I I m -N Al B&B INFoRmA6iriom & IMASE MANASEMENT 300 @omcc Mmmuc"n R=uLxvmm Ulmosen P4^"Lnooto, MAL owl* ZD'772 11 Us^ * taol) 24@l 110 w I A STUDY OF THE REGIONAL MEDICAL PROGRAM VOLUME II HISTORICAL BACKGROUND _VGIONALIZATION FACILITATION EVALUATION RELATIONSHIPS 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 D Little, Inc A STUDY OF THE REGIONAL MEDICAL PROGRAM TABLE OF CONTENTS Volume II Introduction ............................. Chapter I Background ............................... Chapter II Regionalization .......................... Chapter III Facilitation ............................. Chapter IV Evaluation ............................... Chapter V Relationships ............................ Chapter VI Program Planning and Budgeting ........... Appendix A Other Regionalization .................... Appendix B Roles and Functions of Relationships ..... Appendix C Arthu r 1) l,i t t le, Inc. I. INTRODUCTION Arthur 1) l.ittle, Inc I. INTRODUCTION This report has been prepared jointly by Arthur D. Little, Inc. (ADL), and the Organization for Social and Technical Innovation (OSTI), both of Cambridge, Massachusetts, from work done under contract PH-43-1014 with the Division of Regional Medical Programs, DRMP, since replaced by the Regional Medical Programs Service (RMPS)@ The study which began in July of 1968, was to be a 2-year comprehensive analysis of three central aspects of the Regional Medical Program: (1) The concept of regionalization as it applies to the@Regional Medical Program and elsewhere in other Government and non- Government programs. (2) The evolving relationship between Regional Medical Programs Service in Washington and the individual Regional Medical Programs. (3) The need to develop a comprehensive framework for evaluating the Regional Medical Program at both the national and regional levels. The contract also,required us to consider the applicability of program planning and budgeting systems (PPBS) and other economic cost/benefits analyses to RIV. Early in the study, responsible officials of RMPS agreed with us that these deserved only secondary attention. The reasons are pointed up in Appendix A to Volume II, which deals with this subject. Finally, we were required to look rather broadly at other re- gionalizing experiences to see whether they might provide clues for RMP development. The limited findings of this investigation are given in Appendix B to Volume II. We have chosen to present our report in three separate volumes. Volume I -- Summary presents a concise overview of the Regional Medical Program. Volume II Background, Regionalization, Facilitation, Evalua- tion, and Relationships -- discusses regionalization processes, strategies of planning and action, a unique approach to evaluation in a scheme of systems transformation, and finally the basic relationships between RMPS and the regions themselves, and the outside community. The volume also contains three appendices. The first concerns program planning and bud- geting for RMP; the second is a brief paper on regionalization efforts outside the Regional Medical Programs; the third presents in table form roles and functions of various relationships among those in the RNP system.** * The change accompanied a major reorganization of HEW health agencies in June, 1968. ** To orient the readerwho may not read all of this report, the Introduction is reproduced in both Volume I and Volume II. Arthur D Little, Inc VolumeIII presents descriptions of five regions operating within the RMP structure; viz., North Carolina, New Jersey, Greater Delaware Valley, Northlands, and Memphis. A. CHANGES IN RNP AND ITS ENVIRONMENT DURING THE STUDY During the two years in which the study was in progress, many developments have occurred both in the Regional Medical Program itself and in the larger societal context. The main areas have concerned: k'l) Shifting societal values toward more concern with the pgor, with the environment in which we live, with the costs of health care, and with the need for local initiative as a way of obtaining genuine commitment and action. (2) There has been a growing sense in our country of the need to rationalize, supplement, or otherwise improve health care delivery in the face of indications (reflected by comparisons such as infant mortality and life expectancy figures) that the delivery of health care in the United States, in spite of renowned medical education and reseatch institutions, is not adequate, particularly for those who cannot afford medical care at prevailing rates. Many people believe that the solution lies in the evolution of a more effective pattern of health care delivery within the present system; others, seeing no Itope for the present system, are pressing hard for more radical solutions. Meanwhile the demand for health care grows at a fast pace. (3) There have been many changes in personnel in the Regional Medical Programs Service (RMPS) and its parent, the Health Services and Mental Health Administration. Dr, Marston, the first Director of the Division Regional Medical Programs, left to head up the Health Services and Mental Health Administration and then al- most immediately thereafter to head NIH. Other people such as Karl Yordy, Deputy Director, DRMP; Steven Ackerman, Chief,- Planning and Evaluatl.on Branch; Daniel Zwick, and Maurice Odoroff, Special Assistant for Data and Analysis, have left @ S. Also departed are Dr. William Mayer, Chief, Continuing Education Branch: his successor, Dr. Alexander Schmidt; Dr. Michael Manegold, Associate Director, Division of Professional and Technical Development; and Mrs. Martha Phillips. Recently, both Dr. Joseph T. English, the second administrator of the Health Services and Mental Health Administration, and Dr. Stanley W. Olson, the second Director of the Regional Medical Programs Service, have left as well. During 1968 and 1969, @S, along with other Federal agencies, experienced a severe personnel freeze, which left the Regional Medical Programs Service unable to add quali- fied staff during a period of rapid program expansion. In i-2 Arthur D Little, Inc part, to compensate for this development. the Chronic Disease Control Program was transferred to the Regional Medical Programs Service in the hope that some of the energies and talents of its people could augment the human resources available to the Regional Medical Programs. Un- fortunately, the process of acquiring and integrating the Chronic Disease Control Program consumed an unexpectedly large amount of the time and energy of top,RMPS people. Thus in terms of personnel, capacity, and program management, the shift was for many months a net drain. (4) Over the past two years, the individual regions have evolved and matured considerably. Many have taken on new forms of organization as the@imensions and needs of the program be- came clear. All but one of the fifty-five have now moved from the planning stage to full operational status. The concepts of the nature of a region, its function, and the functions of the regional core staffs have evolved considerably. Two developments are of special note: A marked shift in emphasis has occurred in some Regional Medical Programs from primary concern with the categorical diseases, continuing education, and technological transfer to the functions of a health system change agent-ultimately affecting (although not delivering) primary care. From this shifting view, projects can be both desirable activities in themselves and vehicles for collaborative efforts leading to desirable systems change. RMP has emerged as the only authentic organization on a national scale for "connecting up" the Federal government with the medical establishment and particularly the practicing physician. (5) Finally, the past two years have been marked by increasing fiscal constraint, manifested-in many ways including the per- sonnel freeze mentioned above. During the early stages of the program, more money was available than could be usefully spent considering the amount of time needed for the regions to get organized and plan before "going operational." But as more regions came on stream and built needs for more funding, the financial situation tightened to the point where there were, as of June 30, 1970, about $30 million in approved but unfunded projects. In other words, a reasonably clear balance between funds available and the need for funds has never really been achieved and maintained. The current deficiency of fundstd support even completely approved (and therefore presumptively worthwhile) projects has added a substantial element of uncertainty to the con- fusion of newness and its accompanying lack of positive program definition. i-3 Arthur 1) 1-ittle, Inc. In the Table on the following page there is a summary of the authorizations, appropriations, and amounts obligated from the beginning of the program through fiscal year 1970. Also shown is the rate at which regions entered the planning stage and became operational. It can be seen from this Table that all but one of the regions has now gone operational. What does not show in the Table is that the amount of funds approved by the National Advisory Committee exceeds the amount of grants because the amount available for obligation would not permit full funding. B. METHODS USED IN THE STI'DY To carry out this study, the ADL/OSTI team interviewed people both within RMP and in the medical field outside RMP. We interviewed staff at all levels of HSMHA and NIH, Congressmen and congressional'staffers, and experts on special aspects of health and health care delivery. Of central importance to the study were the investigations under- taken in the field to give us an understanding of processes and problems in the individual regions. ADL and OSTI staff visited 18 regions in all. Of these, four.were chosen for intensive study of 8 to 12 man-weeks each.- These regions were Greater Delaware Valley, New Jersey, North Carolina, and North- lands. In these regions we sought as much information and as many points of view about RNP as we could find, including the reactions of those engaged in the program, those who know little or nothing about it, and even those known to be outspokenly opposed to it. We engaged in frank and open discussions with: (1) Practicing physicians, nurses and other medical professionals, (2) Representatives of medical societies and nursing associations, (3) Deans, department heads and other professional staff of medical schools and schools of public health , (4) Hospital administrators and directors of medical education, (5) Administrators of extended care facilities, (6) Directors of hospital planning councils, (7) Representatives of voluntary health agencies, (8) Directors of state and areawide comprehensive health planning agencies, (9) Staff of OEO, Model Cities, Neighborhood Health Agencies, and the like. i-4 Arthur D Little, Inc Budget and Grant History (Dollars in thousands) FY 1966 FY 1967 FY 1968 p@' 1969 FY 1970 Authorization -------- $50,0(YO $90,000 $200,000 $65,000 $120,000 Appropriation: grants ----------- 24,000 43,000 53,900 56,200 73,500 Amount available for obligation 24,000 43,934 48,900 72,365 78,500 Amount obligated grants ------------ 2,066 27,052 43,635 72,365 78,500 ------------------------ ---------------------------------------------------- Regions in: Planning @ctatus New ------------------ 7 41 6 1 - Total ---------------- 7 48 54 55 55 Operational Status New ------------------ 0 4 18 19 13 Total ---------------- 0 4 22 41 54 Includes carryover amounts I-5 Arthur 1) Little- Inc Within the RMP offices,, we interviewed: (1) RMP coordinators and their staffs, (2) Members of Boards of Directors and Executive Committees, (3) Members of RAGs and sub-regional advisory groups, (4) Key participants in task forces engaged in solving a wide variety of problems, (5) Project leaders and participants. In connection with RMP-interviews, we reviewed operational plans, reports of activities (including projects), budgets of both core staffs and projects, minutes of policy-making boards, and internal staff memoranda. We also attended meetings of boards of directors and other executive boards, RAGs and sub-regional advisory committees, core staffs, and task forces. In addition, the ADL/OSTI team visited 14 other regions for short periods: Alabama, Arkansas, California, Connecticut, Georgia, Intermountain, Iowa, Maine, Memphis, New Mexico, Northeast Ohio, Northern New England, Tri- state, Western Pennsylvania. Volume III of this report describes five of the RMPs visited: the four selected for detailed study, plus Memphis, which proved to be of special interest. During the course of this study, we met at frequent intervals with the people in RMPS in Washington to appraise them of what we were doing and thinking, and during the latter months of our work we involved them in our field trips. We are grateful to them and to the individual regional co- ordinators, RAG members, core staffs and others for the support, cooperation, and the generous contributions of time they gave us. The membership of the ADL/OSTI team included: from ADL, Phi-lip Donham (project leader), Diana Beatty, John Bruckman, James J. Dunlop, Homer J. Hagedorn, Edward M. Kaitz, Moshe Katz, James Mitchell, Alexandra Walcott, and N. Conant Webb, M.D.; and from OSTI, Ralph Muller, Evelyn Murphy, Gerald Rosenthal, and Donald Schon. C. PERSPECTIVES ON RMP We attempt in this report to bring to the surface the realities that RNP people talk about when they are off the record and not preoccupied with procedures. When the National Advisory Council and the Review Committee put their papers aside, they are concerned with who has captured the program; what is the price of involving some particular community or institution; what are the health politics of an area -- in terms, for example, of such i-6 Arthur D Little, Inc issues as private and public medicine, academic and private practice -- and where the power is. The national staff and the National Advisory Council and Review Committee informally evaluate regional programs in terms of these issues. We have interpreted the work statement to include an invitation to say what we believe RNP should be in light of the activities actually going on in RNP, and in light of e'merging national health issues. For us, these realities organize themselves into a theory asserting RMP's role as an agency assisting "systems transformation" in the delivery of health care. While this assertion is found principally in the chapters on regionalization and facilitation, some perspective concerning it is neces- sary at the outset of this report. We studied RMP at a time of national transition. 1. Three Views of the Program We saw three principal positions taken: (1) With the history of NIH, it was easy and accurate for' a number of the national staff to regard RMP entirely as a grant program in the NIH mode. (2) Others sought "strong central leadership," a view that had consistency with the notion that the headquarters of a Federal program ought to administer the program (and eventually would because all Federally operated programs turn out that way.) (3) The third view, more amorphous, emphasized the notion that RNP was somehow "about change." Many saw RNP as a combination of (1) and (3) -- a program of local initiatives to bring about change, supported by a familiar grant mechanism. Everybody could agree that in some sense PM was a "change agent." Those who took the concept of the grant program or the concept of the administered program as their principal position could still see that RMP was affecting the relationships among components of the health care system. Few in DRNP, however, seemed to regard change-agentry as the essence of the program. 2. RMP as a Change Agent During the two years we have worked with the program, there has been considerable change in the viewpoints of people espousing all three positions. Though the grant program exponents continue to favor a hands- off view with respect to the regions, there is no question that they see many differences between a grant program under NIH and a grant program under HSMHA. Not only does project content have to change, but the criteria used in grant review must also change,- and they change in the direction of many of the criteria one might use if one were trying to shape RMP to be literally and exclusively a change agent in the health care delivery system. I-7 Arthur 1) Little, Inc Similarly, some of those in RMPS who favor central leadership and who want to respond positively to what they perceive as regional requests for direction are now more clearly aware that whatever happens will happen in the regions. They are coming to view central direction as guidance, enabling the regions to produce strategies, to think in programmatic terms rather than project terms, and to deal with the local issues of the health delivery system. These shifts in viewpoint seem to show a convergence toward the feeling that RMP is in fact a change agent, though one constrained by the historical process by which RNP was created, the terms of the legislation authorizing the program, and the beliefs, interests, needs, and capabilities of the constituency available to it. We see RNP as a program about change, whose essence lies in social and institutional change processes, and not one for which these processes are merelv incidental. The central aim of our report is to present this view of RMP, with its implications for the future shaping of the program. The administrative machinery available to the division, however, is that of a grants program or a centralized government program; as a result it is historically easier to view RMP as a program about change within one or both of these structures. We wish this report to suggest that RNP can be explicitly modeled on a third basis that in our view would be more completely consistent with the pattern imposed by its legal con- straints and the emerging health issues of the 1970's. This report is a still picture of what is essentially a moving target. It thereby suffers from at least two limitations. First, it cannot adequately convey the sense of motion and change which characterizes the Regional Medical Program. Second, it cannot really convey the diversity of viewpoints, the drama, and the differences in development among the many regions. The report does, however, detail our findings and conclusions in the three main areas of investigation -- regionalization, relationships, and evaluation -- and further tries to convey a sense of what the Regional Medical Program was, is, and can become. i-8 Arthur D 1-ittle, Inc. II. BACKGROUND TO PL 89-239 Arthur D Little, Inc II. BACKGROUND TO PL 89-239 A. FORCES SHAPING THE REGIONAL MEDICAL PROGRAM The enactment of PL 89-239 reflected some trends that had been developing for a long time. These trends had to do with the concept and practice of regionalization, the role of medical research and the research establishment in the United States, changing public attitudes and values with respect to health and health care, the general nature of the medical care system in the United States, and the national political situation in the United States in the 1960's. 1. Regionalization . For decades, a succession of American public health leaders has been urging regionalization of health services. These leaders have deplored weaknesses stemming from what they call the fragmented nature of our health care system, the lack of connection among community hospitals and between them and the major teaching centers, and the independent and entrepreneurial nature of practicing physicians. In most discussions and reports of commissions dealing with regionalization, the concept of regionalization under discussion has been a center-periphery system built around major medical school-teaching hospital complexes, with links between these and the community hospitals for teaching purposes and for referral to the teaching center of the more difficult cases that community hospitals could not handle. Over the years, a variety of reports have come out urging regionalization and continuing education for physicians built on this model. Among these reports, some are cited with particular frequency: the Lord Dawson report of 1920 in England; the findings of the Commission on the Costs of Medical Care of the early 19@O's; the 'Dryer Report of 1962, Lifetime Learning for Physicians'; and the Coggeshall Report, Planning for Medical Progress Through Education in 1965. There have been several reasonably successful and highly publicized examples of such regionalization, which have served to provide empirical support for the theoretical regionalization model. The examples used in the books about "regionalization" are repeated over and over: the Bingham Associates plan linking the Tufts New England Medical Center with community hospitals in Maine; the Albany Regional Hospital Program linking the Albany Medical College with five hospitals in New York State and Massachusetts for post-graduate medical education and consultation; the Rochester Regional Hospital Council linking the School of Medicine and Dentistry of the University of Rochester to 18 hospitals in the Rochester area for joint planning, joint operation, and teaching; and the Hunterton Medical Center in New Jersey, which joined with the NYU School of Medicine for teaching and referrals. Two major examples, often proposed as models for regionalization, come from the Armed Forces. These are the military hospital system and the Veterans Administration hospital system. The military rationale calls for ii-i Arthur 1) 1-ittle, Inc- battle casualties to be treated at forward stations, with the severe cases being sent to intermediary or base hospitals. The VA hospitals some years ago linked with medical schools in order to serve systematically as teaching hospitals for those institutions. Also, within the Veteran's Administration hospital system, there are selective referral patterns; for example, in Boston the Roxbury VA hospital takes care of all the spinal cord injuries in the New England VA region by referral. These examples are not intended to constitute a prehistory of regionalization in the medical care system. Once regionalization has happened it will be possible to identify the significant precedents and contributors. But these examples do serve to point up two widely held opinions with regard to the practice of medicine and delivery of health care: (1) that academic medicine (medical faculties and large teaching hospitals) must be directly involved in important changes in medical practice and organization, and (2) that the system should relate specialized resources at medical centers to less specialized peripheral institutions. The examples listed all involve the actual or proposed deliberate creation of institutions. Such institution-building attempts are by no means new; they take place all the time in every branch of American life -- religion, business, municipal organization, education, and family or communal life. However, the great majority of such experiments die with the initial enthusiasm of their advocates or are exhausted with the resources that first support them. These examples share still another characteristic. They are attempts to create a "public" medicine. They by no means all depend upon any sort of governmental control or sanction beyond those already imposed on private medicine. But they are all attempts to create connections between patients and physicians that take account of broader relationships between people and the institutions that care for them. Proponents of regionalization in the health care field have long been convinced that federal legislation is needed to bring it about. This conviction was'frustrated in the actual form taken by the original Hill- Burton Act, which provided matching funds for hospital construction, based, presumably, on a regionalization plan. The Hill-Burton program was to be the first in a series of legislative acts recommended initially by Surgeon- General Thomas Paran in 1944 and intended to rationalize the health care system along lines based on his understanding of the Bingham Associates program. However, in the view of regional health planning proponents, the Hill-Burton legislation (or its eventual administrative interpretation) accomplished little if anything in the way of true regionalization, succeeding only in dotting the landscape with small community hospitals. The more recent trial and failure of many of the voluntary local hospital planning councils (most of which have as their mission'to coordinate planning among hospitals in a particular area so as to avoid costly duplication of services) leaves the situation unchanged. Nevertheless, the idea of regionalization persisted. Coordination among hospitals, linkages with university medical centers, and graded levels II-2 Arthur1) l,ittle, Inc of care appeared to make sense in economic terms and in view of increasing specialization. To deliver relatively simple primary care in offices and clinics, to augment these services at small community hospitals, and to concentrate highly sophisticated care at the university medical centers seemed a credible way to organize for meeting needs in terms of their frequency and in terms of using scarce resources efficiently. Corresponding referral patterns would provide a way to get people to the care they needed. Interaction and communication between community-based and university-based physicians would be strengthened. The whole pic,ture was simple and rational in the terms stated, and easily visualized. And this is the model of regionalization which was incorporated into the report of the President's Commission on Heart Disease, Cancer, and Stroke and partl7 embodied in the first draft of the legislation which was to become the Regional Medical Program. In the thinking-that led to this legislation, the limited American precedents, the reorganization of the Puerto Rican health care system, the British National Health Service, and other European systems all were interpreted as center-periphery regionalization. This was what one meant if one talked about regionalization at all. Advocates and critics alike could agree that a system consistent with these examples would give more power', prestige, and eventually relatively more income to professors in medical schools, and that it would be regulated by the government. 2. Medical Research A second trend influencing the development of the RMP legislation was the phenomenal build--up in government-supported biomedical research. The genesis and swift growth of the National Institutes of Health represents the institutionalization par excellence of this trend. Of particular influence on the formation of RMP were the following developments which were evident by the early 1960's: o As a result of general public acclaim for research, the apparent success of medical research, and the natural concentration of research grants and contracts in medical schools and their teaching hospitals, most medical schools became substantially or partially dependent on research money from NIH to augment their programs, construct their buildings, and train additional researchers and potential teachers. Organized medicine tacitly or openly consented to this avenue for providing government funds to medical schools. o The sheer size of expenditures made the medical research budget a vulnerable political target, particularly once NIH reached and spectacularly surpassed annual expenditures of a billion dollars. Like the Department of Defense, whose research expenditures had come under criticism when they became large by established and popular standards, NIH encountered growing criticism of its own research budget. There was mounting and continuing pressure to translate the results of research into clinical practice, or, to put it another way, to demonstrate the applicability of the research and thus justify the billions of dollars spent on it. II-3 Arthur D Little, Inc oThe effects of the research boom on medical manpower reinforced other national trends that were stripping the countryside of its supply of physicians, and probably also intensifying the shortage of physicians in urban ghetto areas. The research boom tended to siphon off medical manpower by encouraging medical students to seek research careers, by encouraging further sub-specialization in clinical practice that could be carried out only in major medical centers, and by impressing young physicians with the idea that proper medicine could be delivered only in very highly developed hospital settings or in-conjunction with such hospitals. The combination of these tendencies made the proposal to regionalize resources for the treatment of heart, cancer, and stroke subject to some rather extreme interpretations. What was ultimately to become RMP looked to some like a defensive bid on.the part of the Lasker group to shore up the edges of the NIH effort by demonstrating that real efforts were being made to apply the results of clinical research. Another interpretation held that RMP must be a means of organizing academic medicine in order to sharply increase its power to encroach on direct patient care. At best, these interpretations were partial, and at worst they were exaggerated, but they were considerations that proposals to create a regional medical program had to deal with; they represented part of the emotional and political atmosphere into which RMP had to emerge. 3. Changing Values and Expectations A third trend has been increasing public awareness of the benefits and need for health care. This attitude has been stimulated by the medical profession, the voluntary agencies, the media, and the experiences of millions of Americans in the Armed Forces. Health care, as the saying goes, has become a right rather than a privilege reserved for those who can pay for the service. The implication that medical care could really accomplish almost any miracle was a part of this belief. The belief in miracles upheld the popular support over the past couple of decades for providing lithe best of health care to every American." The statistical formulation that heart disease, cancer, and stroke were responsible for 70% of the deaths in the United States, and the presumption that some of these deaths could be prevented by getting health care to people who were not receiving it, provided a graphic justification for RMP. But these attitudes also set RMP up for trying to meet some impossible expectations. 4. Politics A fourth trend, located in time more closely to 1965 when the RMP legislation was developed, had to do with the,politics of the Johnson administration. President Johnson hoped for a major legislative program connected with health care. In his message to Congress in January 1965, he presented a monumental legis'lative package dealing with health that included, in addition to what ultimately became RMP, Medicare, increasing appropriations for maternal and child health and crippled children's II-4 Arthur D Little, Inc. services, medical assistance to the poor, improved community mental health services, rehabilitation centers,- an extended program for the mentally retarded, increased Hill-Burton expenditures, support for group practice arrangements, increase in support for the health profession's Education Assistance Act, grants to medical schools, scholarships for medical and dental students, increased spending for health research and research facilities, and consumer protection in the field of health. Most of these bills were redrafts or resubmissions, or otherwise represented a long process of development and siow public education. Not so with RMP. It was a Johnson bill, and was the piece of major legislation in the 1965 legislative package on health which was developed and drafted entirely after the Johnson administration began. B. THE PRESIDENT"S COMMISSION ON HEART DISEASE, CANCER, AND STROKE: 1964 The President's Commission on Heart Disease, Cancer, and Stroke, appointed in 1964, took nine months to do its work. The Commission was headed by Dr. Michael DeBakey and included sub-committees dealing with heart disease, cancer, stroke, rehabilitation, manpower, communications, facilities, and research. In summary, the Commission recommended that the Federal Government give financial or administrative support, or both, to the following: Regional centers for heart disease, cancer, and stroke Diagnostic and treatment stations The development of medical complexes The development of additional centers of excellence A national stroke program unit Community health planning (grants) Community health research and demonstrations Community-based medical programs Statewide programs for heart disease control A national cervical cancer detection program Continuing education of the health profession Public information on heart disease, cancer, and stroke Establishment of biomedical research institutes Specialized research centers Research projects (grants) Contracting authority for research and development General (not earmarked) research funds A standard goverrment-wide policy for payment of full costs of research Expansion of resources for preparation of health manpower Increased recruitment for the health professions Undergraduate training in medical and dental schools (grants) Training for research Clinical training Stabilization of academic physician supply and support Training of health technicians Training of specialists in health communications II-5 Arthur D Little, Inc Continuous assessment of health manpower needs Expansion of patient care facilities Strengthening of the federal hospital program Medical libraries National medical audio-visual center Statistical programs Increased animal resources for biomedical research A clearing house for drug information International research and training programs. The first three of the Commission's recommendations formed the basis for the original bill, S-596, considered by the Sub-Committee on Health of the Senate Committee on Labor and Public Welfare. (In later hearings before the House Appropriations Committee, Dr. Shannon, Director of NIH, said that the other recommendations of the DeBakey Commission -- directed toward improving co=unity-based programs for the application of medical knowledge, the expansion of facilities and-support for development of new knowledge through research, the expansion of resources to train new manpower, and the enlarging of facilities and resources available for teaching, research, and community service -- could largely be accomplished through existing NIH programs in the national Institute of General Medical Sciences, the National Cancer Institute, the,National Heart Institute, and the National Institute of Neurological Disease and Blindness.) C. SENATE HEARINGS ON S-596 S-596 was drafted by Dr. Edward Dempsey, then Special Assistant to the Secretary of Health, Education, and Welfare (also a member of the President's Commission and Chairman of the Manpower Task Force) and his assistant, Dr. William Stewart, who was shortly to become the Surgeon-General. The bill as drafted had the intention of establishing (over a period of five years) about thirty regional complexes, each built around a university medical center (a medical school-teaching hospital-research institute combination) and serving a given geographical area having a radius of about 100 miles and encompassing on the average about two million people. It was planned that in these complexes there would be about 450 diagnostic treatment stations in total for heart disease, cancer, and stroke. The medical centers would assume the initiative for planning and developing each complex. On February 9 and 10, 1965, two months after the publication of the President's Commission Report, hearings on S-596 were held before the Senate Sub-Conmittee on Health of the Committee on Labor and Public Health, which was chaired by Senator Lister Hill. The bill had a fairly easy time in the Senate Sub-Committee hearings. (Congressman Fogarty, in the House Appropriations Sub-Committee held later, said that he was "told that the Senate hearings weren't the best ever held before a legislative committee.") Senator Hill called the proposed S-596 a logical outgrowth of the clinical research center program of NIH begun in 1959. He was supported in this statement by Dr. DeBakey, who stressed the research nature of the proposed centers. HEW Secretary II-6 Arthur D Little Inc Anthony J. Celebrezze stressed in the hearings that the complexes would pull together existing components as much as possible, thus reducing the need for new construction. Dr. Dempsey, his Special Assistant, suggested that perhaps $10-15 million might be enough to establish a fully developed complex. Support for the bill during the Senate hearings came from a variety of sources. Three important supporters, however, wanted some modifications. The Association of American Medical Colleges (AAMC) recommended that the National Advisory Council for regional medical complexes be given more power relative to the Surgeon-General. It also suggested locating the Regional Medical Complex Program (RMC) within NIH. The American Heart Association also came out for a stronger National Advisory Council for regional complexes and for administration by NIH. It urged that the government increase its support of medical schools in the production of more doctors. The Americiifi Cancer Society recommended that Regional Medical Complexes avoid dilution by concentrating only on the categorical diseases mentioned and that "other major diseases" be stricken from the bill. It also urged inclusion of major cancer research centers such as the Sloan- Kettering Institute and the M. D. Anderson Hospital as potential candidates for "centers." Other supporters, such as the APHA and the American Physical Therapy Association, confined their remarks primarily to statements of approval plus an urging of the inclusion of their interests on the National Advisory Council. About the only discordant notes were supplied by Mr. Marion Folsom, former Secretary of HEW, and by the -American Hospital Association. Mr. Folsom talked about the need for community planning of hospitals, the problem of rapidly rising hospital costs, the need for ambulatory services and organized home care; he proposed that local advisory councils supervise the Regional Medical Complexes, that state health departments participate in the program, that expenditures be coordinated with the Hill-Burton and other state or federal-state plans, and that the Regional Medical Complexes serve as demonstration projects and try to get more than the 10% participation from local sources on construction projects. His testimony was different from and d'issonant with that of other people; few of his remarks seemed to be picked up. The American Hospital Association urged that medical schools not be allowed to dominate the program and that small hospitals be used as diagnostic and treatment stations within the context of the proposed plan. The final version of S-596, as reported out by the Senate Sub-Committee, incorporated: (1) A more powerful National Advisory Council, with the Surgeon-General authorized to make grants only upon recommendation by the NAC. (2) More power at the local levels through a requirement for a local advisory group. (3) Most importantly, no funds for new construction, although alterations, remodeling, and renovation were allowed. II-7 Arthur D Little, Inc The version reported out by the Senate represented the first step back from what could be viewed as federally financed (and certainly medical school-controlled) centers. By giving more power to the National Advisory Council and the local advisory groups, this version weakened federal bureaucratic control. By excluding new construction funds, it reduced the possibility of setting up federal centers or stations. MODIFICATIONS IN THE HOUSE OF REPRESENTATIVES The House Committee on Interstate and Foreign Commerce, chaired by Representative Oren Harris, held extensive hearings on the proposed RMC legislation, HR-3140. Between the Senate hearings in February Iand the hearings in the House in July, there had been much speculation about the proposed program and quite a bit of activity by organized groups, particularly the American Medical Associatioh, which had then just lost the Medicare battle. The House hearings started with support for the bill coming from the President, Secretary Celebrezze, members of the President's Commission, and the AAMC. A lot of criticism was expected. Chairman Harris stated that great concern over the proposed legislation was being expressed by a number of people in the health professions. Secretary Celebrezze tried to provide reassurances that no one was trying to put the government into the medical business, that the complexes would operate under local control, that there would be local coordination of available manpower, and that the Regional Medical Complexes would not attempt to duplicate existing resources. Other proponents of the bill also stressed its provisions for local control. In support of the complexes they argued the need for closer communication between researchers and practitioners. Serious challenges were directed to the witnesses by some of the Committee members, notably Representatives Carter of Kentucky, Springer 'of Illinois, Nelson of Minnesota, and Rogers of Florida. The challenges were aimed at some of the premises on which the DeBakey Report and the RMC bill were based. These included challenges to the implication that technology was not available in the smaller hospitals and that there was need to overcome a technology gap or lag. Worries were also expressed about the effect that the proposed program would have on the already short supply of physician manpower. The Minnesota Heart Association recommended a delay of one year in passage to allow sufficient time for study. The University of Minnesota recommended a demonstration or pilot program rather than the elaborate program proposed in the bill. Spokesmen for the private practitioners questioned the degree to which MDs (general practitioners) had had a voice in the preparation of the legislation and the amount of protection offered to the general practitioner from the "monstercenters" which were proposed to be established. They were also worried about pulling manpower out of the rural areas. ii-S Arthur D Little, Inc County medical society representatives asserted that the bill, if enacted, would have an adverse effect on nonparticipating hospitals, would discourage physicians from locating in rural areas, would not effectively combat heart disease, cancer, and stroke, would not improve communications, would be detrimental to those medical schools which were not leaders in the complexes, and would heighten the physician shortage. And besides, they said, there is no serious lag in the dissemination of those new discoveries that are really valid. They quoted the report of the Sub-Committee on Research of the President's Commission on Heart Disease., Cancer, and Stroke, which stated that there wa s no major research breakthrough related to these diseases still awaiting clinical application -- and, in fact, that it knew of no significant body of fundamental medical information that was not being applied. The American Academy of General Practice came out against large specialized complex regio'nal centers. The AAGP objected to the stress on remedial as opposed to preventive care. In addition, it felt that the DeBakey Commission had been excessively dominated by academic medical men. But the big thrust for changing or amending the proposed bill came from the American Medical Association, which deferred testimony before the Sena'te but did testify before the House. The main thrust of its testimony was as follows: o The legislation as proposed was vague. o In fact, there was no serious time lag between discovery and application of research results. o There was ample continuing medical education being conducted by the profession, in particular by the AMA. o There was a well-operated referral system which included hospitals; therefore, the need for linkages in new referral patterns was nonexistent. o Coordinated arrangements among hospitals already existed. 0 The manpower was not available to meet the purposes of the Regional Medical Complex. 9 Regional Medical Complexes would discourage doctors from locating in rural areas. o The Regional Medical Complexes would not improve the communication of new ideas. o RMC would have an adverse effect on nonparticipating hospitals and medical schools. 9 RMC would overburden present facilities. o Patterns of care in the United States would be changed negatively. ii-9 Arthur D L-ittle, Inc o The AMA wanted to write a review and approval of all RMCS. Various other suggestions were made in modification of the bill. At times during the hearings, Chairman Harris injected the notion of collaborative arrangements among equals as opposed to coordinated arrangements with some organizing body in charge. The American Heart Association suggested the inclusion of training among the objectives of the program and suggested that a minimum of two years would be needed for planning the complexes. The Heart Association also suggested that local advisory groups should have broad representation and should be charged with local planning and operational responsibilities. The bill, then, was subjected to many powerful push6s from a variety of interests but few pulls from champions of its objectives. It did have the strong support of President Johnson, but only in general terms. Observers said he had no investment in the detailed contents of the bill, although he did want legislation passed on heart, cancer, and stroke. The enactment of this legislation in the 89th Congress was actually quite remarkable in view of the criticism directed toward it by various components of organized medicine. Also, and even more remarkable, it was the first'piece of major health legislation which had not languished through several congressional sessions before being passed. Medicare, for example, was subject to intense negotiation and major battles before it was passed. By comparison, the legislation for RMP sailed through Congress quite easily. The form in which the bill was finally enacted into law combined the results of pressures from organized medicine, academic medicine, the voluntary agencies, and the professional regionalizers all acting to modify the original concept. It came out looking somewhat the same as the original bill, but in reality it was substantially different. The report of the Committee on Interstate and Foreign Commerce on HR-3140 of September 8, 1965 (House Report No. 963) lays out the changes and the support for them: "Testimony favorable to the legislation was submitted on .behalf of the American Heart Association, the American Cancer Society, the American Hospital Association, the American Public Health Association, the Association of American Medical Colleges, several deans and officers of medical schools and others. "Testimony in opposition to the legislation was submitted by the American Academy of General Practice, the American Medical Association, several state medical societies, and others .... "The AMA President said he was gratified that as a result of these meetings, some 20 amendments to the bill recommended by the AMA Committee were accepted by the administration. filpresident Johnson told us [the AMA] he could not support deferment of the bill, that he favored it and wanted it passed in this session of Congress,' Dr. Appel said. 'President Johnson did, however, direct Secretary Gardner to work with the AMA committee to make the bill II-lo Arthur 1) Little, Inc less objectionable.,,, ... "Dr. Appel said he told administration officials that passage of the original bill would have been followed by a severe adverse reaction from the medical profession.... "The committee has therefore substituted for the phrase regional medical complexes" the phrase "regional medical programs," so as to emphasize the local nature of this.program, its limited scope, and the fact that the primary thrust of the program will be to facilitate arrangements among existing institutions .... the only construction which will be permitted under the reported bill will be alteration, major repair, remodeling, and renovation *of existing buildings, and replacement of obsolete built-in equipment of existing buildings. No new construction will be permitted under this definition.... "...The committee has deleted the phrase 'other major diseases' and substituted 'related diseases.' If at some time in the future it is in the public interest to establish a program for major diseases not related to heart disease, cancer, or stroke, the Congress will give consideration to the establishment of such a program at that time; however, @t present the committee feels that this program should be limited to the three named diseases and other diseases which are related to them. For example, it is known that there is an apparent relationship between diabetes and heart disease .... The committee feels that research should be conducted into diabetes under the program dealing with heart disease insofar as diabetes is related to heart disease. Similarly, certain kidney diseases are associated with high blood pressure which, in turn, is associated with stroke and heart disease. The committee feels that insofar as they relate to stroke or heart disease, these kidney diseases would be appropriate for coverage under the programs established under the bill. ..In several places, the introduced bill provided for coordination' of programs, arrangements, or activities. Fears were expressed to the committee that these words implied the possibility of Federal control of medical practice. The committee feels there is no basis for these fears; however, in those places where 'coordination' is referred to, the committee has substituted 'cooperation' instead .... "...The committee has adopted a further amendment ... which provides that no patient shall be furnished care incident to research, training, or demonstration at any facility unless he has been referred to that facility by a practicing physician.... ... The Committee has been very careful to establish machinery in the bill which will insure local control of the programs conducted under the bill .... Before an application m@y be received and acted on under the bill, the applicant must have designated an advisory group which will include practicing physicians, medical center officials, hospital administrators, representatives from appropriate medical societies, voluntary health agencies, representatives of other organizations Arthur 1) l,ittle, Inc concerned with the program, such as public health officials, and members of the public .... "...At least 2 of the members fof the National Advisory Council], in addition to the 3 previously referred to, shall be practicing physicians. In addition the Surgeon General may not make a grant for any program under the bill, except upon recommendation of this Council .... "...The introduced bill ... provided that one of the components of local programs was to be one or more "diagnostic and treatment stations," defined as a 'unit of a hospital or other health facility providing specialized, high-quality diagnostic and treatment services., The committee has deleted this concept from the bill and har, provided that as a substitute for the diagnostic and treatment station, the local program must include participation by hospitals .... "The Committee notes the agreement among all concerned that full participation of practicing physicians is required for the successful operation of this program.... "One of the objections to the legislation expressed to the committee was that it would have an adverse affect upon the supply of scarce medical manpower, and would discourage physicians from locating in suburban or rural areas. These objections appear to have been based in part upon the theory that the programs established by the bill would involve massive construction of new facilities which would be required to be staffed with doctors and other medical personnel admittedly in scarce supply. Since, as has been pointed out, the bill does not provide for such a program, it will not have the effect feared in this area.... "Fears were expressed during the hearings that the enactment of this legislation would adversely affect medical schools and hospitals which do not participate in the programs set forth in the legislation. ...The fact that one medical school may benefit from a program whereas another school which does not participate is not benefited is not, in the committee's opinion, a valid reason for saying that neither institution should be permitted to participate.... "It would be desirable as an ultimate goal for all medical schools to be involved in programs of the sort contemplated by the reported bill, but some may choose not to participate, and others may become involved in the program at a later stage. "With respect to the effect of the program on hospitals, the committee points out that the intent of this program is not to centralize medical capabilities in a single, or a few, medical centers within a region, but rather is to extend the capabilities now present in the medical centers more widely throughout the region .... The bill is not intended to support programs in competition with existing activities and one of the strengths of the bill is that it provides the flexibility necessary to accommodate the many different patterns of medical II-12 ArthLir 1) l.ittle, Inc institutions, population characteristics, and organizations of medical services found in this Nation." E. COMMENTARY What started out as a series of care-providing complexes mostly based in academic medical centers with a strong, continuing medical education thrust became a program emphasizing continuing medical education and relying on locally controlled regional cooperative arrangements. In order to get off, the ground, the program had to have the cooperation of the practicing physician, and to Congress and the President that meant that the objections of the American Medical Association had to be taken into account. The program probably also had to start categorically in the NIH tradition. Placement of RMP within NIH seemed a foregone conclusion (most witnesses testified in support oj' :Ci). The apparent alternative was the Bureau of State Services, although that organization was having difficulty because its traditional approach was not well accepted or supported. The whole development of the Regional Medical Program legislation and its subsequent history as an operational program can be viewed as a series of steps back from the original concept of "categorical" regionalization built around the center-periphery model. These steps gradually pushed the task of regionalization to lower and lower levels as a price to pay for getting anything done. Dr. Marston, a former medical school dean, was named the first head of the RMP. Under his initial leadership, a philosophy was established in the RMP, which permitted the regions to develop pretty much on their own their regional boundaries and their regional organization. Much of the experience of RMP to date probably results from the fact that the idea was still new when it was enacted into legislation. Since the bill was passed the first time it was submitted, RMP became a reality before many people had a chance to think about it. Small wonder that it was subject to wide variation in interpretation. RMP could be viewed as a kind of political accident, in that no very permanent coalition had been formed to lobby for it. Who would stand up to support it in the long run? To whom would it really belong? Not the Public Health Service, presumably, out of which emerged PL 89-749 (Comprehensive Health Planning) only after RMP passage became a certainty. Apparently not organized medicine; the AMA never endorsed it in the course of its passage. Not the President's Commission; this law was not what they had asked for. Possibly the medical schools, though not quite all rushed to join. Certainly not the Hospital Association. The RMP, in its formative stages, thus became in a sense a projective vehicle for what people wished to see in it. The program was never sharply defined, and therefore people who were interested in research could project research into it. Those interested in continuing medical education could view it as a vehicle to that end; people interested in regionalization could view it potentially as a regionalizing vehicle; those II-13 Arthur D Little, Inc interested in supporting medical schools could potentially view RMP as a source of some support for that effort; people who were interested in not changing the health care system could view RMP as a vehicle for no change (because of local control). Those who were for change in the health care system could look on the RMP as a program to facilitate system transformation. RMP, then, was something to everyone, but not the same thing. In each of its guises it had a few strong supporters, but it lacked unified backing. It had no sanctions nor coercive power to enforce its will. However, it had been passed; it would be funded beyond its early power to spend the money. RMP from its birth was authorized to work with all the major forces in health and medical care service delivery -- but it was also constrained by all the realities, both political and economic. II-14 Arthur D Little, Inc t III. REGIONALIZATION Arthur D Littk Inc III. REGIONALIZATION The purposes of the Regional Medical Program-(RMP) as stated in Public Law 89-239* are: "(a) Through grants, to encourage and assist in the establishment of regional cooperative arrangements among medical schools, research institutions,, and hospitals for research and training (including continuing education), and for related demonstration of patient care in the fields of heart disease, cancer, stroke, and related diseases; "(b) To afford to the medical profession and the medical insti- tutions of the Nation, through such cooperative arrangements, the opportunity of making available to their patients the latest advances in the diagnosis and treatment of these diseases; and "(c) By these means, to improve generally the health manpower and facilities available to the Nation, and to accomplish these ends without interfering with the patterns, or the methods of financing, of patient care or professional practice, or with the administration of hospitals, and in cooperation with practicing physicians, medical center officials, hospital administrators, and representatives from appropriate voluntary health agencies." By its proscription against interfering with the patterns or methods of financing of patient care or professional practice, or with the administration of hospitals, as well as by stipulating a process for creating regional cooperative agreements, the Law has located effective power with- in the regions. The May 1968 Guidelines** underscored the reliance on regional autonomy; the formulation continues to be central to RMP practice. Regionalization was the only thread running through all three purposes as stated in the Law, which called repeatedly for regional co- operative arrangements. But cooperation cannot be viewed as an end in itself, so regionalization from the national point of view must neces- sarily be viewed as a strategy leading to something else. That "something else" is now understood rather broadly as the use of cooperative arrangements to bring about improvement in health care, with emphasis on the categorical diseases. This formulation represented a compromise during the legislative process that fell short of a sharply defined system of regional centers and affiliated stations for the dis- covery and treatment of heart disease, cancer, and stroke. To show how the actual experience of the 55 regions has further defined the meaning of "regional cooperative arrangements" is the objective Title IX, Section 900 Guidelines, p.2 last para. iii-i Arthur D Little, Inc of this chapter. Given the constraints of law, conflicting interests, human capability, time, differing interpretations and emphasis, andfinally the money allotted to RMP, the program could evolve only within the limits these constraints permitted. The result has been something approaching a reversal of ends and means. Where earliest proponents wanted to use re- gionalization to fight heart disease, cancer, and stroke, RNP has come closer to using the categorical disease focus as a vehicle for "re- gionalization," meaning "regional cooperative arrangements." Once this perception is accepted -- or even tolerated -- in a region, the way is open to encompassing the original, prelegislative pur- pose of regionalization (war on heart, cancer, and stroke) with a,new one. Regionalization is what the RMP does in a specific region to help effect systems transformation: to create linkages and patterns that deal with undesirable conditions resulting from the fragmentation of the health care system. (This is set forth in more detail later in this chapter and in Chapter V.) This chapter categorizes the styles of regionalization we have observed, and then presents more fully the concept of regionalization as a voluntary (and, therefore, legal) systems transformation in RMP. RMP regionalization should be looked at on two levels -- the national scene and the individual regions. Examination of the regionali- zation processes occurring at the regional level reveals currently ob- servable alternative forms, strategies, and processes, and offers some options for proceeding in the task of building a region. But to provide context, let us first consider how regionalization has developed on a national scale, and some possible alternative ways it could have developed. A. THE DEVELOPMENT OF REGIONALIZATION FROM A NATIONAL PERSPECTIVE AND POSSIBLE ALTERNATIVES In recommending the establishment of regional centers of excel- lence in heart disease, cancer, and stroke, the Presidentis Commission apparently intended these centers to be located in the major teaching and research complexes typically associated with our medical schools. The DeBakey concept, as it has become known, envisioned a kind of "solar system" approach with medical schools at the center, auxiliary treatment centers in major community hospitals, and less sophisticated diagnostic and treatment stations at the periphery. As such, it represented an ap- plication of the basic "center-periphery" model of regionalization for health resources developed earlier by various health planners, as noted in the preceding chapter. Public Law 89-239, which authorized RMP, did not, in fact, legis- late a center-periphery system, partly because the American Medical Asso- ciation and others resisted the anticipated effects of such a system in 'increasing the power of both academic medical centers and the Federal Government over the patterns of medical practice and patient referral. III-2 Arthur D Little, Inc Also, the concept of upgrading the skills of the private practitioners by exposing them to the techniques employed in the academic medical centers was perceived as imputing lower-quality medical skills to them. This insinuation aroused serious resentment among practitioners everywhere, many of whom felt that the kind of medicine practiced in the academic medical centers does not recognize some of the realities they encounter in private practice and so falls short of true excellence. A system that looked down on the private practitioner was unacceptable. Instead of a national system of centers of excellence surrounded by a diagnostic and treatment station, the Law set up a flexible regional program with considerable local autonomy. The possibilities for diversity were myriad. The diversity began with the definition of regional boundaries. As it turned out, regional populations vary from 20 million to 500,000, and in area from Washington-Alaska to the Metropolitan Washington, D.C. region. Some regions overlap others, such as New Jersey and the Greater Delaware Valley RMPS, which share South Jersey; the Bi-State and Illinois, which share Southern Illinois; and the Tri-State and Albany RMPS, which share Western Massachusetts. Thirty-one regions confirm to pre-existing state boundaries, (somewhat to the surprise of RNPS), 24 encompass parts of states or are multi-state regions. Some regions have one medical school, others a number of medical schools, and a few others (such as Maine) no medical school at ali. Some contain large cities; others do not. The result is a pattern of RMP regions which does not consistently conform to any other existing regionalization pattern. This has produced some problems. For example, where RMP regions have cut across political lines, there have been questions of how to relate to state-based Public Health departments and CHP agencies. On the other hand,, the new pattern does seem to have taken advantage of, or created, entities potentially capable of dealing with emergent health care issues in ways significantly different from pre- existing state-based agencies. In many regions, the RNP has been organized in a way that builds new links among the health care professions. The RNP has secured at least nominal commitment and involvement of thousands of physicians, members of voluntary associations, nurses, allied health personnel, hospital admini- strators, government health officials, and lay people; and it has created regional structures relatively accessible to the influence of, and com- munications among, all these professions and some of the institutions in which they work. In some regions, RNP has permitted (and enabled) a strong alliance to emerge among different categories of health care providers, leavened by the presence of lay people. (In Northlands, for example, doctors and nurses are building closer working relationships than ever be- fore, using coronary care units as a means to that end. Maine, New Jersey, and North Carolina have also moved to bring the several health professions into closer relationships.) In other regions, a pre-existing providers' alliance has been broadened and its social utility potentially increased. (The Mid-South Medical Center Council of Memphis expanded its activities significantly as the Memphis RNP came into being.) Pressure to change III-3 Arthur D Little, Inc or adjust the regional boundaries has for the most part been met con- structively. In those regions where territory overlaps, competition appears to be manageable, and the local pattern of playing off one re- gion against another is not viewed as a significant problem. RNP's regionalization pattern has recognized several medical catchment areas that do not conform to political boundaries. For example, South Jersey relates for medical purposes strongly to Philadelphia. Yet politically and in some ways socially it is tied to New Jersey. Both re- lationsl,.ips were recognized inthe regionalization pattern, which includes South Jersey in two regions. Similarly, Southern Illinois relates strongly to St. Louis (Bi-State RMP), Northern Mississippi relates to Memphis (Memphis RNP), and the Pittsfield area in Massachusetts relates to Albany, New York. In the instances of markedly slow regional development of which we have been appraised, several factors are alleged to have been critical: 9 Program perceived to be "dominated" or "captured" by one of the parties of interest (medical school(s), medical society, core staff); o Program in the hands of an inappropriate program coordinator (unenergetic, unable to cope with a social process in a highly political mileu, unable to communicate with a broad enough spectrum of people, passive); o Program unable to deal quickly with the range of complexities facing it (big city with several medical schools, region with a raging, locked-in conclift that is built into basic RNP structure). Since we have visited no regions that could be judged total failures, we can only acknowledge that these factors would be strong nega- tive forces wherever they are found. They are conditions that are risked in any situation where regionalization is allowed to develop on a self- selecting basis. Other possible forms for regionalization can be envisioned,, but each carries with it certain inherent disadvantages that might have made it less viable than the voluntary self-selection process that actually took place. 1. Regionalization along State Lines - Regionalization mandated .in accordance with the political subdivisions of our country would perhaps be the most logical alternative to the present system and would have had the potential for securing more support from the political establishment in the governors' offices and in the states' departments of health. However, there are obvious drawbacks. Some of the large states cover areas with vastly different medical, economic, geographic, and demographic characteristics. New York City, for ex- ample, is far different from upstate New York; to have included the III-4 Arthur D Little, Inc entire state under the aegis of one program would have been immensely difficult and would have done justice to neither area.* In addition, a gulf often separates state health departments and pri- vate medicine. If a regional medical program were to come too heavily under the influence of the states' departments of health and "state politice," its potential for attracting the interest and constructive .attention of organized medicine would have been drastically reduced. 2. Reaionalization on a Medical School-by-Medical School Basis Regionalization centered around medical schools would have come closer to the original model suggested by the President's Commission on Heart Disease, Cancer, and Stroke, but, if attempted, would also have faced many basic problems. Many local physicians would have reacted in terms of the town-gown syndrome that exists pretty generally through- out the country. Furthermore, regionalization around medical schools and their teaching hospitals would probably have required substantial restructuring and rearranging of the relationships between medical schools and community hospitals, a prospect not necessarily welcomed by the latter. In addition, in most large urban areas with several medical schools, the "turf" overlaps, which could exacerbate competitive problems. We should note, however, that in some areas of the country such as California and upstate New York, the geographical distribution of medical schools does form a reasonable basis for regionalization. In other areas, relationships between medical schools and other health care institutions are tbinly developed. The problems of sorting out connections between peripheral hospitals and medical schools, severing some and establishing others, might well have posed an impossibly long and frustrating task. In summary, while there are ways in which regionalization could have developed on a consistent nationwide basis, each appears to have carried with it major difficulties in implementation, a critical risk of alienating practicing physicians, or both. In retrospect, the way that regional boundaries grew up under the RMP was functionally effective, though it may have looked chaotic at the time and certainly has resulted in "regions" put together for diverse reasons. Our general conclusion is that regionalization could have hap- pened in none of the other ways outlined because, in each case, the new program would have been viewed as beholden to a pre-existing activity, already well understood, and then would have been dealt with accordingly. The legislative process through which PL-89-239 emerged helped to keep FM free from such entanglements. The subsequent administrative history also helped: the switch of RNP from NI)i tothe new HSMHA structure made more valid the concept of RNP as a relatively free-floating entity that could be trusted not to reflect any of the familiar federal or private health or medical interests too narrowly. Of course, the change also left RMP without a strongly entrenched, well recognized champion. It is possible that some day the division of upstate New York into four regions will be viewed'as overdoing the recognition of differences. III-5 Arthur D Little, Inc B. REGIONALIZATION EFFORTS VIEWED FROM WITHIN THE REGIONS We see three archetypal patterns of regionalization being de- veloped, or at least employed, to varying degrees in the regions: (1) The center-periphery model, (2) The nucleation or subregionaliz-tion model, and (3) The centerless network model. None of these models exists in a pure state in any region; they are not necessarily mutually exclusive ways of carrying on the 'rocess of p regionalization. One (the center-periphery model) has not even been at- tempted on a region-wide basis in some of the regions, though we repeat that it was the original model f6commended by the President's'Commission on Heart Disease,, Cancer, and Stroke. These models should be discussed in some detail since they representthe patterns we have observed in RMP practice. The importance of these three regionalization models lies in their very different political implications. Specifically, the models differ significantly in the degree to which they force acceptance of power concentrated in one place as a precondition for anything else to happen: o Center-periphery regionalization defines the "peripheral" elements as subordinate in some respects to a more powerful center; a Nucleation or subregio-.ialization is ambuguous as to the con- centration of power; 9 The centerless network is a guarantee that power will be con- centrated only by consent of the governed, consent being granted under circumstances in which the governed have a reasonably good idea of what they are consenting to. Other differences exist and these will emerge in the descrip- tions and illustrations that follow. But one factor characterizes most of the regionalizing experience of RMP: at present, nobody is in a posi- tion to enforce center-periphery regionalization, and almost nobody wants it to happen except on the assumption that he will be identified with the "center." The other two approaches to regionalization, as will be shown, represent attempts to make feasible an otherwise unworkable model. 1. The Center-Periphery Model of Regionalization a. Structure and Operation The center-periphery model, based on a center of excellence (gener- ally or in terms of certain specialized resources) and related peri- pheral institutions, was developed and ramified in the Report of the President's Comission and is the basic conceptual model which many III-6 Arthur D 1-ittle, Inc health planners adopt when they think about "rationalizing" the health care system of the United States. The model is easy to visualize and is grounded in the logic of equating the level of care needed and the capability of the resources to give it. It is designed to develop graded health care delivery, education, and research. Small hospi- tals on the very edge of the periphery* typically provide routine primary care as well as certain kinds of specialized care which have to be located close to the population being served; for example, in- tensive coronary care or emergency and obstetrical services. The cen- ter of excellence, on the other hand,, is devoted to high-technology medicine and clinical research, and is familiar with, and qualified in, difficult, expensive, complex, and highly specialized procedures. Intermediate facilities for commonly experienced problems requiring equipment too costly for the periphery, but using procedures so well established that they do'not have to be confined to the research cen- ter may also exist. The center, in this model, is a teaching insti- tution where doctors are exposed to difficult and rare medical cases. The model is built on the principle of hospital-based, acute-care medicine as viewed from the perspective of the academic medical center of the early 1960's. The fLow of patients in the completely developed center-periphery model is inward and upward as the severity or complexity of ailments increases. For example, in surgical terms, given the conditions of the 1960's, appendixes are removed at the peripheral institutions (community hospitals) and hearts are repaired at the medical center. Routine X-rays are taken at the periphery, and neuroradiology and angiography are performed at the medical center. Intermediate pro- cedures, like hemodialysis, may be carried out at larger community hospitals. The flow of information and expertise in this model is in the op- posite direction, i.e., outward and downward. Techniques which are developed or refined in the center are disseminated to hospitals and practitioners at the periphery, usually through a program of continuing medical education or communications media such as newsletters, tele- phone tapes, closed circuit television presentations, and the like. Planners collect information about regional resources, the skills available at each level, and other kinds of data needed to ensure a rational, orderly, sensible flow of patients and techniques, and this information is shared with physicians and administrators. In this model, continuing education programs bring doctors from the periphery to the center for refresher training. Perhaps missionaries or licircuit riders" are used to participate in rounds and perform other kinds of teaching activities in community and local hospitals. Distance between center and periphery here refers to size and sophisti- cation of the hospital: geographical distance from the center of excel- lence may play a part, but is not the governing factor. III-7 Arthur D Little, Inc b. Purposes Served by Center-Periphery Regionalization The linking of peripheral institutions to the great teaching centers, which the center-periphery model encourages, can increase the attractive- ness of internships and residencies in the outlyiag community insti- tutions because of the academic affiliations. House officers, typically in short supply in community hospitals, can assist in the work of the hospital at relatively low cost and provide the medical staff of hospi- tals with a climate of intellectual challenge that is not present with- out them. In return, the medical center can insist on exercising some degree of control over the clinical training and operation of the peri- pheral hospital. v Another intended purpose of the center-periphery model is to bring about a more rational allocation of resources, meaning the avoidance of unnecessary duplication. Tlle example of radiation therapy facili- ties is frequently cited in this connection. Similarly, physicians can usually agree (and laymen can easily understand) that open-heart surgery, organ transplants, and other complicated procedures should be carried out only in those institutions where the volume of work will be sufficient to keep the surgical teams "tuned up". The center- periphery.model allows people to address this issue directly by deter- riining where in a region particular kinds of work will be done and providing a kind of template for the construction of new facilities. The rational allocation of resources postulated in this model is highly compatible with the interests of the medical centers and associ- ated physicians who need to have access to cases for teaching and re- search purposes. It also matches the interest of the public in mini- mizing the cost of facilities while ensuring access to highly trained people when highly complex procedures are needed. However, the center- periphery model can work to the disadvantage of doctors who are not affiliated with the medical center. They may feel excluded, unable to sharpen their skills, restricted in their referrals, and in some cases denied continuous access to their patients. The model may also conflict with the aspirations of certain community hospitals which are trying to become broadly capable medical centers. The patient who must travel and stay away from home when sick can also be considered at a disadvantage. In this model, institutions on the periphery do not have to feel iso- lated or constrained to work toward the costly objective of being com- pletely self-sufficient. When they are part of a center-Deriphery system, the community hospitals have access to the resources and talents of larger, more complex institutions that contain high competence in certain specialties or subspecialties and that have expensive faci- lities and equipment the peripheral hospital cannot afford. By the same token, the medical center, being assured that the routine needs of the community will be well served by the peripheral insti- tutions, can devote the bulk of its energies, talents, and resources iii-8 Arthur 1) Little, Inc. to working on solutions to challenging medical problems -- I)articulariy those judged to have teaching and research merit -- assured that their relationships with doctors and hospitals on the periphery will provide sufficient patients to meet this teaching requirement. The more tightly organized the system, the surer the referrals. In terms of power and influence, the center-periphery model has the effect of reinforcing power in the center, placing the academic medical center in a stronger position to influence reftrral patterns and to control the operation of individual hospitals to influence the alloca- tion of construction dollars, to control training and research, and to increase their staffing in the subspecialties. The shift does not neces- sarily imply an equivalent decline in the power of the individual hospi- tal or doctor. Through councils, boards, and affiliation bodies, indi- vidual hospitals can potentially exert more influence on the center than if the regional pattern did not exist, 1)ut the degree of influence and its overallsignificance depend on how the center-periphery system is organized and how the organization works in practice. Influence of the periphery over the center is not inherent in the model; some degree of centralized rationalization and control is. Peripheral institutions have to relinquish some of their independence. The center-I)eriphery system tends to promote stability, at least on the more obvious levels. It specifies -- or at least clarifies -- re- lationships, coC[ifies agreements, and prescribes and circumscribes be- havior. If hospital B ties to medical center A for teaching and patient care, the conditions of relationship are usually spelled out in some detail. It can improve the quality of care by concentrating specialized resources and talent. Its proponents view all these factors as being a more or less desir- able way of ultimately offering health services to a population in the most efficient, least expensive, and expeditious way possible. c. Experience with Center-Periphery Regionalization in the RNP We found a number of instances where relationships between teaching medical centers and outlying hospitals were encouraged through the ef- forts of the RMP, but in no place did we see anything approaching a fully developed center-periphery system on a region-wide basis. The most nearly complete examples were found in the Memphis and Intermountain regions, the latter centered in Salt Lake City. These two regions each have a single, large population center, and a single, dominant medical school closely interacting with a strong group of private physicians, many of them specialists having real interest in reaching a large popu- lation. The medical schools in both regions had traditional ties with hospitals and doctors in the surrounding areas that enabled a fluctua- ting but perceptible degree of practicing physician influence to permeate the medical schools. The RMP came to a situation, in both cases, where a fairly well-developed center-periphery system already existed in transportation, commerce, and finance, and to a significant degree, in medicine itself. iii-9 Arthur D Little, Inc In other regions where center-periphery regionalization was at- tempted -- or appeared to be attempted -- it usually met with con- siderable resistance or was converted into some other form of region- alization, such as subregional formation, as a reaction against the perceived imposition ofthe center-periphery model. Some examples: (1) In Connecticut, the State Medical Society, despite its involvement in the formation of the RW and thp development of its program, posed serious objections to the attempts of Dr. Henry Clark, the Coordinator, to develop a center-of- excellence model of regionalization and a "Third Faculty" based on community hospitals. In part, the Medical Society was opposed to the "planners -- who favor a system of cen- tralized, academic, and theoretical management of medical affairs, and, further, who evidently contemplate using non- voluntary leverage to impose that system on the Connecticut professions. . ." * Over the succeeding two years, the State Medical Society and the Connecticut RMP have become closer, but the originally proposed "grand design," incorporating affiliations between the Yale-New Haven Medical Center and the.35 community hospitals in Connecticut is still a long way from materializing. However, some ot@er kinds of re- gionalization have begun to appear. In several instances, for example, community hospitals have initiated joint planning efforts with neighboring hospitals to provide community servi- ces. Moreover, there seems to be a reasonably broad ac- ceptance of the subregional division of the state into 10 health service areas, though no subregional RNP organization has yet been formed. (2) In the Greater Delaware Valley (GDV-RNP), Philadelphia, with its six medical schools is explicitly referred to as "the Center." Everything else is in "the periphery." But there has been relatively little success so far in the attempt to build a center-periphery system between the academic centers and community hospitals outside Philadelphia. In fact, even regionalization planning has not been completed and accepted in any depth. People outside Philadelphia tend to resist domination by the center city in health care as in other sectors of activity. In part as a reaction tothe perceived power and dominance of the medical schools, and in part as a planned strategy, area-wide planning groups are emerging and are being developed by the GDV-RNP. While it is too early to say whether the "areas" will develop to the point of representing a substantial force to interact with the medical schools in Philadelphia, they have gained positions on the governing board of the GDV-RMP. Explicit center-periphery Correspondence from the Connecticut State Medical Society to the Division of Regional Medical Programs. III-lo Arthur D Little, Inc regionalization seems still possible in the Greater Delaware Valley, but less likely than regionalization in other forms. (3) In the Northlands Region, despite the existence of two geo- graphically separate centers of obvious excellence -- the Uni- versity of Minnesota Medical School and the Mayo Clinic -- no significant region-wide attempt has been made to implement a center-periphery model of regionalization. Historically, re- lationships between the University Medical Center andthe great majority @f community physicians and hospitals have been weak. The University was looked upon as a place which would never let you know what happened to patients you had referred there. Until recently, there was little noticeable outreach from the University Medical Center as viewed by physicians in the countryside. With Mayo, the situation is somewhat different. For years Mayo had a policy of cultivating relationships with community physicians in Minnesota and nearby states, and it has built its referral network carefully. But still, in nearby communities the local physicians fear being overshadowed by Mayo. In either case, had there been an assertion of "centrality" through the RMP, the community hospitals and physicians would al- most certainly have been alienated from the program. As it hap- pened, both Mayo and the University agreed that they should not control the MT, though neither took a totally passive role. Action an their part was imperative if hospitals, physicians, and allied health personnel were to be expected to assume active roles in the process of regionalization. Recently, the University Medical Center has undertaken some activities which, as they succeed, could lead to closer rela- tionships with community physicians. These include a family practice curriculum at the Medical School and the active seeking of referrals throughout the state. (4) In North Carolina, the Charlotte Memorial Hospital resisted the idea that it might be a "peripheral hospital" with respect to any or all of the three university medical centers in W71nston- Salem, Durham, and Chapel Hill. As a reaction it attempted to pull together the medical resources in Mecklenburg County, thus precipitating another form of regionalization -- a reinforce- ment of outreach and center-periphery development with Charlotte Memorial as the hub. While comprehensive center-periphery regionalization has not been a widely successful RMP strategy, nevertheless there have been a number of instances in which RMP has facilitated 'university medical center out- reach. None of these instances blankets a region. Those outreach efforts that have the broadest and most consistent coverage tend to represent special purposes. By no means do they intend to effect com- plete center-periphery regionalization$ but they do reflect the theory that there is a "center"'and that it can relate to entities outside Arthur D Little, Inc itself in an outreach mode and in such a way that information flows from the center to the periphery and referrals flow from the periphery to the center. The following examples describe projects that began in a form capable of becoming part of a center-periphery system, though some soon took courses that precluded that possibility and none depends on the full articulation of center-periphery regionalization for its viability. While awareness of what a center-periphery region could be is one of the factors that shapes these efforts, it is not the only factor and is usually not the dominant one. o In North Carolina, RNP supported the "Berryhill Project," which (as one of its several activities) linked the University of,North Carolina Medical Center to the large community hospital in Wilming- ton, North Carolina. Through exchanges of physicians, ties between the University and the locaL doctors in Wilmington were developed. The project enabled the local Wilmington physicians to visit and profit from the technology and expertise available at Chapel Hill. More surprisingly, in view of the original continuing education objectives stated, it enabled faculty members from the North Carolina Medical School to learn something of the very real excel- lence of health care in Wilmington and of the practical realities of first-line care. o In the Northlands Region, RMP is supporting Mayo, the University, and the American Rehabilitation Foundation (ARF)* in developing relationships with three distant parts of the region to introduce and develop stroke rehabilitation. Mayo is taking responsibility, roughly for the southern third of the state, ARF for a broad band in the middle, and the University of Minnesota for the northern part of the state. o In the southern Minnesota communities of Austin and Albert Lea,, RNP is helping to support merger discussions between the community hospitals. o Physicians in Austin, some 40 miles from Rochester and the Mayo Clinic, are actively considering ways of using Mayo as a diagnostic resource (perhaps through closed-circuit TV), whereas formerly Mayo had been viewed largely as a competitor for patients residing in the northeastern part of Mower County. In most regions we have visited, the center-periphery model was never considered, or, if considered, was immediately rejected as an RN]? strategy for the region as a whole. Maine, for example, stimulated by the Bingham Associates Fund,- had had a long potentially "regionali- zing" relationship with the Tufts-New England Medical Center in Boston. But the Maine RMP never seriously considered,developing its own center- periphery system around the Maine Medical Center in Portland because experience with the Bingham Associates Fund, while generally positive, had not convinced local doctors of the advantages of close (subordinate) connection with a Medical Center, or even of its feasibility. As the Formerly The Sister Kenney Foundation III-12 Arthur D Little, Inc hub of a regionalization scheme, the Maine Medical Center, in 1967 the most obvious candidate in the state for the "center of excellence" title by virtue of its size, staff capabilities, and teaching pro- gram, was no more acceptable than Boston in the eyes of local doc- tors and other leading community hospitals in @Aaine. For people in Bangor and Augusta, going to Portland for medical care was seen as undesirable -- and not justified merely to satisfy the theoretical advantages of "regionalization." We have chosen to describe Maine because of its earlier, somewhat related experience with the Bingham Associates Fund, and because an attempt to regionalize in some sense had been made. But the experience in Maine was no different from that in other places where there had been no prior experience with center-periphery regionalization: it simply did not match the perceived needs of the medical profession or their patients. In California, to select another quite different example, it was abundantly clear that no one medical school could be the model center, so the region could not have a single center-periphery system. It was equally clear that two center-periphery systems, one for the North and one for the South, would probably exacerbate the political and economic divisions between the two areas. The California RMP therefore settled on a division into eight subregions (nine, if Watts-Willowbrook is included as a subregion), each with its own medical school. Whether the activities of these subregions were themselves to develop into "center-periphery" regions (in any way except that each subregion is equipped with a medical school) was left for the subregions to decide. d. Some Conclusions about Center-Periphery Regionalization Among the things we can learn from RW experience with this form of regionalization are the following: (1) While center-periphery regionalization may not become the strategy of choice in a region -- not even attainable if chosen -- the suggestion of this model as a possibility, or steps taken in that direction, can precipitate other forms of regionalization. For instance, the most common response is a defensive reaction. Health providers goaded by the threat of center-periphery regionalization decide to band together -- at least among themselves -- in some other posi- tive cooperative arrangement. Thus, if an RMP coordinator can use center-periphery regionalization as a concrete starting point, he may well precipitate real movement, though not in the direction first indicated. (2) When attempted, center-periphery regionalization almost always remains limited in terms of its content and of realized relationships between the center and the periphery, even when it is pushed hard. What makes sense in terms of center-peri- III-13 Arthur D Little, Inc pheral regionalization in a single category (open heart surgery, medical information retrieval, radio networks) may not fit very many other categories. "Islands of excellence" can and do exist almost everywhere, and "centers of excellence" can and do contain extensive "islands of mediocrity." Accordingly, it is often unreasonable to extend a perfectly plausible center- periphery regionalization scheme based on one service, tech- nique, or type of facility to others. What we see in practice is thus usually limited to one purpose. It us;ually consists of a program in continuing medical education, with perhaps some coordination around a tumor registry, a DIAL-access system for information on the categorical diseases, or perhaps"the recognized leadership of the center in some particular aspect of heart disease, cancer, or stroke. This may be all to the good, but it is hardly what "regional planners" have in mind as a goal when they think about comprehensive regionalization. (3) Physicians on the periphery, by and large, tend to resist domination by a university medical center, particularly after they have been in independent practice for a while. To this group, it is their work that constitutes the center, and the university with its principal hospital facilities is merely a handy place to which they can refer patients from time to time for really specialized attention. The failure of a university