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Interview with Dr. William L. Kissick
Date:  September 13, 1991
Interviewer:  Dr. Donald Lindberg
Location:  National Library of Medicine
           Bethesda, Maryland
Transcriber:  Techni-type Transcriptions/DDR




Lindberg:  I'm Donald Lindberg, and I'm Director of the National
Library of Medicine.  I have the privilege today to conduct an
interview with Dr. William Kissick as part of NLM's study of the
history of Regional Medical Programs in the United States.
     Bill, you were head of the Office of Program Planning and
Evaluation in the Office of the Surgeon General of the Public
Health Service from '66 to '68, is that right?

Kissick:  That's correct.  

Lindberg:  So you saw a whole lot of RMP boiling up and getting
started, some of its at least early and middle history.  Then you
went to Pennsylvania and worked in RMP, did you not?

Kissick:  That's correct.  Not directly; as a faculty member of
the University of Pennsylvania.

Lindberg:  We're very pleased you could take the time to be with
us.  I'm particularly interested in what insights you'd be able
to give us about the early times and the role of the surgeon
general in implementing this legislation.

Kissick:  I'd like to start with the beginning of the legislation
and the program as I knew it.  It really had a dual birth, if you
will, or a parent, both the father and the mother.  There were
two activities under way in 1964 that were related and working in
parallel.  One was the President's Commission on Heart Disease,
Cancer and Stroke that was directed by Abe _______feld, a
professor from Hopkins, and it was chaired by Dr. Michael
DeBakey, the noted cardiac surgeon.  The President's Commission
was announced formally, I believe in March of '64, and reported
to the president in December of 1964.  It had some three dozen
recommendations--I believe thirty-five, to be precise--and one of
those was for regional medical complexes.  That recommendation
came out of the Manpower Subcommittee, which was chaired by Dr.
Edward Dempsey, at the time the Dean of Washington University
School of Medicine in St. Louis.  The concept was related to the
desire to link medical practice in the community with the
educational needs of practitioners in the community, with
academic health centers, where the research and clinical
developments were being initiated.  
     The second activity was the White House Task Force on
Health.  It was one of eleven Great Society task forces created
by President Johnson.  This was not announced to the public; it
worked in secret.  Its chairman was George James, the
Commissioner of Health for the City of New York.  He was very
concerned with some of the same problems from another
perspective.  As Commissioner of Health, he was wondering how the
services could be orchestrated, developed, disseminated among the
people for whom he had a responsibility.  
     The concept of restructuring health services was pursued in
that task force very intently.  A point of crisis came when two
positions were articulated: one, that financing health services
without restructuring would lead to extraordinary inflation in
the cost of health care.  The contrary position, that although
that may be correct politically, financing is all that could be
achieved.  
     The two groups, each reporting in December of 1964, were
brought together conceptually in the Office of the Assistant
Secretary for Health, who was Mr. Beaufeuillet Jones, and his
deputy was Bill Stewart, who became surgeon general in '65.  I
was the third professional appointment in the office.  There, in
developing the 1965 Health Message that was delivered by the
president to the Congress on January 7, 1965, we tried to bring
these philosophies together.

Lindberg:  Did you help put that together?

Kissick:  Yes.  I was the third staff person, and when they had
more important things to do, I kept working on these things.  
     The vehicle of Regional Medical Programs became very
prominent.  If one reads the Health Message, you note that there
was a request of the president for the support of the development
of group practice through a grant program.  This was not adopted
by the Congress.  But regional medical complexes became the
vehicle for looking for voluntary, pluralistic, pragmatic
university and community initiatives to come to grips with those
needs.

Lindberg:  It wasn't a single plan; it was a process to develop a
plan.

Kissick:  It was a process to develop plans, a very decentralized
initiative.  The conceptual roots were first the land-grant
college movement, the Morrell Act of 1868, I believe, which had
been widely developed around the country through the Extension
Service, bringing together eduction, research, and service to the
American farm family.  This was the basic conceptual root.

Lindberg:  It worked very well.

Kissick:  In that area, extraordinary.  Extraordinarily
successful.  The companion concept came from the Mountin Report
of 1945, from the Public Health Service, the Office of the
Surgeon General, to the Congress.  That report addressed
coordinated hospital and coordinated health services.  This was
the basis for the Hill-Burton Program.  So these two concepts
were then brought together, moving really a long the Hill-Burton
concept of decentralization and voluntary initiative within the
communities and services.

Lindberg:  Was there ever any confusion as to what a regional
medical complex is?

Kissick:  There was a lot of confusion.  There was a lot of
confusion.  Since I trust that the dissemination of this tape
will be limited, I will tell you about one very significant
confusion.  [Laughter]  A reporter for The Wall Street Journal
wanted to do a story on Regional Medical Programs.  He
interviewed Ed Dempsey, Bill Stewart, and myself, separately.  We
had been working together for approximately two months on a
common concept.  His interviews pointed out that each of us had a
little different idea of what the medical complexes really were. 
That was their strength, as well as their weakness, because
looking out at having some five dozen of these across the
country, in implementation, to my knowledge there were no two
alike.  

Lindberg:  That's right.

Kissick:  There were no two alike.  That is the genius and
strength of our health care enterprise.

Lindberg:  Sure.

Kissick:  In some three decades, I have visited more than 500
health care institutions.  In every state in the union, with the
exception of Wyoming, Montana, and the Dakotas, I have yet to
encounter two alike, even when they are part of a large system
such as Kaiser.  Kaiser Southern California is not Kaiser
Northern California.

Lindberg:  They're actually a separate corporation.

Kissick:  Yes.  It is certainly not Denver, Cleveland,
Connecticut, or North Carolina.  The diversity is extraordinary. 
RMP tried to play to that diversity as a strength.  Now, as a
weakness, the dissemination of information, the sharing of ideas,
the whole infrastructure, as I look back on those years, I think
one of the most significant lessons I ever learned was provided
for me a December evening around ten o'clock at night when we
were working on the Health Message, and Wilbur Cohen said to me,
"Bill, you've got to remember that health policy is ten percent
legislation and ninety percent implementation."  I think Regional
Medical Programs confirmed that aphorism.

Lindberg:  You were responsible for drafting up some of the
legislation, were you?

Kissick:  I participated.  I remember the comment by President
Kennedy, "Success has a thousand fathers.  Failure dies an
orphan."  At one point, RMP was a success, and I think there were
a thousand fathers and mothers.  In terms of drafting the
legislation, I probably did the most writing of the three of us
in the Office of the Secretary.  I guess the individual who did
the most intensive work on drafting was Karl Yordy, working with
Jim Shannon at NIH and trying to bridge the concept with the
existing infrastructure and the real potential.

Lindberg:  What was NIH's attitude toward the concept of Regional
Medical Programs?  Did they help?  Did they want to see it
succeed?

Kissick:  [Laughter]  What was NIH's attitude?  Another lesson
comes to mind.  This is reported by Schlesinger in his History of
the New Frontier.  President Kennedy was in the Oval Office with
his brother Bobby, Attorney General of the United States.  The
president says, "Bobby, I agree and you agree, but does the
government agree?"  Well, what does NIH think?  You'd have to
poll.  I think at the time--now this is my perception.

Lindberg:  How about Jim Shannon?

Kissick:  At the time there was an ambivalence that Regional
Medical Programs, as they became known, would pull NIH off of
their principal mandate, which is research, and get into the
development area.  Now, that's a real concern.

Lindberg:  Although it was a tiny amount of money compared with
the overall.

Kissick:  At that point.  But is it the camel's nose under the
tent?  When you look at research, development, testing,
evaluation, the research investment is about ten percent of the
continuum.  If you have all the investment in the research part
of the continuum and you see this being stretched out in
development, testing, evaluation, and then service, you have an
apprehension.

Lindberg:  It gets increasingly more costly, I'm sure.

Kissick:  Yes, much more costly.

Lindberg:  We have about forty approved clinical trials we can't
fund right now at NIH.

Kissick:  Yes.  This is big science!  This is very big science. 
I don't think this is a digression, but the cover article in Time
magazine about three weeks ago about "Science Under Siege,"
they're looking at all the needs in big science, be it in
physics, in human genome projects, and so forth.  You have to
choose among and between these.  
     NIH, particularly in 1965, was focused mainly on acute
undifferentiated research in R01 projects of individual
investigators.  So I'm sure there was apprehension in seeing it
move in that direction.  At the same time, there were others that
were saying, "Look.  We're doing the research.  We've got to come
to grips with the prevalence of cancer, heart disease, or things
of this nature.  Therefore, we've got to move in this direction." 
So I think both forces were at work.  I think that NIH went for
the control of RMP by having it positioned in NIH because of the
conviction that whatever happens, better we control it than it be
outside of our control.

Lindberg:  Although ultimately it did go outside.

Kissick:  Ultimately it shifted out.  I have not been able to
conclude, in my own thinking, as to precisely why.  I suspect
that over time there was a shift in the constituency.

Lindberg:  Yordy's view is that they were happy to see it go off
to service-oriented agency in return for getting health manpower
back in NIH.

Kissick:  That was a good political swap, because in addition to
controlling the research, you want to control the manpower. 
That's the internal analysis.  Looking at it from the outside, or
trying to look at it from the outside, I have assumed that what
was happening was a side effect of Medicare.  

Lindberg:  Same year, wasn't it?

Kissick:  Same year.  Medicare passed on July 30, 1965, signed by
President Johnson in Independence, Missouri, at the Truman
Library with former President Harry Truman as his witness, which
must have been a great experience for President Truman.  RMP in
October of 1965.  
     If you look at their developments in parallel--and this gets
back to your question about the concept of RMP--the concept of
RMP was complex.  If they weren't regional medical complexes,
they were certain complicated concepts.  No question about it.  
     Medicare, on the other hand, was a very simple concept. 
What we did in Medicare is say, "We will use federal money to buy
Blue Cross and Blue Shield for those sixty-five and older."  Less
than ten percent of the population.  So that although it was big
bucks, conceptually these programs had been evolving since 1929,
when the schoolteachers in Dallas, Texas, struck a deal with
Baylor University Hospital to pre-pay the potential costs of
hospitalization--fifty cents a month per schoolteacher.

Lindberg:  I didn't know that.  That's a good deal.

Kissick:  That was a good deal.  That was a very good deal.  So
this is what Medicare did.  Now, RMP is trying land-grant college
concept, coordinated health services, Hill-Burton, putting them
together in a political domain that wasn't understood.  I think
NIH said, "We control academic medicine."

Lindberg:  Gee, I hope we didn't say that.

Kissick:  Well, I hope they wouldn't say it, too, but I bet they
did.  [Laughter]  "We control academic medicine, so we've got to
have RMP, because that could be very powerful.  But we'll trade
it off for health manpower several years later, because in the
interim, Medicare has funded medical education through their
clinical practice funds, through the delivery of services."  So
now if you look at a very large successful private academic
health center--and I'm on the faculty of one and a trustee of
another--approximately forty to forty-five percent of their
income is for research.  Another forty to forty-five percent is
coming from the clinical practice fund.  So the character of the
institutions shifting over time enables them to trade off
regional program.  "We don't know how to handle those people out
there anyway, so we'll move it to that part of the organization
that has the mandate."  I suspect that there were those kinds of
forces.  
     One of the questions that we discussed and you asked me to
contemplate was what happened to RMP.  I think they lost their
constituency.  I think that the research went with the academic
health centers, the clinical practice funds went, the hospitals
are now working more with a concern over the regulatory
phenomenon.  We've got diagnostic-related groups.  We have a
whole constellation of activities under way.  The difference
between the health care enterprise in 1965--oh, by the way, it
was then accounting for six percent of gross national product.

Lindberg:  So it's almost doubled.  

Kissick:  It has more than doubled.  We're now at 12.2, and HCPHA
[phonetic] says we're gong to hit 15.

Lindberg:  Of course, I always thought the constituents of RMP,
in our case, were patients, particularly patients in
disadvantaged areas and social groups and rural areas.

Kissick:  How do you hear from patients?

Lindberg:  That's exactly right.  They might not have known that
they were the people we were trying to help.  

Kissick:  The way we hear from patients now is through the
American Association of Retired Persons, known affectionately on
Capitol Hill as "the geezers from hell."  They can really come
forth with a lot of letters.  They've got a lot of time, they
know how to write, they've got phones, and they've got special
MCI and AT&T programs.

Lindberg:  I sure wish that we had had an AARP [Association of
American Retired Persons] to be talked to about Regional Medical
Programs.

Kissick:  We had an AARP for Medicare.  They were a different
group then and they were formed by Amy Forand, who had been a
congressman and decided not to run for Congress in order to
organize a lobby of senior citizens to support what was then the
King Anderson Bill, which was an outgrowth of what he had
introduced, the Forand Bill.  Patients, per se, where do they
express their views?

Lindberg:  Labor unions.

Kissick:  Through labor unions, through AARP, at the local level.

Lindberg:  In those days, labor was a much higher percentage of
the population than now.

Kissick:  One of the key players on Capitol Hill for Medicare
were AFL-CIO, American Medical Association, American Hospital
Association, and American Nurses Association.  
     Now, a digression which I think is relevant to Regional
Medical Programs.  At the present time, there are more than 100
physician associations with political lobbying, twenty-nine
nurses associations.  So there's been a very interesting
dispersion of that kind of focus.

Lindberg:  Bill, let me shift the question and present it to you
in the range of patients and RMP activities.  What was the best
you saw?  What was the high point?  What was the most worthwhile
achievement?

Kissick:  I can't say "best," because since no two were alike,
you're always comparing apples to oranges.  As you know--and I
don't want to embarrass you--yours was one of the best.  

Lindberg:  It won't embarrass me at all.

Kissick:  It won't embarrass you at all.  The University of
Missouri Columbia, across the board, really was impressive.  I
think at your height, you had something like 250 to 300
professional and technical people involved in the program,
working in a classical land-grant college philosophy, linked
throughout the state relating to hospitals, physicians
individually, physicians in groups, physicians in political
organizations like the State Medical Society.  
     Another one, very different, Connecticut, used Regional
Medical Programs to draw a Maginot Line through the center of the
state.  Yale affiliated with everybody on their side of the line,
and University of Connecticut affiliated with all the hospitals
on the other side.  They now have a linkage of training programs,
sharing of residencies, medical students moving out into health
care settings they would not see in an academic health center. 
     An unknown and little appreciated dimension of RMP in
Connecticut was CUPIDS, Connecticut Utilization Patient
Information Data Systems.  CUPIDS enabled them to analyze the
utilization of services at all thirty-five Connecticut hospitals,
and brought forth diagnostic-related groups.  

Lindberg:  Oh, my gosh.

Kissick:  This was the conceptual base.  Washington launched
WAMI, Washington, Alaska, Montana, Idaho, for making a broader
opportunity for medical education, relating it to graduate level.
     Iowa was sort of out front to start, but made just
incremental modifications in a classic model that they had.  One
of the experiences I found most exciting was in and around the
University of Tennessee in Memphis, because there they tried to
put together the Regional Medical Program Advisory Council and
the 749 Comprehensive Health Planning 314B agency as a common
agency to link an academic health center with health services in
five states.  
     A local experience which I knew fairly well and I mentioned,
even though we were not successful to the degree we'd hoped, was
the University of Pennsylvania in Philadelphia, and there we
attempted to bring together the Regional Medical Programs around
Penn to mental health services in West Philadelphia, community
health centers, and the Comprehensive Health Planning, to
attempt, in an almost amateurish fashion, what you were doing in
Missouri, but we didn't have a land-grant situation.  

Lindberg:  Big cities are very difficult.  

Kissick:  We had a population base of 400,000 people in
Philadelphia, west of the Schuylkill River.  We developed data
that was just a matter of collecting secondary data,
collaborating with the health department, and we developed an
understanding of the problem.  We made very little progress in
improving services.

Lindberg:  Do you think if the program had continued anther five
years, you might have solved the problem, as well as defining it?

Kissick:  Another five years, that gets me from '74 to '79.  No. 
It's all contextual.  It's all compared to what?  I don't think
organized medicine was frightened enough.  I know they weren't in
'79.  '82, it didn't really bother them.  Their cages didn't
really get rattled until resource-based relative value scales,
late eighties, and therapeutic protocols, which the AMA calls
practice guidelines.  Well, they may be practice guidelines to
them, but I think they're going to be therapeutic protocols.

Lindberg:  I think the law calls them practice guidelines. 
[Laughter]

Kissick:  Like regional medical complexes, right?  [Laughter]

Lindberg:  That's ten percent of the story.

Kissick:  That's ten percent of the story.  What about that
ninety percent?  Where I come out is, here we are in September of
1991, and my question is, where are Regional Medical Programs now
that we need them?

Lindberg:  Right.

Kissick:  We were quoting, in 1965, Victor Hugo, and we were
quoting him because Everett McKinley Dirksen, then senator from
Illinois, would love to do it in mellifluous tones on the floor
of the Senate.  "There's nothing so powerful as an idea whose
time has come."  And we said, "RMP is an idea whose time has
come."  I think it was an idea whose time was premature. 
Conceptually, right now, in my opinion, they're desperately
needed, and without them, academic health centers are in real
trouble--in real trouble.  Because I don't think society is going
to continue to be excited by biomedical star wars.  I think
they're going to be after the very things you were experiencing
in Missouri in 1966 and '67.

Lindberg:  Looking back on that, what's the lesson?  How can we
do it better this next time?

Kissick:  What's the lesson?  

Lindberg:  Clearer goals?  Broader constituency?

Kissick:  Goals are part of it.  We had goals.  We did not have a
referendum on those goals.  Recalling some of the national
meetings around Regional Medical Programs, we spoke many tongues. 
Well, here's the lesson.  Academic health centers represent a
fruition of the Flexnerian model.  Flexner reported in 1910.  His
concept was launched by Johns Hopkins in 1889.  So it was under
way for twenty years before he published.  So when he went around
the country and they said, "Abe, what's a regional medical
complex," he could point to Johns Hopkins.  He could point to
Johns Hopkins.  We couldn't point to anything then.  We had a
premature concept.  But now we look at academic health centers
and we look back over a century since the concept was launched in
eight decades since Flexner implemented it, and Flexner's secret
was he left Carnegie and went to Rockefeller Foundation, with
Rockefeller's money.  He was a mini-NIH implementing his own
concept.  Well, if he had been alive and working in the fields in
1965, I don't think he would have had the concept.  There's not
something he could have pointed to.  
     I think now we can begin to point to some things that are
happening around the country, some successes, and I think that we
could exploit some of that.

Lindberg:  There have been tremendous changes, and a lot of them
really were part of the more advanced RMP ideas.  The prominence
of out-patient clinics, for instance, home care and graduated
care, hospice, visiting nurse, and all those were still really
quite new ideas, at least in Boome County.

Kissick:  Yes.  Very new.  I think that as we were trying to do
it back in '65, I think we had the right concept, but we didn't
understand the culture.  We didn't understand the culture.  When
I point to the fact that Medicare was not a difficult concept and
it had been around--Blue Cross and Blue Shield--for three
decades, we'd learned a lot during those three decades.  The
concept had become clarified very, very significantly.  I think
that now that we have a quarter-century under our belt since
Regional Medical Programs, that all we've got to get is Congress
to enact them all over again, and this time around we'll do a
better job.  

Lindberg:  Okay.  Wish the country better luck this next time.  

Kissick:  Better luck.

Lindberg:  Thanks so much for being with us.

Kissick:  Thank you for having me with you.  I really enjoyed it. 

[End of interview] 
                          Addendum to Interview

Question:  Tell Dr. Lindberg all about it.

Kissick:  What happened to the constituencies of RMP can be
looked at from a variety of perspectives.  I think the dominant
development was that the main constituency, academic medicine,
became supported by both biomedical research and clinical
practice funds, so that they could do what they wanted to do and
needed to do from their perception without the linkages through
RMP.  

[End of recording]


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