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          MISSOURI REGIONAL MEDICAL PROG@RM
          ANNUAL MEETING OF REGIONAL ADVISORY GROUP
          Crown Center Hotel, March 28, 1974

                 m.hank you.  Thank you.  And now the real Nathan Stark has

          stood up.

                 Ladies and gentlemen, it is indeed a privilege and an honor

          to be here and to have this opportunity to share some thoughts

          with you on your involvement in programs for bettc@r health throug

          comprehensive planning and action.

                 A few weeks ago, I was speaking in another city.  In conver-

          sation at the luncheon table I mentioned my scheduled appearance

          before you today.  My table companions, professional health people,

          were a little less thari encouraging  We had been talking about the

          spate of health legislation we have had in the last few years.

          Mentioned were the complexities of new program!s; how does one

          implement them in Regional Medical Programs, Comprehensive Healt

         ,Planning, Y-edicare, Medicaid, Health Professions Education

         -Assistance, etc, etc?  How do we go about mobilizing the needed


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          men, women, money, physical facilities to achieve these goals  for

          all our people?

                  I admitted it had taken some temerity for me to accept the

          invitation and that I had some real misgivings about it.  With this

          in mind, I thought of the story of the seriously sick man who  was

          asked by his minister if he had made his peace with the Lord  and

          renounced the devil?  The patient responded:  "Considering the

          fix I'm in.- I'm not going to make an enemy of anybody!"

                  I trust we are not here to celebrate an event marking  the

          end of an era. I hope none of you will be discouraged by the  O.MB

          pronouncement in the fiscal 1974 budget wherein the rationale  for

          the discontinuation of the Regional Medical Programs is:   . . . there

          is little evidence that, on a nationwide basis, the RMP's have

          materially affected the health care delivery system." If  so,  we

          should certainly not have this kind of session in the  future.  I

          choose to believe that programs such as you are attending today

          will have a continuing value and that the subject should be discussed


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          again and again in the future.

                  UThen Doctor DeBakey and his colleagues first gave their

          report, they hoped it would result in great heart, stroke, and

          cancer centers spread over the U S A       perhaps, because of his

          origins beginning in Houston, Texas.

                  The centers were to give citizens access to the finest

          fonew frontiers" 'in medicine.  They would reach out to sub-units.

          And with this, continuing education of all health professionals and

          the health care education of the public was to move in and out to

          the center and then to the sub-units.

                  As you know, this did not happen.  In fact, RMP was essentially

          banned from direct federal involvement in health care.  The decision

          was made that RMP was to be a "grassroots' program.  This grassroot

          was to be-anchored by the medical schools.  Thus, the ultimate

          bill resulted in regional medical programs -- not centers.  The

          only,thing from the DeBakey report that one could recognize was

          the word "regional."


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                  In many respects the RMP enabling act -- Public Law 89-239

          is quite extraordinary.  Its genesis and Promotion are intriguing

          to say the least.  The diverse interpretations among various observers

          of its long-term objectives suggested many misunderstandings and

          an uncertain but hopefully great future.  The zeal and enthusiasm

          of the men and women -- including numerous medical leaders --

          reflect the dramatic appeal that it had for many individuals  of

          good will and high hopes. The vaguely defined authority  of  the

          act has seemed to many inadequate to bring about the  innovation

          and organizational changes they seek. The Act's promise  was  to

          facilitate the planning, organization, and delivery of health

          services within a functionally-based regional framework, capable

          of circumventing state-local political boundaries and orthodox

          health channels.  Additional excitement centered on the possibility

          that, once launched and successfully demonstrated, the application

          of regionalism might spread to encompass a number of other problems

         ,pressing in on the health field, and might lead eventually to  a


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                  Doctor Marston once said, "These programs face the challenge

          of influencing the quality of health services without exercising

          federal or state governmental control over current patterns of

          health activit4les."

                  Doctor Charles L. Hudson, a past president of the  American

          Medical Association,,@ointed out that no one was so naive or so

          radical as to say that government spending for health should or wil

          stop.  He pointed out that the centralization of planning under a

          system of Social Security, or any other, brought with it the hard

          fact that one removed from the local community any rights whatsoever,

          and surrendered to a central voice an opportunity to make decisions

          which might or might not be beneficial to an individual  community.

          It was with this opinion that he further stated:

                  "Recently I have paB more attention to a point that I  made

          in my first inaugural address, that to avert the trend toward

          dependence on government one should help to stimulate local community

          responsibility for health care. This is a  divided  responsibility,


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         consumer-provider, peripheral or central, governmental, or private,

         but it has the virtue that no lines of opinion or bias need impede

         the activity.  There is something for everyone to do."

                  Congress, as we axe aware, has established Regional Medical

         Programs and Comprehensive Health Planning Programs, both with

         Doctor Hudson's thought in mind and both involving regionalization

         of health services.

                  What forced us toward the regional concept?  Without

         dwelling too long on this, let me cite just three of perhaps

         several reasons:

                  1.  The growth of our metropolitan areas and the

                      relationship of the city to the suburb.  We can no

                      longer plan solely on the basis of the small community.

                  2.  Costs must be held down by greater attention to

                      organization -- more efficiency.

                  3.  And perhaps, it arises, as Lester Breslau points out,

                      from growing recognition within the health field that


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                       the present complexity and  specialization  of  health

                       care requires exploration of new patterns of

                       organization.

                   I have been involved in community health  planning  for  a

          number of years;  I know planning around the  nation.  I  must  admit

          it has not been well done, if at all, nor has it been comprehensive

          in nature. By congressional  action,  Regional  Medical  Programs  and

          Comprehensive Health Planning, it was hoped that  it  could  be  done

          comprehensively and those of us here whether directly related

          through this field of medical care or as  beneficiaries  of  a  health

          care system, have a major stake and if we  take  advantage  of  our

          privilege and right, a major voice in the quality of planning.

                  In his report tothe President and  the  Congress  on  Regional

          Medical Programs, @@Surgeon General         967) set forth at  length

          a number of issues and roblems  which  face  the  Regional  Medical

          Programs. Some of these surely  derive  from  characteristics  of  our

          country's general health make up -- we are essentially voluntary


          and private. Today, we measure ourselves as  a  multi-billion

          dollar health industry with all the complexities of  manpower

          limitations and rising costs.  The law itself spells out other

          characteristics -- defining a region, the significance of disease

          categories, use of advisory groups, interpretation and distribution

          of information concerning advances in diagnosis and treatment, and

          others4

                  The Regional Medical Program was established,to  help

          narrow a large and disturbing gap which exists between what medical

          science knows today and the actual care and application that is

          available to the vast majority of the public. The  focus  was

          to be on heart disease, cancer, and stroke.

                  The problems will be resolved when we know the answers

          to such questions as these:

                  How can we cope with the actual logistics of getting the

          best available health care directly to the greatest number of

          people, both healthy and diseased?


                  How can a doctor use his already overtaxed time more

          efficiently?  Can we devise tools -- such as new instruments,

          new tests or computer programs -- that can help h4M?

                  How can the doctor keep current with the burgeoning mass

          of new and important information that keepspduring out of medical

          and other research labs?

                  What actually can, or should, the profession do to help

          educate the public about such matters as early detection of disease?

                  How best can intensive and comprehensive care be administered:

          in hospitals, clinics, homes?

                  How best can the busy practitioner avail himself from a

          distance of the particular skills of the specialist or of the

          special knowledge available in medical teaching centers?  How can

          better rapport be established between the two?

                  The most important thing that this legislation should have

          orovided was the opportunity for innovation.  Legislation has

          provided the dollars required to place professional talent on the


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          development of these  programs.  To  insure  that  the  professional

          team would not create a  static  institution  revolving  about  them-

          selves or their programs, the Congress  'A delegated    decision-making

          and hence ultimate power to the regional advisory group.  In

          Missouri, this ia a committee -- originally appointed by the

          Governor -- of members  of  the  medical  profession,  administrative

          officials, nurses, and laymen and laywomeh, including essentially

          all of our health and health-related agencies.  This committee

          held the purse strings and decided  what  programs  would  meet  the

          law's aims.  Then there were twelve -- now with your RAG structure

          there are sixty, and I think this is good!

                   In 1942, the President's Commission on the Health needs of

          the Nation  called for a wider range of regional systems of health

          services.   These objectives would have entailed a heavy commitment

          of medical  schools and teaching  hospitals  in  extension  services,

          postgraduate education,  and  sharing  of  medical,  technical,  and

          Administrative resources. The  realization  of  this  plan  was  not


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           achieved, according to  one  observer,  "because  of  the  traditional

           reluctance of medical  school  faculties  to  project  their  services

           beyond the campus, the shortage of medical teachers, and the

           burgeoning of biomedical  research  programs."  And  now  we  have  the

           Regional Medical Program.  The law invited medical schools, research

           institutions and hospitals to get programs going for patient care.

           What has been the response?  I        t speak for  the  national  progr

           only for Missouri.

                   Let me,,Idigress for just A       d,.to relate facts  about  an

           individual who shares much of the responsibility fortiRMP.  Few

           people in this state, yes, this country, have been involved as long

           or intensively with matters of medical and health affairs as

           Doctor Vernon Wilson. I first  knew  Vern  as  an  associate  dean  at

           K.U.  Then to Columbia . . . the brilliant concept of Hospital Hill.

           A medical school in Kansas City . .  .  a  new  approach  to  teaching

           medicine . . . and most important, the development of a model

           health care delivery system.  Before all this was more than a


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          glint in Verne's eye along came the @P.  Most programs got off to

          a slow start.  Not so with our dynamo . . . he had organized the

          Council, the bylaws were passed; the application submitted . . .

          a staff retained        and guess who was first to get an organizational

          grant and then the first operational grant?  So, obstetrician

          Wilson delivered the baby and took it  through  its  first  growing

          pains.  Verne has that something called the "touchstone of the

          professionaL"  When Verne left for Washington, D.C. to head HS-@,

          we were already taking bets on whether Washington would change

          Wilson or would Wilson change Washington.  A book recently

          published--"The Dance Of Legislation"--says of "7erne, "Wilson  was

          already somewhat notorious in Washington for like Egeberg he had

          displayed maverick tendencies within weeks of taking office."  The

          record will probably not be available for some  time  but  my  bets

          are still on Wilson.

                   In the case of our program,initially large grants were given

          to the University of Missouri to be used for the purpose previously


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         st@- MRMP is,  therefore,  closely  associated  with  the  University

         of Missouri.  The interdisciplinary research group included professors

         of medicine, engineering, and communication who  studied  intensively

         the delivery system for health in the region; scientific d-evices

        -which were needed but lacking,  a communication facility which

         possibly could be adopted for purposes of the program.  The

         research group functions as a medical experiment station drawing

         together the talents of all university disciplines to contribute

        -,,to the definition or solution of health care problems.

                 Lest Y" ge@ the idea that the MRMP program is university

         oriented, let me assure you that it,..,Utilize* maximum local planhinj

         and initiative with regional emphasis upon coordination of efforts

         and review of quality of endeavors.

                 Because of the stated intent of the program to  improve  care

         by increasing the effectiveness of present systems, attention was

         directed to early detection of disease, methodology for systems

         to provide maximum economy and effectiveness, and initially a


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          small number of models of delivery systems, planning for service

          to a specific population of people with emphasis on  delivery  of

          care as close to the patient's home as is consistent  with  economy

          and quality.  With this in mind,

          in community hospitals, s2rincrfield, Smithvi le-  d      s

          one of the satisfying results of an effective PMP effort, we believed,

          was to be in the improvement of the environment of  more  hospitals

          for learning and the improvement of the capacity of more hospitals

                   p                                                   atment.
          for the a placation of new and more effective methods of tre
                                                         7k,

                  One can readily see why the public  comes into the picture.

          I referred to lay members of the public on  the top council of  the

          regional advisory group.  But every member  of the public has a

          ,z,take in the law.  It is not only that we are all likely to be

          patients, one day, at the mercy of these great diseases,  but  we

          can all do a great deal to make this law effective.

                  Remember also that the public is increasingly able to

          evaluate quality health care -- and increasingly vocal  in.,their


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          demands for it. Their criteria for evaluation are  becoming  more

          reliable in that they equate quality with the availability of

          qualified personnel and accredited facilities.  And they are

          finding increasing ability to pay for what they want, either

          through congressional action or voluntary prepayment.

                      A couple of years ago Dr. Wilson asked me to       an

                                          @- 145^fl4A
          extraordinary consultant committee,,with four able health profesdonals.

          I guess he tnought I must know something a@t the lealth field

                                    11         IV
          because I was then head of operations and in charge of Hallmark's

          "Get Well Cards." At the time,w6 could have used  sympathy  cards

          as well.

                  So, it. let me leave Missouri and put on my  national.glasses

          for a few minutes   . . the Regional Medical Program -- as much as

          I would like to think of it as having a permanent abode -- was

          shifted from one agency to another -- from NIH to HSMHA and now

          Health Resources Administratopt). The directorship changed far too

          rapidly       Marston, Olson, Schmitt, Margulies . . . Herb Paul . . .


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          all men of stature . . . all personally known to me as dedicated

          individuals whohave shifted to other areas of work.

                 What @ the role of Regional Medical Programs 0 today?  RMP

          can be a major link between the federal government and the providers

          of personal health services.  It can, thus, serve as a professionally

          oriented vehicle for upgrading the health care system, and provide

          technical expertise necessary to develop workable plans and

          determine the feasibility of programs.

                  RMealso provider  a link from the federal government  to

          the nedical and other health professional schools.  It can tap

          this important source of knowledge for programs of broad  social

          significance and service in a way that conventional grant programs

          to the universities and other schools cannot do.

                  RMP can be viewed as the agency that monitors and  helps

          maintain the quality of health care.  To do this, T.U4P,,sponsors

          continuing education programs for health professionals, promotes

          education of the public, and conducts research upon and demonstrates


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          new and better methods of patient care.

                  @MP's are an unusual expression of decentralization of

          policy and decision-making responsibility.  They  are  responsive

          exclusively to laally determined need.  They  are  non-bureaucratic

          in that staff function is limited to facilitation of  the  policv

          making and the implementation responsibilities of a  consortium  of

          voluntary, local expertise.

                  In     lest terms, the PMP functions as a     elo  mental

             nc   the cata@st 2f @rovider response to      the need identified

               M rehensive health planning.

                  Let me list a few problems and issues concerning RMP.

          Despite the discouraging outlook for RMP coming from the present

          administration, it can be reversed by a change of strategies.  The

          -most consistent shortcoming of the national program appears to  be

          its lack of a clearcut strategy. Although each PMP  has  its  own

          parochial goals and programs, and these vary  greatly  from  region

          to region,- RMP has not been an effective vehicle for  expressing


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          regional goals and priorities for the delivery of health services.

          !he basic common denominator of the PMP programs is their methodology:

          cooperative arrangements and conversations between various provider

          groups. The effectiveness of RMP varies greatly.  A  few  regions

          have outstanding programs; a majority have satisfactory ones;  and

          a few are clearly unsatisfactory. In general, the  development  of

          satisfactory programs has been slower in the large metropolitan

          areas than elsewhere.  It is not clear whether or not RMP is a

          categorical program. Since various parts of the law  support  the

          position that it is both a categorical and a non-categorical program,

          the law itself is confusingly,

                @ If the RMP law is not a perfect mechanism for creat     a

          unifying instrument, it is the closest approximation on the current

          scene.  And while the results of its implementation are not altogether

          .orderly and uniform, they are, in sum, encouraging. I won't  now

          repeat what you have already heard in your morning seminars  about

          those accomplishments but merely emphasize their importance.


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                 The fragmented medical service, the rising costs of care,

         the shortages, the impersonalized and disjointed system, and the

         educational imperfections are the fabric of our health care crisis.

         ThOse are real challenges, unmet.  Perhaps, a new strategy using

         the RMP process can help to overcome.

                 And now I conclude with a portion of the code for Physicians

         written several hundred years ago:

                 "If physicians more learned than I, wish to counsel me,

         inspire me with confidence in and obedience toward the recognition

         of them, br the study of science is great . . . grant me the

         strength and opportunity always to correct what I have acquired,

         always to extend its domain; . . . man . . . today can discover

         his errors of yesterday, and tomorrow he may obtain new light on

         what he thinks himself sure of today."  (Maimonides)

                  I thank you.

                                                  t4o,-T@ st@rk