inevitably it suffered from difficulty in explaining
what was being done, what ultimately would be the goal.  What are
we working toward?  Are we working toward complete elimination of
heart disease, cancer, and stroke?  Are we simply working toward
the establishment of solid cooperative relationships in each of
the regions of the country?  That, I'm afraid, was not completely
understood.        Another thing which hurt a little bit was that
the programs had been channeled.  I think the AMA had something
to do with this, but it was not the only group, channeling a lot
of the energy into the subject of continuing education not only
for physicians, but also for nurses, for allied health workers,
for all health providers.  Many people seized on this and many of
the good things which came out of RMP were the result of
initiation and continuation of good, effective continuing
education programs.  But as inevitably happens in something like
this, when people begin to examine how much money there is and
what it's being spent for, the facts stuck in many people's craw
that the government was putting up money for the continuing
education of rich physicians who could easily afford to provide
their own continuing education.  That was seized upon and was one
of the bases of attack.  
     Whatever the reason, obviously the sum and substance was
that it made it a convenient target to shoot at and, of course,
the best way to hit that target or to bring it down is, I think,
to use the Rogers metaphor, is to strangle it, which it seemed to
me is what happened.  It was strangled by cutting off the funds. 
It doesn't really matter whether you gain the day in your
arguments or your justification if somebody at the same time is
shutting off your funds.  You're not going to live very long.  I
think probably that was the thing that happened.  While there
were some people in the programs around the country who were
annoyed and antagonized by this, some of them chose to fight it,
and those who entered the suit to recover the money which had
been not provided, the fact was that there was not a single
concerted effort by a large group of people who had effective
political power through their regions.  I don't know whether this
was never tried or whether it was done imperfectly or perhaps
thought of too late, but the relatively minor and--it's unfair to
call them trivial, but the ineffective things which were done to
fight it were never supported by a massive movement in the grass
roots.  Consequently, the issue was politically dead.
     The concept of combining RMP with Hill-Burton and CHP, when
I first heard about that, I thought, "That's the kiss of death,"
because you're tying it to two other things which have very
little to do with it.  The goals are different.  Hill-Burton
goals had been met.  There really wasn't much enthusiasm for
building more hospitals.  The CHP program, if anything, the
legislation was more difficult to read and understand than was
the proposed legislation for RMP.  In my contacts with at least
the practicing physician community, I don't think the medical
community ever understood the CHP legislation.  To put the RMP in
with it, instead of strengthening either or both, I think
weakened both.  I think it really resulted in the RMP being
killed.        Sorry to be so long, but that's the story as it
appeared to me.   
Wilson:  Thank you, Bill.  Dr. McBeath.

McBeath:  I'd like to begin by raising the name of Leona
Baumgartner, who was one of our distinguished colleagues among
the coordinators of Regional Medical Programs and one of our
colleagues who in recent years I've had opportunity to
occasionally have contact with.  She died a few months ago, but
if she were here today, she would repeat a chorus that she gave
to me two or three of those times about how important it would be
and what a contribution it would be if somebody would get
together some of those who were involved in RMP and look at its
history and some of its contributions, some of its life cycle. 
So Dr. Lindberg, I'm sure that she would be one who would be
commending you along with the rest of us today for having done
this.      It's probably appropriate at this time to issue some
disclaimer about the fact that certainly on this panel none of us
have not only not had any collusion, we haven't had any
communication about what we were going to say, and we follow this
great video which Bill Leonard and others have put together.  You
may see an awful lot of common strains in it that make you think
that somebody's plagiarizing.  But I came up with some of the
same kinds of conclusions in my thinking about the factors that
have influenced the termination of RMP as a national program.  I
emphasize "as a national program."  I found myself finding it
very hard, having been a coordinator of one program, to keep from
translating things that might have been unique to our situation
to the national scene.  
     I came up with three factors that I thought were important
enough to mention to this group.  One of them was the uncertain
programmatic focus, another was the inadequate program
constituency, and the final one was the changing political
context.  Those are themes that will not be new to any of you.  I
tried to force them, after I'd chosen them, into some kind of a
model or a metaphor or paradigm, maybe a death certificate.  You
know, immediate cause and contributing cause and mechanisms, or
maybe even more an epidemiological causal tree or something.  But
I thought of John Pahl's [phonetic] book about clinical
epidemiology, which was influential to me back when I started in
these games, in which he focused on seed, soil, and climate. 
Maybe with a little pressing, I pressed these three factors into
seed, soil, and climate, kind of a picturesque way of getting the
rather traditional triad of any ecological study.        I will
list them in that order, the way John Pahl did, of seed, soil,
and climate, but I think their importance is just inverse.  The
first having to do with the seed.  I think the uncertain
programmatic focus was something that persisted throughout the
life of RMP, and the lack of any consensus as to the purpose of
the national effort which we could uniformly communicate to
others, I think was a persistent nagging irritant to all of us. 
We seem to need, in retrospect, a more focused purpose that was
better able to be communicated and conceptually presented to a
large group of audiences that became important for not only the
planning and the implementation of the program, but for its
defense in its final days.        That focus, of course, had pros
and cons to it, and all of us who were coordinators certainly
used the advantages of such a diffusion of goals.  It's as if we
had a seed package that had a great variety in it, and we enjoyed
in each garden planting to beauty and to varieties that appealed
to our local needs.        I think, in looking deeper, the seed
might be better compared to hybrid seed, because, as has been
pointed out today, the nature of the changes that came as we went
from commission, as we went to legislation, as we went to
implementation, at least to my view, clearly carried forward two
major kinds of classifications that you could have made for the
seed.  One were those who wanted to focus and emphasize some kind
of system rationalization which they thought would bring the best
of care to all the people, and others who continued to want to
emphasize the categorical initiatives that were emphasized also,
most particularly the commission activity and continuing in the
legislation and implementation.
     I'm long removed from my rural grandfather who came from
Missouri, but I understand that a lot of hybrid seed doesn't
reproduce.  It makes a lovely produce, but doesn't reproduce.  I
am convinced that was one of the factors.  Among our friends, it
was okay.  It was always an advantage.  It was a strength.  But
among the skeptics, among the critics, and, in the end, among the
Congress and others, it was difficult to live with.        The
soil.  I use the soil as the constituency, the groups that we
wanted not only to benefit from RMP and to be involved in it, but
to nurture and support its continuation.  I don't think we really
ever had a strong, persistent, clearly identified RMP-specific
constituency, and the uneven kind of support that came about in
NIH and certainly in the PHS, and in the regions certainly some
of us experienced that diffusion, and in the Congress, where it
finally counted, I think we really were losing a constituency
that was effective in the Congress.        I would think maybe
it's because it's the one that I had least influence over, at
least the part of participating in, but the most important,
though, was the changing political climate.  There's been much
reference to that already.  The competition for the funds in the
Nixon administration was a dramatic change from what we'd seen
before.  
     When I really got to thinking about these, I changed my
topic that I had written here, "Factors influencing RMP's
termination," to "RMP's life cycle," because the political
climate, as we've seen and talked about here today, was very
instrumental in the generation of RMP.  The support of a Texas
president who had a great interest in new health programs was a
great, positive initiative in the initiation just as "Cap the
Knife" was in his termination.
     So I feel that the shifting ideological grounds are very
important today.  I could go on, but my time is probably about
up.  I'll close with a story which I think may be appropriate. 
There was this local politician who had been out celebrating till
too late in the evening and came home inebriated.  As he was
tiptoeing in to avoid detection, he tripped over an umbrella
stand and created quite a havoc.  The lights came on, and at the
top of the stairs appeared an irate spouse.  He looked up from
the floor and said, "I have decided to dispense with my prepared
remarks and take questions from the floor."  [General laughter]  

Wilson:  I don't believe that needs further comment, Herb. 
[Laughter] 
Pahl:  That's very good.  I represent that hidden part of the
agenda which says that there was a Washington contingent living
through all this catastrophic end.  I first want to say that it's
really a privilege for me to be here.  I'm sorry my predecessor,
Dr. Margolese, was not able to be located to be here, because he
was both my predecessor and my mentor, and he led me into a
wonderful world of people and programs.  For that I would like to
thank him even at this very late stage.
     I'd like to start with a bit of an anecdote, because we've
seen some very wonderful pictures of what happened.  I'd like to
go back to 1973 at another meeting that I attended, where I stood
before the assembled coordinators, fifty-six Regional Medical
Program coordinators.  We also had invited the chairmen of the
various regional advisory groups, and we also said they could
bring certain key staff members, particularly in their evaluation
activities.  This took place in a ballroom over in Crystal City
across the highway in Virginia, and at that time that we held the
meeting, the National Association of Regional Medical Programs
had engaged a lawyer and had instituted a lawsuit for the
impounded funds, some $126 million of fiscal '73 and fiscal '74
funds.  The coordinators assured me that they were not angry with
me personally.  However, I was the spokesman there at the
meeting.  
     Upon reflection, having received a copy of the lawsuit in
due course, I felt I should make known my position on this matter
to everyone in the audience, so I noted that the face page of the
lawsuit, since it's the first one I've ever received (and
hopefully the last one I ever receive), had on it, since they
couldn't sue President Nixon directly, they struck as somewhat
lesser individuals, and the first one was the Right Honorable
Caspar Weinberger, Secretary of Health, Education and Welfare. 
The second individual was George Humphrey, Secretary of the
Treasury, obviously providing the funds.  The third name on the
face page was Roy Ash, Director, Office of Management and Budget. 
All of them right honorable.  The last one was Herbert B. Pahl,
Ph.D., Director, RMP.  I thought what I might do is file a
countersuit of discrimination, because I did feel I was trying to
be as right honorable as the other gentlemen.  [General laughter] 
However, I was too busy in those days to do so.  
     It is interesting, however, that the lawsuit, in a way,
brought us together in a wonderful way because we had been
working well.  I think one of the things I would like to say here
is that it was one of the most enriching times in my life to be
in charge of a program and to work with such a group of people. 
That feeling holds today.  I have never before worked with a
group that's stayed friends, close associates, as has happened
with the Regional Medical Programs.  It's a rich personal
experience for me.  I did tell them that.  I phrased it in
different words since the lawsuit was on everybody's mind and
they wanted to know what I was going to say, so at that time I
said, after going though this litany of who was on the face page,
"I would like you to know that my feeling is I have never before
been sued by such a wonderful group of people."  [General
laughter]      Now to a second point.  I would like to take just
a moment before raising a question.  An individual who is not
here today is Paul Ward.  I'm one of his younger associates. 
Everyone holds him in highest regard, and I found him to be a
pillar of strength and a source of wisdom for me throughout my
tenure.  I'm sorry he's not here, and I hope you will excuse me
if I take the privilege of reading a short section from a piece
that he wrote in May of 1974 called "The Curious Odyssey of
Regional Medical Programs."  It's several pages, but I did not
intend to read that.  I do want to read just the opening two
paragraphs.  This has to do with the topic under consideration,
and it's called "The Curious Odyssey of Regional Medical
Programs."      "During its eight years of existence, Regional
Medical Programs (RMP) has developed a history marked by many
changes of fortune.  No social program enacted after World War II
has experienced the ups and downs, the changes in direction, or
the praise and vilification that have befallen RMP.  Some
programs like model cities and the Offices of Economic
Opportunity have peaked and then fallen from grace, but none have
had the spectacular roller coaster ride of RMP.  Those involved
in the program believe RMP has proven its worth and provided many
improvements in the health care system, but it has also served to
test the stamina of those directly involved in the program, for
it has been like riding the roller coaster through a wind tunnel
with the wind direction changing every few minutes."  I think
this is why I'm reading it to you, because that's the way I felt.
     "The changes of fortune have resulted mostly from an unusual
number of changes in philosophy at the top level of the
Department of Health, Education and Welfare, the multitude of
quarrels HEW has had with Congress, and the intrusion of the
Office of Management and Budget into program decisions (which OMB
is ill- equipped to enter, especially in the health care field,
where its expertise barely equals zero).  Finally, the courts
have entered the scene with the ruling that the program should be
returned to the course charted by Congress and that the funds
appropriated by Congress should be made available for the
purposes of the program.  If we could end the story on that note,
it would be like the classical novel plot: the beginning, the
problems faced in the middle, and the happy ending.  But in real
life, there's probably more trauma to come.  You'll have to read
the odyssey to know the ending."  You know the ending, but you'll
have to read it to find out Paul Ward's inimitable fashion of
explaining what happened.
     There are so many questions that could be raised, and I do
want to ask one or two.  First, I hope people from the floor,
particularly those who have been involved with the Regional
Medical Programs directly, will feel free to respond.  Before
asking the question, I want not to lose this, because from my
point of view as director of the program, I want to say how much
I value the work of the earlier and the later initial review
committees, scientific review committees, that did such
magnificent work throughout the entire life of the program to
establish standards of quality.  I want to commend the staff of
RMP, both those who were there before I came and those who were
there during my tenure, of translating the discussions of those
meetings back to the regions, because I truly believe that one of
the reasons we are enjoying the meeting today is because we're
all proud to have been associated with it, and it was a give and
take between professionals, some in government, some in the
regions.  The regions couldn't operate without us and we couldn't
get anything done without all of the dedicated people.  It is the
communicators back and forth, from the review groups, the
national advisory councils, and the staff and the workers in the
regions that made this possible.  I believe that it was one of
the best programs that I have seen in government, where funds
were sent directly from the Washington offices to community
groups and held them responsible on a competitive basis for their
own activities and renewals.  I would think we could solve more
problems if we could have that similar thing today.
     The question that I have, I guess I would like to direct to
Bill McBeath, but to others in the audience.  I find it strange,
for example, that Secretary Finch, under President Nixon, with
his staff developed a national plan of health priorities for the
nation.  No one could quarrel with the importance of the
priorities that were listed, the health care of migrant workers
and minorities and the disadvantaged and so forth.  The other
side of it is, to the best of my knowledge, and I would like
comments on this, I have yet to come across a single Regional
Medical Program director who had any input whatsoever, directly
or indirectly, into informing the plan developers as to what the
actual priorities are as seen by the citizens of this country in
fifty-six ongoing regional activities supported by the
secretary's office.  So we have the right hand developing
worthwhile national goals, and then when you match those stated
goals with what the Regional Medical Programs are doing, many of
the same things are being accomplished, but not under those
titles.  Again, it's a political framework because we all were
trying to do the same thing: improve the health services to the
communities and citizens of the communities.      So I would like
to ask Bill what was your experience in trying to inform your own
local congressmen, senators, not lobbying for specific funds, but
just informing them as to what Regional Medical Programs were
doing in your area, and what, if any, experience did you ever
have of any inquiry coming from such an office as to what kinds
of activities you were doing with this secretary's funded
program?   
Ruhe:  I think that in the last years of RMP, from '72 on, I
think that was an effort that was trying to give an alarm call to
all of us that it was time for us to do more in the area of
preparing material that could be used, even in direct lobbying,
but in many ways to work with our constituencies.   
Barrow:  I only want to ask one question.  Should we have begun
to pay more attention to the rising cost of medical care in RMP
earlier than we did?  I think it's what finally terminated us.  I
think that the poor economy that was going on at that time,
Congress having to cut back somewhere, and the fact that, as most
of you have already mentioned, there was not any good consensus
of what the program ought to be, all these had a factor.  But I
think that if earlier on we had done the same kind of job of
looking at the cost of medical care in our communities in the
same in-depth way we did in cooperative programs with the other
medical schools and the practicing physicians, I think it would
have been a different proposition.  What do you think, Dr.
Wilson? 
Wilson:  I was going to turn that over to Bill Ruhe.

Ruhe:  The answer is yes.  

Wilson:  That's not quite fair, though, because my guess is that
while we could have addressed the question, I don't think we
would have found a solution anywhere near in time to meet the
needs of perpetuating RMP.  I think the problem was too large,
resources too small, and the discussion too complicated, really,
to solve it. 
Barrow:  I'm in agreement with you, but the fact that we were
looking at it and trying to do something about it and bringing it
to the forefront, instead of apparently dodging the question, I
think might have been one of the finishing blows.  

Lindberg:  Questions from the floor?  Thanks very much, Vern.  I
might add to that that you don't want to underestimate the
importance of the American Cancer Society, American Heart
Association, and those kinds of groups, which are tremendously
important in this town and are really listened to.  There wasn't
anything comparable at all, but had there been, I think it would
have been listened to.  That's my own guess.  Dr. DeBakey?

DeBakey:  I'd like to direct this question to Dr. Ruhe, because
he referred to the report.  Dr. Ruhe, let me first say that
you're quite correct that while the term "conquer" was used, it
was obviously for political reasons.  We were realistic about the
fact that we're not going to do it in our lifetime.  But
hopefully that was the direction.  The term was simply used for
political purposes.  
     The question that I want to ask you, since you did refer to
the report, in connection with the matters that you've very well
explained, in your opinion, the cause for the demise of the
program, is this: had the recommendations of the report itself
been implemented in the formal legislation, as some of them
were--for example, regional medical libraries--rather than the
way the RMP legislation was developed, do you think it would have
made a difference in terms of both the program and its survival? 
As you may recall, one of the most important aspects--and this is
what really provided the concept for the Regional Medical
Programs--was the centers of excellence and the development of
the other aspects of the centers of excellence in the
recommendations were to provide funding for communication and
education of the public.  This was never a part of RMP.  In fact,
it never has been done, to be perfectly honest with you.  That
recommendation was never followed through.  I was wondering if
you'd comment, since you did read the report, obviously, even
though you said you didn't understand some of it, if you'd
comment upon the part you understood. 
Ruhe:  I didn't understand the proposed legislation.  It was
difficult to track from the report to the proposed legislation,
even to be sure that the proposed legislation was written with
the report as a base. 
DeBakey:  You're quite right about that.

Ruhe:  I think the report was well done.  I don't mean to be
critical about it.  I think you did what you were asked to do and
had to do in a remarkably short period of time.  I can't think of
any similar report of such far- reaching comprehension as this
one has been done in such a short period of time and then
followed almost immediately by proposed legislation and a bill
signed and programs in existence in a relatively [short time]. 
Altogether I think the first operational grants were only about
fifteen months or something like that. 
DeBakey:  That's right.

Ruhe:  From the time that the president gave his first health
message.  That's breakneck speed for something as complicated as
this was.  I think that's one of the things that resulted in
being pushed through quickly, but it's also one of the things
that came back to be a problem later on. 
Wilson:  You've given us the AMA approach.  Mike asked another
question.  Supposing that the legislation had been in agreement
with the commission's report.

Ruhe:  Well, it wouldn't have passed.  [General laughter]

Wilson:  That's still an AMA answer.

Ruhe:  Well, there would have been too many bulls being gored if
all those thirty-five recommendations had been enacted into law. 
There's just too many people who would have gotten together and
defeated it.   
DeBakey:  On the other hand, I think it's important to point out
that while the centers of excellence never got anywhere except in
cancer, and the only reason they got in cancer was because, as
you know, the cancer establishment, after Nixon came in, took it
over.  

Ruhe:  See, that was the next push, and it narrowed down to one
categorical section and got behind it, and the rest was just
allowed to languish.  

Wilson:  I think that may be a tactic that Karl Yordy and his
panel ought to think about.  Perhaps this broad program is not
the strategic way.

Lindberg:  Question?

Unidentified:  This question is for Dr. Wilson.  It seemed to me
not just with RMP, but that's a specific example we want to
address, there's a propensity on the part of the federal
government as needs change, as perceived by the federal
government, to insert into existing programs various other
programs and initiatives which have the effect of diffusing the
purposes of that initial program, therefore making it much more
difficult to, as Dr. Ruhe has said, for everybody to face in the
same direction.  I believe that contributed to the demise of RMP,
not the primary cause, but contributed, because the constituency
was then very much diffused.  My question is, how do we learn
from that?  What can we do with that?  It's a political fact, I
guess. 
Wilson:  I don't think in this instance that it really had
anything to do with the demise of RMP other than perhaps
affecting the time.  There were some funds diverted to other
activities.  But in my measured opinion, the decision had already
been made two years before that RMP was going to be closed down,
and very methodical steps had been taken to get that done, many
of which were not discussed outside.  You ask, "What was the
bureaucracy doing, tampering with the funds when they were too
small?"  That's really your question.  All I'm saying is that it
was looking, at that stage of the game, for other outs that might
accomplish the same purpose, but had accepted the fact that RMP
was going to disappear.   
Lindberg:  Dr. Flagle?

Flagle:  This is a question for the whole panel.  Is it true that
the Regional Medical Programs were killed in fact, or perhaps
only in name?  Because it was a short time after the demise of
the RMP program formally that large funding was available to the
institutes.  The National Heart, Lung, and Blood Institute, for
example, had a very large outreach program, and those of us
working in the field, who began our work in high blood pressure,
for example, with grants from RMP were able, in short order, to
continue that work funded by NHLBI.  For us, the only difference
was that the check came from a different agency.  When we say
that the work we did in RMP is alive today, it's because there
was a continuity of funding, and only the names were changed.   
Lindberg:  We're doing a long-range plan for NIH right now, and
these matters are under consideration, but it turns out that NCI
and NHLBI are outstanding in their long-term outreach programs,
and they're unique.  The other institutes really don't have that
either in legislative language or in reality.  So you've
identified the two hot ones.

Wilson:  I think the programs persisted because there was a
constituency out there that wanted them.  RMP really died in the
organization of which it was supporting and operating.  It died. 
I think that's what we're concerned with.  We're happy that the
programs persisted.  Herb Lewis? 
Lewis:  Still staying more or less on this same subject, Bill
McBeath, you talked in your analogies about the lack of
programmatic focus.  That probably is a subject which has been
with us for most of the day and will be with us in the final
session.  In your judgment, what should have been, or what could
have been, the programmatic focus for RMP?  If you are able to
identify it, why, in your judgment, was that focus not
politically--in a good sense of the word--acceptable?  What could
or should have been the programmatic focus of RMP and what were
the political problems behind having that programmatic focus
accepted? 
McBeath:  We've talked about the great diversity among the
programs.  So if you ask me what I think it should have been--

Lewis:  In the legislation.

McBeath:  I would give you my unique (maybe) viewpoint of that
and it would almost demand equal time from all the others.  I
will tell you, in our region we wanted to focus on system
rationalization, much more classical regionalization.  That's
what we would have liked to have seen greater emphasis and
attention given to.  If you say, "Should it have been that?" or,
"Could it have been that?" you know, the honest answer may well
be that Congress would be no more willing to pass that, maybe
even less willing, than they were to pass centers of excellence. 
It's what I meant when I said that these things that I was
talking about weren't only factors that influenced the demise of
RMP, they probably influenced, in like manner, the generation of
it.  If we hadn't had that appeal of being all things to all
persons, we might never have gotten the approving authorization.  

Lewis:  Let me see if I understand you.  In your region, in your
area where you had a program, system rationalization could or
should have been the programmatic focus.  Why wasn't Congress
ready to buy that programmatic focus?

McBeath:  I think that's a very abstract thing in some sense. 
Lewis:  Not abstract.  It's very political.  

McBeath:  That's what I would come to.  It clearly couldn't be
done without interfering or influencing the patterns of medical
practice and the normal relationships that even existed then. 
When we talk about maybe doing that today, after twenty years of
market-oriented operation within the health care system, I
couldn't help but think, as Stan was talking about his
son-in-law, who under private auspices and without any kind of
system has developed a center of excellence for radiology--I'm
willing to give him that; I don't know his son-in-law-- but I
would imagine that it would be much more difficult today to try
to find all of those types of centers of excellence that are
generating large amounts of income, greatly increasing the cost
of care in this country, and to make for a more rationalized
regionalized system.  I think the dreams that we had in RMP would
probably be harder to come about today.  

Lindberg:  There is one country that has boards of
rationalization, and that's Sweden, but I wonder if anybody here
would get a big parade behind that.  

DeBakey:  I'm not sure they're happy with it.

Lindberg:  No, they aren't.  They aren't, but they've done it for
forty years.  Dr. Creditor? 
Creditor:  I'd like to follow up on Bill McBeath's response,
because I think we came to believe, towards the end, that systems
rationalization should be our primary goal.  Then if you looked
at regionalization as being the pathway to systems
rationalization, one had to be very honest and say that although
we had lots of regional cooperative arrangements, we really
didn't have true regionalization.  Very few of those cooperative
arrangements included people who didn't have something to gain by
it, certainly nothing to lose.  In any attempt at
rationalization, there have to be some losers as well as winners. 
Particularly at a time when health care costs were becoming an
issue, we could not really demonstrate that we had been involved
in rationalization in a sense that would really affect health
care costs.  

Lindberg:  It seems to me regionalization and rationalization are
means to achieve an end.  I may have been the only guy in RMP who
was trying to get first-class care for everyone.   
Creditor:  Come on.

Lindberg:  Too bad I was a pathologist.  [General laughter]   
McBeath:  I think that those of us who had any effort put forth
about regionalization probably were looking to models that were
largely rural.  I've been struck by the fact that I don't know
what would have happened in these urban areas, as I've heard
people talk about that today.  That would have been a big
problem.        I think a big thing that overtook us as part of
these changing political climates was that about the same time,
as has been pointed out, came along Medicare and Medicaid.  RMP
and whatever it was trying to do began to become more and more
peripheral to the organization and financing efforts to the one
big granddaddy, and maybe grandparents, of them all.  

Lindberg:  One brief thing before we break for coffee.  Bob
Maynard, please stand up.  He is director of the Office of Public
Information.  If you can steal twenty or thirty minutes for a
tour of our National Library of Medicine, Bob will arrange it
today or some other time.  Bill Leonard made the TVs, and I think
he did a wonderful job.  [General applause]  
     We will reconvene at 3:15, please.