. @ I ,I'll I * .101,11iii@!tll I# 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 ba§is 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 bett