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            CNA -Conference of Coordinators of RegionalMedicalPrograms//1968/Arlington, Va./
            Ti - Papers presented./G
            TI - Papers presented, Conference of Coordinators of Regional Medical Programs/
            IM   [Washington,/U. S. Govt. Print. Off.,/19681
            CO - 174 p.
            CA - WA 540 AAl C55p 1968:02NLM
            EL  FULL LEVEL
            IT  MONOGRAPH
            MT - CONFERENCE NAME MAIN ENTRY
            DA - 700528
            Ul -0244271










                             a ers

                             rese e


                  Conference of Coordinators
                       of REGIONAL
                           MEDICAL
                           -PROGRAMS





                  September 30--October 1, 1968
                        Arlington, Virginia










                                        PREFACE



                The Fall 1968 Conference of Coordinators of Regional Me ica
           Programs was called to provide an opportunity for all Program
           Coordinators to meet for a full discussion of the present and
           future course of Regional Medical Programs, with special emphasis
           on administrative problem and on relationships between the Division

           and the individual Regions.

                The contents of this publication reflects the major concerns of
           Regional Medical Programs at this point in time.  The two-day Conference
           brought these issues to the fore and presented opportunities for dis-

           cussion of them.


                We express our sincere appreciation to Dr. Marc J. Musser, Coordinator
           of the North Carolina Regional Medical Program and Member of the
           Steering Committee of Coordinators, for acting as spokesman for his
           colleagues during the me eting.  By voicing their main concerns at the
           outset of the meeting and later re-stating and sumarizing these and
           others which had emerged during the day and one-half Conference'.he gave
           the meeting a framework within which these papers have relevance.


           October, 1968                      Stanley W. Olson, M.D.
                                              Director
                                              Division of Regional Medical Programs







                                          CONTENFS


                                                                                Page
            "Report from the Division"  ........................................

            STANLEY  W.  OLSON.  M.D.
            Director
            Division of Regional Medical Programs
            Health Services and Mental Health Administration
            Bethesda,    Maryland


            "Relationship of the Health Power Structure
            to  Regional   Activities ............................................  28

            PAUL D. WARD
            Executive    Director
            California Committee on Regional Medical Programs
            San Francisco, California


                                                                                  39
            "Health in the Troubled City"  ....................................

            H. JACK GEIGER, M.D
            Professor of Preventive Medicine
            Tufts University School of Medicine
            Boston, Massachusetts
            Co-Director
            Columbia Point - Mound Bayou Health Centers
            Boston., Massachusetts - Mound Bayou, Mississippi


            "Principles of Management of Coope  rative
            Health    Activities" ...............................................  60

            RkY E. BRDWN
            Executive Vice President
            Affiliated Hospitals Centers
            Harvard    University
            Boston, Massachusetts


            "The Responsibilities of Medicine in Advancing
            Our  Health  Care  System ........................... ................  74

            DWIGHT  L.  WILBUR,  M.D.
            President
            American Medical Association
            San Francisco, California





             CONTENTS, Continued
                                                                                    Page
             l'Opportunities and Challengesli     ................................... 94

             PHILIP R. LEE, M.D.
             Assistant Secretary
             Health and Scientific Affairs
             Department of Health, Education, and Welfare
             Washington, D.C.

             "Issues and Concerns of Regional Medical Programs'       ............... 105

             MARC J. KJSSER, M.D.
             Program Coordinator
             North Carolina Regional Medical Program
             Durham, North Carolina


             "Review of Issues and RelationshiDS       .............................. 123

             DONALD R. CHADWICK, M.D.
             Deputy Director
             Division of Regional Medical Programs
             Health Services and Mental Health Achinistration

             "Specific Issues and Reldtionships Dealing with...
                 Grants Program  Conce-ptualization and Stratevv      ............... 135

                 RICHARD B. STEPHENSON, M.D.
                 Associate Director for Operations
                 Division of Regional Medical Programs
                 Health Services and Mental Health Adininistration
                 Earmarked and Other Comitted Funds and Proiects       .............. 140

                 RICHARD F. MANBGOL1), M.D.
                 Associate Director for Progrxn Development
                   and Research
                 Division of Regional Medical Programs
                 Health Services and Mental Health Administration
                 Resource for Development of Cont-                              '...145

                         ER M. SCEMIDT, M.D.
                 Chief, Continuing Education and Training Branch
                 Division of Regional Medical Progrwns
                 Health Services and Mental Health Administration



          CONTENrS, Continued                                                 Page
             C      ications and Relationships with and between
                                                             .a
             the Divi ion of Regional Medical Programs, th,
             54 Regional Medical Programs, Other Institut o@,
             Organizit-lons, and gyms     ..................................... 151

             MARGARET H. SLOAN, M.D.
             Associate Director
             for Organizational Liaison
             Division of Regional Medical Programs
             Health Services and Mental Health Administration

             EDWARD M. FRIEDLANDER
             Assistant to the Director
             for Commications and Public Informtion
             Division of Regional Medical Programs
             Health Services and Mental Health Administration


          "Issues and Concerns in Retrospect,    .............................. 157

          MARC J. MUSSER, M.D.
          Program Coordinator
          North Carolina Regional Medical Program
          Durham, North Carolina


          GENERAL DISCLJSSION     .............................................. 161





                              "REPORT FROM THE DIVISION"

                                 Stanley W. Olson, M.D.
                                      Director
                       Division of Regional Medical Programs
                  Health Services and Mental Health Administration
                                 Bethesda, Maryland


            The office I now hold., Director of the Division of Regional Medical

       Programs, is one to which Dr. Robert Marston lent such great distinction

       as he guided the Division through its first formative years.  Under  his

       leadership, Regional Medical Programs received wide acceptance, and a

       functioning Program was launched in a remarkably short time. We  in  the

       Division of Regional Medical Programs, and you who carry major responsibility

       for the 54 programs now covering the country, are faced with the difficult

       task of managing an ever-inc-reasing load of responsibility.  We must guard,
       as Dr. Marston has done, against the emergence of bureaucratic  rigidity

       We must continue to foster  instead, the spirit of innovation and

       creativity.


            Most Regional Medical Programs were faced with the difficulty, at

       the outset, of judging how best to approach the complex task of achieving

       voluntary, functional., regionalization.  The Division of Regional Medical

       Progrmns and its National Advisory Council wisely resisted the temptation

       to establish a model which could be adopted by those Regions for their

       planning.  The all-too-easy solutions offered by experts in systems

       analysis organizations.were also rejected. Instead, leaders in  each  of

      .the developing Regions began to cope with the unique relationships

       peculiar to their own area.  Initial planning efforts were directed

       toward the creation of a climate of cooperation within which regionalization

       among traditionally independent, autonomous elements of our  pluralistic
       health care system could proceed.




           I am no more inclined to prescribe a national pattern or model for
        the Programs than those who have guided it so well in its beginning years.
        it is possible now, however, to describe some of the, locallv derived
        features that characterize those Programs which are meeting with success
        in achieving regional objectives. This is information which I  believe
        will prove useful to all Regions, and will assist them to formulate
        better solutions to their own problems.

            I should like to describe the elements that characterize successful

        Regions:
            Success in this, as in every large-scale, practical endeavor,  has
        been unequal and progress has been uneven.  And while it is true that no
        single Region has as yet achieved full regionalization, some are clearly
        more advanced than others.  The success of the more advanced Regions
        can, I believe, be attributed largely to several significant, common
        characteristics, specifically, leadership by the    ram coordinator,
        organized comitment of the health Dower structure, sound program concgt
        and design, effective implementati   f -rogram, and evaluation of progress.
            The first of these critically important attributes is strong, dynamic
        leadership. Progress in regionalization frequently comes  through  the
        leadership of a single individual, the Program Coordinator.  This is not
        to say.that leadership must be "singular."  Clearly, a larger leadership
        element than that of the Program Coordinator or of any other single
        individual is required; but the ability of the Coordinator to-mobilize
        the larger leadership within the Region is often determinative of  its
        success.  He exercises personal leadership to secure organized institutional

                                          2



       comitrnent, as well as individual support, for Regional Medical Prograins,
       support which is essential if the Program is to wield the influence
       required to bring about significant change.  I should like to coment on
       some of the observed actions of effective Coordinators.
          Coordinators secure the.confidence of leaders in the medical centers
       in their Regions, or practicing physicians and hospital administrators,
       and gain their understanding and support.  They establish contacts with
       key health leaders of the Region to evoke from them a working comitment
       for Regional Medical Programs.  They acquire information of the health
       characteristics of the Region, its resources, its problems, its politics
       and its style of getting things accomplished.
           The successful Coordinator exhibits his leadership by attracting
       a competent and respected staff.  He develops an organizational framework
       to perfom the functions of administrative planning, implementation and
       evaluation.  His core staff is diversified and includes physicians,
       nurses, hospital administrators, education and public informtion
       specialists, allied health personnel, experts in behavioral sciences,
       and others.  Such professional diversity among the staff contributes to
       a rounded and balanced program.  The Coordinator typically is full time.
       Undertakings of the magnitude of Regional Medical Programs do not flourish
       under part-time leadership.
            A nmber of universities and Tnedical centers have assisted in the
       recruitment of able Progrm Coordinator  (and of other keX staff members)


                                        3



       by offering academic and staff appointments.  Such appointments facilitate
       access to the academic and clinical resources of the medical center and

       to the faculty.

          Tho@ institutions which have sponsored Regional Medical Programs are
       not likely to find individuals with all the capabilities described above.
       They can, however, select with care individuals who have administrative
       ability and have had experience in dealing with health care problems both
       in the medical center and in the community.  Having appointed the
       Coordinator, they have a responsibility for maintaining a continuing
       -relationship with him. He will welcome all the guidance and support he
       can obtain as he negotiates for the involvement and commitment of the

       groups described above.
           The Division of Regional Medical Programs, too, has a responsibility
       in this regard. The staff of the Division has discussed ways  in  which
       it can provide relevant information to Coordinators as they and their
       staffs and their Regional Advisory Groups address the task of  securing
       funds through the grant application route.
           We are prepared to structure a series of three to four-day seminars
       in Bethesda for groups of Coordinators to discuss in depth with them the
       organization of the Division of Regional Medical Programs, its administration,
       its resources, and its grants review and management procedures.  We hope
       also to use this seminar as a medium through which Coordinators may
       supplement their knowledge of Regional Medical Program activities
       throughout the country.  This undertaking, which will necessarily be

                                       4


        experimental at the outset, will be carried on under the guidance of
        Dr. Richard Manegold and his staff, and we shall be prepared to initiate
        the first of these seminars as soon as we have requests for participation
        from a group of six to ten Coordinators.
            Beyond that we are making plans now to experiment with a "war  games"
        approach to teaching the techniques of long-range planning.  Dr. George Miller
        and his staff at the University of Illinois College of Medicine have agreed
        to put on a program of this kind as a substitute for one of the irregularly
        scheduled sessions on medical education, probably in June 1969. We  shall
        make announcement of the course as soon as the details of the program can
        be formulated and distributed.  In the discussion sessions that will be
        held du ring this Conference we should welcome any comments or  suggestions
        you may have about either of the above proposals.
           . Organized Comittment of the Health Power Structure:  The  successful
        Coordinator recognizes the critical elements in the health power structure
        and the order of priority in which they must be brought together,
        actively involved, and comitted.  The key groups with which he deals

        include the following:
        Medical Centers and Medical Schools - These have provided much of the
        initial Program impetus.  A close relationship between them and the Program
        must continue because medical centers constitute a reservoir of professional
        expertise,and competence that must be drawn upon for the transmission  of
        new knowledge and techniques.  They have considerable potential for
        serving as a "change agent" and they are a highly specialized resource

                                         5


       for obtaining quality health care.  This is not to say that medical schools
       can or should control the Program. To the contrary, continued  exercise  of
       control by this or by any single ins titution or group will @e and
       retard the involvement and comitment of other. key groups.  But without
       medical center involvement and commitment, there is little chance that  the
       Regional Medical Program can succeed.
           Another important group includes practicing       cians - and by
       extension, State medical societies and their component organizations.
       It is essential that practitioners be involved in Regional Medical Programs.
       Not only are they the first point of contact with the health  care  system,
       but many significant improvements in the quality of care and in the health
       status of a population can be achieved only through their  direct  efforts.
       But simply "involving" individual physicians is not enough.  Organized
       medicine -- State medical societies and their component organizations --
       must participate in the Regional Medical Progrxn  decision-making  process.
       In terms of the health power structure, organized medicine rep-resents  the
       collective voice of physicians. We have seen  instances  where  failure  to
       involve these groups in decision-making has create d obstacles  to  program

       advancemerr..
            A third and equally important group includes       tals.  They
       represent the major institutional focus for health care  in  this  country.
       Diagnosis and treatment are increasingly hospital-oriented and hospital-based.
       Moreover, the hospital represents an important interface with the c       ity

                                           6



       which surrounds it and represents both the providers and consumers of
       health care.  The involvement and comitment of the hospitals, therefore,
       must be broadly structured to include the administration, medical staff,

       and trustees.

           Fourth, Official and Voluntary Health Agencies - It may be easy to
       overlook these groups or to wait for them to ask for participation and
       then to expect from them only a nominal contribution.  Such a policy'is
       short-sighted and self-defeating.
               State and local public health agencies play a significant
               role in the provision of health care.  No Region can afford
               to ignore or proceed without the understanding and backing
               of city and State health officers, many of whom have the
               ear of a Governor or a Mayor.  Nbreover, the statewide and
               are,u,ide comprehensive health planning agencie@which will
               play an increasingly important complementary role in
               structuring the health care system, are by law related to
               state and local governments -- often through their health

               departments.
               Voluntary Health Agencies such as heart associations and
               cancer societies have a real contribution to make.  They.
               have built up a c      ty organization which can be a
               source of education, support, and leverage within the
               c    nity.  This apparatus can be made available to
               Regional Medical Programs to sponsor training and to
               assist in other operational projects.

                                           7




           The                          is the voice of the health power structure.
        public Law 89-239 established it as an essential component of a Regional
        Medical Program and defined its responsibility in the same broad charter-like
        terms that characterize the other components of Regional Medical Programs.
        The Guidelines issued by the Division of Regional Medical Programs described
        the responsibilities of the Regional Advisory Groups in more precise terms.
        In this discussion of the elements that characterize the more successful
        Programs, I should like to describe how Regional Advisory  Groups  are
        relating to sponsoring organizations and to comment on the specific
        functions they perfom. Some Regional  Medical  Program  sponsors  look
        upon the Regional Advisory Group as a body which the law  requires  be
        established but whose function is a nominal one, that of approving
        operational grant proposals. It may be looked upon as  a  force  which
        threatens the role of the sponsoring  organization.  Not  infrequently the
        chairffmship of the Regional Advisory Group is retained by  the  chief
        executive officer of the sponsoring organization as a means of controlling
        this aspect of the Program.  The fear may exist (although evidence to
        support this fear has been notably lacking) that Regional Advisory Groups
        may exceed the policy-making functions assigned them in  the'law  and  in
        the Guidelines and seek administrative control of  the  Program.  We  are
        pleased to note that many sponsoring  organizations clearly recognize
        'that the Regional Advisory Group must become  the  dominant  organization
        expressing pol icy on behalf of all cooperating health  interests  in  the
        Region.  One such institution -- the University of Washington -- has
        identified its role as that  of administrative trusteeship,  which  means
        that it will exercise the obligations imposed upon it with respect to
        administrative policies, while at the same time encouraging the

                                            8





                                                                role in
      Regional Advisory Group to assume an ever more significant
      guiding and directing the policies to be followed as the Regional
      Medical Program develops.

          It clearly takes time for a Regional Advisory Group to become
      organizationally mature, to come to grips with important policy problems,
      and to begin resolving them wisely.  Where Regional Advisory Groups are
      functioning actively, one finds that they have a membership that comprises
      the leadership of the major health interests and power groups of the
      Region (i.e. medical centers, practicing physicians, organized medicine,
      comunity hospitals, and other groups).  Not only are they geographically
      representative, but they include strong public representatives who have
      significant regional influence and social and economic "clout".  .-
      Where.they are exercising a real trusteeship, the groups have a significant
      and substantive voice in setting pol icy.  They determine the overall
      scope,, nature and direction of the Regional Medical Program and establish
      priorities.  They provide a forum for the forces of change as well as for
      the traditional health power structure.

          It is too early to determine whether those Regional Advisory Groups,
      which are functioning under the chairmanship of the chief executive officer
      of the sponsoring organization, will in fact become a representative
      voice of the many elements of the health power structure in the Region.
      This arrangement at least has the saving grace that its actions are
      closely coordinated with those of the sponsoring organization.

                                         9


                       ing and perhaps the most destructive arrangement we have
     The Tnost frustrat                                            .  s a Regional
     observed is One   in wi,,ich the sponsoring  organization  appoint    le and
     Advisory Group as required by law but refuses to identifY its TO
                                   s necessary to transform a collection Of
     neglects  to   ta.ke those step various health interests into a strong
      individuals representing the                       Regional medical program
      functi. it which can indeed infuse into the
      that measure of support which it can    obtain in no other way.
      Pro  am Conce t and Desi                             f the more advanced
            The  third  critical  element  characteristic  o
       Regional medical P'rOg'r@ is the abilitY to formulate a soLmd progrl
                                                                      tion of leadership.
       concept and design. This  too,  is  a  derivative  of  the  fLmc
                                   isite to the elaboration of a     Iecific strategic
                                                                     SP
            A fundamental pre'requ           s a clear understanding of the role
            ept for the individual   Region i
       conc                                  tecl to PlaY in establishing a more
        Regional Medical programs are expec
                                              United States.  This understanding must
        rational health care system in the                                     directlY
                   only the program coordinate and those imwdiately and
        guide not                          it must be conveyed to and shared bY the
        connected with  his core staff,
                                                           iously referred to as the
         larger health cO@ty          the  key  groups  prev
                                    Region.  These groups and individuals must
         health leadership Of the                                      is, in the final
         -Lmderstand and -recognize that a  Regional  medical  PrOgran'
                                                        re and health status of
         analysis, concerned with   imp-roved health.ca    and thatalthough it is only
          individuals,  that ,ts focus  is  on  the  patient this long-range goal) it
          one of a number  of  activities  and  forces  with
                                                           e skills and services of
          has as its direct  target,  the  upgrading  of  th

                                                10



       those who provide care.  Categorically oriented, it has a strong technological
       bent -- the latest advances in heart disease, cancer, and stroke and related
       diseases, but it is-concerned with linking as well as strengthening health
       resources, a linkage which is the essence of regionalization.  A Regional
       Wdical Program requires a wholeness of program that cannot be achieved by
       an aggregation of loosely related projects; it fosters innovation and change
       not in the relationships between physician and patient, but in the
       relationships among providers of health service.

           Thus, Regional Wdical Programs emerges on the American health scene
       as a voluntary mechanism that depends upon the organizational behavior of
       health-related institutions -- a "coalition politics" of health, if you will.
       This is as much a part and parcel of Regional Medical Programs as is the
       substance of the information related to the latest advances in heart disease,

       cancer, and stroke.

           Against this background which represents the broad national policy
       establishing Regional Medical Programs, let us look at some of the specific

       patterns we see emerging.

           Many Regions a-re in the process of developing a "grand desi@' that
       will permit them to proceed with specific projects, each of which will
       fit into the larger pattern.  This process is not unlike the one we are
       using to create the Interstate Highway System for ou'r country.









           284 0 - 68 - 2



          Initially, some Regions have placed greater emphasis on action,
    others on planning for action, but the following tactics have been fairly

    comon to all Regions:
          Their planning may best be described as "consensus" planning,
          that is, once leadership has emerged and organizational
          involvement has begun, certain immediate needs and problems
          were so obvious that they could readily be agreed upon.  Similarly,
          there were available certain kinds of ready solutions, such as
          coronary care units and continuing education programs, which also
          ,Could be agreed upon as mechanisms for initiating operational

          activities.
          The more advanced and successful Regions have moved from the initial
      consensus planning to the establishment of long-range planning.  This has
      been expressed by the creation of categorical and other task forces, of
      special committees at the regional level, at the subregional or commity
      level or even local action groups within the comunity.  The achievement of
      this kind of laye---d p.1--aiming contributes to better understanding at all
      levels and provides a mechanism  for achieving widespread involvement and
      commitment.  Properly done, it requires a great deal of organization and
      supervision from the core staff.  As these planning groups address themselves
      to specific problems of diagnosis and treatment for heart disease, cancer,
      stroke, and related diseases, the need for an adequate data base becomes
      ever more apparent.  The data available is often fragmentary or lacking

                                         12



    and Regions are then faced with the decision as to whether they should
    begin to collect the data they need.  It is well recognized that we have
    as yet no adequate national system to collect the data required for
    effective management of health care.  Scattered and sporadic efforts to
    collect data will not solve the national problem; not only is the
    information derived from diverse sources not comparable, but data which
    is not continuously updated prevents its most effective use -- to tell us
    how well we are succeeding.  Without such a mechanism, the cross-sectional
    data obtained by local groups have only limited value.  Scanty as it is,
    however, such data as is available must be used by planning groups to
    make appropriate analyses and to derive as much benefit as possible from it.
    Regions are reluctant, and properly so, to set up elaborate.data collecting
    mechanisms.  We continue to look for the early development of this
    critically important national health tool.
        Regions developing their strategic plan may begin with a realistic
    assessment of the elements peculiar to the Region, including such things
    as resources, gap areas, regional ecology and traditional attitudes within
    the Region.  We see emerging in certain complex multi-medical center
    Regions, a geographic or functional division of responsibility with specific
    areas assigned to each medical center.  Division of geography tends to
    delineate responsibility more clearly; it permits those areas, which for a
    variety of reasons may be able to move ahead more quickly, to do so --
    the pace of all is not determined by that of the slowest element.  It is
    too early to tell whether such division within the Region will, in the

    long run, advance the program.

                                        13



        Comon to all Regions is the phenomenon of subregionalization.
  In the more successful Regions one sees this in terms of a subregional effort
  and identity based on referral patterns corresponding roughly to what might
  be termed "health market areas."

        In sum, we see that Regions are:
     . making cooperative arrangements the guiding principles for action.
     .  Encouraging and even suggesting projects and proposals that fit

        that strategy.
     .  Promoting efficiency in terms of regional health manpower and

        other resources.
     .  Fostering interagency relationships and com=ication.
        Striving for adequate program balance.
        Two-examples:  We can cite one Region which has adopted as its
    strategy the establishment of a series of hospital-based centers of
    excellence for heart disease and for cancer throughout its Region.
    It hopes subsequently to add facilities for excellence in stroke also.
        In another Region the strategy has been described as a series of
    related thrusts.  The first of these thrusts concerns approaches to
    imp-roving the effectiveness and efficiency of patient care at the local
    level.  The second concerns the development of working partnerships
    between key hospitals and one of the university medical centers leading
    to the creation of a "third faculty."  The joint appointment of.full-time
    chiefs of service in selected hospitals would be made by agreement between


                                     14



   the hospitals and the medical center. A third thrust is  concerned  with
   smaller hospitals which often cannot support the implementation of  many
   of the recent advances in diagnosis and therapy.  A proposal has been made
   to develop selected services on a centralized basis, and alternately  to
   strengthen other specialized services on a decentralized basis.

   Effective Implementation of Program - Given leadership, the  involvement
   and commitment of key health groups (including the effective functioning
   of the Regional Advisory Group), and a carefully thought out regional
   strategy or design, there remains the problem of formulating operational
   activities for implementation of the Program.  It is in the implementation
   or action phase where the,impact of Regional Ntdical Programs may best be

   seen.
       The more adequate the implementation, the greater its impact will be
   in terms of overall Program visibility.  Properly achieved, this visibility
   will encourage local identification with the Program on the part of  the
   medical centers, the hospitals and the physicians in the Region.

        Decisions as to what kinds of operational activities to undertake
   have, in the main, been governed (consciously or unconsciously) by a
   short-range strategy aimed at demonstrating success and achieving visibility.
   These general tactics have  characterized even the most successful Regions.
   On the other hand, just as initial consensus planning must be superseded
   by long-range planning, so the initial tactics and "off the shelf" solutions
   must be superseded by the development of long-range projects.


                                        15




          The initial operational projects not only provide evidence of regional
     strategy, but reflect regional cooperative arrangements.  They are not
     just isolated projects aimed simply at expanding and advancing the diagnostic
     capabilities of individual institutions, physicians, and other health resources.
     But they illustrate realistically how cooperative arrangements among medical
     centers, hospitals, and physicians can be implemented.
          One sees, for example, as in Louisiana, four hospitals in the same
     community pooling their resources in cooperation with the State Heart
     Association and one of the medical centers to establish a single, high quality,
     coronary care demonstration and training unit.  This unit is designed to
     improve the care of all patients with myocardial infarction in that area.
     Instances such as this provide the real test of regional cooperative
     arrangements.  When individual institutions are, in effect,, required to
     give something up, or to do things differently than they have in the past,
     one may judge whether these institutions are truly willing to move from a
     competitive approach in the solution of health problems to a cooperative one.
          In the Washington-Alaska Region-, we see the example of a. high-energy
     radiation source planned for one of the Anchorage hospitals.  No longer
     will patients in that vast subregion have to travel to Seattle or elsewhere
     for such treatment.  Planned and approved by both local and,Regional
     Advisory Groups, the radiation unit will be operated as a regional resource.
          In a funded operational project of the Georgia Regional Medical Program,
     the faculty from two.medical centers will travel to institutions participating
     in the development of hosy,)ital-based centers of excellence. Consultants
     will see patients with practicing physicians in those hospitals and will


                                       16



    utilize the consultation mechanism to promote the continuing education
    of both physicians and allied health professionals.
         similarly, one already sees in the early operational proposals
     of many successful Regions, an indication of concern for and attention
     to program balance.  Needs in stroke and cancer are being addressed
     as well as those in heart disease, which appear to be more readily
     identified and dealt with.  Areas of prevention and rehabilitation are
     -not being ignored.  There is functional balance among research, training,
     continuing education, and patient care demonstration activities.

     Evaluation of ProRress
          We come finally in our consideration of the c @ acteristics of
      successful Regions to the subject of evaluation.
          Adequate data is, of course, essential to proper evaluation.  As
      noted before, we are badly handicapped by the lack of data concerning
      the quality of care.  We suffer especially from a lack of data concerning
      the ambulatory care of patients.  We know next to nothing about quality
      of care provided in physicians' offices.  We are plagued, too, in evaluating
      Regional Medical Programs because we are not entirely sure what our
      "Product" is.  It may, indeed, be true that in Regional Medical Programs,
      as some say about television, "the medium is the message."
           If we are having difficulty in evaluating our efforts, we are. surely
       not alone in this respect.  Nor should we be prevented from moving forward
       simply because our evaluation techniques are not as clearly defined as
       we should like them to be.  If one considers such as a venerable social
       institution as education,, we find that it has served us well for centuries

                                          17



      even though many observers today believe it has a faulty evaluation
      system. Success in education has been judged by measuri.ng the amount of
      retained knowledge.  This way of measuring success has influenced teaching
      and learning techniques for a very long time.  Those techniques are being
      changed as we begin to reach agreement that it is more important to judge
      the change in behavior of students than to measure the amount of knowledge
      that can be reproduced on an examination.
         But the existence of difficulties and problems in no way minimizes
      the importance of evaluation for Regional Medical Programs.  To the contrary,
      evaluation is critical to our effort and much more attention must be paid
      to it in the immediate years ahead.
          in almost one-third of the Regions we find neither evaluation staff
      nor consultants in this field, and only one-half of the Regions have
      developed an organized approach to evaluation.  Some have highly-developed
      efforts.  For example, the North Carolina Regional Medical Program has a
      Division of Planning and Evaluation, headed by a prominent medical sociologist
      and a competent staff.  It is making a major effort to incorporate
      evaluation as an integral part of the overall regional effort.  The
      evaluation division of that Region works closely with the executive comittee
      and the Regional Advisory Group and will seek to determine the progress of
      the Program in meeting its stated objectives.  In making this analysis, the
      effectiveness of each project in changing the status of health care will
      be ascertained.  In addition, it will be the function of the Region's
      Division of Planning and Evaluation to work closely with each project
      director to assure the inclusion of evaluation proce(.ures.

                                           18



       A Look at the Future                                look to the future
         Let us now turn from what we have been doing, and
       of Regional Medical Programs.
          To begin with, we might look at the imediate future.  Clearly, we
       are moving from a circumstance in which there has been a surplus of funds
       (at times an embarrassing surplus) to one in which the reverse will be
       the case.  Based on applications in hand, we can predict that the aggregate
       demand for grant funds will exceed our appropriations in the fiscal years
       1969 and 1970; and beyond that, the amoLmts which the Review Camittee
       and the National Advisory Council will likely recomend for approval will
       also exceed the available funds.
          This matter was discussed in depth by the National Advisory Council
       at its meeting in August of this year.  The Council has indicated it will
       continue to judge programs and operational grant applications on the basis
       of quality.  They have rejected the principle of a distributive mode for
       the allocation of ftmds based on population or geography.  Inevitably,
       this policy will lead -to a backlog of approved but unfunded applications.
       I know of no better way to bring to the attention of the members of the
       Congress the requirements for adequate fLmding, than to present such a
       record.  This is particularly necessary because in the past the Congress
       has expressed impatience with the slowness with which the Programs have
       developed, and with the disparity between.the amounts of fLmds authorized
       and appropriated and the amounts actually spent.



                                          19



         These policies recommended by the National Advisory Council bear
       directly on the application and approval process at both the national and
       regional levels.  It does not appear possible to provide applicants with
       an appropriate review within a three-month period.  A review.of multimillion
       dollar grant applications requires critical analysis by our own staff,
       a site visit by a team of consultants and staff members, analysis of the
       project by the Review Committee and finally, consideration by the National
       Advisory Council.  Applications which are well organized and lend themselves
       to orderly review will ordinarily be actedupon within four months after
       application deadline.  In general, they will be acted upon in the order

       received.
          Begiming with the next fiscal year, the number  of  annual  review
       cycles will be reduced from four to three.  The deadline dates for submitting
       applications, tentatively, will be August 1, December 1, and April 1;
       but you will be given definitive information on this matter.
          We are attempting to define the appropriate input of each group to
       the review process. We shall expect the staff in its review not  only
       to summarize the proposals but to express judgments which can be clearly
       identified as staff judgments.  We are looking critically at the function
       of the site visit teams in order that the contribution of this important
       group may become more effective. You may expect that  the  procedures
       with respect to site visits will change as we attempt to identify the
       specific contribution this group can make. We are asking  the  Review
       comittee to make an objective scientific and technical evaluation of
       applications rather than to make value judgments.  This latter function

                                          20



     is properly the responsibility of the National Advisory Council.
        During the developmental phase of the Program, minimal standards
     were set by Council as a means of insuring quality and insuring also that
     every Region would be encouraged to begin the task of regionalization.
     As we enter a period in which funds exceed requests, Regions will be
     judged coffpetitively.
        We shall look to the Regions acting in their own self interest to
     improve the quality of their applications.  Evidence that the applicant
     is moving in the direction of the longer range goals and objectives which
     it has set for itself in its strategic design will have great weight.
     Individual,project proposals will be reviewed to determine how they
     relate to the Regionts own grand design.  Review groups will look for
     the relationship of individual projects not only to the overall Program
     concept but to each other.  They will expect clear descriptions of what
     is intended to be accomplished, set forth in specific and, where possible,
     quantifiable terms, to insure. that evaluation of progress and success
     will be undertaken.  (In a program such as this with its emphasis on
     innovation, both sociological and technological, we must expect some
     projects to fall short of expectation. What is not tolerable  is  failure
     to distinguish between effective endeavors and those that lack effectiveness
     in improving care. We must learn to make such distinctions and  to  alter
     or abandon projects based on these judgments.)
         We shall look for evidence that the application has been given a
     discriminating and qualitative review at the regional level so that  only
     those projects are sent forward which (1) have merit, (2) are capable  of


                                        21



      implementation, and (3) are clearly related to the Region's own strategy
      for regionalization.
         we shall look for better information about the role of the Regional
      Advisory Groups, not only with respect to how they review and evaluate
      specific proposals but how well they function in setting the overall
      direction and scope of the total program.
          The degree to which many applications have failed to reflect accurately
      the actual degree of development achieved within -the'Regibns is perhaps best
      indicated by the experience of site vis it teams.  Their reports have
      frequently materially altered or reversed the preliminary impressions
      obtained from the written applications by staff, Review Comittee members,

      and Council.



      Other Issues
          I should like now to coment on two major issues relating to Regional
      Medical Program objectives that have been interpreted as imposing divergent
      pressures on the regions.  They are the problems of the cities and
      continuing education.
          The first issue relates to the matter of how Regional Medical
      Programs may serve an effective function in improving the care received
      by the large population groups in our cities and especially that received
      by our poor and disadvantaged groups living in the ghettos.  The complex
      problems our cities present, pose a national crisis of the gravest order.
      The health of the poor who live in the cities is of deep concern to
      Regional Medical Programs.  True, we suffer from several constraints


                                         22



     as we attempt to deal with this problem.  Facilities are needed, but we
     have no authority to use funds for construction of facilities.  Neither
     may grant funds be used to pay for the cost of medical services or the
     cost of hospitalization. Nevertheless, there are major  contributions
     which Regional Medical Programs can make but which can be made only if
     we understand the nature and mechanisms to be employed in Regional Medical
     Programs, and understand also the nature of the problems faced by our
     cities in improving health care for the poor.
         The long-established system for the health care of the indigent is
     now in the process of major change. Over the next seven to ten  years
     more dollars can be expected to be placed at the disposal of 'the indigent
     to purchase their care.  The process for doing so is only now being
     structured and we are in that unhappy period of transition when the old
     system is being allowed to deteriorate and new solutions have not yet
     become effective. The problem with us today is that many of the  poor
     have neither an adequate indigent type of service nor funds to purchase

     their own care.
         If there is any group which should be in the fore in creating a new
     system of health care for the urban poor, it is the providers of health
     care.  Regional Medical Programs are functioning organizations specifically
     designed to link the providers of care together for the purpose of
     collectively improving services to patients.  These Programs can and should
     contribute significantly in planning general health services for these
     populations because it is only in this fashion that we can come to grips



                                         23



      specifically with the problems of heart disease, cancer, and stroke.
      Regional Medical Programs can assist in the improvement of health service
      activities through projec@s that,su-pplement elements of both old and new
      systems aimed specifically at the urban poor.  To do this, Regional Medical
      Programs must enter into cooperative arrangements with the many local and
      Federal programs already addressing themselves to health problems of the
      urban poor.  But regions must first be able to function as Regional Medical
      Programs.  We recognize that the complexities involved in developing
      regionalization in urban areas have delayed the development of regions
      in the very areas where their services may be most needed.  This is a
      matter to which I have already given a great deal of my time and to which
      I am prepared to devote more of my personal efforts.
          The second issue is that of continuing education.  From the.begiming
      there has been some degree of controversy about the role and significance
      of continuing education in Regional Medical Programs.  There were some
      who saw continuing education as the whole program.  Others saw very little
      purpose to be served by supporting the kinds of ineffective continuing
      education programs which rely mainly on information transfer, which reach
      relatively small numbers of physicians and which appear not to change the
      behavior of physicians to any significant degree.
           I am convinced that continuing education is the most significant
      single component of Regional Medical Program activity. What is at issue
      is not whether we should support and extend continuing education but what
      kind of continuing education we should encourage.  Efforts of Regional



                                          24




   Medical Program in this field must improve both the knowledge and skill

   of physicians, nurses, and other providers of health services.  They must

   encompass a variety of innovative techniques which will involve them in

   an active rather than a passive -role.  These efforts should result in

   behavioral changes leading to improved diagnosis and treatment of the

   patients they serve.  Further, our continuing education efforts and

   activities nust be structured in a way that promotes the cooperative

   linkages upon which the ultimate success of Regional Medical Programs

   wil I depend.

       Having identified these two issues which would seem to be polarized,

   as are so many national issues today, on the needs of the cities versus

   the needs of the rural areas, I should like to reject firmly the notion

   that we are unaware of the health needs of the rural poor or the'importance

   of including them as beneficiaries of a system of voluntary functional

   regionalization.  Equally, I should like to reject the notion that physicians

   in the urban areas are not in need of continuing education simply because

   of their proximity to the centers of learning.  In our larger cities

   many physicians practice independently, without hospital appointments,

   and are subject to none of the influences which are of major benefit to

   all physicians who do conduct a substantial part of their practice in an

   organized hospital setting.  We can ignore neither these physicians nor
   the patients they serve.







                                      25



        In the presentation I have just made,sme  of  the  factors  leading
    to the establishment of successful Regional Medical Programs have been
    described.  Special problems such as those encountered in the larger
    urban areas have also been identified. We have shared with  you  some  of
    the management problems associated with a very large and complex grant

    program.
        But we are wide of the mark if we regard  Regional  Medical  Programs
    simply as another Federal program which uses grant funds  to  implement
    a specialized objective. The categorical restraints  in  PL.89-239  are
    clearly recognized.  But equally recognizable are the legislative actions
    which have broadened the program to include additional  related  diseases
    and to use the Regional Medical Program mechanism for such activities as

    clinical trials.
        The true significance of the Regional Medical Program effort can be
    understood only if we recognize that a test is being made, nationwi e,
    to determine whether the quality of health services can  be  continuously
    improved by means of voluntary, functional regionalization.  We are
    engaged in resolving an issue of critical significance to. the future  of
    the American health care system --'a system which in the aggregate involves
    the life and welfare of 200 million persons -- a system in  which  more

    than $50 Billion is invested annually.
         The best estimates we have of the cost of a fully established
    regionalizatim program suggests  that we may require $400'to $500 Million
    annually.  If these figures are realistic we should be planning the



                                        26



   structuring of a system that will involve every element of the health

   care process.  We are called upon to perfom this task at a time when our

   country is beset with severe economic problems.  We are faced with the

   necessity for establishing our national priorities at a time when there

   are many urgent problems to be solved, each of which requires large

   sums of money.  Regional Medical Programs are under real pressure, therefore,

   to present evidence that this Program does indeed have the potential for

   improving the quality of health care that its advocates have held out.

       Ours is a program that has its primary impact on the providers of

   care rather than on the public directly.  We depend, therefore, on those

   professionally involved in health care to interpret the success of our

   efforts.  They in turn must communicate their understandings of the value

   of the Program to the Public and to the Public's representatives in the

   Congress.

       We are only now beginning to see the results of our efforts over

   the past two and one-half years.  The limited evidence we have of the

   validity of the Regional Medical Progrwn process must be used as feed-back
   into the system to guide our own further planning efforts.  It must be
   used to inform the groups most directly interested in Regional Medical

   Programs about its effect on health care.  It must also extend the

   base of cooperation upon which Regional Medical Programs ultimately will

   depend.







                                   27

    327-284 068 - 3




                 "REIATIONSHIP OF THE HEALTH POWER STRUCTURE
                           TO REGIONAL ACTIVITIES"


                                Paul D. Ward
                            Executive Director
             California Committee on Regional Medical Programs
                         San Francisco, California


         When I accepted this assignment to speak to you on this  subject,
    I did so with some trepidation. To many of my associates  in  this
    program the need to acknowledge the existence of "pressure groups,"
    "power blocks," "special interest groups," or whatever you may

    desire to call them is in itself a deplorable  factor.  One  sometimes
    gets the feeling that those who do engage in the art of  obtaining
    consensus from various pressure groups for any given goal  are  indeed
    practicing some form of Satanism. It is like being the  father  of
    Rosemary's baby without ever having known Rosemary.  The  only  solace
    I take in all of this is to note that when the connotation of  evil
    is applied to any grouping, it is always the other manes organization
    that is evil. We only belong to good groups to  protect  ourselves

    from the advances' of those other groups. Anyone who admits  seeing
    some good in the vast majority of the groups, and who tries to mold
    portions of their efforts together in order to obtain a working
    consensus on which progress toward a given goal can be  made,  becomes

    contaminated with the "oth6r man's evil. Further, to  openly  admit

    that you are a member of none -- in effect isolated -- and  sitting
    as if naked atop a beehive,.not knowing whether you're about to  be
    seduced by the queen bee or attacked by her suitors..,That is  why
    there is some danger, at least to me, in this topic of  discussion,

    and I must add I feel much as Lincoln must have felt as he  was  being

     'dden out of,a small Southern town on a rail after  the  Emancipation
    rL

    Proclamation: "If it wasn't for the honor of it all, I'd  just  as

    soon walk.11


                                         28




            To those of you who would practice tne art or OL)LaJ-n.Lng L:UL12SULLbU@
       and keep quiet about it, there is little danger.  In  fact,  at  times  it
       can be quite rewarding if you can find a way  to  silently  give  yourself
       credit for that which has been accomplished in the names of others.
       I fear, however, that like all voluntary collective efforts in the
       social field, observable progress toward a given humane goal is all,

       and should be all, the reward we should expect.  The legislative
       framework, the Congressional Committee imperatives and the Guidelines
       offer a unique opportunity to determine on  a  broad  national  scale
       whether or not the components of the health power structure can work
       together voluntarily for the general good of the public.  It may not
       be virgin territory upon which we are treading but  at  least  it  is

       wild enough to make life interesting.


            What are the specific mandates set forth by the law and Congress

       that we are obligated to observe insofar as  the  health  power  structure

       is concerned?  It seems to me that there are at least three main
       postulations that we must be aware of.  The first is the unique wording

       of the law itself.  Section 903 states that grants under this section

       ma  be made only if the Advisory Group includes "practicing physicians,
       hospital administrators,  representatives  from  appropriate  medical
       societies  voluntary health agencies  and  representatives  of  other
       organizations." Secondly, Section  904  which  covers  operational  grants

       states that they may be made only if  "recommended  by  the  Advisory

       Group" as described in Section 903.  This type of language gave
       virtually unique recognition in the legislation  itself  to  the  Regional
              power structure.  This recognition in effect took the form of

             ght to veto.


                                          29



           Thirdly, Congress went even further in its subsequent  reports  on
       the Program. It used the term "voluntary partnership"  when  referring
       to research centers. ..Practicing physicians and community hospitals
       indicating a co-equal status.  Hearings this year brought out the
       very deep concern on the part of Congrqss that components of the
       health power structure may not be involved uniformly in all Regions
       to the degree Congress intended.  Some sentiment on the part of the
       national health power group structure tended to support this  position
       although it was pointed out that the problems were sporadic in nature.

           At this point in time, Congress seems determined that there  be  a
       co-equal involvement of components of the health power structure,  not
       only in the design of the Program but in its operational  surveillance

       as well.

            How does one determine what constitutes the health power structure?
       In this case the law is unusually clear.  It identifies medical center
       officials, hospital administrators, practicing physicians, representa-
       tives from "appropriate",medical societies, "appropriatell voluntary
       health agencies, and other organizations, institutions and agencies
       concerned with activities in RMP plus informed public members.  The
       statute  uses key modifiers, in effect, to identify the power structure
       that legally must be involved in the decision making processes of the

       Program.
            Unlike the typical legislation which establishes citizens"Advisory
       committees, this act specifies that certain specific kinds of representa-
       tives must, not may, be included on the Advisory Committee.  It certainly

                                          30



      follows that at least Congress looked upon these classifications as
      the primary power structure involved.

          From a practical point of view there may be others,  but  they  are
      not legally specified.  As an example, at least one Governor unofficially
      proclaimed his State a Region and apparently his remarks  carried  some
      weight.  At least one State Legislature caused a shotgun marriage
      between RMP and community health planning and seemingly those involved
      took note of this act.  Whether the marriage has been consummated

      only the principals can attest.

          Although these extra-legal forces are important, time does not
      permit their discussion here except to mention the fact that eventually
      we will have to deal with public health power blocks such as those
      interested in O.E.O. facilities, model cities programs,  Medi-Care  and
      Medicaid, crippled children's programs, health planning councils and

      community health planning among others.


          Some interesting conclusions can be drawn from the   unique language
      used by Congress to establish RMP.  First, the Program was described
      as a partnership implying an equal role in the decision making process
      by the partners involved. The only mechanism provided in  the  Act  for
      exercising this role was the Advisory Group which must advise on and
      approve' the actions of the Region.  Later, Congress used the term


      oversee.


           Secondly, the term "medical center official" was used in place of

      .a
        representative of radical centers."  An official is one with the
      authority' 'to commit his organization or institution to a given course

      of action.
                                         31



           Thirdly, it spoke specifically of "hospital administrators," not
       representatives of hospitals.  This again implied a specific level of
       authority and function within the hospital world.  It further implies
       that this person or persons would have the authority to  speak  for

       others in his category.


           Fourthly, the Act specifies both  "practicing  physicians"  and
       representatives of "appropriate medical  societies."  The  modifier
       "practicing" would simply differentiate this physician from those who
       might be in administrative or other capacities.  But  the  modifier
       "appropriate" would seem to have more specific connotations.  From
       the legislative history we must assume that this was to be  a  person
       with the authority to speak for organized medicine in  the  Region.
       Even without the benefit of the legislative history, "appropriate"
       logically would refer to the organization that historically  has  had
       the greatest policy impact on medical practice, the most significant
       legal impact, and geographically covers the area concerned.   In  the
       vast majority of the cases, "appropriate" could only mean  the  state
       medical society. There are situations where  in  multi-state  Regions
       more than one state society must be represented and there is at least
       one instance in which the state society may be described as slightly
       bifurcated but there can be little doubt as to the general appropriate-

       ness of state societies.

            Fifthly, the same modifier, "appropriate," is used  to  describe
       voluntary health agency representatives, as members  of  the  legal

                                       32



       Advisory Group.  Again, the structure, function, and coverage of
       each voluntary health agency would determine the appropriateness
       that is, whether it should be the statewide organization that is
       involved2 or some other level.

           But, from a practical point of view, it would seem that RMP would
       want to assIociate itself with the voluntary health agencies at the
       point in the agency's structure where the major policy decisions are
       made.  This point differs to some extent among the voluntary agencies
       from state to state.  It is evident that to take full advantage of the
       relationship with the voluntary agency, RMP has to be plugged  in  at
       the decision-making point, the point at which new programs are
       designed, objectives set, data and other information accumulated and
       stored, financial determinations made and general organizational
       policy established and executed.

            In most cases, this appears to be the  state-wide  organization.
       Not to involve the voluntary associations at the policy making point
       will result in much duplicative effort and the lack of ability to
       fully utilize all of their existing resources on a coordinated basis.
       More important, perhaps, is the difficulty in  obtaining  a  definite
       commitment for support of RMP objectives if  this  relationship  does
       not exist at the policy making and  management  level.  Agreement  on
       issues without the authority to commit support,  funds  or  resources
       is as worthless as pursuing the vote of citizens of Washington, D.C.

       for a Virginia election.


                                      33




           Even though representatives may be chosen from the  "appropriate"

      body -- that is, chosen from the level within organized medicine,  the

     .hospital association and the voluntary health agencies where the vital

      decisions are made and the policy is set -- there is more that must be

      done if progress is to be made. It amounts to giving the  partners  a

      sense of confidence that their role in the Program will not be  sub-

      verted. This is especially difficult because the  relationships  that

      have existed in the past between these partners have been  extremely

      limited and even then, some were viewed with suspicion.


           Some times those of us who live with the Programs tend to  forget

      that a massive amount of planning activity has been thrust upon  the

      health leadership.  This activity seldom is based on long established,

      firm relationships; thus, there is bound to be some uncertainty.

      This uncertainty requires a profuse amount of reassurance and  recon-

      ciliation to keep the new partnership intact. Let us  recognize  that

      this partnership is voluntary, something even less secure than a

      common law marriage, and until there are abundant children in the

      form of successful operational projects, it may be hard to keep  the

      faith.


           Because of this, I believe it is the Regional Coordinator's  role

      to know intimately the decision makingunechanisms of the health  power
      groups primarily involved in his Region. Not only must  he  understand

      the mechanics of their decision,process, but he has to have a  fairly

      good knowledge of the people involved and what causes them to take


                                       34



       the positions that they do.  He has to have some assurances that the
       representatives of the various power groups have the authority to
       speak for the decision making apparatus within their own organization.'
       He has to have some assurance tl-at the power group's organizational
       framework will back up their representative in controversial matters
       If the representative's authority is limited, as it is almost certain
       to be, the Coordinator should know these limits and compensate for them.
           The Coordinator is further obligated to back up the representative
       of the concerned group by personally providing information and assurances
       to the decision making bodies within the representative's group on
       matters of controversy.  In most cases, this will mean routine appear-
       ances before the Executive Councils of the state hospital association,
       the state medical society, the various voluntary health organizations
       and medical center groups.  It means, above all, that he has to be
       prepared to negotiate differences in as amicable an environment as

       passion will allow.
           There are other problems within.the health power structure that
       face the more complex Region.  Although they may not directly affect
       each of us, at least to the same degree, they nevertheless may have a
       very profound effect upon the reaction that Congress has to the Program.
       To date, Congress has indicated an unusually favorable reaction, but
       this reaction could reverse itself if these problems are not dealt
       with properly and soon.  in my own self defense, I have not mentioned


                                       35




       California) and I do not intend to, but let me quote from an article
       written by a man for whom I have the greatest respect, George James, M.D.,
       Dean of Mt. Sinai School of Medicine, New York.  It appeared in "New
       York Medicine", April 1968.  I quote without his permission:

           "What problems are associated with Regional Medical Programs
       and how is New York City going about resolving them? New  York  City
       has a particularly difficult problem.  Those of you who have been
       associated with the review process of the Heart, Stroke And Cancer
       Program in Washington have noticed that it is very easy for a  state
       with a single state'medical school, a single state health department,
       and relatively few really vital agencies to organize for a  Regional
       Program.  This is true for some of our Midwestern states where the
       entire process is very simple with a single state Governor, a single
       state legislature, a single state health department, a single  state
       university with most of the doctors in the state being alumni of the
       state university. All of this makes for a very  simple  arrangement.

            "In New York City we have seven medical schools, we have a large
       number of additional sophisticated agencies and  institutions.  This
       takes for quite a bit of trouble.  It creates major 'toblems for
                                                           p

       intercommunication among groups which have not been notable for
       their.ability to communicate before.  Now, in addition to this,
       New York City has very great needs, and they are very visibl e needs.
       If there are any of you who feel incapable of adequately recognizing


                                         36



     these needs, there are at least three dozen agencies in the state that
     will be very happy to point them out.  There is great citizen demand

     for services."

        Dr. James stated the problem of the complex community clearly and
     briefly.  It is not as easy to isolate, understand and describe the
     decision making process in the areas where the most people are, where
     the most voters are, where the most Congressmen come from.  This
     poses a far greater problem than most of us realize if you stop to
     think where the mass of our health problems exist and who votes the

     dollars in support of the Program.

         As Coordinators and as individuals interested in the health of
     this nation, we face our greatest challenge during the next two years.
     We are faced with marshalling the health resources of the metropolitan
     areas which contain our most complex problems in terms of relationships.
     We have to seek a greater understanding on the part of all the health
     power structure that this Program, which all of the leadership seems
     to prefer, may be significantly modified if momentum is not gained

     in the highly complex urban areas.

         At this point in the Program if a speaker raises problems, he
     Ought to have some Pat solutions to them.  Frankly, I do not, except
     to say that 'we should proceed as we have been with more of our
     energies focused on the urban problems.  We should not lose sight of
     the fact that although there have been problems of relationships,


                                      37





                                                  I
       they have been relatively minor compared to other programs.of this
       magnitude and especially programs as unique in approach as this one.

             It does seem to me that in facing these problems the main challenge
       to the Coordinators over the next few months will be to maintain the
       integrity of the Program.  If the partnership concept is lost --
       that is, if it becomes predominately a medical society program or a
       hospital program or a medical center program in place of a balanced
       program between the partners -- then its lustre and innovativeness
       will be lost.  We can develop models and pilot projects until we are
       inundated with the reports involved, but they won't mean a thing
       unless they are accepted by the total health manpower through their
       involvement from the ground up.  Obviously, there is a price to be
       paid for involvement, enlarged staffs for the schools, easier access
       to continued learning for the professional person, and improved
       service facilities for the institutions.  The test will be the amount
       of dividends that are paid to the people in terms of better health care.















                                            38





                     '@TH IN THE TROUBLED CITY"

                          H. Jack Geiger, M.D.
                    Professor of Preventive Yiedicine
                  Tufts University School of Medicine
                         Boston, Massachusetts
                              Co-Director
              Columbia Point - Mound Bayou Health Centers
            Boston, Massachusetts - Mound Bayou, Mississippi


        When the suggested title for this paper was first sent to
     me it was "The Relationships of Regional Medical Programs to
     Poverty, Urban Health, and the Urban Crisis."  That's a complex
     title.  Subsequently the title was changed to "Health in the
     Troubled City" -- a simpler title but by no means a simpler
     problem.  The problem is complex and formidable in nature, and
     we seen to be able to have only marginal impact on it even with

     maximum effort.
         I certainly have no single formula for the problems of urban
     health care, and I'm sure none of the panel does.  I think the best
     we can do is to elucidate some of the inter-connections of the major
     aspects of the-problem.  And even in doing that we must beware not
     to invoke the kinds of explanations that are longer on charm than

     they are on truth.
         I'm reminded of the answer on a science examination written by
     a little girl in grade school.  In her examination there was a
     question that said: "On some nights, it is very clear and we can
     see the moon very clearly, and on other nights it is just as clear
     and yet we can't see the moon.  Why is that?"  The girl thought for
           while and then she wrote: "Because of the invisible clouds.


                                       39




            I think the temptation is always before us to invoke such
        invisible clouds to explain the things we don't really  understand,

        and I will try to avoid that today.
            For once,.in a discussion such as this, the word  "crisis"  has

        been left out -- a word so abused that, in a sense, it is now
        meaningless.  It is hard to call something acrisis  when  everything
        is a crisis, when one is living in a crisis. Certainly  this  Ipplies

        to what we comonly call the "Urban Crisis."
            What is this crisis? It is a crisis in the  cities,  though  not
        merely of tJie cities.  But it is also a crisis in health, a crisis in
        response to the people imprisoned in poverty, a crisis in  education,
        a crisis in the choice of national commitments and the ordering  of
        national priorities, and above all a crisi s in race --- a fundamental
        confrontation with the issue of race in Amrican life.  We  are  faced
        with a continuing major social upheaval that is bubbling,  erupting
        and exploding in every area of our national life, not just  health.
        And while we may focus on health, it is crucial to remember that
        health merely reflects and illustrates the four central issues in
        this national upheaval. These central issues, I believe,  are  race,
        poverty, migration from rural areas to the cities, and explosive

        urban growth.
            First, and briefly, the question of health and pove@.  I
        won't bore you with all of the details and figures. But  the  health
        of the poor in the United States is a national disaster that we  have
        known about for a long time, though we haven't fully faced  it.  Poor
        pe le are sicker, they get less medical care, and they  die  sooner.
          OP

                                        40


     Whether we examine the urban or the rural 1-)oor, this is what is haDDeiiing
     today -- in the central cities and ghettos of the urban North., in the share-
     cropper I s shacks of the rural South, in the migrant f arm workers I
     hovels that can be found an hour's drive,from New York City or Los
     Angeles, in the poor-white coalfield slag of Appalachia, among the
     Mexican-Americans of the southwest, and  among  the  Indians  on  the
     reservations, to name the  most  obvious  groups.  Thirty-five  years
     ago we were told that one-third of  our  population  was  ill-housed,
     ill-fed, and ill-clothed. Today  it  is  estimated  that  about  one-
     fifth of all the people in this affluent  society  live  in  poverty.
     The apparent improvement from 33% to 20% conceals the growing health
     gap between the poor and the rest of the population.  In 1940, for
     example, the infant mortality rate of non-whites was 70 percent
     greater than that for whites.  In 1962, 22 years later, it was 90
     per cent greater.  A few years ago, Dr. George James estimated the
     annual excess mortality among the poor in  New  York  City  alone  at
     13,000 lives a year.  And he added, "It is no exaggeration to state
     that these deaths are caused by poverty."
         Some 50 percent of.poor children are incompletely            ized
     against  smallpox and measles; 64 percent have never seen a.dentist;
     45 percent of mothers delivered  in  public  hospitals  have  had  no
     prenatal care.  For the poor, the risk of dying under age 35 is four
     times  the'natimal  average.  In  Mississippi,  the  Negro   maternal
     mortality rate is six times the white rate -- -and 74 percent of those
     deaths are due to causes that we commonly classify as preventable.


                                       41


         To forestall any snug northern superiority, let me add that there
         are a number of northern urban ghetto census tracts in which the
         infant mortality rate exceeds 100 per 1,000 live births. In these
         areas, we have reached the level of Biblical plague -- every tenth
         newborn baby dies.  And this says nothing of the   i   of life

         for those who survive.
            Second, health and race -- a topic almost but not quite
         coterminous with the question of poverty.  It is hardly startling
         that the association between race and poor health is even stronger,
         for here the crushing burden of racial discrimination is superimposed
         on the effects of economic and social deprivation.  There is a.phrase
         in  the Book of Common Prayer that is tragically precise in
         describing our national performance with respect to the healt@ of
         the Negro population. It-reads: "We have left undone those things
         which we ought to have done; and we have done those things which we
         ought not to have done; and there is no health in us."
             The.undeniable fact is: infant or adult, man or woman,
         northerner or Southerner the Negro is substantially less  healthy
         than the white.  He  gets less medical care, less adequate medical
         care, and less assistance in meeting its cost.
             The effects of racial discrimination and economic disadvantage
         begin before birth   and never stop.  Most Negro expectant mothers
         S:Lmply do not get the basic prenatal care that most white expectant
         mothers take for granted. Fewer Negro mothers have  their  babies
         in hospitals than do white mothers.  The national Negro infant
         mortality rate is almost twice the white rate.  And women without

                                          42



    prenatal care are about three times as likely to give birth to
    premature babies than those who do receive proper care.  Very
    small premature infants are ten times more likely to be mentally
    retarded than full-term children.  And some of the infants who
    do survive -he year, particularly in the rural southeast, are
    likely to be systematically and chronically malnourished. We  are
    just now beginning to explore the contribution of that kind of
    malnutrition to mental retardation.
       Nor is all of this merely the effect of the greater concentration
    of poverty among Negroes.  In one carefully detailed study in
    New York, for example, comparing perinatalmortality among Negroes
    and whites by social class, the mortality in the Negro population
    was higher than that in the white population in every socioeconomic-.
    group -- and, indeed, the mortality in the infants of the Negroes
    of the highest socioeconomic group (teachers, professionals and the
    like) was greater than that among whites of the lowest socioeconomic

    group.
         tual case may make this more -real than any recitation
    Of@@ igmres.  Consider this report from the Tufts-Delta Health Center
    in    al Mississippi:
         "Miss Jessie Mae and family.  A mother and 11 children,
    ranging in age from 9 months to 16 years, living in a  three-room
    s@k@off-Highway No. 8.  She   is employed as a day worker rotating
               white families.  Her average earnings are $15.00 weekly.
            first heard of Miss Jessie Mae from a young man who expressed
            or one of,her daughters who frequently had Iblackou t
                                     43




                                        I s knowledge the child had
     spells' that lasted for hours.  To hi-
     never been seen by a physi cian.  Upon arrival, I found seven
                                 d.  The older girl in the group (age
      children playing in the y,
      was caring' for the baby who was nursing himself on bean soup
      while resting in a bed made out of a paper box.  Although the
      temperature was 40 degrees, four of the children were without
      shoes and coats.  A five-year-old girl had an open wound on her
      foot, covered with layers of dry blood and dirt. We  were  told  by
      a neighbor that she had broken her toe with an axe.  When questioned
       regarding care) she stated that children usually seem to get  well
       fast and that most people didn't bother to take them to the doctor.
            "Miss Jessie Mae arrived after I'd been there for about  one-
       half hour and related the following information regarding her

       situation:
                She had been burned out mne months ago and now owned
       one bed, a table, and three chairs. Straw mats were  used  by  the

        smaller children.
             2.  The children were out of school for lack of shoes and

        clothing.
             3.. She di@'t have money to see a physician.
             4.  She realized that the baby needed better attention, but
                     thers to feed and take care of.
        she had  ten o
              S.  She gave the children grits for breakfast, pecan nuts for
         lunch, and rice, beans and greens for supper.  Fatback was to
         expensive but sometimes she fished and occasionally the boys would

                                           44




    run down a rabbit."
        This family I must add is not in southeast Asia.  It is in the

    southeast United States.
        But what has this got to do with the urban crisis?  Everything,
    for Mississippi -- and Alabama, Louisiana, Georgia, the Carolinas
    and other southern states -- are now our back yards.  The migration
    of Negroes from the south to the urban north and west -- toward
    expected improvement in employment, educational opportunity,  and
    living environment -- reached a net total of 1.5 million  persons
    in the 1940-1950 decade. Another 1.5 million  conservatively  are
    estimated to have migrated between 1950 and 1960.  This year alone,
    the number will approximate 150,000. This is the  most  extensive
    movement of a single group in American history -- yet there has
    never been a single, coordinated Federal program focused upon it.
    At the source of this migration, we fail to equip prospective
    migrants with reasonable health, functional literacy, or a marketable
    job skill.  At the terminals of the migration -- Chicago, New York,
    Boston, Detroit, Los Angeles, Washington, and elsewhere -- we fail
    to do anything effective to ease this enormous transition.  As the
    opportunities for a decent job, a decent education and decent housing
    in our central-city areas decline, the evidence increases that for
    many of these people this hopeful migration is self-destructive,
    destructive, of family, destructive of children.  It is perhaps
    ,Symbolic, in a nation built on migration, that this great movement
       human beings goes on behind the back of the Statue of Liberty;


                                      45


      she faces the other way.  And so, today, we are reaping the
      whirlwind of four decades of neglect, and all of us who are
      struggling with the problem of health care for the urban poor
      are reaping that whirlwind very specifically.
           Finally, and briefly, urban growth itself.  The demographers
         11 us that within 30 years most of the population of the United
         ates will be living in four or five huge urban megalopolis  One
       of them, with more than So million residents, will be Bos-Wash --
       a continuous urban belt from Boston to Washington.  Another, with
       more than 30 million people, will be Chi-Pitts -- Chicago to
       Pittsburgh; and a third, with 20 million, will be San-San --
       San Francisco to San Diego.  The prospects are about as distasteful
       as the names -- but they are real, and we will have to start to
       deal with them now, and recognize their magnitude.  In health care
        and in other areas, it is just no use to build a better mousetrap
           when the problem is elephants.
             And so, in summary, we have a whole segment of our population
           the poor, the Negro, the rural migrant, the central city-dweller
           sinking into the lower depths, isolated more and more from the
        mainstream of American life.  They are aliens within our own
        country, with a powerful and despairing conviction that the major
         institutions of American life do not serve them, are not intended
         to serve them.  And the consequences are apparent in their health.
              We ask,how this can be?  Look at our magnificent teaching
         hospitals, our medical centers, our medical schools, our networks
         of community hospitals, our public health departments and their vast
         arrangements of clinics, our great array of social service agencies

                                          Ar,



    and voluntary organizations.  And the poor, the Negro, the in-migrant
    --- regardless of ability to pay -- can got medical care of the very
    highest technical quality!  It must be the fault of the poor
    themselves -- they are apathetic and uncooperative.
        This convenient fiction has been called the Mt. Everest
    fallacy, a name I think is very apt.  If we construct awonderful
    medical center, complete with  a  trained staff, the latest
    equipment, open to rich and poor alike, with a huge  outpatient
    department and all of the necessary diagnostic and therapeutic resources,
    and then put the whole thing on top of !-@t. Everest, and then find that
    the bnly regular patients are Tenzing Sherpa and Sir Edmund Hillary,
    obviously the rest of the world is apathetic and  uncooperative
        I am saying that many of our health services for the poor,
    while they are of high technical quality, are characterized by a
    series of nearly insuperable barriers to access.  For poverty
    populations these include the barriers of time and distance  --
    the simple physical remoteness of many health facilities, the
    inadequacies of public transportation in slum areas, the long
    hours of travel and waiting time.  We have all heard over and over
    again the story about the Watts area of Los Angeles where it was a
    two-hour bus trip    if you could find a bus -- or a ten-dollar
    cab ride to the Los Angeles County Hospitalls outpatient
    department. If you were sick, the question-was whether  or  not
    You were "'ten dollars sick."  Or if you were willing to lose half
    a day Is pay (for, after all, the outpatient department is only open



                                    47



                          and the jobs available to most poor people
    during working hours,
    a-re not characterized by sick-leave provisions). Or if there were
     four children at home, and no one to care for them.
         Add to these the barriers of cost and confusing, complex, and
     contradictory eligibility requirements. Add to these the barriers of
     discontinuity, irrelevance and impersonality--what Dr. Alonzo Yeiby.has
                                               And then, finally
     called "the pervasive stigma of charity.                     add the barrier
     of fragmentation of the health care system, the biggest barrier of
     all and one that must be of overwhelming concern to Regional Medical
     Programs.  "Well-child" care in one place -- but someplace else for
      the same child when he's sick; adult care somewhere else,
      ambulatory care at another place, in-hospital care unconnected with
      all of these, and social work and visiting nurse resourc es at still
      other places.  One of the reasons for the great rise in the use. of
      the hospital emergency room at night is simply that the so-called
     "apatheti(!'poor are mAing highly intelligent use of the health-care
      system- they have discovered that you can get the same piecemeal,
      episofic, discontinuous  uncoordinated medical care cheaper and
       faster in the emergency room at night than in the outpatient
      q@epartment in the daytime!
            It is within the usual outpatient department, however, that the
       system really becomes absurd, and let me turn again to Dr. James
       for a case example that is I think only a little extreme.  He states:
            "Let me give an actual case history of a man of 76 who lives
       in a housing project in Queens.  He has the following medical
       problems: cancer of the larynx; he has a tracheotomy, and speaks
        through the use of his esophagus with special equipment.  If he
                                           48



    would go to one of our good teaching hospitals, he would go to
    the ear, nose, and throat clinic, and the cancer clinic.  He has
    a cataract of his left eye, so held go to the eye clinic.  He has
    chronic bronchitis, so he'd go to the chest clinic.  He has a
    hypertrophied prostate, so held go to the GU clinic.  He has
    varicose veins, so held go to the vascular clinic.  He has
    arteriosclerotic heart disease and an old coronary thrombosis,
    so held be followed in the heart clinic.  He has marked constipation,
    a diverticulosis sigmoid colon, a hiatus hernia, a diaphragmatic
    hernia, -- and so held go to the medical clinic.  He also has
    diabetes mellitus -- so held go to the metabolism clinic.
       Iliere's a man of seventy-six who happens to live four miles
    from the nearest available hospital, and must go to ten different

    clinics. I I
        Now this may- be a wonderfully-@@@ficient system for the
    training of interns and residents in the medical specialties.  It
    may be an efficient way to run a hospital, from the point of view
    of the hospital.  It may be a wonderf@l system for the diagnosis and
    treatment of diseased organs -- but the system doesn't work for sick
    people, and most diseased organs come in.that kind of a package.
    And it doesn't work for sick families, and most people are part
    of a family.  The system has nothing to do with communities, yet most
    families live in communities -- and family and ccnmamity are powerful
  @@@,@determinants of health and illness from the standpoint of the biological,

  -,,,Social and physical environment.
        @But how did all of this happen?  It didn't come into being


                                     49



       because health.professionals -- physicians, nurses, social workers,
       hospital administrators and others -- just didn't care,
       or haven't tried hard, or aren't concerned and trying
       hard now. -It happened because- for the-past fifty -years wQ
       have been experiencing the revolution of scientific medicine:
       accurate diagnosis, powerful therapy, and a very real ability to
       save lives.  We have made the hospital the center of this revolution,
       and more and more medical care -.- the complex equipment, the
       multiple diagnostic procedures and the concentration of specialist
       resources --- has been pulled centripetally into the hospital  and
       medical center.  In medical care, the hospital is the hub of the
       universe and this has had an enormous and important effect on  the
       quality of medical care.  But it has left the community, the people,
       and a whole set of deeper social needs, behind.
           And so, on the upper floor of the  o             ave the  very
       best that American medicine can offer.  And down on the street
       floor -- or in the basement -- we have that great medical soup-
       kitchen, that cafeteria of clinics, that Siberia of medical  care,
       the old-fashioned outpatient department.
            Sir Geoffrey Vickers has defined the history of public health.
       as a series of "successful redefinitions of the unacceptable.''  If
       the old outpatient department is unacceptable and innovation is needed,
       then the Regional Medical @rograms need to be very much concerned
       'with a new'redefinition of the unacceptable.
            One kind of innovation -- and I am not going to dwell -on it in any
       ,detail at all -- is the Comprehensive Neighborh
                                                      ood Health Center network


                                          50




                                                                      ing the
             the Office of - Economic C)OPOrtufli@.  It is a way of Putt
   funded by                                                    t going
   existing package together a little bit differently.  I am no
   to describe it because I know it has been described .to all of You
                                         I ou a little bit of the data
   many times.  But I would like to give y
   on results of this reorganizing effort in one comunitY --.the
                              the population served by the COlInbia
    6,000 people who comprise
    point Health Center in Boston.
        We are able to have some measurements of impact here because of the
    oBols wise provis        ese         ev
                   . ion of'r   arch and   aluation money which gave us the
    unusual opportunity to take baseline measurements before we opened clinical
             'before we changed the system$ as a reference point for comparison
    s6rvices,
    with the measurements at a later period of time.  After we had been open
     for just two years, we found we had managed more than 72,000-patient
     visits, mostly at a rate of more than 200 patients per day, or
     three percent of the Columbia point population every 24 hours for
                                             the so-called apathy of the
     -real and evident problems-  So much for
     poor with regard to health care!
          we had assumed from the beginning that we would have to turn
      on  a variety of health education programs -- how to use this new
                                                     - to make people
      source of care, how to utilize it effectively
                                 health care.  We have been too busy
      concerned about health and
      since the day the doors opened to ever get around to .these programs.
                                                      ity every 24 hou-rsL
      Remember -- we see three percent of this co
      The rate of ambulatory health care utilization by this ccmunity has
      more than doubled.  Before we openedoonly 72 percent of the co      ity
       had identified itself as having any regular source of medical care.

                                         51



       Today that figure is over 90 percent and overwhelmingly represents
       the health center.  Two years ago only 15 percent of the population
       felt it had a good source of advice about health problems; today
       the figure is 44 percent.  Two years ago, 23 percent of Columbia
       Point families stated that they had put off needed medical care
       during the preceding months.  The comparable figure is now only
       5 percent.  Two years ago, 28 percent of the residents had ever
       had a physical examination for preventive purposes -- that is,
       when no known illness was present.  Today the figure is S5 percent.
          Before the health center opened, 70 percent of the Columbia
       Point population reported that it took from two to five hours to
       leave home, get medical care, and return,home.  Fourteen,perc6nt
       said it took from five to nine hours.  Today 89 percent of the
       co@ty reports that the door-to-door time for medical care is
       one hour or less -- a figure much more consistent with the needs of
       large families, working mothers, many young children and limited

       transportation.
           And finally, and most strikingly, we have just conducted a
       study of hospitalizations in a small sample (54 Columbia Point
       families) for the year before the health center opened and for the
       two years since.  These 54 families ( a random selection of those
       continuously on public assistance which is typical in this
       co   ity) consumed 200 hospital days in 196S, the year before the
       health center opened.  The first year we were open,in 1966,
       these same families required 110 hospitalization days; and in 1967,
       the second year we were open, a total. of 40 days.

                                      - 52




                     le of families, then, the health center has
        In this samp
           hospitalization by 80 percent in just two years.  I didn't
      reduced
      believe the f igures so we went back and did a much more careful
      study on a substantially larger sample of families.  We also
      contacted every hospital in the Boston area that was a possible
      source of hospitalization for any of these people. On the bais of
      this new data, I have to tell you that the 80 percent figure was
      wrong.  The accurate figure is an 86 percent reduction in hospi-
      tal days for this community over a two year period.
         That's one kind of innovation.  But it's not the only kind.
      I will suggest the bases for considering other innovations. The
      promise of health action alone is not enough. In the urban crisis,
      and for the Negro population that is at the center of the urban
      crisis, it -is absolutely clear that the biological, social, economic,
      and political environment of the ghetto is incompatible with
      healthy life, and no amount of health service as such will alter it.
      There is just no point in treating rat bites - - and ignoring the
      rats. This is the reality we must face -- and the reality we  have
      been avoiding as health professionals, preoccupied as we are either
      with technical medical concerns or with hospital -development. - To
      equip a concentration camp with a medical center is not only futile
        it is an expression of the deepest moral cynicism.  We cannot
      simultaneously have health and Harlems, health and slums, health
      and racial discrimination, health and a second-or third-class
      education, health and unaided in-migration.
           If ill health is not a matter of mer@ technical medical concern,
      what then are some of the things that an organization such as  the




     Regional Medical Programs might do?
         I've talked about innovation.  It seems to me that Regional
     Medical Programs,,precisely because they are not primarily devoted
     to the construction of new facilities or the operation of new
     service programs, but rather to the linking together of the old in new
     ways, has a particular role to play with regard to innovation,
     particularly innovation in the organization of care.  In taking this
     path, let me just suggest some ideas to you and to the panel for response.
          First of all, I would like to ask, why are we so narrow
     about our definition of health service?  What is a health service?
     Why do we approach, for example, the problem of lead poisoning by
     defining  only the following things as health services --
     screening, case finding, treatment, follow-up remedial care, long-
     term care for those with neurological damage?  We all know that this
     is a great problem in the slums of our cities; yet we send 98 percent
     of these child-ren,after treatment,back to the same slum to eat the
     same lead poisoning paint off the same crumbling plaster walls!  Is
     it not a health service to do something about those walls?  No,
     we say that is not a health service.  It doesn't.concern the same
     people who are concerned about diagnosis and treatment.
         Why is transportation not a health service?  Why is it not
     included and considered as an integral part of the whole package
     by Regional Medical Programs and other organizations concerned
     with health services?  We all know that the existing health care
     system is run by and large for the convenience of the professionals; they
         one of the important groups in the system, but not the only one.  Yet
        is the shortage of health professionals, the need to cater to their




    convenience, that forces our outpatient departments to be open only
    from 8 a.m. to 4 p.m.  I often wonder what would happen if, for the same
    reason, we ran our subway system only from eight o'clock to four
       said that after that it had to be an emergency problem!
        What can be added to the planning process?  I know there has
    been talk about the involvement of health professionals as a primary
    participant in health planning processes, particularly in urban areas.
    But, I think that the most important thing that can be added to the
    planning process is the community -- not just the health and related
    professionals.  This is particularly true with urban ghetto communities,
    and when we talk about urban health problem, we are increasingly

    talking about ghetto problem .
         I am not talking merely about the peculiarly political definitions
    we have given to community control, community participation, community
    veto over programs and all of the rest, nor about the resulting
    political conflicts.  I think there is something else, something which
    is very often left out when we try to identify the parts of a community.
    That is the community as a set of resources, a set of strengths.  We
    are so trapped by wringing our hands over what we believe to be the
    unique pathology of ghetto populations that we forget too often to
    even look for the strengths that are there.
         Let me give you just one example.  It's from a rural environment,
    but I am sure there are many urban -parallels.  Our Mississippi health
    center has to cover nearly 11,000 people spread across SOO square




                                     55



      miles.  That's a lot of territory, with a lot of patients to be
      t
      brought in to the health center, and returned.  Also, health center
      staff of various kinds @t travel those 500 .square Tniles.  It became
      clear to us after struggling with,the transportation problem that
      there just weren't enough wheels in the world to do the job adequately.
          The community came to us and said: "Why are you killing your-
      selves over this transportation problem? Why do you do such stupid
      things?  This territory is travelled one way or another every day.
      You must take advantage of this existing travel."  The upshot was
      that we a-re taking a significant portion of our transportation budget
      and giving it to the 12 health associations we have helped to organize
      in the area. The health associations, in turn, found local  people  in
      old cars to tour the local networks, pick up the patients, bring  them
      to us, wait for them and bring them back.
           There was the strength in the commity to run this system very
      effectively, and we are finding the same strength over and over again.
      There are all kinds of skills and strengths out there in the comunities
      and I think they must be taken into account in our planning for new
      ways to put things together.
           One last item, again in.terms of  innovation.  What  contribution
      can Regional Wdical Programs make to change in licensure laws?  There
      is just no po' t in talking sensibly about new health careers, new
                                                     .ess we are voino, t
      do something about the legal restrictions that prevent us from
                                                     systematically taking


                                        56




              a physician what can be given to a nurse, from  the
               can t)e            S, and so on down the line.
         if there is an encouraging thing to be said about this  cr.isis,
    this vast set of problems, I think it's the fact that  asking  health
    professionals to face them poses nothing really new.  It merely
    asks that we health professionals rediscover the  social  commitments
    we made more than a century ago, when we were leaders in the fight
    for sanitary reform, for an end to slum housing, for the abolition
    of child labor.  Let those who think this is radical listen to the
    words of John Simon, the first health officer of London,  during  the
    first great urban crisis -- the explosion of the cities during
    the industrial revolution in the 1840s:
         "I feel the deepest conviction that no sanitary system can
    be adequate to the requirements of the time, or can cure those
    radical evils which invest the under-framework of society, unless
    the importance be distinctly recognized, and the duty manfully
    undertaken, of @roving the social condition of the poor."
         "I would beg any educated person, to consider what are the
    conditions (of urban life); to learn, by personal ins ection, how
                                                          p
    far these conditions are realized for the masses of  our  population;
    and to form for himself a conscientious judgment as to the need
    for great, if even almost revolutionary, reforms.  Let any such
    person devote an hour to visiting some very poor neighborhood in
    the metropolis ... let him breathe its air, taste its water, eat
    its bread.  Let him think of human life struggling there for years...
  "..,Let him, if he have a heart...gravely reflect whether such sickening

                                     57



     evils ought to be the habit of our labouring populations; whether
     the legislature, which his voice helps to constitute, is doin@  all
     that might be done to palliate these wrongs; whether it be not a
     jarring discord in the civilization we boast, that such things
     continue in the midst of us, scandalously neglected...
          "If there be citizens so destitute that they can afford to
     live only where they must straightaway die -- renting the twentieth
     strawheap in some lightless fever-bin, breathing from the  cesspool
     and the sewer', so destitute that they can buy no water -- that milk
     and bread must be impoverished to meet their means of purchase,  that
     the drugs sold them for sickness must be rubbish.or poison:  surely
     no civilized community dare avert itself from the care of this
     abject orphanage.  If such conditions of food or dwelling are
     absolutely inconsistent with healthy life, what clearer right to
     public succour than that the subject's means fall short of  providing
     him other conditions than these?"
          These are the words of a revolutionary -- a health  professional
     and a revolutionary -- calling for reform, and he and his  colleagues
     led the way in a great social upheaval.  It was the sanitary reform
     movement of the nineteenth century, and it was a first answer to  the
     urban crisis of that era.  Today, in the face of another urban
     crisis, we need analogous social reforms, and we need the participation

     of health professionals.
          If physicians could testify then as to the maximum permissible
     amount of filth in the municipal water,supply, then they  can  with
     equal propriety testify now as to the minimum amount of green grass


                                       58



      per growing child, or the minimum standard for accessibly and
      availability of health care or the effects of racial discrimination
      on young minds and personalities.  Through such institutions as
      their medical schools they can reach into the slums not merely
      to give service but to start recruiting, at the third-grade level,
      the future candidates for professional education -- and that means
      paying the tax money to support as good an education in the central
      city as in the suburbs.  It is time  once again, to redefine the
      unacceptable, not as "crime in the streets" or some other
      euphemism for racial prejudice, but as the social and physical
      conditions that produced last year's and this year's mass convulsions
      in our cities.  The real crimes in the streets of our cities from
      the point of view of health professionals, I suggest, are the
      crimes of slum housing, slum education, slum jobs or no jobs -- and,
      among other things, the infant mortality rate, the dead babies.
           This doesn't ask that the health professions abandon their

      technical concerns.  It does suggest that they add to them a sense
      of passionate involvement in the social issues that underlie health.
      Any narrower definition of our proper interest in health. I submit,
      is an abdication -- one that will leave us once again with "no health

      among us" and no freedom, either.










                                        59


        327-284 0 - 68 - 5






                                 Ray E. Brown
                           Executive Vice President
                         Affiliated Hospitals Centers
                              Harvard University
                             Boston, Massachusetts



           After Dr. Olson called and asked that I discuss with you the manage-

      ment principles that should be operative in the work of cooperative health

      associations, I started reflecting on what would be most relevant to  your

      situation and responsibilities.  The thought occurred that Stan was not

      really talking about the principles of management. Those of us  who  teach

      in graduate schools of business actually don't have much in the way of

      principles to teach. The great thought today in management is  the  parti-

      cular situation in which the manager is operating. We have  seen  success-

      ful management jobs often done by people who were never formally exposed

      to the principles but who understood the situation in which they were

      operating.  So I have decided that for my presentation I would examine with

      you very briefly in the short time allowed me, the sorts of obstacles or

      pitfalls that your particular management situation represents.

           The important thing to you and to the mission you have is to develop

      a staff and to inculcate into that staff awareness of the very difficult

      administrative situation, the very complex situation, that confronts  them

      as they try to get the job done. You have a number of difficulties  that

      simply are not faced by any other type of organization that I know of in

      this country.  I can say truthfully I do not know of a more difficult

      management job than yours. And here, I am not talking about  you  managing

      your own organization. That I think is relatively easy because  you  don't






                                       -60-




     have very mucn or a snow in iLseij-.  ILL f2 5 LZ:L.L L LLlr, U.L @UUJ. @C LO Ui
     because of the low salaries you are able to pay.  Finding the type of
     person that fits into the responsibilities you have is difficult.  But, in
     general, as to managing your own organization, it could be done with your
     left hand. The real difficulties you have is managing  the  situation,  or

     what we would call program management rather than  enterprise  management.

     This is the most difficult sort of management because it is up to you
     to get other people that are not in your hierarchy, not even organizationally
     related, to carry out the purposes, the charge, the mission for which you

     are responsible.
           So it is the unique situation that confronts you that we should

     examine with the thought that good common sense will handle  the  rest--

     if you can just orient your staff as to the situation in which  they  are
     operating. I have listed some eight or ten obstacles, or  you  might  even

     call them pitfalls, that very seriously affect what it is that  you  are

     trying to do.

           I. have mentioned the first of these already--that is that you  are

     program administrators rather than enterprise or operation administrators.
     You must put across your assignment through other agencies,  through  the

     efforts and contributions of people who do not have  line  responsibility

     to your own organization, who are not under a system of  inducements  that

     you control, except through such grants as you might influence.

           Second, your own staff, and indeed you yourself, are  atypical  to

     the situation in which you are working. You are likely to  be  much  more

     mission oriented than the people with whom you are working, or the

     people whom you are attempting to convince. That is, you  would  not  be




     just a little differently from all of those outside of  your  immediate
     organization with whom you are working. This is  because  if  everybody
     saw things like you do, there would be no need for you.  We would already
     have in operation the arrangements that Regional Medical. Programs  seeks.
     But in any movement of this sort, and especially to its pioneers, there
     must be a high degree of evangelism, a degree almost of  fanaticism  in
     support of the goals Regional Medical Programs is trying to accomplish.
     If you did not, or do not, possess an emotional bias toward these goals
     you should not have gotten into the movement anyway. I am  sure  you  have
     seen this as you asked people to join your staff. You  have  had  turn-
     downs from a lot of very capable people simply because they were not
     fired-up in behalf of the cause, so to speak.  This is a movement that is
     long past due. only a few people have fully recognized how  needed  it  is
     and it is those people who are willing to give up other positions  to  get
     the job done.  These are capable people who can put the job across for you.
     But they have been willing to come with you because they were  like  you--
     just a little queer, just a little odd. They believed  in  something  that
     few others recognized and to that extent you and your people have to be
     careful that you see the situation through the eyes@of the average person
     engaged in the agencies or activities whose participation you  are  trying
     to enlist.  You must realize that you cAn't assign to. everyone in a Region
     the same sort of interest, the same sort of evangelistic effort  that  you
     and your staff have. This is a problem in any  movement.  We  forget  this





                                      -62-




                            riders  try to roll over the top of people without
      fact and become  rough
      selling them,  without convincing them, without creating an understanding
      of what it is you  are try'lng to do.  We must not start from the position
      that everyone else  is as highly motivated as we are.  There is nothing
      that creates resentment more on the part of the other fellow than to
      roll over him or to push him, or to pressure him into something he really
      is not sold on, really does not understand.
           The next pitfall would be that the Programs represent a threat to
      the status quo.  As I said earlier, if your charge was widely accepted,
      if the regions were already functioning as you feel they should, and just
      a few refinements were needed, this country would not need  the rather
      elaborate organization of Regional Medical Programs.  in that case your
      program would be proceeding historically, it would have its own traditions,
      it would have many of its own mores already established.  But this isn't
      the case.  You are indeed undertaking something that is a real threat to
      the status quo.  If it is put across in the next couple of decades, if we
      can after some twenty years of your effort see visible effects of this
      linkage of our health system, then I think all the efforts, concern, and
      money that will have been devoted to it will have been much worthwhile.
            But to every person now involved or engaged in health activities,
      Regional Medical Programs do represent a threat to the status quo.  Of
      course, by over-emphasizing your threat to the status quo I could be giving
      You what I call an excuse for alibi administration.  You could go too slow,
      You could lose the momentum of th e Act itself, of the great start it has
      gotten.  But at the same time, as you work with people in the many diverse






                                       -63-



       agencies and institutions concerned, you will lose them pretty quickly
       if you out-run them.  Also you can frighten them as you proceed.  I don't
       believe people resist change as much as many psychologists  say  they  do,
       but every person and organization will resist change to some extent and will
       do so strongly and stubbornly unless it fully  understands  the  implica.tions
       of that change to its own welfare, to its own  existence.  The  RMP  agencies
       can expect resistance.  You are a threat and you might as well recognize
       it.  If you do what you are supposed to do you are a real  threat  to  the
       established and traditional patterns and practices in carrying out the

       function of health care.
            Next, the forces of inertia are lined  up  against  you.  With  any
       movement, with any effort to bring about change, whether people like
       or don't like what you are endeavoring to do, it is  difficult  to  get  them
       to move off of a dime, so to speak. just  to  get  individuals  and  agencies
       to put out the effort that change requires is in  itself  a  difficult  thing
       to accomplish.  Also, the need for stability in society, and the
       longing people have for the familiar and the routine, fosters
       inertia.  I guess one of the most difficult problems, at least this is what
       we teach in business administration, is that  inertia  keeps  things  from
       happening much more so than ill will and hostility  toward  the  chance  that
       is being advocated. This is not to say that  you  do  not  have  hostilities.
       We will talk about these shortly. You will  have  them  as  you  restructure,
       or as you cause to be restructured and reshaped  and  redesigned  the  health

       care delivery system of a nation.
             Next, you must introduce people that have long worked around each
       other to each other.  In other words, you must cause the   components   of




                                        -64-





      nea.LLLI @aLC uu
      period in the health field that there is quite a difference betw een
      being familiar with what other people are doing and establishing a
      relationship between people or agencies that has meaning to what each
      is trying to accomplish.  That is, you must establish close working
      relationships between groups that hardly speak to one another  officially,
      or agency-wise, or professionally, even though they might know each
      otheris program.  Your program involves a whole new chain of relationships.
      Again, these relationships are hard to establish because it means  dis-
      rupting other relationships, perhaps turning away from those with  whom
      you have worked closely in order to function in a new alignment.  It
      can also mean the awkwardness of attempting to work with the same groups

      in a different way.
            Next, there is a great diversity of agencies with which you  must
      deal. The health industry, or the.health field, is marked in  our  country
      by extreme proliferation. This, of course, is no secret to  you  coming
      from the health field--and also from the short time you have had to see
      it from your present vantage point.  We are made up of many, many agencies.
      This partly grew out of the fact that there were so many different  facets
      of the field involved. Not only is there a great diversity of  task  or
      assignment, each agency having a small segment of the total health  job
      to doi but also the'proliferation of ownership and control. We  have  a
      pluralistic system.  This means we ar e highly diversified as between  pri-
      vate entrepreneurship, non-profit and public. We-are  also  diversified
      in relation to the way our various agencies get their funds.  Some





                                         -65-




      providers get them from the client or the consumer, others get them
      indirectly from third parties, some get them directly  from  the  govern-

      ment, some get them almost entirely from  philanthropy.  But  which  ever

      way you turn in the-health field, you find this  great  proliferation  of

      origin, great proliferation of support, and great proliferation of identity,
      so to speak.  You are charged in your duties of Regional planning to bring
      together a host of diverse interests and diverse types  of  agencies,  to

      ,get them to work together to accomplish a common job.  This proliferation

      does not mark any other activity or field in our society as it  does  the
      health field.  The health field literally has no counterpart.  Education,
      the only comparable field  is largely public owned, largely  public  sup-

      ported and operated.  The educational institutions each have a pretty

      clear cut identification.  But, in the health field we have no such clear

      cut identification of roles. We have many sources  of  responsibility  to

      which we must respond.

           Then,, there is a divergency of goals and interests in the health

      field@  There is no use kidding ourselves here, there is no identical

      -set of interests.  Everyone sees the same end goal--the better health of

      people in the Region they are serving.  But to be naive and say that there

      is an identity of goals and interests will only lead you into conflict, or
      lead you into trouble, because each of the agencies and individuals do

      indeed have different goals, institutional goals or individual,goals.
      There is a mutuality of interests, of course.  But it is a common thought

      in management, and also in social organizations, that most movements come

      about rather spontaneously because people sense that they can  do  better






                                        -66-



    @@@@and achieve their own particular goals better together than  they  can
      individually  But my own experience indicates that there is not a
      sensing, nor a reality, relative to  common  and  identical  goals.  The
      planning that you do, the programming that you do, has to bear in mind
      that you are in some instances asking people and agencies to subordinate.
      That is a good word, but you probably better not use it out of this room.
      But to be effective you must secure a subordination of the parts to the
      whole.  This is a sacrifice that few agencies, institutions, and pro-
      fessions are willing to make.  In the same connection, I could say, that
      this divergence of goals and interests means that you have different peer
      groups, you have different reference groups.  Because  of  the  lack  of
      full client payment, except in the actual practice of medicine itself,
      most all of the institutions that have traditionally supported the'doctor
      and provided the resources and facilities for the doctor have been non-
      profit, philanthropically supported.  Philanthropically supported means
      that our institutions are very  much  public  relations  oriented.  They
      are usually looking over their left shoulder at what will help fund raising,
      or what will help the rich widow leave them money in her will, or what will
      help the local industries to come across with checks.  If you try to put
      the pieces of health care together Regionally.then you run into the problem
      of who is trying to impress whom.  Their destiny has depended upon public
      relations much more so than the quality of their effort, or the compre-
      hensiveness of it, or the continuity of it.  There are some who claim that
      the whole health facilities system in this country has been put together
      by public relations people; that the system has been designed much more
      by the desire to' fill a tin cup than from the desire to f  ill the greatest

      need.

                                            -67-



           You are dealing with a broad spectrum of professionals.  If you
      asked what has been the greatest problem, the newest problem in the past
      couple of decades presented to management, especially to industrial
      management, the answer would be the management of  professionals.  We  have
      seen a great movement toTJards research and development and the  consequent
      movement of the scientist into industry.  When you try to administer the
      professional you confront numerous variables.  His outlook is.entirely
      different, his motivations and aspirations are different, and his reactions
      are different. He can be described as being  very  independent.  I  don't
      think it any secret that physicians are highly individualistic.  Physicians
      accept a personal responsibility to the individual and  are  antagonistic
      to anything that binds them into a situation where they are not  in  con-
      trol of the decision-making process relative to the  individual  patient.
      But you are dealing not only with doctors but with a whole host of other
      professionals. All tend toward an individualistic  approach.  You  will  be
      dealing largely with representatives of organized groups both of professions
      and institutions. They were selected because they  have  exhibited  strong-
      willed interest and strong leadership. This means you are  asking  a  group
      of super stars to play on the same team.  And super stars are awfully
      difficult to co-ordinate. They got to be leaders simply because  they  were
      stronger in their opinions, stronger in their  motivations  and  stronger
      in their efforts than those who failed to become leaders.  You are dea ing
      with the strongest people, both professionally, leadership wise, and
      otherwise, in your Region.  To work with these people is a science in
      itself.  It calls for a kid glove technique.  It also calls for an


                                      -68-


      ntellectual approach. it is in no way the same as  working  With  indivi-
      duals who desire to rise in an organizational hierarchy and whose' future
      depends upon your organization.  I don't think that you will find many
      "organization" men in the many diverse groups with which you will be workinE;..
          I'm sure I am not telling those of you who  have been in your positions
      for any time anything new.  Again I would like to repeat that I am not
      talking about your own staff.  I think every individual who has been chosen
      for a responsible position on the staff of a Regional Medical Program
      has already exhibited a high degree of compatibility with  organizational
      goals or he would not have come to the surface sufficiently to have  been
      considered and tapped for such a position with you.  This  can  represent
      a liability as well as an asset, however.  As I stated in an earlier point,
      you are recruiting and developing a staff that in itself is highly motivated
      toward its own mission.  But having a vision is not enough.  You must
      develop a staff that while it remains highly motivated to Regional Medical
      Programs mission., must also realize the difficulties that confront an
      organization whose responsibility it is to get others to share that motiva-
      tion, to get other people to involve themselves seriously in the planning
      function, and then to work hard toward implementing whatever it  is  that

      is planned.
           Another thing to consider.  Your system of inducement is weak, very
      weak compared to the task that confronts you.  Most programs that I know
      don't ask others to do things unless the program is footing the bill for
      whatever it is they are asking. Examine other Federal  programs  and  you
      will find this to be the case. There is a financial  quid  pro  quo  that
      goes along with asking people to put across a  particular  job.  But  you



                                         -69-



        have very little project money compared to your total task.  Your move-
        ment won't succeed  or get very far toward the realignment of our health
        care delivery system if the only thing done is what you can pay to be done.
        In other words, even if you had many times the budget you have, you could
        hardly touch the problem.  All you can do with the resources you control
        is help create the stimulus and help build the momentum.  The resources
        available to you will always be insignificant to the task no matter how
        generous the Congress  might be.  Youtre faced with the fact that you
        have little more than demonstration money.  To a large extent you are
        asking people to spend their own funds in order to accomplish the purposes
        for which you are responsible.  Because your financial inducements in no
        way match your responsibilities, you must excel in the art of leadership,
        the art of administration.  Also, you must not only win converts but you
        must keep them won over the long haul of tedious and slow progress.  It
        is always much easier to get things to fall in line than to get them to stay
        in line.  There is another real handicap you face.  You are operating in
        a glass bowl.  Your business is public business and everything you do will
        be scrutinized not only by 'the local newspapers but by every health agency
        and health professions group.  Your problem is somewhat akin to that of
        Mr. Johnson's misfortune in having to fight the VietNam war over television.
        He is subject to the second guessing of all these arm-chair generals who
        sit before their television set and see only a fragment of the action-
        and none of the troubled factors that led to the course'of action.  The visi-
        bility of your failures will not extend to your successes, however.  They
        will be obscure.  This obscurity of results can cause a dampening of
        interest on the part of the general public, on the part of Congress, on



                                         -70-


        part of the agencies concerned, and indeed on the part ot  your  suaii.
       uaren't going to be able to revolutionize the health care delivery
       .0
       ,stem overn3-ght.  You aren't going to be able to rapidly achieve con-
       ete gains.  if all the projects that have been funded are highly success-
       ful, they will not in themselves make a great dent in the problem you are
       attacking.  There will, of course, be long term results if the projects
       have meaning.  There is no possibility, regardless of the number or
       quality of projects, of instantly changing a thing so complex, so cum-
       bersome, so ingrained as our health care system. To realign it properly,
       to give it continuity, comprehensiveness and economy, is an incredibly
       difficult task. Progress is going to have to come by the inch rather than
       by the mile.  And in many instances things that are done will not prove
       themselves, or even come to the surface, for several years, or in some
       cases for many years.  Further, the successes will have to be accumulative.
       Total success will have to be achieved before the worth of individual
       steps is recognized. In other words it is sort of like climbing a  moun-
       tain to see the other side--you just can't see anything until you get to
       the top.  The top, I'm afraid, is going to be reached beyond the tenure
       of some of the directors now involved in making the tortuous climb up the

       Mountainside.
           The elusive measure of your efforts can lead to a tendency  on  your
       part to do the dramatic, to prove your case, to justify your existence.
       The temptation will be to choose the sort of projects that -show up the
       most, even though they count the least.  To use an old expression, yielding
       to this temptation can win some skirmishes but lose you the war.  In




        picKing Lne niubu
        instant success) you can waste your resources and following.  Getting
        mired.in the irrelevant can discredit the entire movement and create
        both diffidence and dissidence toward your later efforts.  Along this
        same line, doing a thing well must not be confused with doing the best
        thing.  We are prone to grab hold of those problems we know we can do most
        and best about.  But these are generally, and especially in the case of
        Regional Medical Programs., the problems that we needed to worry least
        about.  Another axiom of management is that we work hardest @ien we see
        results.  It takes a high level of discipline, as well as conmittment,
        to keep in,pursuit of a goal in which progress is not well defined, and
        where you can't go home in the evening sure of how much and how well
        you did during the day.  But by the nature of its mission this is largely
        the name of the game for Regional Medical Programs.
            I close by emphasizing that I'm not trying to say your job isn't
        do-able.  I think it is very do-able.  I sincerely believe that over a
        period of time we are going to see all of the aspirations of Regional
        Medical Programs accomplished.  The program just makes too mu ch sense to
        believe otherwise.  What I have tried to point out is that there are more
        than ordinary obstacles and that your job calls for the practice of manage-
        ment in its finest sense.  You must work through many diverse elements,
        where the management strings you must pull are held by many different
        groups and individuals.  You can never fully know the true response from

        those strings.
             The problem you have is to develop a staff that is sensitive, as
        well as dedicated; that-they realize they are dealing with real live".



                                           -72-



     jumping people who are also dedicated; that they are ciea.LILLY, WA.L.LL
     people; that they are dealing with people who have a great deal of techni-
                                                                 belong  to
     cal, scientific and professional knowledge; with people who
                                     ople who have spent a good part of their
     other organizations; and with pe
     life getting fixed in the patterns and.circumstances of a system that you
     are charged with realigning and to an extent redefining.
          This management task o.L@ Regional Medical Programs calls for
     the art more than the science of management. It calls for a  savvy  of
     the situation in which management is being practiced. The  best  pilot
     on the Mississippi River can easily run his boat aground on the Amazon.
     Or, to state it another way, as every effective salesman soon  learns;
     You've got to know the territory.































                                        -73-




                 ITH RESPONSIBILITIES OF MEDICINE
                 IN ADVANCING OUR HEALTH CARE SYSTEM"



                       Dwight L. Wilbur, M.D.
                              President
                    American Medical Association
                      San Francisco, California


          First, I would like to compliment Mr. Brown on having
      handled a most difficult subj.ect in a superb way. I  hope
      when I'm finished, I will have at least in part done as well
      in discussing the subject Dr. Olson has asked me to consider--
      "The Responsibilities of Medicine in Advancing our  Health

      Care System."
           I'm really sorry that I was not here yesterday, but other
      duties detained me. I notice from your program  there  was
      discussion of the Health Power Structure and  subsequently
      a discussion of Issues and Concerns. I also see that this afternoon
      there will be further discussion of Issues and Concerns.
           I also have great issue and concern with the title of "Health
      Power Structure."  If there is such a thing, I suppose I could

      be said to represent it.
           But in making these comments I would like to tell you a little
      story about Woodrow Wilson.  In his early days after he finished his
      studies in law school, he returned to his old home of Staunton,
      Virginia, and hung out  a shingle to practice law.  His first
      three cases were tried before a judge who was an old family


                                    -74-



   "friend of the Wilsons.  Woodrow lost all three cases.    He,was
     terribly depressed about this because he knew he had ability;
     he had the interest 'and had worked hard.  And this was his
     hometown and he was 3ust getting underway.  So, one evening,
     he went over to visit the judge. He said, "I would  like  to
     talk to you man to man and have you tell me what my  trouble
     is.".  And the old judge said to him, "Well, Woodrow, you
     have done a superb job in studying these cases.  The  briefs
     you have prepared could be used as models in any law  school
     in this country.  But your basic problem is that you practice.
     law not the way it is, but the way you think it should  be."
         This was exemplified in Wilson's subsequent career,
     particularly in relation to the League of Nations.  He was
     so idealistic that the League had to be only the way he
     thought it should be.  He could not accept the political
     realities at that time of the nations of the world.  My
     concern now is that those who wish to greatly modify the
     health care system in this country, and to do it rapidly,
     may get into the same difficulty that Woodrow Wilson did.
     They may not lose all the cases, but, in the long run, as
     with the League of Nations, they are not going to win.  And
     in the meantime, they will needlessly upset an evolving
     system and do a great deal of harm to many people.  I will
     indicate in my comments why I believe this is so.


                                    -75-


       @i?-284 0 - 68 - 6



          The fact that I have been asked to speak on the responsibilities
     of the profession in advancing A health care system suggests that
     we do not have a health care system in this country now.  I
     have heard this comment made on a number of  occasions.  Of
      course, if you know anything about it, you will know  this
      is not accurate.  We do have a health care system in this
      country.  We have top-flight medicine here.  There is no
      system of medicine anywhere in the world that can compare
      with that in this country.  If you don't believe it, all
      you have to do is note that two generations ago as in my
      father's time, he and all others who wanted to get ahead
      in medicine had to go abroad for their advanced training.  But
      this is no longer the case. Now, all the world  is  coming
      to this country for medical education, for knowledge of
      medical research, for information in regard to our  health
      care system. We are the center of medicine in  the  world.
            I don't mean we have a perfect system. I will  point
       out that we have far from a perfect system.  There are
       many improvements that need to be made.
            Now, what does this system consist of?  Basically, it
       has to do with a physician-patient relationship, the one-to-
       one voluntary relationship of one man seeking and one giving

       relief.





                                   -76-



          Here it is important to stress a point that is vital
      but tends to be lost sight of.  In our society we are
      accustomed to hailing mass methods and mechanization as
      improvements in fields like manufacturing and handling
      traffic and keeping track of bank checks.  Too many people
      transfer this kind of thinking to human matters, and assume
      that mass methods and mass handling will also be improvements

      there.
               This overlooking of the human factor is at the root of
      many of our misfortunes in education. And it can be  the
      root of disaster in our health care.
          The human being is at his most vulnerable when he is
      sick. It is then he needs most the humane attention  and
      understanding of a trusted and knowledgeable expert - of
      the physician he turns to voluntarily and into whose dare
      he trusts his life and well-being. Since we know that  a
      major part of the health of the individual is based on his
      psychological equilibrium, it is clear that this sense of
      trust and well-being is all important in his chances,of

      returning to good health.
           The long-discussed patient-physician relationship is
      the heart of this rule of human well-being.  Without it, we
      may have eliminated "inefficiencies", but we may also have
    @.,@,eliminated most of what health care can achieve.


                                     -77-




          In this country, this relationship occurs primarily  in

     the physician's office.  The physician may be a solo practitioner

     or he may be one of a group.  The physician-patient relationship
     may occur in the setting of the home. But  more  frequently

     today it occurs in the setting of the hospital - in the emergency

     room of the hospital and in the out-patient portion of  the
     hospital.  It occurs to some extent in other areas but these
     are the prime ones, and within this system there is  formal

     or informal referral of patients by one physician to another.

     During this past year this system,provided 1,250,000,000

     visits between the physician and the patient in one or  the

     other of these locations I have mentioned.

          It is a very large system quantitatively and I  believe
     good qualitatively. In this system the work is  carried  out
     by physicians who are either solo practitioners in an informal
     group, or practicing in a formal group of varying sorts.
     They have varying capabilities depending on their education,

     on their motivation and particularly on their  participation

     in continuing medical education.

          These visits-are carried out in physical structures,

     primarily physicians' offices  and hospitals, as I have

     indicated.  Hospitals are fairly well spread over our country,

     although not equally spread. They have  varying  capacities
     and capabilities and are of varying ages and stages of.



                                  -78-



      obsolescence.  They are generally acute general noSPLLULb
      financed in part through Hill-Burton funds since World War II.
          Health care in this hospital system is financed in three
      ways.  The first is voluntary health insurance, which last
      year paid about one-third of the cost ($11 billion).  Second,
      at least a third was financed by government - at the federal,
      state or county level.  The remaining financing - less than

      a third - came from other sources.
          This is a good system and the one we have to -deal
      with as we look to the future.  Those of us in the profession
      have to give some consideration to working with it and

      within it.
          This system has some weaknesses and I would like to
      emphasize them.  The first is the variable distribution of
      health services in this country and their consequent unequal
      availability.  This weakness has to do particularly with
      variable rural and urban distribution of hospitals and physicians'
      services.  It results in variability of the quality of care
      the system can render.  There are certain barriers to getting
      into the system, barriers of entry.  These barriers have
      largely to do with 1) ignorance - ignorance of how to get
      into the system, or that there is a system, or how to find
      the, right physician at the right time in the right place.
            barriers are 2) financial, with which we are all
           iar; 3) geographic, which I don't need to discuss

                                   -79-



    further; and a very important one - 4) social and  psychological
    barriers. This last barrier  will exist a thousand years
    from now because human nature doesn't completely  change.  There
    are many people who, because of psychological and social
    barriers, particularly those related to fear and anxiety,
    do not want to get into this system, want no part of it,
    or want a part of it only at certain specified times when
    pain or some other symptoms drive them to it.  A great many
    people will not use the health-care resources when they
    are brought.to them and provided frpe.  Others seek panaceas
    from quacks or cures from simple nostrums.
        Another weakness in our system is obsolescence - obsolescence
    of some physicians, obsolescence of hospitals or other  physical
    structures.  I shall say a bit more on this later.
        Another very important weakness is lack of progressive
    institutional care where patients can "flow if readily, for
    example, from the intensive care unit after an acute  myocardial
    infaretion to the acute general hospital bed and on to continuing
    care, if necessary, in a bed in extended-care facilities,
    and then home for home-care services.  We have not worked out
    an adequate system that will provide a progressive "flow" of
    patients through these various modalities that should be in
    close physical relationship.  Rather, we now confine this
    care pretty largely to an intensive-care unit at first,
    subsequently to the acute general ho spital bed, and then  home.

                               -80-



          Another weakness in our system is the lack of proper use
       of those in the allied health professions and services. This
       is an area in which the re is great ferment at present.  I
       think there is little question that,as time goes by, we

       shall see great improvement.
           The final weakness is in the financing of health care.
       It is clearly inadequate for many people.  It must be improved
       to, among other things, meet the economic stress of the
       individual who is sick, or whose family is sick.
           Now what are some of the improvements needed?  First.,
       improving health manpower.  We need more manpower and we
       need better manpower.  In terms of physicians this is very
       time-consuming and expensive.  Five new medical schools
       were opened in this country in the fall of 1967, five new
       ones were opened in the fall of 1968, and two new ones
       will open next year.  Twelve new medical schools in three
       years is a pretty good record considering the cost of establishing
       a new medical school.  Existing medical schools have to some
       extent, but to a disappointing extent, increased their
       enrollments.  We do need more physicians.  We also need a
       higher-quality product from our medical schools.  I think one
       can say that at present the quality-of physicians graduating
       from our schools is the  best that has ever graduated from
       medical school in any country, but improvement is needed,



      particularly to meet the rapid developments in medicine.

          We need to improve the existing medical manpower, the

      manpower now in practice.  This basically, I believe, is

      the most important function of the Regional Medical Programs.

      I will attempt to convince you of this, or at least  present

      the evidence that has convinced me.

          Very little is really understood about continuing

      medical education.  In this respect, let me indicate now

      the great discussions that are going on in respect to

      undergraduate medical education, in fact, in respect to  all

      general education in our colleges and universities.  There

      is no agreement as to how best to approach this matter.

      And similarly there is very little agreement as to how to

      educate the physician for practice in the future.  Yet  this

      is the real key to the success of the Regional Medical

      Programs, the key to the success of our health care  system.

          Motivation and communication are the keys to successful

      continuing education.  We need to learn a great deal more

      about what motivates individuals,- and how they can communicate

      better with one another.  These two essential factors must be

      stimulated and used effectively to further the education  of

      practicing physicians.

          We also need to know something we do not as yet know

      why are there a substantial number of physicians who never

      participate in continuing medical education? The  answer  to


                                   -82-



                                       tant, in my view, than
       this question is much more impor
       it is to try to increase the number of  physicians  who  take
       courses and participate in formal programs of continuing
       medical education.  And, as I said a moment ago, the real
       effectiveness of Regional Medical Programs, to  me,  is  that
       of continuing medical education.  How  can  one  successfully
       carry out any program of advance in medical care of patients
       with cardiovascular or heart disease, or  cancer  or  related
       clseases, unless one can do so through the physician  who  is
       going to carry out that responsibility and who  has  this  as
       his prime responsibility?
           We need among other things to  improve  the  capacity  of
       the physician to practice, not only in terms of what he
       knows, but in terms of the facilities he has available.
       Let me point out what I think is one thing that Regional
       Medical Programs have done in a superb way.  This is the
       encouragement to establish coronary care units in many
       hospitals.    couragement of these as they are now established,
       or thought about in an informal way in almost every substantial
       hospital in this country, is a move as effective and important
       as  anyt.hing else that has been done in the last 20 years in
       the whole area of the continuing medical education of physicians.
       it not only has saved lives, but equally important, it has
       made physicians conscious of the need to acquire.more



                                      -83-



        information, more skill, and more capability in the management
        of patients with acute cardiac arrhythmias, acute myocardi al
        infarction, or other acute manifestations of heart disease.
        Furthermore, in most such units there are established basic
        orders: requirements for the care of patients who go into
        these units.  Physicians must learn what these basic' orders
        are and understand the importance and significance of them.
        Furthermore, some physicians, for the first time, have
        taken a serious interest in the immediate as well as long-
        term treatment of cardiac arrhythmias.  This is a prime
        function of the coronary care unit  the prevention and
        management of cardiac arrhythmias  and I suspect the coronary
        care units again have done more to inform the profession of
        the important practical means by which cardiac arrhythmias
        can be dealt with than has any other single measure.  In
        hospitals where such a unit exists, a standard ha s been set
        that has been a very important factor in the education of

        practicing physicians.
             I hope that in some way the same thing could be done
        in relationship to the individual who has a stroke.  Perhaps
        the establishment of cardiovascular units where neurologists,
        neurosurgeons, vascular surgeons, internists, and those in
         eneral practice could working together with specially traine
        9
           ses and subsequently with physical therapists   speech
        nur




                                     -84-



     therapists, occupational therapists and others, bring to
     bear on the individual with a cerebral vascular lesion  all
     that medicine has to offer. This could not be done  in  the
     small hospital, except in an informal way. But  what  could
     be accomplished in the larger hospital, particularly in  the
     teaching hospital, would to a considerable extent  gradually
     filter to the smaller hospital and become another very
     important method of continuing education.
         For the cancer unit, I have less enthusiasm  --  except
     in isolated circumstances. But through tumor  boards,  tumor
     conferences, tumor registries, and establishment of  centers
     for chemotherapy, radiation therapy and diagnosis, many
     similar benefits would bolster continuing medical education.
         Another important approach in improving the medical
     profession's role in the health care system is the  further
     stimulation of peer review. This can best be  done  through
     the medical staff of the hospital - by stimulating the
     adequate function of all those committees that have to do
     with reviewing the health care of the patients in that
     institution. Tissue committees, medical  record  committees,
     audit.committees, abortion committees, evaluation committees
     and utilization review committees have all served very useful
     educational functions and have significantly raised the
     level of medical practice in the hospitals in this  country.


                                  -85-



      Such broad viewing groups as the Joint Commission on
      Accreditation of Hospitals, the Council on Medical Education,
      the AMA and Residency Review Committees for those hospitals
      in which there are residency programs are important mechanisms
      at the national level.  The appointment of Directors of Medical
      Education, of full-time staff physicians, and hospital staff
      consultants who will see patients for other physicians without
      any economic return are means by which, within the hospital,
      the level of practice can be greatly elevated and lead to

      effective continuing medical education.
           Another commendable area in which the Regional Medical
      Programs have been working is bolstering communication between
      community and smaller hospitals and the larger teaching
      institution.  The achievement of rapid communication, particularly
      iri respect to mechanical devices such as electrocardiographic
      tracings and monitoring devices of various sorts, unquestionably
      will,be significant - but of less importance in my judgment
      than some of the other forward steps I have mentioned.
           Regional Medical Prokrams will stimulate planning by the
      medical profession and others with interest in the health care
      field.  This is best done at the local and regional level
      involving physicians, hospital leaders, faculties of medical
      schools, medical staffs of hospitals and those with professional,
      technical and financials interests and skills in the field of

      health care.

                                   -86-




         Perhaps the most effective unit to carry this out is
     the medical staff of a hospital.  I needn't go into this
     further except to say that an effective planning body of
     the medical staff in association with other members of  the
     hospital team can do a great deal to raise not only standards
     of practice, but the caliber of continuing education for  the
     practicing physician. Medical schools and  medical  centers
     can do the same by the expansion of clinical facilities, by
     the expansion of educational facilities, and by aiding  the
     normal flow of patients from physicians to university hospitals
     and medical centers.  When such flows are disrupted, when
     they are disarrayed by some sort of mechanism  -  particularly
     semi-legal or legal ones or by unsophisticated planning
     bodies - there is apt to be very serious disruption of  the
     normal relationships that lead to the best patient  care.  In
     turn, the education of the practicing physician  suffers.  In
     this relationship it is important to stimulate a normal  flow
     and not to attempt to divert the normal flow into  abnormal

     channels.

         At the level of national medical associations much can
     be done'to improve the health care system. This can  be  done
     very effectively by the development of more information  on
     the diagnosis, prevention and treatment of heart disease,
            and stroke, and to correlate the experience of experts
     and of large centers.  I'm aware, of course, of what  as

                                 -87-



     been done in this respect with the support of Regional
     Medical Programs through studies being made by the American
     College of Surgeons, the American Cancer Society, the American
     Heart Association, and the American Neurological Association.
         It is very important not to attempt to establish or
     impose national standards of treatment.  These would be
     helpful at first, without question.  But in the long run they
     would delay progress and delay it seriously.  In this regard
     there may be no better example than what has happened recently
     concerning P.K.U. and mental deficiency.  For a while it
     looked as if such testing was going  to lead to the prevention of
     mental deficiency in a significant number of youngsters.
     Unfortunately, in some forty states, testing for,P.K.U. in
     the urine of new-born infants was frozen into the law.  Now
     these laws will all have to be changed because in the meantime
     it has been learned that this is not the approach to the
     problem, that it is not sound, and that mistakes were made,
     both in positive and negative ways.  For example, in the normal
     infant, it is reported that the limitation of the diet on t e
     basis of a false positive P.K.U. test may produce mental
     deficiency when it did not exist.  So it is very important not
     to freeze into a standard or regulation, not to freeze into
     law, those things that are not clearly proven.
          But much can be done at the national level in respect


                                  -88-


  Lo informing physicians on such important issu@t, a.
  Df anti-coagulants, anti-arrhytlunics, surgical tre atment of
                    legions, and the treatment of cancer.  In
  cerebral-vascular
  the latter in particular, there is much uncertainty at the
  present time in regard to many aspects of the  surgical,  radio-
  logical and chemotherapeutic treatment of cancer.
       Furthermore, national associations can play  a  significant
   role in cooperating with other groups in determining the  value
   of multiphasic screening testing centers and methods  of  early
   detection of cancer. But let me issue a word of  caution  here,
   too.  We really don't know Vnat the benefits are of the
   multiphasic screening process. it's important,  I  believe,  to
   let centers, such as that of the Kaiser Hospital Group,
   determine, among other things, what benefits really flow
    from the multiphasic screening process.  To establish such
    centers all over the country until we know would be a great

    mistake.
         Let's look at detection of cancer, for example.  For a
    while it looked as if everyone should have his  chest  X-rayed
    once each year.  We now know that in terms of the early successful
                   ancer of the lung, such X-ray methods are
     treatment of c
                                               that have proved  to
     essentially useless.  But for those means
        useful, such.as that of-the cervical smear for cancer  detection,
       rther education of practicing physicians in its use should be
       prime function of Regional Medical Programs.  I  think  all
                               -89-



       of you who have cnnUaL;L
       recognize that most physicians now do a cerjical smear as
       part of the general examination of women.
          Let me make a few comments about my views on the role
       of the Regional Medical Programs in the immediate future.
       First look at the title.  Regional - that's the first word.
       It is regional, not national.  And it is very wisely said,
       because these are Regional Programs, they are not national
       programs.  These programs should be primarily educational,
       for the better educated physicians are, the higher the quality
       of medical care they render - the better the diagnosis and
       care of the patient with heart'disease, cancer, and stroke.
       Facilities and financing are important, but of prime importance
       is the widespread availability of high-quality medical care.
       The key to this is more and better education of practicing

       physicians.
           The function of the Regional Me-,dical Programs, as I see
       it, is to be a catalyst - to stimulate those things that
       normally go on to go on faster.  And to improve the educational
       level and understanding of the practicing physician by all
       available means, as I have already indicated.
           How is this to be done?  If there is a health power structure,
       which I deny  the best way to get the cooperation of  hysicians
                                                            p
       in this respect, and Mr. Brown hinted at this very well - would


                                    -90-


  be to stimulate strong support from the profession.  Ttiis can
  be done because the profession will strongly support any measure
  that will improve the health care of the people of this country.
   But they will do so mainly through cooperation and coordination
   on a voluntary basis, not by coercion.  This means the involvement
   of physicians at the local level, in professional societies,
   in hospital staffs, and in other groups where physicians
   normally relate to one another in the professional activities

    they pursue.
        I think we must maintain on a voluntary basis the unique
    American combination of multiple, independent focal points of
    activity and capacity that achieve a commodity that will attain
    our desired goal.  In other words, we need diversity, we need
    regional involvement, we need cooperation.  We need diversity
     so in the long run we will have the basis on which the
     practice of medicine can be improved steadily, particularly in
     relation to heart disease, cancer, stroke and other related
     diseases as they come into the program.
       -  Many people in our society do not benefit from all that
     medicine has to offer.  One important segment is those in the
      slums of urban and rural areas.  We must make increasing efforts to
      bring to them the advances in the diagnosis, prevention  and
         atment of disease.
      tre
           Let me point out that this is not just a medical problem.


                                   -91-



   In fact, in many ways it is not a mecica.L PLUU.L--LLL
    itis a problem in which adequate housing, good food and jobs
    have to come first.  People must have these things before
    they want education and health care,
         We need above all to avoid radical and rapid departures
    from our present system until by trial and experiment in
    certain areas, we can prove that such departures are worthwhile.
    Those who would totally disrupt our present health care system
    with the idea that it is all wrong, that it doesn't work, have
    yet to propose some other type of health care system that is
    better.  The present one, with all its faults, is working
     and serving nearly two hundred million people.
          one doesn't ordinarily consider it wise to undertake a
     radical new form of treatment for a disease unless the disease
     is apparently fatal and perhaps in its final stages.  Until it
     is proved that a new method of treatment is helpful and
     relatively safe, it should not be widely applied.  Similarly
     with respect to our health care system, it's important that we
     do not use radical procedures, that we avoid them until
     we have proved in certain test areas that some modification or
      some other system works better.
           We must avoid national standards.  We must avoid the.impatient
      administrator with limited or great authority.  We must avoid
      coercion.  These do not work in the American system.  For
      evidence of that, just go out to my home area of Berkeley. (Laught
                                  -92-


        itis important to recognize that mucnWULM LL@--- --        - I
                   as Mr. Brown said2 have instant success.  You can t
   that we cannOt2
                                              nstant health center
   have an instant doctor) you can't have an i
                   ommunity health center where one doesn't exist.
    or an instant c               , are working on is a long-time
    What you, ladies and gentlemen                      years hence
    program.  you've got to give your successors twenty
                  to challenge them.  Don't try to settle them all
    some problems                                      al progress,
    this morning.  if one will follow the route of norm
    keeping in mind that regional, cooperative,, voluntary advancement
                                                         key to the
                             practicing physician is the
     in the knowledge of the
     success of Regional Medical. 'Programs2 there is no question that
                             s - ten, fifteen, twenty years from
     Regional Medical Program                                       But
         - will succeed.  I believe the Program will be a success.
     now                             Ss if gentle keys are used in
     it will be a much  greater  succe
                                                  it
                                     ne has called  the Health
     opening the doors to what   someo
                     t
     power Structure'.

















                                     -93-





                           VI
                                 Philip R. Lee, M.D. ientific Affairs
               Assistant Secretary for Health and Sc
                   Department of Health, Education, and Welfare
                                 Washington, D. C.
                      I particularly welcome this opportunity to meet with
               you and participate in this program because the birth and
               growth of the Regional Medical Programs has coincided with
               my own years at the Department of Health, Education, and

               Welfare.
                      Almost more than any other health legislation of
               the past few years, and there has been a good deal of it,
                the RMP has carried the promise of creative, original,
                cooperative adventures in the health field.  Although the
                defined arena has been to improve the care of patients with
                heart disease,,cancer, and stroke, it has been apparent from
                the beginning that the larger interests of patient care would
                be served at the same time.
                       Further, the unusual structure--some might say
                "unstructured" administration of RMP has in a unique manner
                challenged the Nation.
                        I have used the word "unstructured" and I think all
                 of us would agree that it has been this quality which has





                                             94



                made the challenge to you both exciting and at the same
                time alarming.  Exciting because here was a Federal agency
                which did not attempt to tell you what your region needed
                or should do, but instead said, "All right, ladies and
                gentlemen, you have long expressed the need for funds freed
                from bureaucracy.  Here are such funds.  Put your regional,
                cooperating intellects to work and develop the program
                     gion needs."
                your re
                     And, as I have said, this challenge to  you  also
                has been alarming. It is much easier to point out  the
                faults in a program when one can criticize someone else's
                leadership. But when the leadership is not  elsewhere,
                when success or fumble rests in one's own hands, then the
                unstructured  nature of the program can certainly alarm.
                      I think all of us who have participated  in  the
                Regional Medical Programs have appreciated the  quiet,
                sustained determination of Dr. Marston and his staff.  They
                firmly held to the goal that the ideas, energy, the very
                motion, of RMP must come from the people in the regions
                and not from the central agency.  There were times when it
                seemed that delays at the periphery would jeopardize the
                program, when it seemed that the too slow trickle of planning






                                             95 -



                 grants and active programs was eviu,,,,,
                 program was futile and the periphery sterile.
                       The final proof of the merit of RMP will take  years
                 to be apparent.  Perhaps there are no real yardsticks with
                 which to measure the success of such a program.  I know
                 that facts and data will be assembled and will be used to
                 justify the future legislative support of RMP.  However,
                 as far as I am concerned, we already have the best proof
                 one could want that this program is meeting a real need in
                 medicine. I am referring simply to the quality of the  men
                 and women who have put their energies into this new program.
                        As I look around this room and note familiar  names
                 and faces, I thinki here is the true expression of
                 endorsement of this program.  I know of no other single
                 health legislation that in so brief a time has caused such
                 a remarkable cadre of talent to step forward and declare
                 itself.-  Knowing that you and many, many others have
                 joined this effort, makes it clear to me that there was  a
                 need, a void, in the American medical scene which RMP is

                 filling.
                         Now, with Dr. Marston leaving RMP and taking on the
                 huge responsibilities of NIH, one would ordinarily feel




                                             96




               insecure in naving a cnange OT ieauersnip jUbL ctb IIIU@ll VI
               RMP is becoming operational.  However, any of Us who know
               Dr. Stanley Olson knows very well that here  is  a  very
               mature, sensitive, calm, competent, compassionate, and
               committed man.  I cannot share anyone's concern over RMP.
               It has superb leadership, it is  demonstrating  the  vitality
               in our system, it has strong support from the Administration
               and Congress.  RMP is a success story!
                        I am well aware that within the staff of  RMP  there
               have been concerns over the transfer from NIH  to  the  new
               Health Services and Mental  Health  Administration.  I  can
               well understand the inherent sense of security in remaining
               within the tried and true academia  of  NIH.  However,  RMP
               is   specifiIcally directed towards improving  the  health
               services of the people in  certain  disease  categories.  RMP
               is an active involvement in health services; that is what the
               Health Services and Mental Health Administration is all about.
               In fact, I don't in the least expect RMP  to  disappear  into
               a new bureaucracy.  instead, with the energy, drive,   and
               talent already operating within'RMP, one  will  be  very
               surprised if the very style and cadence of HSMHA is   not  to
               a major extent due to the examples set      RM






                                           97




               which must occur if your efforts are to succeed is a quality
               which RMP must extend with missionary skill and zeal.
               Cooperative arrangements must be worked out in all directions
               and at all levels.  Nationally with the Veterans Administra-
               tion; with the Department of Defense; with the Bureau  of
               Health Manpower; the new Lister Hill Biomedical Communica-
               tion Center and the categorical institutes of NIH; with the
               Office of Economic Opportunity; with the other  operating
               units within the Health Services and Mental Health
               Administration; with the Medical Services Administration,
               the Children's Bureau and the Rehabilitation Services
               Administration in the Social and Rehabilitation Services;
               and with the Bureau 6f Health Insurance in the Social

               Security Administration.
                      There are many other groups to consider and involve--
               professional associations, consumer groups  representatives

               of State and local government.
                      At the State and local level we need to develop  a
               network'of cooperative arrangements that will assure  the
               kind of change in the system that is needed.








                                           98



                    In a recent article "What's Ahead for Medicine"
               Dr. Dwight Wilbur noted:
                    "Now we are in the midst of a third great movement--
               a national commitment to health and health care, a phenomenon
               of the 1960's.  The health laws of the 89th Congress--
               Medicare, Medicaid, Regional Medical Programs and compre-
               hensive health planning set the pace and clearly indicate
               the Federal Government's substantial investment in medical
               affairs.  Indeed we are traversing one of those great
               transitional periods in which the roles of government and
               the medical profession seem in the balance."
                     I fully agree with Dr. Wilbur that we are in the
               third great movement in American medicine in this country.
               The first was in medical education after the Flexner
               report, the second in biomedical research after World War II
               and now in health and health services.
                     To do the job we need a new alliance for health.
               We cannot stop by merely allying those already allied.  We
               must work for the active participation of those who have not
               been effectively represented and those whose needs have been
               so disastrously neglected.
                     This will not be an easy task.  We have many vested
               interests in health and health services who believe with a



                                          99



                passion that the only way to meet the need as they see it
                is to have a special category--be it a voluntary organiza-
                tion or a tax supported program--and maintain it at  all
                cost.  The birth of the regional medical program represents,
                in part, the fusion of such categorical  interests.  Its
                ultimate success, however, will depend on the extent  to
                which it forms the backbone for comprehensive health

                services.
                       Can a new alliance for health meld the variety  of
                categorical interests so that the needs of all the people,
                particularly those in greatest need, can be met?
                       It is here that we can take a cue from the  Urban
                Coalition and its approach to the greatest crisis of  our
                time. At long last groups with a common interest  in  the
                cities of this Nation--business, labor, minority  groups,
                and government have joined together in common  cause.  In
                years past they went their separate ways ignoring the
                problems and the opportunities.
                       The RMP provides American medicine, the  consumer,
                local government, labor, business and minority groups  a
                unique opportunity to develop the new alliance for health
                that can pull down the barriers to understanding, can








                                          100 -




               examine and test new ideas and can develop the necessary
               vitality to overcome the inertia in our health care

               delivery system.
                     How can the Regional Medical Programs  accomplish
               what has been beyond our reach in the past?  The RMP can do
               it by providing a new mechanism for cooperative action.
               It builds on the strengths of the existing system, and it
               provides for local participation, planning, and action.
                     It i,s apparent that the professionals who have
               been attracted to RMP represent the long sought third
               force in medicine.  The traditional roles have been private
               practice and academic medicine, organized medicine, and
               the medical schools, town and gown.  To oversimplify it
               I might describe the interests as those represented  in
               part by the American Medical Association and the Association
               of American Medical Colleges.
                      Now an entirely new instrument of expression, the
               RMP, has given you men and women a cohesiveness, a vehicle,
               a place to stand.  With the talent represented by the
               cooperative arrangements that are developing, with  the
               muscle supplied by public funds, one can confidently expect
               you to act as the new third force in American medicine.





                                         101



              One can expect that you will provide the leadership  nec-
              essary to establish and maintain the new Alliance for  Hea lth.

                     The third force in medicine will include not

              only teachers, investigators, administrators, and  practi-
              tioners, but students in the health professions.  We  have
              already observed the active participation by students  in
              studies to identify needs, in the planning process and
              in programs of action designed to meet health needs.  They
              will provide a continuing source of stimulus, energy  and
              enthusiasm to this effort.  Their concerns, their compassion

              and their commitment must be a vital ingredient in all  of

              these efforts.
                     Another new element is the consumer.  They too will
              bring new insights and perspectives to the third force  in
              medicine. They must have a strong and effective  voice  in

              these efforts.

                     The third force cannot be limited to these elements

              alone.  In each region, the character of the need, the
              availability of resources, the interest of individuals and
              groups should determine the character and composition  of

              the third force.
                     This third force is urgently needed.  The  need  is

              for coordination, for mediation, for help in defragmenting







                                        102



              the multitude of health programs.  In the past four years,,
              31 major new laws have been enacted that have increased
              the Department's responsibility in the health field.  The
              total Federal investment in health has grown from $3 billion
              in 1960 to nearly $14 billion in 1969; HEW health investment
                                          llion in fiscal year 1966 to
              alone has tripled from $2.6 bi
              $9.6 billion in fiscal year 1968.
                    Although your charge is heart, cancer, stroke, and
              allied diseases, it is apparent to all that in carrying out
              this primary mission you will set the pattern for the whole
              scope of health services.  You will deal with the ghettos, the
              poor, the needy, the uninformed, with physicians at all
              levels, public health agencies, community hospitals, volun-
              teer health organizations.  It is your job to prove that
              cooperative arrangements are possible.  It is your job to
              find ways to accommodate the antagonistic physician, the
              recluse medical faculty, the uninformed patient, the
              demanding legislator.  It is your job to seek out new
              ideas, to be the local arbiters, to get those things done
              we have all said needed doing, if only there were funds and
              a mechanism.  I believe RMP has provided that mechanism
              and Congress has shown its commitment by the flow of funds,
              even in a time of retrenchment.





                                          103




                     I believe we have been singularly fortunate having

              Dr. Marston and now Dr. Olson to provide leadership.  I am
              very pleased that RMP is now firmly based within HSMHA in
              a central provocative position, and can set the pace for

              this new health services organization.
                     Now some of you may quote back to me John Gardner s
              definition of his former job:  "A series of insoluble
              problems cleverly disguised as a great opportunity" and
              suggest that is equally a definition of your task.
                     I just happen to have great enthusiasm for RMP and
              I would offer you a second quotation, this time from

              Franklin Roosevelt:  "New ideas cannot be administered
              successfully by men with old ideas, for the first essential
              of doing a job well is the wish to see the job done at

              all . "

                     RMP a new idea and it is apparent that it has

              attracted men who want this new idea to work.  I can

              assure you of my own commitment to this program.
















                                         104





                                                              PROGRAMS"
                    IIISSUES AND CONCERNS OF REGIONAL MEDICAL

                                   Marc J. Musser,@M.D.
                                   Program Coordinator
                         North Carolina-Regional Medical Program
                                Durham, North Carolina
                    Each of the series of meetings we have had here  in  Washing-
               ton since January, 1967, has come to be a landmark  in  the  evolu-
               tion of Regional Medical Programs.  Each has concentrated upon
               the compelling circumstances at a particular point in time  -----
               beginning with the initial stage setting efforts to  amplify  the
               altruistic goals which the program was capable  of  accomplishing,
               through the subsequent periods of:
                    The conceptualization of the interrelationship of the
                    planning and operational phases,
                    The much needed exchange last January between regions

                    of project design and objectives,
                    And now the constructive sharing between the Division
                    and the Coordinators of the issues and concerns that
                    have emerged as we have been more and more intimately
                    involved with the realities of the situation and
                    have had to concentrate more of our time, energy, and
                    ingenuity upon the mechanics of making the right things

                    happen.
                    From the standpoint of the record, there can be no more
                positive evidence of the increasing involvement of  the  Regions
                in health affairs and the growing substance of  operational  ac-
                tivities----.nationwide, than is provided by these landmarks.

                    Central to the success of this accomplishment  has  been  the
                splendid cooperative arrangement between the Division and the

                                                   105



       Regions.  This has been a forthright, mutually supportive, and
       decisive relationship - that has clearly recognized that we have
       many more questions than answers, but has kept our goals in major
       focus and has expedited tremendously our progress toward their

       accomplishment.
           It is indeed remarkable that in such a short period of time  we
       should have reached this point in the promotion and realization  of
       a concept that has been espoused for several decades but  seemingly
       could not be incorporated in the complex and diffuse health  system
       which has grown up more or less like Topsy in our society.  Not only
       did Public taw 89-239 come along at just the right time, but also
       because of its nature it was able to attract the support of  people
       with the degree of perception and dedication necessary to assure
       its implementation. The existence of these circumstances  has  been
       appreciated increasingly as we have learned that it is much  easier
       to talk and legislate about cooperative enterprise for  coordinated
       planning and the most effective and economic utilization of resources
       than it is to accomplish all the details necessary to assure  their
       reality and durability.  As the issues and concerns increase in
       number and complexity, the need for the right answers becomes  more

       and more acute.
           Several months ago the Division sent a questionnaire to each
       coordinator asking him to indicate the issues and concerns which in
       his region seemed to be the most compelling.  These have been consoli-
       dated and I have been asked to summarize them. By  and  large,  the


                                      106




                                                                egories:
       issues and concerns reported can be divided into three cat
           (1) those relating to events and activities on the Washington
           stage, (2) those having to do with interregional relationships,
           and (3) those relating to interregional activities.  Pervading
           each of these categories, however, is the interrelationship

           between the regions and the Division.


                 THE REGIONS AND THE FEDERAL GOVERNMENT

           The reorganization of the Public Health Service and the realign-
       ment of health programs within HEW has, of course, been a matter of
       concern to everyone.  Probably there is no group of health adminis-
       trators in the United States more keenly aware of the need for better
       communications and coordination between these health programs -----
       particularly as they operate in the field --- than the Regional Medi-
       cal Program Coordinators.  No other group relates as intimately
       to the broad array of health professionals and health interests.
           Hopefully , the newly formed Health Services and Mental Health
       Administration will be able to interrelate Regional Medical Programs,
       Comprehensive Health Planning, Chronic Disease Control, (Vocation
       Rehabilitation), Health Services Research, and Mental Health so
       that their mutually supportive and complementary features can be
       more effectively utilized in the interests of the public health.
       A great deal of this has to be worked out at the state or regional
       level; and some states have made considerable progress in this
       direction.  However, since it appears that everyone takes his cue
       from what goes on in Washington, it would be immensely helpful if

                                        107


         327-2a4 0 - 68 - 8



      a prototype cooperative arrangement between these programs within
      the Administration were more clearly visible so that field
      representatives would have a stronger motivation to share problems
      and experiences and work together.  Undoubtedly @ has something
      to contribute, but the real problem is in getting into the ball


      game.
           There are other federal health interests inside  and  outside

      HEW that well might be brought into this cooperative  arrangement.
      Regional Medical Program efforts to contribute to the improvement
      of the health care of the poor have established contact  with  the
      programs of HUD, OEO, Labor, Commerce, just to mention a few.
      Efforts to generate education and training programs  have  created
      a need to know more intimately the sources and nature  of  support
      inside RMP.  The importance of a mechanism for better coordination
      of all of these programs becomes more clear when it is recognized
      that all of them tend to be directed at some point in time and

      involve the same groups of people ----- be they health educators,
      community or regional health planners, practicing  physicians,  or
      allied health professionals.  At least in our region more and
      more of these groups are turning to the RMP for advice as to where
      to go and what to do., and we are f inding  this an increasingly

      difficult challenge.
           The increased experience with Regional Medical Program acti-
      vities and their ramif ications has led to several concerns relating
      to the executive and legislative branches of the government.  One
      of these has to do with the stability and longevity of the Program

                                      108


     and the growing need for some assurance of both.  The need springs
     from the pragmatic realization that the full accomplishulent.of
                                ffair.  Hard won cooperative arrangements
     objectives is a long term a
                                          e secured at this early stage
     and the benefits therefrom can only b
     of the game by our integrity and ability to produce.  The recognition,
     confidence, and support we have attained at a regional level can
     disintegrate in the face of a threatened short life, or increasing
     evidence of modification of concepts and administrative policies
      that would deprive regions of their prerogative for determining the
      nature and modus operandi of their programs.
           The greatest asset to acceptance at a local level has been the
                                                               and local
      assurance of local determination, local decision making,
      administration.  There are many with whom the coordinators and their
      staff deal every day who still don't believe this is really true
      and are continually on the alert for any indication of bureaucratic

      intervention.
           This is especially true of practicing physicians.  Their full
       commitment to the Regional Medical Program is of critical itportance,.
       now and for the future.  Fortunately, we have been able to obtain
       a large measure of this because of the sound principles upon which
       the Program is based.  Interestingly enough the intensity of commit-
       ment to the Program seems to run parallel to the intensity of feeling
       about the principles.  Recently a key physician in our Program
        summarized the state of affairs very succinctly, "Regional Medical
        Programs has been accepted in its original intent, and as such is
        good.  with conceptual changes and if allowed to be inf iltrated it
                                       109




      will die aborning. Be assured I will turn 1800 for  what  little

      that is worth."

           Perhaps pertinent to this consideration is the issue  raised

      by one of the coordinators - local planning vs. national planning.

      Thus far, the bulk of planning at the Division level has been  in

      support of the needs of the Regions, and this has been good.  Con-

      cern has been expressed, however, that over-enthusiasm or impatience

      might lead to centrally conceived projects which might appear  to

      compete with local initiative. Unfortunately, the  earmarking  of

      certain funds by the Congress last year was interpreted by  some

      as an example of this, and thereby a fair number of ties more

      strained.

           Indeed there is a need for frequent exchanges and joint

      planning between the regions and the Division in regards to issues,
      problems, mechanisms, and needs.  We also need to share knowledge

      of what is working and what isn't.  As we become more involved in

      registries and reporting systems, the value of uniformity of basic

      data becomes obvious, and this emphasizes further the value of
      cooperative planning. The,leadership which the  American  College

      of Surgeons is taking in working out with coordinators,' the

      National Cancer Institute, and the Division staff, a concept  of

      cancer registries which might be adopted nation-wide, is a  fine

      example of how some of these things can be accomplished.

           Finally, it is important that neither the legislative nor

      the administrative branches of our government lose sight of  the

      fact that for the first time in the history of our country,  the


                                   110



     health professionals and the health interests ar,- ju-L,,,,,5
     to make our health care system more cohesive and more effective$
     not by legislation or with large sums of money, but by involvement
     of the right people, communications, good judgment, and a challenge

     to local initiative.


                    INTERREGIONAL RELATIONSHIPS

         The anticipated need is now materializing to refine concepts
     and procedures for interregional activities and relationships.  This
     is reflected in an increasing enthusiasm for interregional meetings.
     Some of these are on-going; more are being planned, and it is likely
     that many of the questions and issues can and will be resolved among
     the coordinators.  Some will require decisions at a Division level.
         There is a growing need for exchange of more detailed planning
     and operational information between regions, especially adjacent
     regions.  This creates problems of supply and demand.  No ideal
     solution exists at the moment.  There is a fair movement between
     regions of annual reports, operational grant applications, and
     project proposals, but the very volume of most of these negates
     their practical utility.  A while back, Ed  Friedlander conceived
     the idea of a brief, but complete, profile of each region's program
     - something that could be periodically updated to assure currentness.
     A satisf actory f ormat f or this hasn't been worked out thus f ar, but
     it still seems a good idea.  Also, it has been suggested that
     broader use could be made of the splendid project summaries
     Martha  Phillips and her staf f prepare.  These could be incorporated



       in the profile of a region; and as of this morning they have
       been.   In each coordinators packet are  summaries  of  his  region's

       projects. Also, these summaries  could  be  regrouped  on  a  disease
       category or subject basis and made  available  whenever  there  is  a

       need to know what is going on nationally.

             For example, many regions have concerned themselves with the

       care of the acute coronary patient.  Perhaps there are twenty-five
       to thirty projects dealing with one aspect or another of this problem.
       It would be helpful to a planning group to  be  able  to  review  the

       essential features of these projects, and also, when such information

       becomes available, to have some assessment of a projec    t's effectiveness.
       Presently there is no way to get this information unless one corresponds
       with every region. And yet it seems  to  me  the  availability  of  this
       information for bibliographic purposes would contribute materially to
       improved project design.  The Science Information Exchange has provided

       a service to this type for some years.

            Yesterday a group of directors  of  hypertension  projects  met  to
       consider the feasibility of a uniform  system  of  data  collection  and
       reporting. They also had an  opportunity  to  discuss  their  plans  and
       share experiences.  Perhaps this will become an increasingly attractive
       mechanism for interregional communications and coordination of

       activities.

            The problem of information exchange will be compounded as

       regional programs grow and become more complex.  If indeed we are
       preaching the availability of the "latest advances" we need to practice

       it within the family.


                                      112




        The desirability has been expressed oi -LnLeLLC6.LQLLa@ @@,
    appropriate, national libraries for support materials, such as
    audiovisual aids, and the like and also of a multi-regional speakers
    bureau.  In this latter regard, it would be helpful if such a
    bureau were coordinated with other organizations that provide speakers
    such as the American Cancer Society and American Heart Association.
        Efforts at regionalization have generated planning activities which
    cross the borders of adjacent Regional Medical Programs.  Mostly these
    reflect the identification of hospital service areas or the firming up
    of long standing functional relationships between communities.  There
    seems to be no reason why these border adjustments cannot be
    accomplished between the regions involved.  Some difficulties might
    arise when funds from other than the RMP, such as county or state funds,
    are required.  Experience has indicated that county commissions are
    extremely careful with their money.  Also, there may be some problems
    with reports and statistics, particularly those compiled on a state

    basis.
        Concern is growing over the coordination between RMPS, expecially
    those serving the same geographical area, interregional programming,
    and the mechanisms for handling interregional projects.  Much of this
    depends upon core staff interrelationships.  The forthcoming guidelines
    for the implementation of Section 910 of the new RMP law (HR 15758) may
    clarify this to some extent.  However, a number of potential problems
    can be foreseen.  One coordinator has found that the attitudes of
    public officials or official agencies (part of the power structure) are
    not always conducive to interregional planning, particularly between
    states.  Also, if interregional projects must compete within a region
    with other projects which the region has generated independently, and

                                   113



       particularly if tight money causes advisory councils to have more and
                                          n of project priorities; they might
       more rigid criteria for determinatio
       fare less well than they deserve.  Thus, it may be necessary to establish
       a separate funding mechanism for interregional projects.
           The growing need for interregional activities necessitates a serious
       review of core staff organization and functions.  Productive inter-
       regional relationships will relate directly to staff input -- and few if
       any of us have made provisions for this in our present staff organiza-
       tions.  Other unanticipated demands upon core staffs have accentuated
       the problem.  Many of these demands require the availability of skills
       and knowledge which are not readily available.  One possible mechanism
       suggested for the resolution of this situation is the availability of
       consultant services between regions and the sharing of staff members

       with special skills.
           We have had an interesting,experience in regard to the need for
       special skills.  A year ago we began to make consultative services
       available to community hospitals in the areas of design, equipping,
       and operation of Coronary Care Units.  This was done in collaboration
       with the medical schools, the North Carolina Medical Care Commission
       (Hill-Burton) and the Duke Endowment, which long has acted in an
       advisory capacity to hospitals.  As this service became more popular,
       it emerged that one of the major needs was for expert architectural
       and engineering consultation.  It turns out that there are no available
       guidelines for the proper design of these units and for the elimination


                                      114



     of the various hazards which can be of catastrophic consequence.  The
     part-time architect-engineer whom we retained in conjunction with the
     Medical Care Commission, and who now has acquired a considerable amount
     of expertise, has been able to properly advise hospital authorities,
     and in so doing he has saved them well in excess of $100,000.  So
     important has this service become that we are in the process of employing
     the architect full time, providing him with further opportunities to
     expand his knowledge and expertise, and among other duties, to have him
     prepare the guidelines and standards which are necessary.  Chances are
     these will be of value to other Regions.
         An expanded role also is forseen for the liaison officers of the
     Division, since they can be immensely helpful in the resolution of
     many of the problems relating to interregional planning and operations.
                         INTRAREGIONAL ACTIVITIES
         Probably the major concern within regions is the accomplishment  of
     an optimal degrees of cohesiveness among participants in program planning
     and operations.  More and more this has become a core staff responsibility,
     and yet a willingness to cooperate on the part of participants is essential.
         A variety of factors contribute to this problem. One  is  that  the
     participants have not had,much experience working together, and at least
     at the onset have been inclined to fall back upon their more firmly
     established patterns of operation when they contemplate the nature of
     their Regional Medical Program involvement. Thus the  medical  schools,
     not accustomed to service responsibility at a community level, have



                                    115




     tended to prefer to conduct educational and demonstration  activities

     within their walls and to try to maintain independent planning staffs.

     This attitude prevails more strongly at a departmental level than  in

     the Deants Office.  Community hospital boards, administrators, and

     staffs have found it difficult to think in terms of regional services,

     even though they have@depended for years upon referrals from within

     their service areas.  They also are intensively preoccupied with their

     own needs and problems. State and County medical  societies,  curiously,

     seem to have been excluded from a large number of organized health

     planning efforts in the past and consequently find it difficult to
     suddenly be in the mainstream.  The universities, community colleges,

     technical institutes, State Boards of Higher Education,.or Divisions of'

     community colleges, though involved in health education have not

     coordinated their efforts and thus find it difficult to look at the total

     array of health manpower needs within a region. State  health  agencies,
     particularly Boards of Health, first were caught in the confusion of  a_
     change in the federal funding from categorical to block grants, and
     then in trying to decide how they might relate to both Regional  Medical

     Programs and Comprehensive Health Planning.

          Slowly but surely, however, these and other groups are  becoming

     more comfortable in this new situation and are beginning to work more

     effectively together.  However, experience is demonstrating that-meaningful
     participation per se requires a sustained investment of time and  effort
     by participants which they are not organized or staffed to provide.
     Thus there emerges as one coordinator has stated a certain  "cost  of



                                    116




                                          ifically identified  in  dollars
  togetherness" which hasn't yet been spec
  and cents but which the realities of the situation require  be  recognized.
       Crucial to the productivity Of these new ties is  the  availability
  of a competent and adequate core staff. There  must  be  some  mechanism
   to bring plans or concepts into reality9 to manage the  countless  number
   of administrative details necessary to assure smooth operation,
   continuity and evaluation) and to interpret these properly to the

   Advisory Council.
        More and more, the position of the Regional Medical  Program  becomes
   that of a way station between the medical schools and  medical  centers
                     d the system of delivery of health service on the other.
   on the one hand an
   This interposition is ideal for the purposes of  catalyzing  stronger  and
    more meaningful ties, and of trying to determine how scientific knowledge
    and resources can be used more effectively to meet patient  care  needs.
    Concern with patient care needs rapidly leads to an identification and
    understanding of those individuals,  organizations  and  agencies  which
    in one way or another are involved in ministering to them.  Concern with
     the medical schools, medical centers, and other  academic  institutions
     allows for a sharper identification of the resources available and  those
     that must be developed.  Only with these two bodies of information  can
     effective and coordinated operational activities be generated.
          it is not beyond the realm of p .ossibility that this  unique  role
     @of the core staff will become one of the major Regional Medical Program
      contributions to the improvement of our health care system.


                                      117



          Much of all this points up the increasing complexity of core staff
       functions.  As these are more clearly identified, their documentation
       would be particularly helpful in better acquainting advisory councils,
       planning groups, participants, and project directors with the mechanics
       of Regional Medical Program operations.
          Money, of course, is and always will be an issue.
           One concern has to do with the projected fiscal potential of the
       Regional Medical Programs.  More specifically, this could be expressed
       by asking what can we expect to be able to support three, five, and

       ten years from now.
           Clearly, the longer range potential will depend upon what the program
       produces -- how well it attains the objectives of Public Law 89-239 --
       with appropriate concern for economics, organization, and administration.
       The shorter range concerns are more pressing, and yet they have relevance
       to what might happen in the more distant future.  Each Region, in order
       to mount a visible operational program, has begun cautiously by under-
       taking limited feasibility studies or pilot projects.  In these early
       stages, visibility, solidification of cooperative arrangements, and a
       beginning impact upon the improvement of patient care have taken
       precedence over the amount of money available.  Very soon though, the
       point is reached where tested projects should be expanded, and an
       increasing number of new project proposals are submitted, reflecting to
       a large extent the success of efforts to stimulate participation and
       planning.  It becomes important at this stage for those responsible for



                                      118



   decision making to know how close to the belt they must operate, how
   restricted a priority range they must adopt to stand a reasonable
   chance of funding.  With limited availability of funds, it becomes the
   tendency to support the winners -- to Put one's money on the favorite.
   However, Public Law 89-239 encourages innovation -- and innovation is
    the untested, unproved -- very often the long shot.  Restricted funding
    at too early a stage is apt  to discourage innovation and thereby
    seriously limit the program's potential.  Certainly there never will or
    should be unlimited funds, but it must be hoped that sufficient money
    will be available to enable regions to adequately explore and evaluate
    new and innovative approaches and to determine how those that are
    successful can be incorporated into the health care system.
         Eventually, it should be possible to free up funds by terminating
     unsuccessful projects and by devising measures by which good projects
     can be self supporting.  However, as  experience increases, project
     design and relevance to objectives should improve.  This could
     necessitate some very hard choices by Advisory Councils, should limited
     availability of funds force a choice between continued support of a
     good project or recommended support of a new one that looks better.
     Some recourse might be provided by the availability of other than
     Regional Medical Program funds.  To a large extent, this might depend
      upon how well federal health programs are coordinated from now on.
           On a more simple level, a need has emerged for the clarification
      of a mechanism for a large number of small, short term fiscal


                                      119




      transactions.  The original guide-lines indicated that the involvement
      of community hospitals should be accomplished by a letter of affiliation
      which would make the hospital a participant.  Also, they provided for
      participant faculty and staff involvement on a part time salary basis,

      and not as consultants.
          Becoming a participant requires conformance with certain Bureau
      of the Budget regulations, it also makes indirect costs available which
      in turn eliminates such items as rental charges.  This is fine for the
      long term, permanent type of participation.  Thus far, however, most
      of the transactions with community hospitals have been short term
      affairs involving small sums of money -- for which the letter of
      affiliation is not practical.  Fortunately, the new guide-lines
      provide a mechanism to purchase necessary services in a less complicated

      and more acceptable manner.
           In a similar vein, there are some faculty members with long term
      commitments to the Program who can be employed part time.  However,
      the need is increasing for a simple  reimbursement mechanism for

      occasional or limited services.
           Concern has also been expressed over the most practical and
      realistic manner to deal with equipment that is provided to cooperating
      hospitals and other institutions.  Existing government regulations are
      directed to a large extent to the established situations where equipment
      remains under the direct supervision of the grantee.  Such will seldom
      be the case with Regional Medital Program equipment, for it must be



                                      120



    placed in the field where it will do the most good.  There is some
    uncertainty over how this can be accomplished in accord with the
    existing regulations; particularly in regard to the long term responsi-
    bility of the grantee, the availability of a mechanism for the eventual
    transfer of title or the disposition of the equipment, and the extent
    to which the transaction should be influenced by the revenue producing

    potential of the equipment.
        And finally we come to the issue of evaluation.  Concern with what
    we get for our tax dollar is long overdue.  The extent to which
    evaluation has been emphasized and required as a component of every
    Regional Medical Program is realistic and desirable, even if we haven't
    been able to devise a suitable procedure for every type of activity.
    It is essential that we have dependable measures of program effectiveness.
        However, the impact of Regional Medical Programs cannot and should
    not be judged on project accomplishments alone.  In fact the philosophic,
    organizational, and administrative impact of Regional Medical Programs
    upon the improvement of our health care system may far overshadow the
    impact of a wide array of projects.  Core staffs, members of Advisory
    Councils, and other Program participants are involved increasingly in a
    wide variety of i  ortant considerations and activities not directly
                     MP

    concerned with projects.
         Already there is a stronger commitment across the country to
    cooperative effort and regional planning than heretofore existed.
    Efforts to cope with the health manpower shortages are emerging from
    the talking and statistical stages and going into production.  Physicians


                                   121



     and other health professionals in rapidly increasing numbers are
     seeking opportunities to acquire new knowledge.  More and more this
     determination to improve our health care system is reflected in the
     attitudes of organized medicine, the hospital association, professional
     and voluntary organizations, and other health interests.  All this
     indeed is progress, and rapid progress. It's reasonable, I think, to
     give the Regional Medical Programs some portion of the credit  --
     and this should accrue to the evaluation of their over-all effectiveness.
          These then are some of the issues and concerns as you reported
     them a short while ago.  By tomorrow we probably will have added some

     more.






















































                                     122





                  "REVIEW OF ISSUES AND RELATIOI@SHIPS"

                        Donald R. Chadwick, M.D.
                           Deputy Director
                Division of Regional Medical Programs
           Health Services and Mental Health Administration
                         Bethesda, Maryland


      onal Medical Program Authorization Bill in Con  ess
          congressional action on the RMP extension bill is nearly completed,
   and the major decisions have been made by the Senate-House Conference
   Comittee.  We have kept you informed on the progress of this bill through
   the News, Information, Data publication.  In summary, the new Bill extends
   the legislation two years and authorizes funds, provides that up to one
   percent of the funds can be used for evaluation, includes areas outside
   of the fifty States, such as Puerto Rico, the Virgin Islands, etc.,
   changes certain wording regarding participating agencies, increases the
   membership of the National Advisory Council from twelve to sixteen,
   permits funding of services to two or more RMPS, permits dentists to
   refer patients, and permits participation by Federal hospitals.

          The differences between the Senate and House versions of the
   Bill involved the length of the extension and the amount of funds
   authorized.  The Senate version provided a three-year extension at levels
   of $65, $140 and $200 million.  The House version provided a two-year
   extension at $SO and $100 million.  The resolution in Conference provides
   a two-year extension at $65 million for fiscal 1969 (the Senate version),
   and,$120 million (a compromise figure) for fiscal 1970.




                               123




                    "The bill as passed by the House authorized a total of
                $50 million for the fiscal year ending June 30, 1969, and $100
                million for the fiscal year ending June 30, 1970, for regional
                medical programs for heart disease, cancer, and stroke, and
                related diseases. The Senate amendment authorized $65  million
                for the fiscal year ending June 30, 1969, $140 million for
                the fiscal year ending June 30, 1970, and $200 million for
                the fiscal year ending June 30, 1971, for this program.
                    The Conference substitute authorizes $65 million in
                appropriations for the fiscal year ending June 30, 1969, and
                $120 million for the fiscal year ending June 30, 1970.
                    Although the authorization contained in the conference
                substitute is limited to a 2-year period, the managers on the
                part of the House wish to emphasize that this program,
                although a newly established one, has already proved its
                value, and should be considered as a permanent program,
                subject, however, to periodic congressional review and
                legislative oversight.  The managers on the part of the
                House agreed to a 2-year limitation in order to provide
                an opportunity for the 91st Congress to review the operation

                of the program."

                It is not certain at this time exactly how much money will  be
       available for this fiscal year.  Action by the Congress on the appropriation
       has not been completed.  If the amount which is contained in the Senate



                                  124


     appropriation bill is passed,.a total of 99 million dollars will be
     available, including a carryover of 36 million dollars from 1968.
     There are, however, two factors which can reduce that amount.  One
     would be a lower figure agreed upon in the House-Senate Conference;
     the other would be a reserve placed on funds by the Administration
     in order to meet the -requirements in the legislation which established
     the ten percent surtax.  In any case, we will keep you informed.
            Several important developments should be mentioned in regard
     to the passage of the RP extension bill.  As Dr. Manegold will discuss
     with you later this afternoon, it looks as though we are going to be
     faced with another earmarking of funds this year--a  min@  of  five
     million dollars for studies of the effectiveness of Atromid-S in
     lowering the frequency and severity of myocardial  infarctiom.  The
     Senate Comittee, in our authorization bill report, expressed concern
     that "enough emphasis is not being placed on clinical research, with
     particular emphasis on the evaluation of various important therapies
     which show promise of reducing morbidity and mortality."  They go
     on to point out that the RAP mechanism is ideal in their view for
     carrying out broad field trials of the efficacy of various d-rugs, and
     they refer to the f ield trials of the Salk vaccine.  I I d like to quote
     you their concluding paragraph on this point:
                   lqbe Comittee, therefore, in full agreement with  the
             position of the House, urges officials of the regional medical
             programs to encourage clinical field trials to fulfill  the


                                    125



                intent of the Report of the President's ComissiOn On
                Heart Disease, Cancer and Stroke.  The Conmdttee realizes
                that plans for such programs must develop out of the thinking
                of State and local regional advisory groups.  However, the
                testimony 'received indicates that these local groups are
                eager to conduct such field trials, but they need encourage-
                ment and technical assistance from the top administrative
                officials of the regional medical programs.  This encourage-
                ment and technical assistance should and must be provided."
                Clearly, the At-romid-S earmark and previous earmarks in the
         Regional Medical Program are symptomatic of things that we can expect
         in the future.  It's important to @hasize that the Congress has given
         us very clear signals that they expect this kind of program to be carried
         out under regional medical programs.  It's up to us, those of us here
         in the Division and all of you in the S4 Regional Medical Programs, to
         figure out how we can carry out these programs so as to strengthen,
         rather than damage, the regional programs.
                 Another item that appeared in the Senate Comittee Report on our
          authorization bill was a reference to kidney disease activities under
          regional medical programs.  There was no earmarking of funds, but the
          Comittee did say that they "heard testimony which confirmed that  there
          is sufficient relationship between kidney disease and heart disease to
          include kidney disease within the scope of regional medical programs
          as a I related disease. III They also went on to say that "Regional Wdical

                                         126


   )-rograms offer an appropriate and effective framework for the exploration
   )f the best approach on a regional basis to the great challenges presented
   )y the prevention and treatment of acute kidney disease.  The Committee
   fishes to encourage the use of the regional medical program mechanism
   or this exploration of how to deal iwst effectively with the ravages
   )f this disease . . . 11  Thus, the Comnittee is telling us that planning
   Eor taking care of the kidney disease problem is an appropriate activity
   in regional medical programs.  This does not seem to us, however, to call
   for change in the previous policy of regional medical programs not to
   support service programs such as hemodialysis therapy.
   '4erger of Activities of National Center for Chronic Disease Control and

          A,z part of the recent reorganization, a major portion of the
   National Center for Chronic Disease Control was moved over to form, with
   the Division of Regional Medical Progr     a new organization called
   the Regional Medical Programs Service.

          A consideration of the origin and functions of the Chronic Disease
   Center shows, I think, the logic of this move.  Indeed, the principles
   and concepts which led to the formation of the chronic disease program
   are quite similar to those that led to the regional medical programs.
   Both involve an attempt to find ways to foster and promote the application
   of the latest research advances in the care of persons suffering from
   chronic diseases like heart disease, cancer and stroke.  Indeed, certain
   program elements of the chronic disease program had their origin as
   elements of the National Institutes of Health in order to promote

                                 127




      application of research findings.


              The Division of Chronic-Diseases, as it is now called  (and

      this interestingly reflects a reversion to the name used prior to  the
      last reorganization of the Public Health Service), includes eight
      categorical programs, most of which are disease categories.  These  are
      cancer, chronic respiratory disease, diabetes and arthritis,  heart
      disease and stroke, kidney disease, neurologic and sensory diseases,
      the nutrition program, and the National Clearinghouse for Smoking  and
      Health.  The mission of this Program has been to foster the development
      of improved methods for the prevention and control of chronic  diseases
      and to promote application of these methods. The  developmental  effort
      has been carried out through the contract mechanism, by  supporting
      projects to develop, test and evaluate improved health services related
      to the categorical diseases.  An example or two may serve to clarify

      this function.


              Soon after research developments in hemodialysis for  end-stage
      renal failure made long, continued dialysis therapy feasible,  centers
      were supported throughout the country by the Public Health  Service
      through grants for carrying out dialysis in @he hospital.  It was
      immediately apparent that something needed to be done to reduce the
      cost of this procedure in order to make it available to the large
      numbers of persons needing such treatment. The Kidney  Disease  Control
      Program, therefore, in 1967 initiated a contract program to test the
      feasibility of home dialysis. Twelve institutions  received  contracts



                                    - 128


   to train patients for home dialysis and to gather and supplY -LRe
                                which to evaluate this te@ique.  This
   necessary experience data on
   Study is currently in progress.
                                 example is the  coronary  care  nurse  tra@g
           A somewhat different
   program initiated by the Heart Disease and Stroke  Control  program.  Back
    in 196S and 1966, when more and more coronary care units were being
    established, it was apparent there was a need for training Programs to
    prepare the nurses for their -responsibilities.  Ten programs were
                                serve as models for the kind of training
    developed under contract to
    program that was necessary and to begin to supply at least a small
    proportion of the need.  Some of these programs are phasing into
    Regional Medical Progr
             The -relationship with Regional Medical programs@ I think_, is
                                           cerned with fostering the application
     fairly obvious.  Both Programs are con
                                                       The one, Re ional Wdical
     of -new imp-roved techniques for health services.            9
     Programs, is concerned primarily with organizational framework and
                                                        will take place-  The
     cooperative arrangements whereby this  application
     other is concerned with the content Of the individual  health  services.
                                           e which is looking at the waY 1-n
     Dr. Olson presently heads a task forc
                                          ied out and coordinated in order
      which these efforts can best be carr
                     objectives in a way which will be mutually supported.
      to achieve the
              The two Programs 'represent a somewhat different approach.-  In
                                   proposals are developed peripherally and
      the one case, the ideas and
      reviewed and approved centrally.  In the other case, the ideas are

                                     129




        U",VCIL)jPUU dL LIIC r@U@l-dl -L@vfc:l, ubudily witn ine advice or expert
        committees, and carried out peripherally through contracts.  We  must

        develop ways in which these two efforts can be carried out in order to

        be mutually supportive. The situation is perhaps  somewhat  analogous

        to the matter of Congressionally earmarked funds.


                In sum, we feel that this is a very important favorable new

        development and we will be looking for ways in which the Division  of

        Chronic Disease and the Division of Regional Medical Programs can work

        together to achieve common goals.


        Relationships Between Comprehensive Health Planning and Regional

        Medical Programs

               I am sure you are all concerned and involved in the relationship

        between Comprehensive Health Planning and Regional Medical Programs.  An

        effort is under way at this time within the Health Services and @ntal

        Health Administration to clarify this relationship.  I can't say that all
        the i's are dotted and all the t's crossed, but a fairly clear, and I

        think workable, delineation seems to be emerging.


               Both program are concerned with improving health care.  Two

        elements can be identified in this effort--one involves the setting and

        the resources available for care--the other involves the substance, the

        quality, of care.  It seems clear that planning agencies are primarily

        concerned with the first of these two elements. Comprehensive  Health

        Planning is the mechanism for determining the needs for health facilities





                                    130




       and health personnel-, for iiiiuiiiy, L)UL lluw tv
       setting the appropriate plans in motion.  It is quite appropriate
       that the consumers of health care play a prominent role in this kind

       of planning.

              The second element, the substance of care, or the quality of
       care, is clearly the area of concern of regional medical programs.  The
       whole thrust of the cooperative arrangements in regional medical programs
       is to assure that high quality care is available, that mechanisms are
       set up whereby the latest research findings in health services will be
       quickly added to the arma.mentarium of physicians who have the responsi-
       bility for primary care of patients.  Thus, physicians and other health
       personnel are the prime constituency of regional medical programs.

       Bac                      ittle-OSTI Health Policy Research Contracts

       with Division of Regional Medical Programs
               In early August we advised each of you by letter of a health
       policy research study relating to Regional Medical Programs being
       undertaken by Arthur D. Little and the Organization for Social and
       Technological Imovation.  As that letter indicated, the purpose of
       this Study is to assess the present status of the total program,
       progress to date, and its actual and potential impact.
               The genesis of this Study, and its desirability, dates back
       nearly a year.  A number of us, and particularly those in Planning




                                      131




    and Evaluation          had a major role in pulling together the

    required Report on Regional Medical Programs to the President  and  the
    Congress, felt it would be desirable to have a group of experienced,
    perceptive, outside observers look at the  program--a  multi-disciplinary
    group that could bring a special set of talents and abilities to the
    task and that might lead to fresh and perceptive insights  of  Regional
    Medical Programs easily overlooked by those of us involved in its

    day-to-day administration.


            As a result, an ad hoc group of key Division staff developed

    the specifications and screened the 96 films which  expressed  interest
    in doing the work.  Eventually, five firms were selected and requested
    to submit proposals.  That submitted bl Arthur D. Little, Inc., and
    the Organization for Social and Technological Innovation, as a sub-
    contractor, was judged as best by the ad hoc group and.a  contract  was
    awarded in late June. Both of these organizations  are  experienced  in

    health matters and have a staff of high caliber.


            Four major areas are highlighted for analysis under the Study.

    These are:

            (1) Regionalization - A history of past  regionalization  efforts

                in relation to the development of Regional  Medical  Programs
                and a descriptive report of the organization  components  and
                operations of the program with eMhasis on cooperative
                arrangements, regionalized involvement  and  decision-making.





                                   132



                                          or Regional Medical Programs -  A
               (2) Evaluation Indicator
                               .f acconTlishTnents from the point of view Of
                   description 0
                   the Regions, a surve)r of evaluation techniques in use or
                   available, and descriptive statements which suggest  the
                   utility of projects in moving toward the goals of the
                   program. An important product of this  aspect  hopefully
                   will be criteria which give the Division insight into
                   the ways it should be looking at the progress of the
                   Regions and give the Regions insights into evaluating

                    their own programs.
                (3) Economics o@ Regional Medical Pro2rams - The object
                    here is to express the behavior of RMP in economic  and
                    financial language to permit the future development  of
                    cost and benefit analyses.  Projections of future costs
                    and the relationship of the Program to health care costs
                    generally will be identified and described.
                 (4) The Relationships and Commnications  Flow  Between  the
                     Division     the Regions - The consultative and
                     supportive role of the Division will be reviewed
                     along with the regions' perception of this relation-
                     ship.  It is hoped that suggestions will be made
                     leading to a better two-way flow of information and

                     consultation.






                                        133




            Let me emphasize that the purpose of this Study is not to
     evaluate individual RNTS, but rather to gain a better understanding
     of the nature of the regionalization process we have set in motion

     and how to improve it.

            In the initial phase of this Study, the ADL-OSTI  group  visited
     several regions including Iowa, California, Western Pennsylvania, and
     Georgia, and have talked with many of the people in the Division and
     other parts of the Public Health Service including Dr. Shannon,
     Dr. Marston, Mr. Lewis and Mr. Yordy.  They also have been reviewing
     applications and related materials on hand in the Division in order  to
     gain a better understanding of the Program and its operations preliminary
     to moving ahead in the substantive areas I briefly outlined.

            You may well be contacted in connection with this Study as it
     proceeds since the contract envisages an in-depth study of several
     Regions. Selection of these Regions will be made in  consultation  with
     the Division and the Regions specifically concerned. Your  support  and
     cooperation, needless to say, will be appreciated.

             In concluding, let me note that Roland L.. Peterson, Acting
     Associate Director for Planning and Evaluation, is the Project  Officer
     for the Division on this contract, and that Dr. Phillip Donham is the

     case leader for ADL-OSTI on this Study.









                                   -134-




                    "GRANTS PROGRAM CONCEPTUALIZATION AND STRATEGY"

                             Richard B. Stephenson, M.D.
                         Associate Director for Operations
                       Division of Regional Medical Programs
                  Health Services and Mental Health Administration
            I was asked to speak very briefly to this meeting about the concep-
         tualization and strategy of the grant program presumably because my Office
         of Operations operates the grant program.  The overriding consideration
         in any such discussion is the fact that P.L. 89-239 is a grant program
         and the first section of Title IX, which is our Act, begins by stating
         the purposes of this title are "through grants."  Since, as Mr. Ward
         pointed out to you in his discussion of "the medical power structure,"
         this is in many ways an unusually explicit Act rather than one-simply
         conferring broad granting powers upon an agency andsince much of the
         conceptualization of the grant program is in fact preempted by the lan-
         guage of the Act, it is probably worth tou ching once again on these
         explicit statements in relation to the manner in which they shape the
         further co-nceptualization and strategy of the program.
             Title IX of the Public Health Serv-ice Act begins, as I have indicate
         by stating that its purposes are "through grants to encourage and assist,
         first, in the establishment of regional cooperative arrangements; secondly,
         that these are to be in the fields of research, training and patient
         care demonstrations in order to make the latest and the best in the diagnosis
         and treatment of heart disease, cancer and stroke and related diseases
         available to all; and finally, by these means, to improve generally the
         health manpower and facilities available to the Nation." It  has  been
         apparent, therefore, that while a strong.and strategic categorical thrust
         has been given to the program, it is a great deal more than-a program of
         projects in heart disease, cancer and stroke, because it is first of all
         to promote the development of regional cooperative arrangements and thereby




       iffprove generally health care and facilities.
          The f inal statement of this part of the Act that this is to  be  done
       without interfering with the pattern of patient care or with methods of
       payment has, I think, sometimes been misinterpreted; it seems clear  from
       the legislative history of the Act that what Congress was saying here was
       that this was not an Act designed to interfere with the broad pattern  of
       our voluntary health system, but was rather a challenge to the system and
       to the profession to develop within this system the kinds of  cooperative
       arrangements which are essential to make it work and to bring about
       improved patient care.  The reference to methods of f inancing was primarily
       a reflection of the desire to reemphasize the fact that it was the Medicare
       Act which was being considered at the same time by the same Congress which
       dealt with methods of payffent and that this Act did not, and  was  indeed
       not an Act to, provide patient care at all other than as it related to the
           ses of the Act for patient care demonstrations.  The medical profession
       purpo
       and the providers of health care and education must recognize very clearly
       the nature of this explicit challenge.  It is really A mandate to do
       something about the quality of medical care, but to do it within the
       framework of our voluntary system by establishing regional c   ooperative
       arrangements - in other words a Regional Medical Program, and do all this

       through grants.
            The reason for reviewing this basic conceptjalization is to show
       that the underlying strategy of our grants program derives from it.  The
       early decisions to establish the Division  of  Regional  Wdical  Programs
       within the National Institutes of Health and that this was not  to  be  a
       formula program but a competitive grant program were both related to the
       basic mission of this as a program to improve the quality of health care.
                                           -136-




                                           ill  reflects a preoccupation on
      This initial decision which, if you w
      quality has been reaffirmed many times since by the National Advisory
      Council despite some of the pragmatic compromises which are inevitable
      in getting a program of nationwide scope moving.  It follows that such a
      grant program with these kinds of concerns requires decisions and
      decision-mak-ing processes both at the Regional and National levels.  In
      the Regions these must be made in terms of regional priorities and
      realities.  At the Division of Regional Ntdical Programs the decision-
      making must be in terms referable to the National scene, the availability
      of funds, and in keeping with the mission of the Act.
           lVhile the "seven basic steps to Heaven" of "involvement, identification
      of needs, assessment of resources, 11 etc., are put forth and discussed in
      some detail in the Division's newly revised issue of Guidelines, I would
      like to point out that perhaps even more important and essential is the
      step that precedes involvement which is the conviction that a commitment
      to involvement is needed --the conviction that a Regional Nledical Program
      is in fact a good thing, for until this conviction has occurred in a
      significant part of what Mr. Ward has called the local medical power
      structure, there will not be a Regional Medical Program.
           My definition of the function of an administrator has always been
      that he is very simply an expediter, and therefore the administrators in
      our Grants Office - whether they be Operations Officers, in the Review
      Branch, or in the Management Branch - exist in order to help the applicant
      to obtain a grant and use it for carrying forward the purposes of the Act.
      In order to do this in a competitivegrant program we must have a




                                      -137-




     -reviewable document "with the best possible chance of successful review!'
     Time does not permit detailed discussion but, in brief, what we must
     have is an application which is (1) succinct, (2) reflects accurately
     the Region's status and proposals insofar as possible as they exist in
     fact, and not simply on paper, and (3) that it is cast in a frame of
     reference which will at least, in s @ ary fashion, permit the reviewers
     to understand the relationship of the proposed plan or activity to the
     region's development as a whole.
        Since this is still a young program and in relatively early stages
     of development, and in considerable state of flux, the Division's  review
     process has from the beginning undergone a number of changes to accommodate
     to this and, as' you heard from Dr. Olson this morning, will undergo
     further changes.  Likewise as the Programs have moved from early planning
     grants through early operational grants to the present state of a  rather
     complete mixture of all these and finally some fairly sophisticated
     operational Programs, review criteria have also changed and they will
     continue to change.  In the days of early planning, primary considerations
     were the existence of what seemed to be a viable region with a reasonable
     basis for undertaking planning.  It was clear that many early operational
     proposals were essentially "off the shelf" but could fit into the plans
     that the Region was developing and therefore there seemed no justifiable
     reason for delaying implementation until the whole grand master plan had

     evolved.
         At the present time, the most important consideration in our review
     and evaluation of operational proposals is the consideration  of  whether
     there is in fact the kind of regional cooperative  arrangements  underway
     which will lead to a true Regional Medical Program and that, as I said



          earlier, these arrangements exist in fact and not simply as wishful
          thinking on paper.  in the future when at some point the availability
          of furds begin to plateau, not simply in response to the current fiscal
          crisis but as an inevitable characteristic of any program, there will
          inevitably be a stronger emphasis on the qualities of imaginativeness
          and innovation of individual projects.
              A final word is in order in relation to the Division's strategy of
          being expediters and providing as much help as possible to the Regions.
          Without in any way making excuses, it seems only fair that the Coordinators
          should understand that at this particular point of exponential growth
          and activity of the Programs we are in the midst of as tight a personnel
          freeze as I have ever encountered in the Federal establishment, so that
          the Division at the present time in fact has some 20-odd fewer people to
          do the job today than it had a year ago.  Despite this, my staff will all
          do their best to be as helpful as possible to all of you.



















                                           -139-




                          D @ OTHER CMITI'ED FUNDS AND PROJECTS"

                              Richard F. Manegold, M.D.
               Associate Director for Program Development and Research
                      . Division of Regional Medical Programs
                  Health Services and Mental Health Administra ion


          In the first session of the 90th Congress, Regional Medical
      Programs received its first earmarked funds.  Presumably this will
      not be the last.  For both the Division and the Regions, special
      problems were created by these monies.  I would like to take this
      opportunity to describe the genesis of those earmarks, and thereby the
      genesis of earmarks in general, the philosophy of the Division in
      maInaging these funds, and speculate about the future in relationship
      to designated funds.  Earmarked monies offer a challenge as well as a

      hazard to our program.
          As you may recall, there were earmarks for Coronary  Care,  Community
      Hypertension Detection and Treatment Program, Community Stroke  Detection
      and Treatment Program, Chronic Pulmonary Disease in Pediatrics, and
      Emphysema.  Each of these programs had their advocates.  In the case
      of emphysema, Congress received testimony from the National  Tuberculosis
      Association.,  That Association was concerned that insufficient emphasis
      was being placed on the training of manpower for the growing problems
      of chronic pulmonary disease.  They requested congressional support for
      this activity.  The National Cystic Fibrosis Foundation,  facing
      increasing expenditures of their limited research funds for service
      programs in chronic pediatric pulmonary disease, urged that Congress
      develop support for centers for these patients. The American  College  of
      Cardiology was responsible for testimony in support of programs for


                                     -140-




      In each case the proponents pointedly stated that here were methods

      largely proven for improved care.

           The Congressional Record of the Senate on June 23, 1967,

      will give you insight into the genesis. Dr. Likoff, then President

      of the American College of Cardiology, stated to Senator Hi 11:  "The

      matter which moves this testimony is the extent to which talent and

      competence in the contest against heart disease will be adversely

      influenced if certain structured allocations are not altered.  This

      Committee is acutely aware, I know, that heart disease is the  primary

      health problem of our time with morbidity and mortality rates far

      exceeding any other disease. You, Mr. Chairman, have been  the  author

      and architect of health programs which have strongly supported research

      and education in an effort to modify that fact.  Over the years, specific

      Federal resources have created and maintained health agencies such  as

      the National Heart Institute and the National Center for Chronic Disease

      Control which have stimulated and enlarged the efforts of all of the

      life sciences involved in diseases of heart and circulatory system."

      Dr. Likoff continued his testimony and described the present inadequate

      appropriations for the National Heart Institute and the National Center

      for Chronic Disease Control.  Further in his testimony, he stated:

      "The American College of Cardiology regrets the failure to provide the

      Heart Disease Control Program of the National Center for Chronic Disease

      Control sufficient funds to,carry out its full purposes and dedication."

      Throughout the testimony the discussion related to the benefits to  be

      accrued from the expenditure of the Federal dollar for programs in

      coronary care.  Throughout the testimony, no reference to Regional Medical

      Prog rams was made.  Testimony for the other categoric programs only

      related to the National Center for Chronic Disease Control or the

                                     -141-




      categoric NIH Institutes. Regional Medical Programs was not considered

      until early in October by Congress.
          included in the Senate action was the allowance of a million dollars
      for arthritis to initiate a program of pilot arthritis centers and

      satellite facilities.
          Because of the differences between the House of Representatives and
      the Senate, a joint conference committee was convened in early October
      1967.  The committee reported as follows:  "In general, the conferees
      are agreed on the desirability of the purposes of the Senate increase, and
      are also agreed that a large part of the activities for which the increase
      of over five million dollars was earmarked is so closely related to
      activities financed under 'Regional Medical Programs' that they would
      more properly be administered by the National Institutes of Health under
      that appropriation.11  With this in mind, the managers on the part of
      the House agreed to a four and a half million dollar increase for
      @egional Medical Programs to, cover the Senate's categoric directives whic
      incidentally exceeded 5.5 million dollars.  Thus the earmarks for the
      National Center for Chronic Disease Control were shifted to the maximum
      extent determined to be feasible by the National Institutes of Health.
          Dr. Shannon recognized most of these programs could be undertaken
      by Regional Medical Programs but in a letter to Senator Hill noted:
      "The scope of the Regional Medical Programs legislation would not allow
      us to directly support programs designed to increase the availability
      of techniques for delaying the crippling effects of rheumatoid arthritis.,,
           Regional Medical Programs thus was given the responsibility under
      appropriation for activities in coronary care, community hypertension,



                                   -142-




     community stroke, projects in chronic pediatric pulmonary diseases,

     and emphysema.  These programs were laid on, if you will, Regional

     Medical Programs. To be sure, some of the activities were easily

     identified in planning and operational stages.  Others, such as chronic

     pulmonary diseases in pediatrics, were essentially new activities.

          In considering the methods by which these congressional  mandates
     might be observed, two choices seemed reasonable. Either  the  Division
     could fund these under granting authority or seek to expend the  funds

     by contract. The policy decision was made to pursue the  grant  route.
     First, had the contract route been taken, Regional Medical Programs
     would not have appeared different in mechanism from other  governmental
     agencies.  The opportunity to demonstrate the effectiveness of Regional
     Medical Programs to Congressional directives was therefore uniquely

     offered by pursuing the granting route.  In pursuit of the grant route,
     however, special problems presented themselves, problems with which some

     of you  are acquainted.

          Advocates of various of the activities had long been in the  habit

     of a direct contractural relationship with governmental  agencies.  For

     several, therefore, the problems of involvement and regionalization  as
     represented by Regional Medical Programs seemed a cumbersome delay and a
     source of frustration.  Secondly, the Division was faced with the problem
     of responding to a congressional mandate and at the same time protecting
     the "grassroots" nature of Regional Medical Programs. This  we  strove

     to do with fair success, although not complete.








                                   -143-





                                                                  I
         The earmarked monies then represented basically a challenge by
     which the program could prove itself before Congressional and other
     critics.  In the first go around of the earmarks, the program was able
     to point to activities consistent with regional planning.  In the
     future, we may not be so fortunate.  Nevertheless, earmarks are a
     reality and have been a method by which specific areas are  identified
     for development. These are usually identified through  the  activities
     of special interest groups testifying before Congress.  That such special
     interest groups will not take a continuing and increasing interest  in
     Regional Medical Programs is highly unlikely. The reality is  that  we
     will continue to have earmarks, that the Division will pursue this  to
     theextent possible through a granting mechanism rather than contracting;
     but in those instances where contractural relationships might better
     protect the integrity of local decision making, this route will be
     pursued.  Further, in considering contractual  relationships, the
     Division would expect that the contractee would be through the regional
     mechanism and not directly with institutions or individuals.

















                                      -144-





                              "RESOURCE FOR DEVELOPMENT OF
                             CONTINUING EDUCATION PROGRAMS"

                              Alexander M. Schmidt, M.D.
                                        Chief
                       Continuing Education and Training Branch
                        Division of Regional Medical Programs
                  Health Services and Mental Health Administration
                                Bethesda, Maryland


            Since the inception of Regional Medical Programs, statements delin-
        eating our goals and the role to be played in meeting these goals
        by continuing medical education have been refined and clarified.  Perhaps
        the clearest statement of the ultimate purpose of continuing medical
        education was made at our National Conference this past January:  "The
        principle objective of continuing medical education is to provide for
        constant improvement in medical care.  The problems of medical care and
        medical education are inseparable, and continuing medical education offers
        the greatest potential for the rapid and widespread solution of problems
        and deficiencies in health care."
             This potential has been recognized by most regional medical programs,
        if I judge correctly our conversations and the content of grant requests.
        Nearly one-half the projects funded have been educational activities.
        if one includes patient care demonstrations as educational in nature
        (which I certainly would), then three-fourths of the projects and of the
        dollars granted are dedicated to education,
             These figures  doc ument what we have suspected; that in fact as in
        theory, continuing medical education is a principle means of achieving

        our program goals.






                                             -145-




           null uo accompiisn aii r-nai:.we must, we snouic aim ior une invo.Lv@-


      ment of a major portion of the total health resources of the nation.

      This means involvement with almost 100 medical schools and their

      affiliated teaching hospitals, a sizeable portion of the total of 7,000

      hospitals, some 288,000 physicians active in practice, 600,000 nurses

      and large numbers of other health personnel.

           Dr. Olson has already spoken of involvement and commitment in his

      remarks earlier today.  The importance of this process of involvement and

      commitment was emphasized in our report to the President and Congress,

      in the revised Guidelines recently issued, and especially in recent

      hearings before Congress held in connection with the extension of our

      legislation.  But this process is a difficult one, and has obviously

      troubled a great many of us seeking ways of gaining the involvement and

      commitment to Regional Medical Programs of the significant portion of

      the nation's total health resources.

           I think there is now evidence to suggest that the majority of health

      professionals now want to be -- and feel they must be -- involved in con-

      tinuing professional education,  Yet, it is clear that the more traditional

      forms of continuing medical education have'not been successful in reaching

      many more than 10% of practicing physicians, and have had questionable

      beneficial effect on that small number.  One still hears from all sides

      that physicians have no time to leave their practice, that their needs to

      learn are not being met, and that they simply are bored by the courses

      they have attended.


                                        -146-



           The challenge is obvious: each region must  develop  an  educational
        program that will meet the learning goals of its many professionals, and
        that will secure widespread involvement in and commitment to the program.
           Some  regions are now accepting this challenge.  We have been
        excited by the imaginative approaches being taken by some of our programs
        and by a few other groups in the country.  In studying these, we have
        tried to identify characteristics of continuing education programs which
        will not only meet educational needs, but also insure widespread and
        enthusiastic involvement in our programs.  I believe that I can identify
        four characteristics by which continuing medical education programs
        can be judged,  While these characteristics sound disarmingly simp e,
        they are worthy of our best thought and effort.
            First and perhaps most important, the educational program  must  be
        based in and integrated with the    tice of the professional.  Ideally,
        the educational program should take place where a physician, for example,
        has most of his problems __ usually his community hospital.  His education
        should not be continuing,but continuous ---- daily ----  an  integrated
        part of the process of seeing patients, gathering and evaluating  data,
        and making decisions. His educational needs must automatically  be  met
        by the educational program in such a 'way that he will perceive the time
        spent as an integral part of his professional life, and he won't have to
        "leave his practice."  The mechanism for such an educational program is
        suggested by the second desirable characteristic:  the educational need



                                            -147-


      of the Dractitioner must be met.  The problem of identifying the deficiencies
      in knowledge and skills and the undesirable attitudes that we all have can
      be solved only by systematic study of these as they are reflected by
      our performance. What is needed is some method for looking at  the  end
      results of our efforts in practice.  If a physician were to have some way
      of judging the outcome of his performance and were to see that in  fact
      these were deficiencies, he could then ask himself what there is  about
      his performance which yields less than the desired result.  It seems that
      the only rational way to document scientifically and systematically our
      educational needs is to insure our first characteristic --- that of basing
      the educational system in the daily practice of medicine. Some  of  you
      are now finding new ways to use techniques similar to  the  utilization
      review, and finding that these data on how medicine is  practiced  make
      obvious what changes must take place to improve patient care.
           This suggests the third characteristic: the content and      dures of
      the educational pt   am must be determined by a systematic inquiry into the
      Practitioner's knowledge, skills, and attidudes.  We need highly specific
      educational efforts directed toward resolution of an  identified  need.
      Evidence now supports the contentions that many physicians don't use
      knowledge they already have, and that their attitudes must  be  studied
      and then changed by appropriate educational experiences.  It  may  well
      be that our concerns about motivation can be allieviated by such efforts.'





                                          -148-


       Experience suggests that as we begin truly to meet individual needs t and
       demonstrate to that individual, by means of appropriate evaluation the
       resulting benefits, we can gain the enthusiastic acceptance, support
       and involvement of the medical profession in our porgram.
          Such an educational schema could be a threat to our professionalism,
       if not our profession, which brings me to the last characteristic: the
         tem should be          nall)7 "owned and    ated."  The importance of
       this can be seen now in Oregon.  What will make their experiment success-
       ful is that the members of the Oregon Medical Society themselves decided
       that all members must engage in continuing medical education.  Physicians
       as members of a trusted profession must be dedicated to assessing the
       level of practice as a prerequisite to the design of an educational pro-
       gram. I believe that if the first three characteristics are to be present,
       the fourth must be.  Only in a professionally controlled system of con-
       tinuing medical education can we achieve the necessary others ---- basing
       the system in the profession, surveying performance in order to analyze
       need, and meeting this need by problem-oriented teaching programs occurring
       as part of a practitioner's everyday life.
            Such programs are now being developed, and resources are available
       to assist in building others.  Some of you are getting valuable assistance
       from centers of adult education or offices of research in medical education.
       The Division staff is eager to be of assistance whenever we can.  We will
       be sending you pertinent information as it becomes available, such as the
       report of the AMA National Plan for Continuing Medical Education.


                                            -149-



          I hope that these characteristics might assist you in judging your
     educational program, its effectiveness) and its promise@, and give some
     insight into how continuing medical education can be a principle means

     of involving professionals in our program.
















































                                        -150-




                            ICATIONS AND REIATIONSHIPS
                          WITH AND BETWEEN
                THE DIVISION OF REGIONAL MEDICAL PROGRAMS,
                   THE 54 REGIONAL MEDICAL PROGRAMS,
                    ORGANIZATIONS) INSTITUFIONS AND GROUPS"
                        Margaret II. Sloan, M.D.
                          Associate Director
                      for organizational Liaison
                Division of Regional Medical Programs
                         Edward M. Friedlander
                       Assistant to the Director
              for Coomnications and Public Information
                Division of Regional Medical Programs
           Health Services and Mental Health Administration
                         Bethesda, Maryland
          During the past year the Division of Regional Medical Progr@
       has been reorganized to met the changing needs and demands placed
       upon it in fulfilling its mission of implementing Public Law 89-239.
          One of the areas of activity to which a new emphasis was given
       in that reorganization was that of developing and maintaining -relation-
       ships between the Division and national professional and volmta-ry
       health organizations and specialty groups.  As a result, the Office
       of Organizational Liaison was established within the Office of the
       Director.  Although not initially given an official role in this new
       endeavor, the existing Office of Com=icaiions and Public Information,
       also a part of the Office of the Di-rector, has worked with those
       involved with organizational liaison and contributed to that relation-
       ship as an important and integral part of its own total program.
       Together, these two Offices now'are assuming primary responsibility
       for developing and maintaining relationships and co    ications with
       and between the Division, the Regions, other national organizations,

       institutions and groups.
            At the Divisional or national level, these activities are carried on
       by utilizing a matrix of the professional and institutional groups



       who are the providers of health services and are actively involved
       with the Division of Regional Nbdical Program and the Programs
       themselves, and the public who are the recipients of those services.
       The first group can be identified as including representatives of
       the hospitals, medical schools, physicians and their specialty groups,
       allied health professionals, and all voluntary and public health org-
       anizations.  The second group comprises all of the people in whose
       interest the first group operates but subdivided so that the educational
       or informational effort directed to that complex of publics, is tailored
       to meet the specific needs of each group.  Only by utilizing this matrix
       can an integrated series of activities be planned and implemented that will
       effectively achieve goals of understanding, acceptance, support and cooperation
       among the various professional groups, on the one hand, and among the
       various publics that they serve on the other.
           There must be parallel planning and effort at the regional level so that
       the activities of the Division cannot only be supportive of those of the
       Regions, but supplemental to them -- and vice versa.  A successful result
       can only be achieved by a clear understanding of what constitutes effective
       planning and programming at both levels in organizational liaison and
       co    ications and public information..
           There is already tangible evidence of the success of the Division in
       working with such organizations as the American Medical Association, the
       National Medical Association, the American Hospital Association, the
       American Cancer Society  the Am erican Heart Association, the American
       Public Health Association, the American Academy of General Practice, the
       Colleges of Surgeons, Cardiology and Neurology, and the nursing'and allied
       health professional associations.


                                        -152-




         The cooperative effort of a number of these organizations is
       exemplified by the three contract activities aimed at developing criteria
       for measuring the quality of diagnosis and treatment of patients with heart
       disease, cancer and stroke as required by Section 907 of the Regional
       Medical Programs legislation.  In each case, one professional or voluntary
       health organization is accepting the responsibility for coordinating the
       work of other groups engaged with them in developing such criteria.  It is
       expected that a report of the Committee on Cancer will be available by
       Spring of 1969, and those on heart disease and stroke shortly thereafter.
          The national professional societies have also been encouraged to
       assume an advisory and consulting role in Regional Medical Programs.
       Their major contribution to date has been their help in determining
       what constitutes "the latest advances'l or the highest quality of medical
       care for patients with heart disease, cancer, stroke and related  disease
       which Regional Medical Programs should help physicians and hospitals
       make available to their patients. Similar efforts at the  regional  level
       are also underway and are helping to set the pattern for strengthening
       these relationships in the Regions.
          Another example of joint action between the Division and a major
       national organization was the American Hospital Association's Invitational
       Conference on Hospitals and Regional Medical Programs held in June of this
       year.  In addition to the material already distributed in the form of the
       reprints of July 1, 1968 issue of Hos                 which help  explain
       this relationship, it can be expected that the proceedings of the meeting
       expected to go to press shortly will further clarify the issues.  Parallel
       action is already occuring at the local level between the state and
       metropolitan hospital associations and the Regional Medical  Programs  in

                                         -153-



         which they are involved -- or should be.
           Education of the providers of health service actively involved in
         Regional Medical Programs to the philosophy and development of Regional
         Medical Programs is being carried out through the efforts of both the
         Division's Office of Organizational Liaison and the Office of Communications
         and Public Information.  This is being done in concert with the organizations
         already named and others, both in terms of program content at scheduled
         meetings, and through their own journals and other quasi-professional
         publications.  For example, a full section on epidemiology at the last
         annual meeting of the American Public Health Association meeting was
         devoted to Regional Medical Programs.  Similarly, the Sixth National
         Cancer Conference in Denver earlier this month added a day-long workshop-
         conference on speci al Regional Medical Programs activities.  In addition,
         such publications as the AMA Journal and News. Bulletin  of the American
         Cancer Society, the American Heart Association, Medical World News,
         Medical Tribune, Medical Economics. American Journal of Nursing,
         and Hospital Practice, to name a few, have written and'publisbed
         definitive features on Regional Medical Programs for their own  special
         readership groups which in many instances overlap nationally and locally.
            Much in the same way, the journals of the Medical Associations of
         North Carolina, Georgia, Utah and the Northwest (Oregon, Washington and
         Idaho), to name a few, have been most constructive in detailing the
         Regional Medical Program activities in their Regions to their own readers.
         So too have the state and regional publications of the Cancer  Society,
         Heart Association and voluntary and public organizations which have given
         special regional emphasis to the material issued by their national offices
         in the interest of the Programs in their areas.

                                        -154-




            A combination and extension of this kind of activity at both the
       national and regional level must be encouraged.  Only in this way can
       there be an understanding of Regional Medical Program issues in both

       national and regional terms.
            There still remains much to be done in terms of  inter-Regional
       exchange of information. Unfortunately, too little has been done  to
       meet the demands for various informational elements that have already
       been identified.  There is, however, some promise and progress in this
       area.  In response to Dr. Musser's suggestion, we are pleased to announce
       that the Directory of Re ional Medical Programs will incorporate some
       of this type of information in its forthcoming issue. Included  will
       be a listing of all approved projects in the 23 operational Programs
       funded to date.  Coordinators and Directors of these Programs will
       find summaries of their projects for review and approval in their
       folders. Also, the selected bibliography Dr. Musser asked for is  in

       press.
            For the past 18 months, the Division of Regional Medical Program
       has assumed the presumptuous role of providing a wide range of informational
       materials, including its News, Information and Data publications, to any
       and all who asked for them, either on a one-time basis or regularly as
       they became available.  The concept of the Regions developing their own
       materials for their own audiences now requires a re-evaluation of this
       policy.  The Division's mailing list is now in its final stages of being
       regionalized.  The question now arises of how best each Program can further
       maintain and develop that list to include all of the people with whom
       that Program must communicate, and then assume responsibility for doing
       so as part of a total informational program for that Region.

                                       -155-
        19,7-9,RA n - 68 - 11




          Regional Medical Programs, unlike any other Federal program, not
       only has put roots down into the 54 separate Regions, but each Program
       is indeed a special kind of autonomous entity.  Each is separate in
       many ways not only from the Division of Regional Medical Programs, but
       from the other 53 Programs as well. As such, each Program  must  develop
       its own relationships and systems of con = ications and  information  among
       the various groups within its own Region to meet its own needs and demands.
       But each Program is still a part of a national effort being funded  with
       Federal dollars and operating under Federal law.  Therefore, all   Programs
       have an obligation not only to keep their own Regional  audiences  properly
       informed and aware of their activities and progress, but also those  who

       represent those constituencies in the Congress.
           These facts add up to the unique factor of Regional Medical Programs
       that makes them different.  Separately, each develops activities which are in
       the best interest of those who live in their Region. Together,  they  do
       the same for the entire country and, as such, have the potential for
       providing a collectively significant influence on the kind of support that
       is needed to insure the success of all of the Programs.
           "Grant me the strength and intelligence to change those things  I  can;
       the patience to bear those things I cannot change; and the wisdom  to  know
       the difference."  As this quote applies to Regional Medical Programs, we
       quote the Frenchman who said "Vive la difference!"










                                       -156-




                      "ISSUES AND CONCERNS IN RETROSPECT"

                               Marc J. Musser, M.D.*
                                Program Coordinator
                      North Carolina Regional Medical Program
                              Durham, North Carolina

           I will now attempt to highlight for you the "Issues and Concerns"
       as they appeared to have emerged last evening during the six dinner

       sessions.
           First, I would like to express the appreciation of the Coordinators
       to those members of the Division Staff who served so ably during last
       night's dinner sessions as recorders and secretaries.  Without their
       help we certainly would not have been able to have had any kind of a
       meaningful activity this afternoon.
           The discussions last night fell into three general areas:  Opinions,
       Issues and Questions.  I would like to explore each of these categories
       with you.  Concerning opinion, there seems to be a consensus that there
       should not again be a large general meeting such as this Conference for
       the time being unless some special purpose should arise.  Instead, smaller,
       targeted meetings, as suggested by Dr. Olson, were favored.  In such
       meetings the various disciplines of the core staff could meet to discuss
       their own problems as related to those of other Regions and also as
       related to the activities of the Division of Regional Medical Programs.
       It would also appear that Coordinators would like some kind of a business
       meeting at least once a year but prefer that there should be limited

         General Discussion begins after Dr. Musser's initial summary of
         topics and issues brought up in the Dinner Discussion Sessions
         the previous night.




                                        -157-




       attendance and adequate time for full discussions. These might  even  be

       accomplished on an inter-regional basis with appropriate members of  the

       Division staff attending.'

          Incidentally, the Division had hoped to provide more time for dis-

       cussion at this meeting.  It had to compromise this desire, however,

       in the interest of the material that needed to be shared - or at least

       it felt it needed to be shared - with the Coordinators.

           There was also strong opinion last night that the entire communica-

       tions and informational efforts of the program should be improved and

       expanded, Division to Program, Programs to Programs, and groups of  Pro-

       grams to groups of Programs. However, no specifics were advanced  as  to

       just how "bigger and better" communications should be achieved.

           I would like to note here that the Division is very much aware that

       as the Programs become more sophisticated, so must be the case with  the

       development and dissemination of information.  Mr. Friedlander talked

       yesterday afternoon of the re-evaluation presently going on in the
       Division to meet these increasing needs at both the national and regional

       level. Some of these plans should be ready for discussion shortly.

       This would seem to be an ideal occasion for "targeted" meetings.

           It would also appear that, while the need to educateand more

       deeply involve members of Regional Advisory Groups is desired, this could

       best be accomplished if the Advisory Group members and the  Coordinators

       participated jointly.

           In the area of improved relationship between Division  and  Program,

       one novel suggestion was made.  Why not permit Programs to make site



                                      -158-




       visits to the Division?  Certainly such visits would enable the Programs
       to gain more familiarity with the problems, philosophies and procedures
       of the Division.  This suggestion might also reflect the concerns of
       Regions over the lack of feedback to them following site visits or staff
       visits from the Division.  There is a strong desire to know the bases
       upon which judgments were made and also to obtain as much constructive

       criticism as possible.
           These were the opinions.  Now, I would like to summarize the
       several issues that seem to be paramount and then take them up indivi-

       dually with the panel.
           Certainly the most widely discussed subject -- the most pressing
       issue -- was the relationship of P.L. 89-749 to P.L. 89-239.  This is
       getting to be a very tired horse, it seems to me.  There appears to be a
       widespread anticipation that some high and unimpeachable authority will
       provide the answer as to how these two programs can and will live and work
       together forever hereafter.  Chances are this will not happen in the near
       future.  It must be noted, however, that in some Regions reasonably
       adequate working relationships have been established without the benefit

       of an oracle.
            There was also a great deal of discussion concerning the issue of
       the urban poor -- just what Regional Medical Programs could or should do
       to bring about more and better care for these people.  There seemed to be
       the feeling among some that the Division was attempting to tell us








         327 -284 0 - 68 - 12




       yesterday -- without really saying it -- that there has been either a

       policy change or a higher priority assigned to projects in this area.

       In this connection some wondered how such a national priority might re-

       late to regional priorities.

            Planning, evaluation, priorities, involvement, and continuing education

       each came in for their share of discussion.  It would appear that those

       Programs having difficulty in these areas would greatly appreciate assis-

       tance from both the Division and from the more advanced Programs.  This

       cry for help, I believe, is a part of our earlier remarks concerning the

       need for more sophisticated communication procedures.

            Another issue -- and I am not sure it is as much an issue as it is

       a sensitivity -- is concern over the way in which Regional Medical Programs

       need to be developed to assure long range goals and at the same time

       generate short term activities that demonstrate viability.

            As Dr. Wilbur and Mr. Brown pointed out, change must be accomplished

       slowly in so complex a health system as ours.  Yet, at the same time,

       the public is impatient for quick solutions to long-standing problems.

       This, indeed, is our dilemma.

           The last issue that seemed to come through clearly was what I

       choose to call the '!coordination of the concepts and strategies" of

       the Regions and of the Division in the development of initial operational

       and subsequent proposals.  At this early stage it is probably true to say

       that neither the Division nor the Regions have been able to crystallize

       fully their concepts and"grand strategies" and thus progress toward





                                         -160-




       these ends will be made more rapidly with a free exchange of ideas,

       good faith and open minds.
           So that the Panel might respond to some of these issues, let me ask
       Dr. Olson if he would like to make any comment concerning the relation-
       ships of P.L. 89-749 and P.L. 89-239.


                              GENERAL DISCU SI@ON

       DR. STANLEY W. OLSON, Director, Division of Regional Medical Programs:  I
       suspect that the trouble with trying to get the position of the relation-
       ship between 239 and 749 straight is that while you can see 239 in your
       own Region and in other Regions and get some fairly tangible evidence of
       what it is doing, you can't do the same with P.L. 89-749.  The develop-
       ment of the 749 program is not nearly so advanced.  When we try to give
       a theoretical description of what it ought to be, one looks to see what
       basis of reality there is against which to test his conceptual idea.  It
       is so diffused and so varied from state to state that we are tempted to
       say, "They are trying to tell us in different words what the law says,
       what it means as a Federal conceptual strategy."  Well, that's all right.
       But when we come right down to it we can't find anything that conforms
       to our individual notions of 749.  And since we are realists, this

       doesn't help us any.
            Mr. Peterson, who is in Planning and Evaluation, did a very nice
       analysis of 749 for me based on available information.  I thought, as
       I read this analysis, that one would be hard pressed to formulate it

       into a describable program.




            I would suggest to you that it is only just now becoming possible

       to do this with Regional Medical Programs -- and we have been at  it  for

       two and a half years in a fairly intensive way. I think  we  are  terribly

       fortunate in being able to recruit the kind of talent assembled  here  in

       this room. This, to my mind, is why Regional Medical  Programs  has  moved

       ahead more rapidly than the other program. This is not to  say  in  anyway

       that the other program is of less importance.  Rather, it is to  say  that

       749 is trying to collect a different element within the community  to  do

       somewhat different things with the health care structure and that  it  may

       be some time before a recognizable pattern will emerge in that area as

       it has in 239.


            I don't know that we can clarify this any more.  But, perhaps we

       can clarify what Coordinators ought to do in the absence of a more definable

       749 pattern.  Clearly, I think Coordinators must keep fully abreast of

       what is going on in the development of Comprehensive Health  Planning  in

       their area.  They may wish to do as Paul Ward has done -- offer to provide

       specific help.  Mr. Ward has trained 749 personnel in his office in order to

       give them the benefit of what information and  organizational  activities

       have been pulled together by 239.  Clearly this, or any other form of

       cooperation, is well within the purview both of 239 and  749.  More  than

       this, I think it is entirely appropriate.  I would advise that Coordinators

       send the person in charge of 749 in their Region copies of  -applications

       including budget, so they will have full information about what  is  going

       on in the 239 program.  Also, in a cooperative venture such as this, there





                                        -162-




         is nothing wrong with Regional Medical Programs assuming leadership if no
         such leadership is presently apparent.  The only caution I would urge is
         that Coordinators assume this leadership in a kind of a trusteeship capa-
         city and at such time as the leadership of 749 does emerge, when the
         staffs become organized, that 749 be allowed to occupy the ground that
         is rightfully theirs.  Do not dispute that ground with them.  Clearly
         749 and 239 have complementary roles and it would be dangerous to confuse

         those respective roles.
             Dr. Baumgartner suggested last night that the two groups sit down
         together and stop worrying about what their roles were.  They should simply
         decide what each group, including other participating groups, can do
         best and then let them go ahead and do it.  Only in the doing of what
         each program must do, will the role of each emerge.
             Clarification is bound to emerge.  But I'm not at all sure that it
         will emerge at the rate Coordinators would like it to. Perhaps this  will
         be a test of some of the challenges Mr. Brown pointed out this morning
         a test to prove the Coordinators ability to deal with complex problems
         and complex groups that they don't manage, don't feel comfortable with.
         I think this is as much as I can contribute -- unless there are some

         specific questions.

         DR. MUSSER:  We might move on.  I don't think we'll clarify this issue

         any further.
              Another issue raised last night was whether, indeed, the Division
         was trying to convey a message to us that there was now a different


                                         -163-



      emphasis upon the importance of Regional Medical Programs involvement
      with the health care of the urban poor.  And, if this were indeed true,
      how could this emphasis at the national level be reconciled with some

      of our own regional priorities.
      DR. RICHARD F. MANEGOLD, Associate Director for Program Development and
      Research, Division of Regional Medical Programs:  There are no new signals.
      There is, however, an emphasis of old signals.  You will remember that
      the N ws, information, Data  reported last September on the concerns of
      the National Advisory Council.  These concerns related to the relative
      visibility of Regional Medical Programs.  In January, Mr. Irving Lewis,
      then of the Bureau of the Budget, emphasized the importance of the urban
      health problem.  Thus, there have been two major statements -- one from
      the National Advisory Council and one from the Bureau of the Budget in
      regard to this problem.  Dr. Marston and others have made numerous references

      to this area throughout the year.
          The new Guidelinneess, in describing the Regions, state that they must
      be relevant to the complete population coverage.  Nevertheless, one
      recognizes that Regional Medical Programs require time for their develop-
      ment, that regional priorities vary, and that the protection of the Regions'

      integrity is crucial.
           Clearly there are difficulties in developing programs for the poor.
      The health status of ghetto populations is too well known to this group
      to require recitation.  You are equally aware of the difficulties of



                                       -164-


       developing cooperative arrangements in areas where provider systems are
       thin.  Therefore, special innovative approaches will be required.
       Solution to the urban problem will come from those with the imagination

       for innovation.
          The signal means emphasis.  We are only re-emphasizing a problem.
       If the signal means "'cool it baby' and put it all in the ghetto," then
       the signal is being badly misinterpreted.

       DR. MUSSER:  Any more questions about this one?
       DR. RICHARD H. LYONS, Program Coordinator, Central New York Regional
       Medical Program: I have a question in reference to Regional  Medical
       Programs involvement with the health problems of the urban poor.  How
       do we do this?  Do we operate through a grant request --through planning
       grant requests?  What kind of mechanism do we have without putting in
       a new planning grant request to get around your auditors?
       DR. OLSON:  I don't believe there is anything the auditors would take
       exception to if you use your planning funds to do planning for  your
       entire Region.  1 don't know of any aspect of planning which is restricted.
       Is there any question on this?  You may not have as much money as you
       would like to identify needs.  But I hope no one believes they must have
       a special planning grant to plan for the poor.  This is not consistent
       with any experience 1 have had. I hope we are clear on  this  point.




                                          -165-


      VOICE FRO-M THE FLOOR:  Dr. Olson, how does this question of Regional
                                           oor relate to your earlier dis-
      Medical Programs assisting the urban p
      cussion of 749?  It would seem to me that 749 would be the more logical
      approach to the solution of the urban poor problems.  How should Re-
      gional Medical Programs concern itself with the health problems of the

      ghetto?
      DR. OLSON: Planning funds are awarded to the Regions to help  them  to
      carry on those things they believe are relevant to their  mission.  If
      some Regions say they do not need to concern themselves with the health
      problems of the ghetto, and have some data and information to  support
      such a.pqsition,.I don't believe they will be challenged.  Remember,
      Regional Medical Programs has a non-directive type of approach.
          I think what Dr. Manegold is suggesting is that if the Regions
      studiously ignore the ghetto the Division may raise the question:  Why
      aren't you interested in the ghetto?  But that doesn't mean there is any
      special directive to move in the direction of the ghetto.  I think this
      is a matter that is generally understood.
            ... As far as I'm concerned planning is a continual process which we
      will be involved with as long as we're involved with Regional Medical
      Programs. When projects with respect to the ghetto  are  proposed  you
      must take a look at some of the constraints that -are imposed upon Regional
      Medical Programs in terms of neither being able to provide services, nor
      being able to construct facilities.  This is where we begin to talk with



                                       166-




      the 749 program, talk about their ability to accomplish these facets
      of a total program.  The 749 program can indeed support the more active
      financial phases of bringing health care to the ghetto.  The activities
      of 239 must be complementary to those of 749 in this area.  Specifically,
      Regional Medical Programs is concerned with the quality of care that will
      be provided in terms of heart disease, cancer and stroke.  Clearly, the
      Office of Economic Opportunity will be a third mechanism for the solution
      of ghetto health problems.  Granted, this is a complex approach, but
      any approach by the nature of the problem will be complex.

      DR. JOHN BUCHNESS, Public Health Service Regional Office, Denver:  I would
      like to go back to Dr. Manegold's earlier statement and say that in my
      opinion there has definitely been a change in signals.  I speak from
      the viewpoint of the Department's Regional Offices.  The signal is very
      clear.  it is fundamentally important that all of us understand the
      urgency of the urban poor problem, and the extent to which this urgency
      must be woven into a total program -- Comprehensive Health Planning,
      Regional Medical Programs, Model Cities, OEO Clinics, --- and so forth.
      If we're going to sit around and wait for years and years of planning to
      see what we should do, then I think we are regressing rather than pro-
      gressing.  There must not be competition between programs, but concerted

      action to get things done.

      DR. J. GORDON BARROW, Program Coordinator, Georgia Regional Medical
      Program:  I think we are being told that we must pay more attention to
      the problems of the urban poor.  I also believe this goes against the



                                       -167-


     grain of the most popular facet of Regional Medical Programs -- that
     its activities are non-directive.  I would suggest that assistance to
     the urban poor is a"ldirected" activity.  Not withstanding the fact
     that I sincerely believe there is much urgency in this area of the
     urban poor I do believe this urgency should be stressed to Coordinators
     in a private way and not by news releases that go to so many people in
     the Region.  I say this because I find growing resistance to this
     approach in my area. My people have been given the impression that  they
     are being pressured by Secretary Cohen.  And, as most of you know, he
     is not a popular fellow in my part of the country.  I think that  concern
     for the urban poor, or in my area, the rural poor, must come  originally
     from the area itself and not from Washington.  I would suggest that it
     would be a whole lot more diplomatic, and a whole lot more effective  if
     the Federal government's concern in certain areas would be transmitted
     quietly and not broadcast throughout the entire Region.
     VOICE FROM THE FLOOR:  We talked yesterday at some length about earmarked
      funds.  I would like to ask either Dr. Olson or Dr. Manegold whether
     they believe that the great importance of the ghetto problem might in
     the future entail the earmarking of funds for application in this  area.
     DR. OLSON: Other national priorities have been set  besides  the  ghetto
     area.  But funds have not been earmarked for these other national
     priorities. I would hope that none would be so marked for  the  ghetto,,




                                        -168-



      because earmarking is inconsistent with the mechanisms whereby funds

      are allocated to Regional Medical Programs.
              I would also like to speak in reply to Dr. Buchness' belief
      that there has been a change in the signals.  To my knowledge there
      has been no directive to Regional Medical Programs as to what they
      must do in respect to poverty problems.  The fact is that the poverty
      problem exists and Regions may wish to use some of their funds to
      study-tlie problem.  This is certainly an appropriate use for planning
      funds.  But, as the law specifies -- operational projects must be
      approved by the local Advisory Group.  These Groups must set their
      own priorities,: and must determine how to distribute awarded funds

      among approved projects.
            There is no message going out to Coordinators from the Division
      that they must shift their funds into the urban poverty areas.  Nonethe-
      less, having said this, I would remind you that the urgent.-problem
      of the urban poor remains.  Major needs must be resolved, and if the
      opportunity exists for Regions to solve these needs in their way,
      they should do it.  Ignored needs will not go away.  This, I think
      is the only special signal that the Division is trying to make."

            DR.@ DEAN W. ROBERTS, Greater Delaware Valley:  The problem in
      Philadelphia is not so much in not wanting to deal with the ghetto problem,
      as it is how does one effectively relate Regional Medical Programs to the
      problem.  In Philadelphia, as in most large cities, there are numerous agencies





                                         -169-



      that are trying to do something about this problem.  Unfortunately,
      there is relatively little relationship between these agencies.  Also)
      many of these agencies believe they have a direct mandate to deal with
      the ghetto problem.  The relationship of Regional Medical Programs seems
                      peripheral.  I do not see any particular niche where
      to be relatively
      Regional Medical Programs might make a particularly significant contribu-
      tion.  It would seem to me that if there is any one thing the ghetto does
      not need, it would be a special emphasis on categorical diseases such

      as heart, cancer and stroke.
          I believe that the contribution Regional Medical Programs can make
      to the ghetto health problem will be the effect of its planning on
      other agencies, its influence in getting them to work together.  I believe
      a direct approach on the part of Regional Medical Programs to the varied
      problems of the ghetto would be similar to walking into a cul-de-sac.
      DR. MUSSER:  I don't believe it possible to identify a niche for Regional
      Medical Program involvement in the ghetto that would be nationally appli-
      cable.  No Region has exactly the same resources available as another.
      Whatever contribution the Regions make in this area must have some rela-
      tionship to the resources they have at hand.  Again it is a question of
      local initiative, local innovation.
      DR. BARRY DECKER, Program Coordinator, Northeast Ohio Regional Medical
      Program:  I would like to speak to the question raised by my colleague
      in Philadelphia.  I believe that planning toward operational funding for


                                        -170-




      programs in the ghetto is only one phase and may turn out to be the least

      important from the standpoint of Regional Medical Programs.       It seems  to

      me that Regional Medical Programs is  the  mechanism  whereby  one  gears  a

      community to set up cooperative arrangements  for  an  attack  on  the  ghetto

      health problems. In this sense,  we  in  Cleveland  are  using  the  Regional

      Medical Programs mechanisms without the need for additional funds to
      approach some of these inner-city problems.      Quite specifically  we  are
      @orking out cooperative arrangements with the Cuyahoga County Medical
      Society.   One of their current activities,  which  we  have  stimulated,  is

      an effort to convince the physicians of this county  that their functioning

      in inner-city areas is quite important.  This type of motivation is

      necessary if we are to realistically  approach  the  problems  of  the  inner-

      city.   I believe that this can be a  real  Regional  Medical  Programs  con-

      tribution. Regional Medical  Programs  with  its  large  body  of  expertise
      is helping to establish a new OEO  center  in  our  area  without  requesting
      additional funds. The point I'm  trying  to  make  is  that  Re'ional  Medical
                                                                    9

      Programs contributions to ghetto health problems need not be tied to
        Oft            -          -
      money. When it is not tied to money,  it  is  not  tied  to  the  limitations

      of the law.


      DR. MUSSER: I would like now  to  get  a  little  dialogue  going  concerning

      the issue I earlier identified as a situation wherein neither the Division

      nor the Regions have been able  to  crystallize  fully  their  concepts  and
      ligrand strategies" concerning the  development  of  initial  operational  and
      subsequent proposals. From time to time  we  see  at  the  regional  level  a


       desire for the Division to make very clear just what kind of material
       should be contained in a grant application.  Also at the divisional
       level, from time to time there is a feeling that the regional people
       should have better documented their application in terms of concept

       and strategy.
         There has'been some sparring on this matter between the Division and
                                 reflected in the expressed desire of some
       the Regions.  This has been                           e
       Regions that there be Division feedback to them after site visits.  The
       Regions feel they would get a much better idea as to whether they were
       on the right track if the Division would give them constructive criticism.
          I do believe, though, that we're better informed on this matter than
       we were two years ago.  Certain concepts have emerged at the Divisional
       level.  This is particularly true in regard to the necessity of establish-
       ing some kind of continuity, some kind of a story of regional activity
       as the Regions begin to send in requests for additional operational projects.
       I wonder, Dr. Stephenson, if you would talk about this.  I believe it

       quite important.
       DR. RICHARD B. STEPHENSON, Associate Director for Operations, Division
          egi                                e@ss
       -'6f'@R '6n@l""@@dical Programs-.  T                  n(          ions
       into some frame of reference does make sense to the Division.  And to
       the Review Committee and Council.  I believe it a matter of just plain
       common sense.  It has been clearly expressed a number of times by both
       the Review Committee and the Advisory Council that supplemental applica-
       tions, or indeed even initial operational proposals, must be related in


                                         .-172-



       some meaningful way to what has gone on before during the planning stages.
       At the Divisional level it must be clearly understood what the Regions
       subsequently hope to accomplish.  The Division must have this frame of
       reference if it is to make a meaningful judgment as to the merits of

       the proposal.
          A simple solution to this would be if the Division staff could
       prepare a detailed summarization of the status of each Region for the
       use of the Review Committee and Advisory Council.  But there are two
       objections to this.  First, the Division could never accomplish such
       a task in as meaningful a way as the Region could.  The other barrier
       is that as of today the Division is shorthanded -- some 25 fewer people
       than it had a year ago.  We are in the middle of the tightest personnel
       freeze ever experienced in the Federal government.

       DR. OLSON:  The big question which the Review Committee, the Advisory
       Council, and the site visitors are always interested in is:  Has the
       groundwork really been laid?  Have regional cooperative arrangements
       really begun?  is there in fact a basis for a viable Regional Medical
       Program.  This is far more important than the content of the individual
       projects in the application package.
           I would like to change the subject at this point.  Many of you are
       anxious to catch your planes and I think we have now come to the time
       where the Conference program should be terminated.
            I would like to express my deep app reciation to Dr. Musser for having
       been your spokesman this afternoon in setting forth the concerns and


                                       -173-


   Issu,es that have been expressed during thi.s Conference.  in the past
                                          re what has gone on these past
   few minutes I have been trying to compa
                               t the .Conference in June of 1967 -- just
   two days with what went on a            ome a long way during that time.
    16 months ago.  This organization has c
    Nonetheless, I suspect many of you are leaving with the feeling that
                                          his Conference.  Many of you came
    far too few answers were provided by t
    to Washington with a whole bag full of problems, thinking that you would
    find someone here who would have an answer for each of them.  Now, here
    it is two days later, you have to catch your plane, and most of your
     problems remain unanswered.  Well, that's the way it is@ You know.
     You are not going to get all the answers out of Washington.  The challenge
     is for you to develop an organization that can provide the answers to
     your own problems.
          I would, however, like to say that some of the problems you brought
     with you to Washington concern the management policies of this Division.
     you do deserve specific answers to these questions and I will see that

      you get them.
           on behalf of all the staff I would like to express my sincere
      appreciation for your participation at this Conference.








                                          -174-
                                                    U.S. GOVERNMENT PRINTING OFFICE: 196a 0 - 327-284