I m Ak . I a B&B INFORmikriom & ImAa3E MAkm^MEMENT 300 @op4mc &=Itncon moulxv^mo uppern P4,am@oltO, MA6*Y"9140 Z077Z S US^ & CXCI) 24@l 10 A STUDY OF THE REGIONAL MEDICAL PROGRAM Volume III - Regional Descriptions Prepared for Regional Medical Programs Service Health Services and Mental Health Administration Department of Health, Education, and Welfare Contract No. PH-43-1014 By ARTHUR D. LITTLE, INCORPORATED and THE ORGANIZATION FOR SOCIAL AND TECHNICAL INNOVATION Cambridge, Massachusetts November, 1970 Arthur 1) I.ittle Inc A STUDY OF THE REGIONAL MEDICAL PROGRAM TABLE OF CONTENTS Volume III - Regional Descriptions Introduction .......................... Chapter I North Carolina RMP .................... Chapter II New Jersey RMP ........................ Chapter III Greater Delaware Valley RMP ........... Chapter IV Northlands RMP ........................ Chapter V Memphis RNP ........................... Chapter VI Arthur D Little, Inc I. INTRODUCTION I Arthur D Littl@ Inc 11 I. INTRODUCTION During the past two years spent in studying the Regional Medical Program, the ADL/OSTI study team has devoted many weeks of time to finding out what is happening in the field. Concentrated attention, by agreement with officials of RMPS, was given to four regions: North Carolina, New Jersey, Greater Delaware Valley, and Northlands. A fifth region, Memphis, proved to be of special interest because of its close formal ties to CHP under a joint council, the Memphis Mid-South Planning Council, which (along with many other activities) brought together all elements of the health system and wide public representation in a unified effort to improve the delivery of health services in the Greater Memphis area. In each region, we began our work by interviewing representatives of all groups known to be interested in medicine. Within RMP we talked to staff, RAG members, and various people on committees and task forces. Out- side RMP we talked to private physicians, hospital administrators, medical school faculty, and, in some cases, legislators. The people interviewed at the beginning usually referred us to others, and we learned much from these additional interviews. We also reviewed RMP records and reports and attended various staff and committee meetings. As mentioned above, we have included Memphis because of its unique organization, which is of interest to all those involved in RMP and CHP. Our field work in the Memphis Region was not as exhaustive as in the four other regions described. Our descriptions of the regions in this volume vary both in pur- pose and in level of detail. Our information on North Carolina, being based on a visit two years ago, is in some respects out of date. There is a new Coordinator, and much has changed since we were there.* Nevertheless, it was in North Carolina that we first began to understand the inherently shifting, flowing nature of the Regional Medical"Programs. Therefore, instead of describing North Carolina's program at length, we have focused our discussion on ideas about RMP that emerged-from our observations in North Carolina, but that have relevance- for RMP as a whole. The New Jersey RMP proved to-be of special interest because of the way realities in the Region focused the attention of its Regional Advisory Group (contrary to its early expressed interests) increasingly on the massive ghetto problem. The write-up on the New Jersey MT reflects that focus. *We have, however, kept in occasional touch with North Carolina RNP of- ficials to follow particular activities (cited elsewhere in this report) which illustrate the "motion" of development. Arthur D Little, Inc The Greater Delaware Valley and Northlands RMPs are described in more detail, since in both cases the material is based entirely on visits in 1970. These regions are as representative as any two can be of the problems and opportunities of other regions, and the approaches adopted by their RMPs have been very different. Both have had some suc- cesses and some failures, again of differing kinds. Memphis is a special case. Perhaps more than any other region, it has clung -- with considerable success -- to the center-periphery model of regionalization. Yet even here some of the most exciting develop- ments have grown up with little dependence on that model. I-2 Arthur D Little, Inc II. NORTH CAROLINA RMP I Arthur D littlp- lrx-- ii II. NORTH CAROLINA: EMERGING VIEWS ON THE NATURE 0 F RMP The North Carolina RMP was visited by the ADL/OSTI team in the late fall and early winter of 1968-1969. It was the consultants' first extensive visit in a region and as such Twas aimed at gathering informa- tion, learning (i.e. understanding) as much as possible, and talking with a wide variety of people so that we could begin to refine our tentative hypotheses about the RMP, its function, and its impact. Because the work was done nearly two years ago, this paper can- not reflect the current situation in North Carolina, and we have made no systematic, overall attempt to keep up to date over the intervening time. We have instead used our experience in North Carolina as a springboard for our investigations in other regions. This paper summarizes and illustrates the themes we-observed at that time and the concepts associated with them. We made oral reports to the Executive Committee of the North Carolina RNP and later to interested members of the national staff. The coordinator of the North Carolina RMP at the time of our visit was Dr. Marc J. Musser. His core staff numbered some 22 people, and his budget for the year 1968-1969 was $1.8 million. The first group of operational projects, some 15 in all, had received funding in July 1968. In accordance with the terms of our contract, our effort was aimed at discovering the important regionalizing and evaluative processes going on in the Region, studying its relationships with what was then called DRNP, and developing verbal formulations to describe the processes and relationships. We concentrated on collecting impressions, opinions, and the reports of various individuals on their experiences with RNP, rather than either accumulating statistical data about the Region and its RMP projects or trying to make sense out of the program primarily on the basis of such statistics as were available. We went to North Carolina with a number of questions and tenta- tive hypotheses based on a reading of the law and other documents pertinent to RMP, talks with people in (then) DRMP, brief visits to so'me half-dozen other regions, and our shared reflections on these experiences. The questions or hypotheses were not necessarily self-consistent. We had quite a number of potentially contradictory ideas in mind: o Since RMP had no sanctions and was legally proscribed from interfering in the patterns and financing of health care, it was not obvious what RMP could do beyond conducting small training courses and demonstration projects in categorically indicated areas of disease. ii-i Arthur D Little- Inc o Without sanctions, RMP could still be a broker, or change agent, acting among the various health and medical interests in the regions. But its function was not obvious. Change in what and for what? How could RNP bring any changes about, considering the restrictions on it? o Within the categorical disease areas permitted, what initia- tive could RNP take? If it was purely a grant program, how could it bring about anything recognizable along lines of firegionalization"? o Was RMP really a mere medical school support program, a way to shore up the threatened NIH grant structure and the health- through-research strategy, as some opponents charged? Did the medical schools control RNP? o Since regionalization apparently was not I)eing centrally imposed and was not taking orderly administrative form, what, if any- thing could the process consist of? Was it, as we suspected, diverse? Was it subject to classification, perhaps five or six major types, corresponding to variations in demography or health care resources? Was regionalization somehow "growing out" from starting points or nuclei that were the original participants in action projects undertaken voluntarily? What would make regionalization happen? o Of what did the NCRMP-DRMP relationship consist? Given the newness of the program, the dependence on review at the Federal level for funding, the anxieties concerned with pioneering a new program (and having to explain and justify it), and what other coordinators had told us, we hypothesized that the amount of meaningful communication between the Region and DRMP would be limited, the relationships rather distant, and mutual perceptions based on imagination and frustration as much.as on experience. o What kinds of evaluation were occurring at the regional level? We hypothesized that no single set of evaluative criteria would suffice, because RMP had so many constituencies, each with a different point of view. Moreover, the evaluation process itself should be flexible and ever-changing. Bu@, because it was difficult to agree upon evaluation methods, the identity of the program was not yet established, and clear guidelines from Washington had .iot been published, evaluation efforts at the regional level were probably minimal. Major themes which emerged from our North Carolina RMP experience, answer- ing some of the questions and correcting or clarifying the hypotheses, are described in the paragraphs which follow. Readers of the main body of the report will see these themes echoed, reshaped, and refined in descriptions II-2 Arthur D Ljttle, Inc of our subsequent visits and in our general formulations about the proces- ses of the RMP and its impact on the health care system. A. FACILITATION IS A KEY RMP STRATEGY During our visits to North Carolina it became apparent to us, as it had to many of the people connected with the North Carolina RMP, that the program's ability to grow, to connect directly to what was -.7oing on medically in North Carolina, and ultimately to accomplish any kind of regionalization of health services depended to a large extent on its ability to avoid being perceived either as a heavy-handed federal program or as "another competitor" staking out territory or creating operating programs which could be viewed as preempting somebody else's already established sphere of activity. As an executive of the North Carolina Heart Associa- tion put it, "When RNP becomes a doer, it dies. Already established agencies and institutions will take the attitude that if RMP steps on their toes, they will scuttle it. But if PM wants to cooperate with those agencies and institutions and help to stimulate their cooperation with others, they will support RMP and work for it." This sentiment was expressed to us in various ways by a number of people in the Region. It seems to reflect the suspicion with which the proudly independent people in this state view federal programs which at- tempt to legislate or coerce behavior and patterns of relationships. We were told that the RMP made a conscious effort, particularly during its early stages, to allay those fears and clarify its function as a grass- roots program aimed at stimulating and utilizing local initiative. The North Carolina RMP had to work, at least initially, in two modes: as a convener of some of the key health interests in the Region (through the Board of Directors, the Regional Advisory Group, area study groups, and categorical committees) and as a supporter of activities which already established groups wanted to undertake but could not because of lack of funds or sanctions or both. Often* the-MC was able to provide some staff help and fresh viewpoints toward developing new activities within ongoing programs. Of the original group of 15 operational projects approved in July 1968, four were specifically identified as continuations of previous work of the grantee. Two more were projects which the spon- soring institutions had wanted to star't but for which funds,from traditional sources were lacking. For example, the assistance and support of the RMP enabled the Heart Association to shift its priorities toward certain communi'ty-related projects such as a coronary care unit training program and a cardiopulmonary resuscitation project. The RMP also picked up and supported the "Berryhill" pro4ect, a complex set of activities based at the University of North Carolina Medical School and aimed,, in part, at outreach to community hospitals. As part of that project it provided air transportation for academic phy- sicians and medical students to the large hospital in Wilmington (there II-3 Arthu r D Li t t le, Inc is an all-weather air strip within four miles of almost every community hospital of more than 100 beds in North Carolina) and for local doctors into the medical center as well as to and from other hospitals, thus enabling specialists from the university to see patients in their own communities, giving faculty and students an opportunity to see how medicine is actually practiced, and giving community physicians an exposure to the academic environment at Chapel Hill. The latter had the advantage of enabling local physicians to get a better sense of the.utility of the capabilities at UNC and of their relevance to problems of the physician. The RMP's emphasis on collaboration and regionalization helped develop these activities beyond their earlier conception which had been more exclus- ively focused on sponsoring "circuit riders" going out to give lectures and consultations. In the State of Franklin, which encompasses six counties in the westermost part of North Carolina, the RNP gave active support to Dr. Karl Killian and others who, through a Development District under the Appalachian Regional Commission, were already attempting to knit together that part of the state economically, politically, and medically. Federal funds had already been attracted from a variety of sources, particularly the Office of Economic Opportunity, but the RMP also significantly helped people in that part of North Carolina to begin seriously working and plan- ning together. The RMP presence was clear and strong in the State of Franklin, according to the people there. It materially assisted six com- munity hospitals to begin to link together, helping with accreditation and promoting a cooperative coronary care unit training program in conjunction ,Lyith Bowman Gray Medical School. It also supported the development of an "Academy of Medicine" which involved nearly all of the practitioners in that area. (This story is told in more detail in Addendum 1 to Chapter IV, Volume II.) In these examples as related to us, it was clear that it was the FdQ's imaginative and sympathetic support, not RMP domination and certainly not simply RNP dollars, which madethe difference. Such examples spoke to the initial hypotheses we brought: the prohibition on interfering in patient- doctor relationships could be respected since the RNP operated only at second hand (through other institutions) in the instances we observed. Fully sanctioned physicians and hospitals carried on all patient care on a basis acceptable to them. The RNP's contribution was facilitative'and supportive and was accepted quite voluntarily; "interference" was not an issue in the minds of the people we visited,, with respect to any activities or 'Conversations they knew about (though many were suspicious of RMP as a federal program, quite apart from what it did.) Were the activities we saw highest in the priority of things that the North Carolina RMP should have been doing? What "should" it have been doing? Could it have behaved in other, different ways? We suspect that, given the need to develop operational projects quickly and the need to in- volve the medical schools and others in concrete ways, the avenues chosen were probably appropriate, at le@ist in the examples cited above. The first II-4 ArthurDLittle,inc involved the Heart Association in a role closer to direct delivery of health services. The second involved UNC Medical School and made explicit some of the objectives of RNP regarding links between the medical schools and the community And regarding the continuing.education of physicians. The third involved RHP in an ongoing regionalizing effort among community hospitals. B. THE SHIFTING CONSTITUENCY IS AN IMPORTANT REALITY AND A STRENGTH FOR RNP, AS WELL AS A SOURCE OF CRITICISM. The MQ in North Carolina was initiated by joint action ofthe deans of the three medical schools (University of North Carolina, Duke, and Bowman Gray) and the State Medical Society. These institutions furnished the core of the original Board of Directors and continue to make up the 'Association for the Nortl-,, Carolina RMP." The deans of the three medical schools, in particular, provided much of the early impetus to the develop- ment of the RMP. Their concerted action was acknowledged by most informed people with whom we talked as having been extremely important to the RMP and also very interesting in that it represented the first substantive, positive, institutional agreement consummated among the three schools. According to the dean of one of the medical schools, the RNP was the only source of real contact among the three medical schools at that time. In addition to forming the basis for regular working communication among the deans (beyond a purely social level; they were already personal friends), it led to coordination of continuing education programs among the three medical schools. Of course, medical school involvement in the RMP did not go un- noticed by other people in the state who were eyeing the program with both curiosity and apprehension, but in any case interest in seeing what could flow from it. To some of these people, there was clear evidence that the medical schools had "captured" or at least dominated the program and that R'MP funds would probably never get past the walls of the medical school, let alone out'into the community where in their-view it could really do some good. The RNP's early sponsorship of the Berryhill project and its substantial investment in a medical school-based project to develop a demographic data base did nothing to quiet these suspicions. Indeed, the first constituency of the RMP could be said to be medical schools, and some commentators then on the scene in North Carolina thought these probably.would remain the permanent and exclusive constituency of the RNP. The initial group of operational projects, referred to as "the cover crop," were developed quickly to help the North Carolina RMP be- come operational. All but two were sponsored by or in cooperation.with one or more of the medical schools. But the RNP had also begun to reach past the medical schools. Its activities in the State of Franklin were related to Bowman Gray, but by no means based there. While we-watched the North Carolina RNP also increased the power of its Regional Advisory II-5 Arthur D Little, Inc Group by giving it policy and review functions. Changes were also proposed in the makeup of the Association, shifting membership in the Association from the medical schools to the universities themselves, authorizing forma- tion of area-wide study groups and including the Dean of the University of North Carolina School of Public Health on the Board of Directors, along with other influential people. All this seemed to us to constitute or recognize a broadening or changing of the RMP constituency, in response to valid pressures from outside the original (medical school-medical society) constituency. By the time of our study in late 1968 and early 1969 , the RMP was also making active efforts to find valid methods to in volve community hospitals in its work. There was also growing interest in involving local practitioners. It seemed to us that steps would con- tinue to have to be taken to prove RNP's openness and willingness to res- pond constructively to strong "outside" groups asking to be recognized and that this process could well continue indefinitely, with different groups successively becoming the principal current focus of RNP energies. Because so many action possibilities exist -- eg., project money, committee membership, RAG membership, Board membership, access to core staff support groups might differ greatly in what they wanted or in what they perceived as evidence of being included in the RNP constituency. We came to view the 'inclusion of other people in the activities of RMP not so much as an expansion of RMP's activities, but rather as a shift involving a changing cast of characters, including partial disengage- ment from those who had previously been central to the program. We have likened this shifting process to a wave cresting at the point at which RNP becomes involved with and connected to a changing set of people and institutions, depending in part on who has clamored most loudly and worked most Effectively to obtain RNP's attention and in part on where energy exists of interest to RMP. With limited funds and manpower, RNP has enough resources to be actively working with only some of the people and institu- tions and issues concerned with medicine and health care at any one time. .As a'result,- there will always be a number of physicians, health care of- ficials, and other people aware of RMP who feel that they have not yet been touched by the program. In North Carolina for example, we frequently heard that the RMP, to that time,.has "done no'thing to help the practicing physicians." The first opportunity to involve significant numbers of local practitioners in the work of RMP came through the area-wide planning or discussion groups set up as a result of a tentative sub-regionalization pattern proposed by Dr. Harvey Smith (who did the initial North Carolina demographic and health care resources study.) The data and interpretations developed by Dr. Smith provided both a rationale and a focus for these groups. It must be said,- however, that what we perceived as involvement was not necessarily perceived by local practitioners as being done in their behalf. For many of them, a feeling of commitment to and involvement in, RMP work, would obviously still be slow in coming. In terms of the life and vitality of the North Carolina RMP, it seemed to us likely, and probably also desirable, that the central cons-ti- tuency of RMP keep changing. We further postulated that if the RMP were II-6 Arthur D Little, Inc I'captured" permanently by any one group or set of groups, then it would probably lose its ability to relate to others and thereby fail to respond to significant current health problems which might be represented by a prospective constituency. The need to (1) become relevant to particular people, groups, and problems, and consequently, (2) allow for continually changing relationships in order to involve new people, groups, and problems, together imply a rather delicate balancing act of enough importance in itself to constitute a central task of the local program coordinator. We view the Regional Advisory Group as having a unique role to play in this shifting constituency process. In North Carolina, we were frequently told by RAG members that they felt they had little or no power with respect to policy formulations for the direction of the RMP. They saw themselves as useful for project review and for receiving reports from the Board of Directors, but felt, at least initially, that they could do relatively little to influencethe course of the program. Later, as we have noted, the North Carolina RMP moved to strengthen the RAG by giving it the job of reviewing and commenting on policy-decisions made by the Board of Directors. But the RAG seemed to us to serve even more importantly as a kind of intermediate staging area for newly emerging interests and groups to which RMP needed to relate, and which needed to discover haw RMP could serve them. C. IMPORTANT REALITIES IN THE RELATIONSHIPS AMONG PHYSICIANS AND MEDICAL INSTITUTIONS, OFTEN EXPRESSED IN A "HOPSCOTCH" OR "CHECKERBOARD" PATTERN OF REFERRALS, MAY HAMPER REGIONALIZATION ALONG LINES OF THE CENTER-PERIPHERY MODEL AND OBLIGE @s, AS ONE OF THEIR CENTRAL TASKS, TO FIND ALTERNATIVE MODELS. In parts of North Carolina (as elsewhere), referral patterns tended to be based in part on the fear of physicians that if they referred patients to nearby specialists (10-100 miles away), particularly those en- gagedin the more general medical specialties, they could readily lose the patients. To guard against this, physicians tended to send referrals to medical specialists located some distance away from the referring physician. The resulting referral pattern looked to us more like a checkerboard or a hopscotch grid than a hub and spokes pattern. We saw this most clearly in the referral patterns between the State of Franklin and the City of Charlotte,, located over 100 miles as the crow flies from the eastern edge of the State of Franklin. The City of Asheville is much closer to the State of Franklin, but referrals tended to bypass Asheville because in the opinion imputed to doctors in the State of Franklin by respondents there (medical and otherwise), "If you refer to Asheville, you don't get your patients back." A report prepared by the Area I Study Committee set up by'the North Carolina RNP, which covered the 17 western counties in North Carolina, acknowledged that there was a "communications barrier-between physicians practicing in the Asheville-Btmcombe area and the remainder 11-7 Arthur D little, Inc of Area I (State of Franklin)." The Area I Committee, on the grounds that it represented the entire Area I which included Asheville, offered to serve as a continuing mechanism for breaking down this barrier. Similarly, in Area III we were told of the threat which Mecklenburg County physicians, particularly those affiliated with Charlotte Memorial Hospital, were perceived as posing to physicians in the surrounding counties, and of the defensive attempts on the part of at least one group of physicians to form a five-county association around a nearby community hospital. The RMP Area III Study Committee, while acknowledging substantial differences in geography, economic conditions, and medical services available in various parts of the Area (which encompassed 16 counties in the southwestern part of the state around Charlotte) nevertheless acknowledged the need to plan cooperatively and to identify health care needs on an area-wide basis. We speculated that without change processes stimulated from out- side, the checkerboard referral patterns would persist. We further specu- lated that their persistence, together with the reasons behind it, would tend to preclude regionalization in the form of the major center linked to its periphery. By the same token, we suspected that the establishment of sub-regions by the RNP explicitly for the purpose of creating a "regional hospital" as the center of the sub-regional referral pattern would probatly not be accepted by either hospital or physicians, evenif the RNP were authorized thus to anoint a hospital. To the extent that checkerboard referral patterns exist more broadly in the United States they represent part of the reality of which RMP needs to be aware, for they affect the kinds of regionalization efforts that will be possible for RMP. The sub-regions (numbering six in all) were delineated in 1968 as the result of a two-year study conducted by Dr. Harvey Smith and his associates at the University of North Carolina. Dr. Smith asserted that North Carolina divided itself "naturally" according to the data into six sub-regions or service areas. Using the data for sanction, the RMP formed the committees mentioned above to consider the implication of Dr. Smith's data and to plan for the more effective delivery of health services in ,each service area. Each committee met and prepared a summary report to the RMP outlining the needs it perceived in its area. At least two of the area committees (Area I and Area III) indicated a desire to continue in operation at the time of filing their'report. Other area committees either saw no reason for continuing their existence or suggested different patterns of area delineation. The Area II Committee, for example, felt that the Area artificially combined three rather distinct sub-areas with very different economic and medical characteristics and problems. The Area v committee felt that "no functional unit could be created out of sub- region five." Clearly, there was some resistance to the perceived imposition of a series of sub-regional center-periphery structures by RNP in North Carolina, even though the entire exercise was very clearly bille4 as sub- regionalization for data analysis and planning purposes only. Clearly, II-8 Arthur D Little, Inc too3l if regionalization processes were to amount to anything, they must take account of such resistances. A form of "regionalization@' that honored existing patterns might have more success than one, however reasonable, imposed from outside. D. THE ASSUMPTION ON WHICH THE CENTER-PERIPHERY MODEL IS BASED--THAT MEDICAL EXCELLENCE IS LARGELY CONCENTRATED IN ACADEMIC MEDICAL CENTERS-- IS WIDELY REJECTED OUTSIDE THESE INSTITUTIONS. As one physician puts it, "The university medical centers can legitimately claim excellence in certain kinds of diagnosis and treatment of disease,, depending upon the specific people at the university, but it cannot claim superiority across the board. In our hospital we can provide care similar in quality, scope, and content to the university medical center. Why, therefore, should we refer patients to the university?" One fairly large community hospital, in particular, rejected the notion of being adjudged peripheral to the nearest university medical center, and actively set about to establish itself as a major referral center. It claimed that its substantial teaching program and comprehen- sive facilities made it equal, in essentially every way, to the university medical centers. It must be stressed that there was no across-the-board derogation of the competence or excellence existing in the three university medical centers, and, in fact, each medical center was acknowledged by at least some of the people with whom we talked as being genuinely expert in one or more of the categorical diseases. Nor was it denied that there existed practicing physicians who simply dispensed "aspirin and sulpha drugs," and who might, in the opinion of their colleagues, need retraining. But the concept that concentric circles of excellence or competence radiate out from the university medical centers gained no additional acceptability from the mere fact that a regional medical program now existed. E. EVALUATION OF MT IS AN IMPORTANT, BUT IMMENSELY DIFFICULT AND MANY- FACETED UNDERTAKING. At the time we began our North Carolina visits, we,had not yet developed a positive theory of evaluation, although we did have some hypo- theses about the need for different points of view and the need to evaluate the ongoing processes in a region as well as whatever tangible results were forthcoming from those processes. During the time we spent in North Carolina, several parallel efforts were under way to develop the outlines of a general evaluative scheme; these led to the concept of various levels of evaluation related to the impact of RMP on different aspects of the health care system and, ultimately, on the health of people. We were fairly well convinced that simple indicators such as measures of mortality and morbidity in the cate- ii-9 Arthur D Little- Inc gotical disease areas would be grossly inadequate as the basis for asses- sing RNP's performance, given both the length of time required for measur- able change in those indices and the complex of factors affecting or potentially affecting them which were not directly related to RNP activity. In the absence of a well-developed evaluation framework of our own, we attempted to be alert to the kinds of evaluative activities actually taking place in the North Carolina RMP. Individual.project applications were reviewed by the categorical committees, the Board of Directors, and the Regional Advisory Group for content, appropriateness for RMP funding, and amount of funding desirable. Each project application had a general evaluative section but, at the time of our visit, no formal process was yet established to review progress of specific projects or to asses their results in any systematic way. (Bear in mind that active projects had been funded only a few months earlier.) But evaluation of specific projects was only a part of the picture. Much of the RMP activity on which core staff and other interested people focused took place outside of the project context, strictly defined. Meet- ings of the RMP Advisorv Grbup, Board, and committee, for example, were bringing together the health interests of the states. Core staff activi- ties in the State of Franklin were affecting institutional relationships in that part of the region. Area planning committees were being convened to assess health car& problems and to propose steps to deal with those problems. Discussion and, presumably, evaluation of these activities seemed to bethe task of the Board of Directors, and principally in the Executive Committee of the Board, functioning very much like boards and executive committees everywhere. The evaluation was usually limited to discussion of reports from the RNP Coordinator and others. The Coordinator and other members of the Board were acutely aware that more systematic evaluation was needed, but at the time of our visit, no significant, explicit retrospective evaluati-on effort was being made either of projects or of the program as a whole. The schemes pro- posed up to that time were expensive and did not seem to accomplish measurement of anything important. F. THE VIEW OF WASHINGTON TENDS TO BE REMOTE. Except for Dr. Musser, few @ people in North Carolina ap- pealed to know the national staff, to be aware of its functions, or to see much advantage in connecting with it. The newness of RNP at the time, the distance between DRYIP and the Region, and the vagueness of function at both levels all made it difficult for the North Carolina people to see much obvious advantage in connecting with DRMP. To some extent, this communications gap between national and local levels was evident in most of the Pb:Ps visited. II-lo Arthur D Little, Inc There was little doubt that some individuals kel)t their eyes on the Washington scene for signs of policy change, for rumors of new pro- grams, for indicators of how best to qualify for grants. If the admin- istrators of Mountainside hospitals felt remote from the processes of research grantsmanship, others had made it their business to learn these processes. However, this was a matter of individual initiative; it did not represent full and close communication between the regional and national components of RMP. As a result, there was too much uncertainty on what RMP was all about on the part of many RAG members, most of the core staff as it then was, and (of course) most particularly those whose participation was being courted. We have recently spoken again with some people in the North Carolina RMP, who report that communications with Washington leave improved. Our impression is that this is also true in other RMPS. Arthur D Little, Inc III. NEW JERSEY RMP I 4 Arthur D Little, Inc 1: I III. THE NEW JERSEY RMP Our work in New Jersey was more recent than that in North Carolina, but even so it is now a year and a half old. Thus, the chief interest it holds for this report is, again, not the details of the pro- gram but the general conclusions we were able to draw from them. In New Jersey we found conditions that did not appear to favor a successful RMP, and an IW that appeared to be moving ahead anyway. We attribute its progress to its readiness to take the initiative in identifying the Region's problems in health care delivery and mobilizing energies to attack them. A. THE ENVIRONMENT FOR RMP . New Jersey is a heavily populated state squeezed between the two great metropolitan centers of New York and Philadelphia, for which it serves as an outsize bedroom community. Its industry is largely absentee-,owned and controlled. Natives wryly refer to it as a barrel with a bunghole at each end. There now seems to be a ground swell in New Jersey for "statehood" -- greater self-sufficiency within the state in all things -- and there is talk everywhere of the need for pulling together. This is more than just a cry for increased regional -- as opposed to federal -- control over the deployment of public funds. There is a sense that identity as a forward-looking state will improve life for all. Whether this will catch hold is not yet clear, but it presents a potentially promising background for the New Jersey PIQ and is a theme heard frequently in conversations about RMP. Medically, also, New Jersey has in the past been relatively unexciting. There are many powerful doctors in the state, but a large proportion of them spend their professional lives in institutions like Columbia Presbyterian Hospital in New York or the Children's Medical Center in Philadelphia. Most of the rest devotia their primary attention to the middle-class white residents of suburban towns. In terms of a ce-,iter-peripho-ry model of medical resources SI New Jersey would seem to be a poor prospect for regionalization; it could be described as consisting mostly of-a strong, but not always united, liperiphery." The two medical schools in the state (which were recently merged at the urging.of the Governor) have been desperately trying to gain a foothold in the established academic and medical community during the past few years. Much too young to have a great deal of momentum in their struggle for quality, they have been too poor to rise strongly above political forces in the State Government and equally weak in facing existing medical and academic institutions. Against this background, the Medical Society of New-Jersey has been an important factor in medical circles. Leadership in the Society iii-I Arthur D Little, Inc has been one of the most obvious ways for a physician to attain pro- fessional recognition in a state where positions of status are in short supply. Men have moved up to positions of leadership by building the personal respect of their peers. This takes time and, in the nature of things, encourages conservatism. The conservatism is intensified by the understandable fear of solo practitioners -- removed by the pressures of their daily work from the central political scene -- that someone in government might "put something over" on them. Thus, when the New'Jersey @ was started, the Medical Society can be believed to have been at least skeptical of what its impact would be. There has been a very strong tradition of self-sufficiency in the many hospitals of New Jersey. Most of the -hospitals have done very well and grown in their independence as middle class institutions. This tradition of independence has been particularly marked in South Jersey, ,a primarily-rural (except for Camden) area which was for many years largely ignored by the rest of the state, from the viewpoint of medicine. Since the end of World War II, the New Jersey Academy of Medicine, the continuing education branch of the New Jersey State Medical Society, has spent a lot of time trying to extend its influence to the southern counties. However, we were unable to find evidence that the Academy's program was having much impact, north or south.* South Jersey to this day remains in a medically ambiguous position, claimed by both the New Jersey RMP and the Greater Delaware Valley RNP centered at Philadelphia. On the one hand, It is pulled toward Philadelphia by its old school ties and its proximity; on the other hand it is pulled toward the rest of New Jersey by law, iicensure regulations, and a natural repugnance to being seen as dependent on Philadelphia in a town/gown relationship. Public interest in medicine in New Jersey extends through several agencies, whose aggregate power is considerable. In recent years most of them have had good leadership. The Department of Institutions and Agencies licenses hospitals, oversees the distribution of Hill-Burton funds, sets Standards of-various kinds in health care institutions, and is responsible for public assistance, child welfare, and mental health. The New Jersey Department of Health is engaged in environmental health, food and drug Supervision, student and camp health, sanitation, chronic disease manage- inent, communicable disease control, blood bankin&, and quality control of laboratory services. It administers Medicare and Comprehensive Health Planning. The Department of Education is responsible for medical schools; and the Department of Law and Public Safety has a number of regulatory functions, including the registration of pharmacies. With strong attention now being given to poverty areas, the New Jersey State Department of Community Affairs has also become a force to reckon with in handling health care problems. As of 1969, when we were in New Jersey, the Academy seemed still-to be heavily dependent on the road-show, lecture system of continuing education, though aware of and experimenting with other approaches. III-2 Arthur D Little- Inc New Jersey has 568 municipal health officers and 21 county health departments. The municipal health officers, largely laymen, exercise considerable political influence because of a strong home-rule tradition in New Jersey. Since the Newark riots of 1967, HEIV and HUD have funded a number of programs in New Jersey's city ghettos, many of them related to health care. When these are added to the programs of state and local agencies, it becomes obvious that anvone who tries to set up new medical relation- ships faces an unusually formidable array of political forces in addition to the vested interests of the private sector. B. BEGINNINGS OF THE PROGRAM .. In early 1966, Dr. Roscoe Kandle of the State Health Department called together leading figures in the health field to consider the desira- bility of applying for approval of an RMP planning grant for New Jersey as a Region. Included in the discussions were key figures from the State Medical Society, the two medical schools, and interested departments of the Statc Government. Following the hearings leading to Public Law 89-239, there was a widely shared fear in medical circles that somehow the Regional Medical Programs might be used to "make over" medicine in a socialized mold. We were told by members of the State Medical Society that this fear was strong in New Jersey and dominated the Society's attitude in assuming the leading role it chose to play in the early development of the RMP. The New Jersey RMP received its initial planning grant effective July 1, 1967, and Dr. Alvin A. Florin was named Coordinator shortly thereafter. The environment in which Dr. Florin sought a strategy for making the RMP worthwhile has been described; to summarize, it was characterized by: 0 A widely shared feeling that "statehood"-would produce big rewards for everyone in New Jersey, with a corresponding resistance toward being dependent on either New York City-or Philadelphia. o' A preponderance of solo practitioners, working largely with the white middle class.in suburban.towns. o Young, poorly financed medical schools having difficulty finding their place in the sun. o A conservative Medical Society whose support was indispensable for any action the doctors might be asked to join in on. o Vigorously independent, competitive hospitals. o Claims on South Jersey by both the Greater Delaware Valley and the New Jersey RMPS, with little obvious interest on the part of either. III-3 Arthur D Little Inc o A strong, but multiple, set of state health agencies. o Considerable HEW and HUD activity in health care in the ghettos, following the Newark riots of 1967. During the planning stages, the principal strategy of the New Jersey RMP seems to have been to attract as many of these interests as possible. The RNP originally had a RAG of 57 members and an Executive Committee of 15. The latter was chaired by a former president of the Medical Society. The RNP was under strong pressure to become operational as soon as possible, and, like most RMPs at that time, began pragmatically by undertaking projects which would not engender much controversy; the projects which survived the Executive Committee and RAG during the planning stage were of a kind acceptable to most Medical Society Members. On April 1, 1969, the New Jersey REP went operational with nine projects. Meanwhile, there were changes in the making. On the national scene there was evidence that RMP was beginning to be seen as more than just a center-periphery continuing education program in three categorical diseases. Yet more significant in New Jersey was the growing realization that health care in the ghettos was a leading medical problem and one demanding responsible attention from organized leaders in medicine. The Newark riots and the ensuing move of the New Jersey College of Medicine to Newark brought this to the forefront of New Jersey RAG discussions. Because of the cumbersome size of the RAG and the fact that it met infrequently, the Executive Committee found itself making most policy decisions for the Region in its monthly meetings. This situation did not appeal to the RAG as a whole, and in Washington there was some feeling that it did not conform to the spirit of the law. In November 1968, the RAG was reduced to a manageable 25 and the Executive Committee was eliminated. The RAG began to meet on a regular monthly basis. C. EMERGENCE OF RNP AS A FORCE FOR CHANGE Here began a development that stands out in our experience of Re@'onal Medical Programs: whether spontaneously or by plan, the,RAG 91 began to coalesce into an active unit seeking change. Prodded particu- latly by open controversy-as to whether urban health care was a legiti- mate target for RMP concern, the RAG moved quickly to discussions of alternative courses and their implications. In short, the RAG took charge of the RNP's destiny; and with careful staff work by the core staff in support of each meeting, and thoughtful, provocative reports from working councils and task forces, it has managed slowly but surely ever since to become surprisingly cohesive in its support of change. This was not easy, particularly in view of the fact that the nine approved projects which had been developed during the planning III-4 Arthur D Little, Inc stage were largely categorical and educational in concept (training courses for CCU nurses in three hospitals, training of physicians in cineangeography and of physicians and nurses in hemodialysis, training of instructors in external cardiopulmonary resuscitation, a computerized pacemaker evaluation, medical tapes by telephone, and the establishment of tumor boards in 13 hospitals). But during the course of the first year, Dr. Florin was able to provide unexpended funds in support of RAG- approved explorations of health care delivery in ghetto areas. Also the RAG chose to support from core funds an innovative program for three ghetto cities: Newark, Hoboken, and Trenton. From its own core staff the New Jersey @ assigned an urban health coordinator to each of the Model Cities offices in these three cities. Their assignments were: (1) to draw up detailed plans for the health component in each Model City, (2) to meet with concerned community groups to'involve them in the planning, and (3) to organize a decision- making process for working out answers to health problems. This experiment in reaching the poor -- and especially the black -- community was followed very closely by a 25-member Urban Health Task Force, which undertook to evaluate the results in each city. The Urban Health Task Force was also responsible for working up plans for other attacks on the health care of disadvantaged persons: for example, a family-centered hospital-based ambulatory care service in New Brunswick; a pilot screening project to determine the morbidity associated with both diagnosed and undiagnosed heart disease; interviews of a sample of stroke rehabilitation patients in two Newark hospitals to learn the nature, extent, and cost of rehabilitation services they received; and interviews of 750 representative families in Hoboken to determine their health atti- tudes and health needs in the context of their general socioeconomic attitudes and outlook. One of the 1969-1970 activities on which the New Jersey RMP would like to build in the coming year was the operation of a mobile van in Newark. Some 800 individuals were given EKGs and chest X-rays, as weli as such general medical examinations as blood p@essure measurement, open cavity inspection, and height and weight measurement. Community recruits were used successfully to persuade people to volunteer for the examinations. As part of the routine, the examiners-appraise-a any previous care the people had received. Follow-up care was recommended, when indicated, to be pro- vided by the individual's own physician or an appropriate clinic if he did not have one. I Another cor'e-centered activity grew out of an application that was turned down as too conventional by the original RMP Executive Committee. The application was made by the Academy of Medicine for a continuing edu- cation project; its rejection led to the formation of a Council on Con- tinuing Physician Education, with representatives of the Academy, the College of Medicine, Rutgers, and the Overlook Hospital in Summit, New Jersey. Dr. James E. Rogers of the RMP staff carried out for the Co@ssion a survey of the ongoing continuing education in almost all of the hospitals III-5 Arthur D Little, Inc in the state. He found much of it to be weak in terms of the criteria he applied and has prepared a plan of state-wide improvement, of which more will be said later. People we interviewed about the hospital situation in New Jersey were all in agreement on one thing: the hospitals need to cooperate in the interest of improved service and reduced over-all cost. This is seen as 'of particular importance in South Jers-ey. Yet with considerable energy coming from both the RMP and the voluntary agencies, progress has been very slow indeed. It has been difficult to achieve respectable attendance at meetings called to discuss possible hospital collaboration. In some cases, the mere suggestion has been met with what we were told could only be described as ridicule. The obstacles to progress in this direction in New Jersey are very strong, and proponents with the strength to over- come them have not yet appeared on the scene. Until strong local proponents appear, one can speculate, South Jersey may not be a place for much real aT action involving collaboration of hospitals toward systems transfor- mation. During 1969-1970, Dr.-Florin joined with Dr. Goodman of the Essex County Blood Bank to institute an experimental blood freezing program. It proved to be a successful way of preserving blood far longer than had heretofore been possible, thus adding greatly to the flexibility of reserve stocks. There are plans for extending this service next year and backing it with a statewide network of intelligence as to where and in what condition blood stocks are at any given time. In New Jersey we encountered a widespread interest in consumer education. Those who were interested in the disadvantaged believed that little ground would be gained in improving their health until the poor people themselves came to understand what care was available to them and what it could do for them. Those who were interested in the middle class thought they ought to be taught both what is the most up-to-date medical practice and how to use it effectively. And in the background was a sense that the consumer has ideas about health care that deserve'a hearing. A year ago,, when we were there, these were all the glinmerings of an idea; little had been done to crystallize them into action programs. In an attempt to move constructively toward action, a Communications Council was established by the RAG in October 1969, with the objective of providing increased health information for the consumer. The membership of the Council includes individuals specializing in public relations and,informa- tion, as well as representatives from Blue Cross-Blue Shield, the State Health Department, the Hospital Association, and the two medical schools. D. LOOKING AHEAD WITH THE PROGRAM During the planning stage of the Region, we see five themes running through the deliberations of the RAG: (1) conventional project support, (2) increased attention to the health of the disadvantagedi- (3) improvement of continuing physician education in the hospitals, III-6 Arthur D Little Inc (4) increased collaboration of hospitals, with special attention to the more-or-less neglected South Jersey, and (5) stepped-up consumer parti- cipation and consumer education. Although the RAG was already becoming a strong force in the RMP by the end of 1968, it was not until February 1969, when Dr. Cross addressed a challenging letter to its members that they began actively. to face up to the establishment of program objectives and priorities, as distinct from evaluating project applications on an ad hoc basis. Since that time there has been a growing cohesiveness in the RAG behind, the delivery of health care in urban areas as the number one priority. A significant component of the 1970-1971 operational budget is directed toward the ghetto. We understand that the first application to RMPS under the new Anniversary Review procedure, in November 1970, will ask for support for very large extensions of the urban service programs that were in an experimental, feasibility, or planning stage in 1969-1970. The New Jersey RAG is really acting on its own top priority. .Conventional continuing education projects in heart, cancer, and stroke remain a major part of the operational budget. This is perhaps a price that must be paid for the growing support of more conservative RAG members for the heavy emphasis on urban problems. The role of the medical schools in RMP remains friendly, cooperative, and important, but not dominant. They appear to have been fully adequate in providing technical support when it was needed. Care will have to be exercised to see that their interests and responsibilities in the ghetto are not allowed to run into conflict with those of PYP. Continued openness in the RAG will probably prevent such a conflict. The survey of continuing education in hospitals carried out by Dr.,Rogers for the Council on Continuing Physician Education has already resulted in some agreement on action. The two medical schools (now one) have agreed to establish a Continuing Physician Education Department to coordinate, supervise, and evaluate continuing,_education programs statewide, to offer expertise in educational methodology, and to provide experts in medical matters. A Basic Unit within the Department will be headed by a Director of Medical Education, who will prepare curricula for use throughout the state, assure that subject matter is not duplicated at adjacent locations, and form a balanced faculty to assist in local continuing education. An Intermediate Organization, staffed by existing Medical Soc'leties, will be responsible for arranging programs on a regional basis. Another cooperative step in continuing education is the merger of central medical libraries in the state. The Academy of Medicine, the State Medical Libraries, and the Medical School Libraries are all being merged into the New Jersey College Library. So far as we can tell, very little progress has been made in developing meaningful voluntary cooperative arrangements among the hos- pitals of South Jersey. The hospitals in the more congested North Jersey III-7 Arthur D Little- Inc have shown some disposition to participate together in activities directed toward the disadvantaged. While it is too early to know what will be accomplished with regard to communications between the providers of health care and its consumers, the RNP is moving ahead in an organized way. As has been mentioned, a Communications Council has been established to take the lead for RMP in improving consumer education. The Urban Health Task Force has been increased in size from 25 to 32, to permit the inclusion of seven Model Cities representatives, including administrators, citizens' health panel members, and consumers. And finally there have been dis- cussions of the possibility of merging RMP and CHP in New Jersey under a common Advisory Group with 51% consumer representation. It is felt by many that RMP might be strengthened by this degree of consumer parti- cipation. So, where is New Jersey RMP going? When we visited New Jersey ,in the late spring of 1969, our first impression was that while a lot of things were under discussion and even being worked on, little clear progress was evident. Even-then, however, we thought we saw most of the RAG, the Urban Health Task Force, and the core staff closing in on tangible goals. We encountered a real appreciation of the fact that RMP could do little itself but would have to persuade others to do the things that needed to be done. We thought we saw the Urban Health Task Force, with help from RAG members, "facilitating" a change in point of ,view of the Medical Society -- no mean accomplishment. Fifteen months later, Lhere 5ee@- to have been real movement In the New Jersey RNP. Yet there are some unanswered questions. The drive for integration under the "statehood" label is-a ,weak reed. It does offer the State Health Departments a rationale for @ifting the center of gravity of public health from the local level. It offers the new combined medical school an argument for money from the State Treasury. It provides the doctors a basis for urging that more patients stay in the state. But the fact remains that New Jersey will ,long remain overshadowed by neighboring New York City and Philadelphia. And the -sea for "statehood" is not nearly as powerful a tool for the RNP in indu(-ing change the RMP's own very careful staff work in support of those who have tangl@'-- endq in view. Progress toward ends in view is, Uneven. It looks as if the involvement in the urban health scene is zrowing in support, and imaginatively fresh in concept. But with the .@.aY,@.. servative bent of the medical profession in New Jersey always in t background, RMP's outreach into the ghettos will need every possible break to continue to succeed. If federal financial support becomes too limited for the perceived potentials of the program, the result could be extremely destructive competition among the cities. From what we are tolds continuing education in New Jersey, especially for nurses, seems to be comparable in quality and impact to III-8 Arthur D Little, Inc what we have seen in other regions. But it is easier to see in New Jersey than in some regions that building projects around the dissemination of technology is far from the only route to improved health care. The dissemination of knowledge about need is at least equally important. When it comes to the goal of hospital cooperation and collabor- ation, most particularly in South Jersey, there is little progress to date. It is to be hoped that some of the smaller hospitals will'j'oin together in Dr. Rogers' plan for sharing DNEs when the statewide continuing education program starts up. There are efforts to enlist participation by groups of hospitals in collaborative family care programs for underprivileged families in North Jersey cities. What have made the greatest strides in New Jersey are those activities of the RAG, its councils and task forces, and the RMP core staff that have stretched the imagination in trying out new combinations of people and ideas. The RAG now sees RMP as a catalyst more importantly than as a distributor of money for projects. And it has just about completely accepted the idea that all possible RMP money should go to the distribution of care, largely in the ghettos. iii-9 Arthur D Little, Inc IV. GREATER DELEIIARE VALLEY RMP f Arthur D Little, Inc IV. THE GREATER DELAWARE VALLEY RMP The Greater Dplaware Valley RMP combines a number of characteristics of interest to this study. It encompasses a major metropolitan center and several highly esteemed medical schools, covers more than one state, shares territory with another RMP (New Jersey), is oriented toward both center-periphery and geographic types of regionalization, and finally, is representative of the great urban-centered regions which, because of their complexity, have moved less rapidly in some respects than regions which have not had large urban concentrations and multiple medical schools. Thus, RMPS and the ADL/OSTI team agreed that the Greater Delaware Valley Region should be among those chosen for close examination. Since our work there was more recent than in North Carolina and New Jersey, our report is in greater detail. .,An early draft of this discussion was checked with several members of the Greater Delaware Valley RMP coordinating committee and staff, who pointed out errors of fact and took vigorous exception to what they regarded as a distorted emphasis on the negative in our description of the Region. We have tried to correct the errors and to put in fair perspective those aspects of the program that may not be going as well as some might hope. A. THE ENVIRONMENT FOR RMP We believe that economic, sgcial, and cultural conditions in a community have a good deal to do with how ready the medical community is to contemplate the kinds of changes in relationships which can accompany a regionalization effort. Because of the long-established, carefully worked out positions of the medical schools in the Greater Delaware Valley, both with respect to one another and in relation to the periphery for referral and outreac@, there has probably been less obvious need to "regionalize" (in the sense of encouraging a shift in relationships or power balance) than in regions with a lower concentration of high-quality medical resources. Also, Philadelphia and its environs have prospered for 100 years without interruption except for the Great Depression. The Wilmington catch basin has had a similar experience. The virtues of stable institutions and established relationships have been amply demonstrated. As for the northern counties,- the almost steady decline of the extractive industries for two generations may have created a climate in which many people feel that their ability to cause significant change is dwarfed by conditions beyond their control. - In South Central Jersey, the institutions of medicine are local, and locally oriented. From the perspective of South Jersey, closer association with the strong medical and health institutions of Philadelphia (or elsewhere) looks like a mixed blessing at best. The prospect of closer association with Philadelphia through RMP was viewed by many with some apprehension. As for the ghetto poor, Greater Delaware Valley has its share. But as things have been going, Philadelphia and other cities in the region IV-1 Arthur D Little Inc have had rather less conspicuous trouble with their minorities than many cities of comparable size (i.e., less violence than Newark, Washington, and Watts). While it is probably true that the national contagion of interest :in righting the wrongs of minorities has been caught by some of the leaders of medicine in and around Philadelphia, it is a new phenomenon and has not progressed very far. An outstanding feature of the medical system in Greater Delaware Valley-is its extraordinary strength and quality. There are few places where such a concentration of talent, competence, and facilities can be found. To the extent that regionalization implied that the autonomy of strong medical institutions might be reduced, it cannot have seemed very attractive to some medical people in the Greater Delaware Valley. People in the relatively strong and well-staffed medical and health care institutions of Greater Delaware Valley can easily conceive larger tasks for themselves and their own hospitals, schools, or professions. They have more difficulty perceiving as useful a role for themselves in which their skills might be diffused in the process of regionalization. There are, of course, those who do see opportunity in new kinds of collaboration among the medical schools and hospitals and between the medical centers in Philadelphia and the practitioners and community hospitals in the countryside, and who are accordingly, willing to devote substantial time and energy to developing such collaborative arrangements. When Public Law 89-239 was passed, the State Medical Society indicated its desire to oversee the initial development of RMP in Pennsyl- vania. It was the primary agent which brought together representatives of all medical schools in the Commonwealth and of practically all other formal medical institutions and groups. It was quickly decided that the Commonwealth split quite naturally into three parts: the Pittsburgh medical watershed, the Philadelphia medical ,watershed, and the central territory between them. The first two were geographically related to existing medical schools, and the initiative was left to them. The third region, to be called the Susquehanna Valley RMP, became the direct responsibility of the Medical Society, since at that time no medical schools were operating in central Pennsylvania. APPROACH TO REGIONALIZATION The Greater Delaware Valley RMP was shaped at the start by the deans of the five medical schools (prior to the active involvement of the School of'Osteopathy). They, like many other deans around the country, seem to have interpreted the law and the signals from Washington to mean that WV was a practical extension of the NIH-sponsored research program which for the preceding decade had given so much support to medical schools. Categorical in nature, designed on the theme of disseminating the latest medical knowledge, RMP was (in that interpretation) a plausible if somewhat unusual program to base in medical schools. It could provide some additional impetus to continuing education of physicians and other forms of "outreach" IV-2 Arthur D Little, Inc. advocated by some people in every medical faculty, and might also contribute to the broadening and deepening of faculty capabilities that is the hope of medical school deans everywhere. These were surely not the only, or necessarily even the most compelling, reasons for the involvement of the medical school deans, but congressional testimony from leading medical school spokesmen during hearings on PL 82-239 and our own discussions with deans indicate that there was at least the possibility of RlfP becoming a direct supporter of the medical schools. The requirement for cooperative arrangements specified in PL 89-239 caused no serious concern. What was continuing education but cooperation between schools and their affiliated hospitals for the purpose of educating local doctors? RMP came at a time when medical schools were seeking actively to anticipate or compensate for potential losses in suitable teaching cases brought about by vast expansions in third-party financing programs in health care services, notably Medicare. Many "charity" cases previously referred to teaching hospitals were (or soon would be) treated on a fee-for-service basis in community hospitals. It was at least reasonable to expect that cooperative arrangements under RMP with outlying hospitals could provide new channels through which to sustain the teaching case load. The possibility of diffusing high-technology medicine and research-oriented knowledge (which NIH money had supported as means for improving medical practice) and so moving toward the Surgeon General's ultimate objective of the best care for all, was clear. Did the deans of the medical schools in Philadelphia share in all of these concerns? We suspect so, although we were not there so we cannot know in specific terms. Understandable competition among the medical schools in Philadelphia. had results that tended to reinforce the "technology diffusion" interpretation of RMP. Although the University of Pennsylvania Medical School had gone furthest and earliest in the direction of increasing specialization and research, by the mid-1960's even such a large and practitioner-oriented school as Jefferson was well on the same road. To the medical schools, RMP appeared to be compatible with these professional strengths. A categorical emphasis in interpreting RMP's mandate fitted this view quite nicely, as did the notion that the medical school specialists had something important to bring to practicing physicians through continuing education. Categorical focus, technical_diffusidn, and continuing education have retained their position as top-priority objectives in the Greater Delaware Valley RMP. In line with the official RMP Guidelines, project grants are viewed as being of primary importance, both as an eviden@e of real output and as a way to interest people in the RMP. This emphasis continues, even though it is now understood that project funding for the next few years may be severely limited. With respect to categorical diseases, the Greater Delaware Valley has sought to improve patient care by stimulating more and better referrals in heart disease, cancer, and stroke and by supporting projects that make the clinical techniques and knowledge of the medical faculties available to local practitioners. Continuing education has been seen as a valid objective in itself and a natural task for the medical schools to undertake. It lubricates relationships that may result in referrals, and it is a IV-3 Arthur f) Little, Inc I direct way to expose new knowledge to a wide audience. It is, of course, seen by many as potentially improving the quality of health care. People oriented toward fostering more profound change in the system for delivery of health care and the relationships among medical institutions have not been in a strong position to influence the direction of the Greater Delaware Valley RMP. Pioneering in the delivery of services requires risking the strengths of medical institutions already stretched thin and already committed to other goals around whose pursuit the leaders- of these institutions are more or less amicably arranged. An overview of all approved Greater Delaware Valley projects suggests that ideas for improving the quality or quantity of care have been found most acceptable when they depended on strengthening rather than shifting the relationships among the schools, other strong institutions, and those providing primary health care. At least two patterns or concepts of regionalization can be identified in the development of the Greater Delaware Valley RMP. The first is a center-periphery model consistent with, but extending, the historical pattern of relationships between the great center in Philadelphia and other medical institutions and practitioners. In this model, "knowledge" flows outward from centers of excellence, and patients flow "inward" or "upward." The second, and more recently developed, pattern, reflecting an interest in giving a more direct voice to concerned people in various parts of Greater Delaware Valley RMP, consists of geographic sub-regionalization through the establishment of Areas. Other possible models of regionalization described in Chapter III of Volume II of this report -- centerless networks, merger processes, shared services and regional agreements to cut down on duplication of services -- seem to have received little explicit attention ' at least to this point, from RMP staff members. At the area level, discussion of these kinds of possibilities has occurred, but it has not yet progressed to the stage of planned action. Physicians who are deeply troubled by their awareness of a crisis in health care delivery to the poor have felt that they could take only limited initiative to turn RMP's attention to that problem. But spreading realization that the underprivileged experience more difficulties with the categorical diseases than the more fortunate population groups has begun to turn this problem group into an accepted target for RMP attention. The community medicine departments of the medical-schools, in some cases with participation of community groups, have begun-to be active in the Region. RMP support, small, but significant in indicating a new commitment, has helped to make these activities possible. In a region as complex as Greater Delaware Valley, it is not easy to reconcile, or even to balance, all the conflicting views of what directions RMP should take or what its basic posture or stance should be, either in general or on specific issues. Washington has been looked to for help and guidance, but because much of the initiative must come from the actions of the regions, clear, authoritative, unambiguous guidelines have not been forthcoming. On the one hand, the Airlie House meetings in the Fall of 1969 seemed to promote "systems change" and call for a focus IV-4 Arthur D Little, Inc. 1. on people for whom primary health care is not available; on the other hand, Guidelines unchanged in substance since May 1968 seem to confirm an emphasis on the categorical diseases, technological diffusion, and continuing education. Under these conditions, forces which once sounded pioneering but now seem conservative have tended to retain their influence in the Greater Delaware Valley RMP. Those who look on RMP essentially as a federal professional grants program find themselves supported by those who wish to change the priorities and the goals but dare not do so for fear of becoming vulnerable'to the chargia' of deviating from the stated intent of the law. "If we are to change, somebody from outside has to indicate what direction we are to go." Both in turn are supported by those for whom the system is working very well and who do not see the need for significant change. We encountered some people representative of each of these positions in Greater Delaware Valley. We also encountered a number of people who see systems change as needed and see RMP as an appropriate vehicle for the medical profession to use in contributing to that change. The balance between the two views can shift and, if the area groups move into a more central position, may indeed shift in some significant ways. But, for the present, the tone seems to be one of reasoned caution, with decisions governed largely by a strict interpretation of the 1967 Guidelines. C. BEGINNINGS OF THE PROGRAM The Greater Delaware Valley RMP came into existence on April 1, 1967. The deans of the five medical schools were heavily involved and strongly influential in its development.* To engage the energies and support of the medical schools, half the RMP core staff budget was turned over to the schools to manage. This move served also to recognize the importance of continuing education and technological diffusion as central aspects of the Greater,Delaware Valley RMP. This half of the core staff was domiciled largely on medical school premises and recruited or selected by the deans. The head of the Greater Delaware Valley RMP was until recently paid less than at least some of the men (presumably responsible to him) who headed up the RMP staffs attached to the schools. While such a situation is not uncommon in medical schools, in this case it was seen by qome as raising questions about these authority relationships in RMP. Consistent with the view of a center-periphery system, and with some apparent support from Washington,'the deans considered the desirability of dividing the Region into sub-regions aligned with the several medical schools. By this time, the School of Osteopathy'had become a formal member of the RMP in Greater Delaware Valley. Osteopathic physicians were relatively numerous (e.g., 400 of 4400 physicians in Philadelphia), and they had been recognized since about 1960 as providing about half of the "primary care" in the Greater * Imputations of "control" of the program by the deans (as articulated by some respondents) may be too strong. The Program Committee (GDVRMP's executive board) included a minority of five members from other powerful-health agencies. It should be noted, also, that from the very beginning of the program the deans prepared the way for sooner or later moving into a less dominant position. IV-5 Arthur D Little, Inc Delaware Valley. In Philadelphia and indeed, generally in the Greater Delaware Valley, most GPs are ODs. It quickly became evident that the "referral" turf is already divided, at least at the periphery, by pre-existing affiliation agreements between individual medical school departments and corresponding services in suburban or more distant hospitals. These relationships, few of which would lightly be sacrificed, had been arranged without any necessity for geographical congruence of outreach boundaries among the several departments of a given school. Geography per se, except within Metropolitan Philadelphia itself, still remains a most unpromising basis on which to try to build cooperative relationships between individual schools and any delineated, exclusive segments within the outlying areas. Although division of turf has historically been one of the most effective methods of avoiding head-on competition among medical centers for referrals, this effort was not the only instance of collaboration among medical schools in the Greater Delaware Valley. Some fifteen years prior to RMP, the State Government had considered establishing a state-supported medical school in Philadelphia. The medical schools suggested their receiving a state subsidy as an alternative, and had subsequently collaborated in their approaches to the Pennsylvania legislature, in a relationship unusual in the United States for private medical schools. Similarly, when a staffing crisis arose at the local Veterans Hospital, they had to their advantage found a satisfactory -nswer through cooperation. Finally, they or the universities to which they are attached had just agreed to the founding of the University City Science Center as a vehicle for obtaining contracts or grants for their staffs. RMP looked like (and became) a natural means of bringing in the first significant income to the Center and so contributing to a larger and partially shared objective. To make this all a reality, the founders of the Greater Delaware Valley RMP, in the spirit of PL 89-239, invited in as participants members of other institutionalized medical groups. Representatives of hospital administration, voluntary agencies, public health, planning agencies, and the Medical Society were all included in the central policy,-board, the Program Committee. Even wider representation, including lay participation, was assigned to the Regional Advisory Group; but its agendas were at first devoted largely to reviewing and approving (or disapproving) grant applica- tions prepared within the Region, as required by law. All members of the original Program Committee were identified with Philadelphia. Five of the ten (later, six of the eleven) members were deans of the medical schools. Both of these facts tended from the outset to enhance suspicions that some non-Pliiladelphians felt of those from the city, and the suspicions that many medical practitioners have of those in academic medicine. This, then, was the RMP as it began business under the fiscal agency of the Science Center. Immediately, and quite naturally, conflicting objectives and strains of new associations became obvious and, as has been the case in other regions having complex medical systems, very hard to- deal with. Prospects for interinstitutional collaboration in situations of this sort tend to become overwhelmed in the dynamism of the individual IV-6 Arthur D Little- lnc- institutions. It is not surprising to find that institutional interests continued to command primary loyalties of the members of program and coordinating committees in the Greater Delaware Valley RMP. The Science Center, perceiving RMP as a potentially important responsibility and its principal business at the outset, tried in a variety of ways to make itself genuinely accountable. These attempts could be, and to an extent were by some people, viewed as an attempt to take over general control of the program, as distinct from merely holding fiscal responsibility. The Science Center did select the first RMP coordinator, but it was finally established that the Greater Delaware Valley RMP could operate without management exerted from the Science Center, that the Program Committee could enforce its own program, and that the role of the Science Center with respect to RMP was to be confined to its accounting responsibilities. Plans to locate RMP within the Science Center building were dropped. D. PROGRESS AND PROBLEMS TO DATE Not too long after the RMP was organized, it became evident that regionalization would mean little to the Delaware Valley as a whole if Philadelphia was the only scene of action. If something was to be done to share the RMP wealth with outlying areas, they would have to be organized in some way and assisted in submitting projects for approval. In support of this thinking at the regional level, Washington appeared to be calling for action at a distance from the medical schools. The RMP Program Committee encouraged the Coordinator to set about to sub-regionalize, and over a period of time six sub-regional Areas were established. Liaison officers were assigned to the Areas and asked to set up area-wide committees with broad representation in terms of geography, institutional affiliation, and occupation. Other qualifications appear to have been that members be known at least indirectly to the liaison officer and be readily available for meetings. The committees, in turn, were urged to set up categorical task forces which, it was hoped, would generate project ideas and applications for funding. Much of the time given by the medical community to RMP for over two years has been devoted to organizing area committees and task forces. This process has been carried out with a good deal of thoroughness, in the sense that someone meeting residential, professional, and sub-specialty qualifications has generally been located to fill slots in the committees and task forces. But, whether the liaison officers will have systematically mobilized the health careIprofessional power structures in the smaller communities, only time will demonstrate for certain. The quality and imagination of the liaison officers will be a critical determinant. Since the medical schools were heavily involved with RMP from the first, since they were already familiar with federal grant-in-aid programs, and since they were given resident RMP core staff members, it was not surprising that only about half of the project money was a" ocated to work outside Philadelphia. Under the circumstances, it is noteworthy that even this high a percentage was developed away from the medical schools. IV-7 Arthur D Little- Inc Of the total 1969-1970 budget of the Region, 67% was devoted to the core staff and half of that was domiciled in the medical schools. Thus, while activity outside of Philadelphia was being supported, the medical schools have been receiving half the total budget. 82% of the total RMP budget has been assigned to Philadelphia and Haverford taken together. This has resulted in political counterpressures from other cities and suburbs, the results of which will be discussed later. It has also led some people in the areas to think it possible that CHP might be more effective than RMP as a tool to bring federal money into health care improvement projects outside the immediate vicinity of the medical schools, and as a health system planning tool. Several other forces are also working to change the historical situation somewhat. The schools themselves are coming to resemble each other much more as to program, the "mix" of students, and the specialized capabilities they afford in the teaching hospitals. This potentially broadens the referral options of community physicians. Simultaneously, as teaching material begins to become less readily available to the medical schools, the "boondocks," which used to be of relatively limited interest, became more important as a source of specialized clinical cases; and the increasing interest in community medicine makes populations and health care services a matter of direct concern to faculty and students alike. Finally, the larger community hospitals have been gaining in competence and capability, and a growing number of NDs have become qualified specialists; thus some of these hospitals can challenge the teaching hospitals in specific instances, services, and specialties. If we may make a judgment, it would be that RMP has progressed further in the Greater Delaware Valley than in most Regions that encompass both large cities and many powerful medical schools. But, by all odds, the most significant achievement of the Region so far has been to excite the interest of more than 500 people -- largely professional; some lay in joining in repeated discussions about what the Greater Delaware Valley RMP can and should do. The people have given more than token attention to the program. In committees and task forces, both centrally and in the areas-, they have confronted issues and forged at least,initial recommendations for program design, policy, and plans for action. There has been, and still is, both disagreement and an understandable lack of clarity about RMP, and its usefulness. Again, let it be said that this is by no means unique to- the Greater Delaware,Valley. With many divergent and important interests to reconcile, it is not strange to'find that@the procedures for processing ideas and projects are somewhat time-consuming. The reviewing machinery has the objective of producing neutral and objective results. In a system designed to encourage collaboration, almost everyone has a vested interest in being informed, and many regard it as a right to review and comment. This stretches out the project processing and review procedure in Greater Delaware Valley longer than anyone really likes. Scheduled to take feur months, the approval process more often takes as long as nine months, IV-8 Arthur D Little, Inc according to the people with whom we spoke. As of March 1970, the record of project approvals since the beginning of the program was as follows: Projects approved April 1, 1969 5 Projects approved October 23, 1969 3 Submitted to RMPS December 1, 1969 8 In process in Greater March 2, 1970 44 Delaware Valley RMP 60 Withdrawn, rejected or inactive 55 The eight approved projects are based in medical schools or large community hospitals, are clearly within the "RMP" disease categories, have to do with continuing medical education, and for the most part involve medical techniques rather well-sanctioned by previous experience. They are easy to interpret as attempts to build up individual institutions, more difficult to interpret as attempt to build institutions together. Six of the.eight are rather conventional programs, though each is distinguished from the traditional single-institution-based continuing education program by drawing on both faculty and students from more than one institution. The other two (pediatric pulmonary disease, and centers for respiratory care) have elements of exploration into new ways of doing things that represent potential changes in the system of health care. We did not attempt to review rejected project applications and so have no knowledge of the total "menu" from which the approved projects were selected. But the three-year record of approvals shows a high degree of caution aq compared to other Regions we have visited. I A Task Force for Health Care to the Poor has been developing ideas for involving RMP directly in this critical problem area. Its preliminary report was sent back by the Program Committee for further development. There are at least two very interesting experimental activities in the ghetto, funded out of planning grants for the medical schools. These are clearly dedicated to getting medical services to people.-in dire need of them, and to doing this by creating new links among existing institutions. But, in the context of the whole Greater Delaware Valley MP, the amount of effort and funds directed toward stimulating the-provision of health care to the poor has been very limited. There are beginning attempts to direct RMP money @ore heavily into the departments of community medicine in the medical schools. Some of this is being aimed at changing the relationships of the schools in the community. But, as yet, there are few evidences of significant health care system change.* There are growing pressures to that end, and tensions exist to test new relationships and prepare the stage for issue-resolutions or a-t least confrontations. (The community medicine departments themselves have not resolved on one position, either, and what services and how much health care * Once again, this is not unique to Greater Delaware Valley. IV-9 Arthur D 1-itt le, lnc- service they decide the "medical schools" should deliver will make a lot of differece as to who will support them.) As RMP project funding becomes increasingly difficult, the core staff and area-wide committees, who see projects as the principal means of getting anything done, tend to be mildly depressed about the impact of what they have been able to accomplish; and, more serious in our view, they are not as hopeful as they would like to be that things can be speeded up. What ardor the task forces had is reputedly diminishing, both at the regional and area levels. Their activities are coming to be seen by them as perhaps not worth the effort -- by the pressure to produce proposals with what some of their members see as insufficient attention to the potential value of the proposed projects, by the unavailability of staff to help them, by the time-consuming selection process, and by the realization that there probably isn't any money to be had anyway. The processes an.d procedures continue to be most appropriate to the generation of really ambitious grants centered where alone sizeable grants can be prepared -- at the universities. The people who live outside Philadelphia are skeptical; everywhere the questions come: can RMP become other than a grant program for the medical schools? Let us place these widely shared concerns in a broader context. The Greater Delaware Valley RMP took shape within a given set of conditions, and the options open to it were to some extent limited by these conditions. The most important of these were the following: the number and strength of the institutions involved (notably the medical schools), the pre- existing conflicts among the medical schools, the tacit divisions of turf, and the great bundle of almost impenetrable influence and agencies that bear upon medicine and health care from outside the immediate control of any single institution, all in the special context of a relatively stable community and a rather conservative institutional development in eastern Pennsylvania. The mere formation of an RMP structure important enough for many powerful people to worry over and disagree about is an accomplishment in itself. Bringing it to a point where it is cocked, poised, and ready to be aimed, responsive to a much broader array of interests than could originally bear on it, is a further accomplishment.- Some specific steps toward progress can-be cited. First, the medical school deans won useful independence for the program from the University City Science Center, allowing program accountability and control to be vested in a sense internally within RMP. As the major figures within the most powerful medical institutions in the Greater Delaware Valley, the deans understandably wanted a strong voice in the RMP, and their contribution at the outset was probably essential if RNP was ever to become viable. With the help of key area figures, they were able to free the RMP of one perceived threat of dominance, ensure its continued physical separation from the Science Center building, and bring about a relocation responsive to evolving regionalization. Sub-regionalization has gained enough strength to earn six positions on the Board of Directors (formerly the Program Committee).* And while the deans never or rarely saw themselves as a unified Thus was achieved the first major step in the deans' early-set plan to move in due course to a position of less dominance in the program than was necessary at the start. IV-10 Arthur D Little, Inc. majority power bloc, there is now a clear majority of non-deans, a fact that should go a long way toward meeting the suspicions of interested parties not privy to the inner workings of the medical schools. This change has clearly reawakened some interest in RMP outside Philadelphia. E. RELATIONSHIPS WITH RMPS AND THE AREAS For reasons 'that are not at all self-evident, communications of philosophy and policy between the Greater Delaware Valley RMP headquarters and the RMPS on the one hand, and the headquarters and area-wide committees on the other hand, have been weak. The Greater Delaware Valley Board of Directors, RAG, and Coordinating Committee all express concern about the direction the program should take, especially since Airlie House. Their uncertainty has been compounded by the signals from Washington suggesting that new,project money (which they have viewed as their life's blood) will be very scarce. Some members of the Greater Delaware Valley RMP governing committees are uneasy about how to move toward more direct attention to primary health care in the face of (1) the prohibition in PL 89-239 against interfering "with the patterns or the methods...of patient care or professional practice" and (2) RMP Guidelines that have remained unchanged since long before Airlie House, where primary health care received such high-level support. Others are unsure of how core staff and planning funds should be directed under a grants program when the funding for the new grants dries up. There is no commonly held idea of how to use area-wide committees and categorical task forces if the preparation of project applications is likely to go unrewarded. The degree to which the program should restrict itself to heart disease, cancer, and stroke is still an unresolved question. These uncertainties lead to repeated expressions in the Greater Delaware Valley RMP such as, "Why doesn't RMPS tell us what we ought to do?" While we suspect that many people associated with the program in the Greater Delaware Valley would be highly resentful if RMPS did tell them what to do, there is a widely shared feeling that somehow RMPS ought to be able to provide more leadership short of dictating program content. Area-wide committees and area task forces were set up when it looked as if promising, well-prepared project applications were likely to be funded. The work of liaison officers in organizing and Motivating prestigious people to join in these committees was impressive in these sub-regions. So long as the committees could keep busy on the organizing procedure itself, a sense of progress could be maintained. However, at about the time they were prepared for action, the question of what'kind of action they could profitably take began to go unanswered. The uncertainties that beset the Greater Delaware Valley RMP Headquarters were reflected in a certain vagueness with which liaison officers responded to the area pleas, "What ought we to do, and what can we do?" Significant numbers of IV-11 Arthur D Little, Inc people are fearful that inactivity may lead to a serious loss of hard- earned momentum. Interest in the Areas has, however, received a shot in the arm from recent events in the Region. The six Areas are now entitled to representation on the Board of Directors. There is hope that this will result in a greater flow of money out to them. Earlier feelings that Philadelphia was getting an unreasonable share of RMP money had grown so strong as to draw the unfavorable attention of Congressmen Flood and Rooriey, both members of health committees in the House of Representatives. The inclusion of Area members on the Greater Delaware Valley RMP board has at least for the time being satisfied these important figures. Another indication that the Areas outside Philadelphia may receive greater attention was the recent invitation to area-wide committees to submit modest budget applications for carrying out activities of particular interest to them. The invitation in effect offered planning funds to the Areas, as opposed to operational funds with all their attendant complex approval requirements.* These moves should go a long way toward relieving the tensions that were building up in the Areas against the Greater Delaware Valley RMP headquarters. More is needed, however, if local interest in RMP is to be sustained. The Areas want stronger RMP staff support to help them formulate proposals for local cooperative activities they believe would be productive. This condition could largely be met if the liaison officers were instructed to give their first loyalty to the Areas and trained to act as their partisan (but sensitive and responsible) supporters within the headquarters office, and if the efforts of other members of the headquarters core staff could be redirected to provide at least limited staff support to the area- wide committees,on request. Their knowledge of the specific capabilities and internal processes in the medical schools and other Philadelphia institutions could also be helpful to the Areas in understanding what 'Id be developed through ties to the center. cou In short, relationships between the Greater.-Delaware Valley RMP headquarters and the outlying Areas seem to be improving at this time. But strong, supportive action will be needed if this improvement is to continue, and to develop into more than the-mere forms of regionalization. A more active core staff could do a lot to facilitate the movement of the Region in any chosen direction and c-ould help clarify the direction. At the present time the core staff tends to act as if it had only a single carrot -- money -- and that shriveled. More money would help; but when facilitation is successful in opening perspectives and changing attitudes, it can move mountains on short funds, even where a large, heavily funded project is not available -- and money might not even budge the mountain anyway. Emphasis on facilitative skills in future recruiting of core staff might prove very beneficial. As yet, the Areas have not submitted any such applications. IV-12 Arthur D Little, Inc F. DEVELOPMENT OF EVALUATION Only in mid-1969 did the Greater Delaware Valley RMP appoint a Director of Data and Evaluation. Thus, early evaluation schemes understandably lacked a certain crispness of design and tightness of administration. Now, however, the Region seems to be preparing itself for more sophisticated evaluation procedures and closer follow-up. 1. Program Evaluation It was not until 1969 that overall formal goals were set for the Greater Delaware Valley RMP. Goals for 1970 were established prior to the beginning of the year, as follows: GOALS 1970 (1) Refine and update overall plan consistent with new national trends of RMPS. (2) Maintain or expand level of fiscal support. (3) Increase mutual awareness and understanding of the unique and significant contributions from both the sub-regions and the medical schools that are essential to an effective, cooperative program for improved health care. (4) Increase involvement of the core staff, including the medical schools, in sub-regional activities.