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Interview with Dr. Edward J. Hinman
Date:  September 24, 1991
Interviewer:  Dr. Donald A.B. Lindberg
Transcriber:  Techni-type Transcriptions/MEF


Lindberg:  I'm Donald Lindberg.  I'm Director of the National
Library of Medicine.  We are investigating by interview and
conference the history of Regional Medical Program and its
legislation in the United States.  I have the privilege today to
be interviewing Dr. Ed Hinman.  
     Ed, thanks so much for being with us.  

Hinman:  My pleasure.  

Lindberg:  As I recall it, you were in a local RMP and also you
later came to work for the RMP office in Washington.  Is that
right?  

Hinman:  That's correct.  I was active with the Regional Medical
Program of Maryland while serving as the director of the Public
Health Service Hospital in Baltimore, and when I left that
hospital I came into Washington to be part of the Regional
Medical Program Service.

Lindberg:  So in that case, you reported to Dr. Margulies?  

Hinman:  That is correct.  

Lindberg:  Which did you like better of those two roles?  

Hinman:  [Laughter]  They were quite different.  I enjoyed both
of them.  No regrets about either.  

Lindberg:  Well, you know we have an interest in looking back
twenty-five years at this program which started out with much
enthusiasm and didn't last as long as its proponents hoped.  What
were some of the merits of the program?  Let's take the good side
first.  What did it achieve in terms of activities you were able
to observe?  

Hinman:  Unfortunately, it didn't reach its full potential.  I
think the things that it did do is it began to get people talking
on the professional side. Not just the consumers, but
professionals talking about how health care services could be
delivered outside the medical school arena, which was, of course,
part of the original intent, to be able to diffuse technology of
one sort from the medical schools out to the practicing
physicians.  That dialogue did get initiated after some false
starts and I think there have been some areas where there was
some impact that still persists.  

Lindberg:  It's interesting that technology is a focus that most
who lived through RMP recall very well.  In looking back at it
all these years later, the technology was kind of simple-minded
compared with what we're talking about now.  Is that right?  

Hinman:  Well, it depends on how you define technology, doesn't
it?  Because the issue was that there were a number of people who
did not have adequate access to primary care services nor to
secondary or tertiary levels of services and the technology was
the technology available at the time for tertiary levels of care
and how to get people access to that.  

Lindberg:  But I mean it's quite amazing to think that in those
days there really were not intensive care units in the vast
majority of American hospitals, only in the most advanced.  Isn't
that so?

Hinman:  Well, I'm trying to remember.  In our hospital in
Baltimore, we had a coronary care unit that went in sometime in
the mid-sixties.  So I guess that for many of the hospitals it
was during the RMP era that CCUs were introduced and some of the
other technology.  Of course, kidney disease was one of the
programs and RMP did a lot of support for the development of
various forms of dialysis and transplantation.  

Lindberg:  I would guess that most hospitals of the time weren't
doing vascular surgery.  

Hinman:  No, they weren't.

Lindberg:  So I mean it's only twenty-five years ago, but it's a
pretty major change in medical technology.  

Hinman:  Extreme change.  

Lindberg:  The kidney business was added, I believe.  Emergency
medical services and kidney dialysis were added on top of heart,
cancer, and stroke.  Is that right?

Hinman:  The original legislation only specified the three things
that you mentioned.  But with the phase-out of the chronic
disease programs of the Public Health Service of the old Bureau
of State Services, those activities came over to RMP and that was
where kidney disease was picked up and the smoking and health
program was picked up and then, due to Vern Wilson's interest, I
think largely, the Emergency Medical Service activities were
emphasized.  

Lindberg:  You think Maryland was unusually advanced in any of
these?  As I recall it, the Emergency Medical Services prospered
in Maryland, didn't they?  

Hinman: Well, certainly they did at the University of Maryland. 
That program is still considered one of the better shock trauma
programs in the country.  I believe most of that, though, was
developed other than with RMP funds.  

Lindberg:  Was it planned for?  I mean, it's one of the few
states I know of with a true statewide system that was the type
of thing RMP was trying to achieve.

Hinman:  I just don't recall the role that RMP played. 
Certainly, once there was the demonstration of what could be done
with the earlier interventions in the multi-system trauma cases,
there was a lot of effort on the part of a number of people in
the state to be able to replicate and to get Marylanders access
to that system, eventually through the helicopter approach.

Lindberg:  One of the interesting technology applications was
automated EKG.  Did that function in Maryland at all?

Hinman:  We had several programs, but again that was originally
funded by the old Bureau of State Services, wasn't it, as opposed
to RMP?

Lindberg:  No, it was RMP.

Hinman:  It was RMP?

Lindberg:  It was RMP.  

Hinman:  That was before I was active--

Lindberg:  Well, of course, the system I worked with was
developed by Caesar Kasaris [phonetic] in the Public Health
Service, but the dissemination outside the laboratory was an RMP
project.  
     Ed, something that a number of experts have talked about
here in the series is the question of did RMP lose its focus. 
That's something that the politicians said had happened and they
listed that as a criticism.  But even people who were advocates
of the program have addressed that question.  In other words, was
it to be categorical, so to speak, heart disease, cancer, and
stroke or was it to be generally directed towards problems of
health care delivery and health care services research and so
forth?  Then, of course, that whole picture was complicated by
then the Congress adding kidney and dialysis and EMS.  In your
view, was there a confusion, and which was the right side, if
there was a right side?

Hinman:  That's a complicated question.  The period when the
initial legislation was passed, there was a lot of emphasis on
categorical programs. It was a period of increasing support for a
number of the different institutes at NIH and the way that money
was made available was through emphasis upon categorical
programs.  I think many of the people felt that to be truly
successful it needed to go beyond just a categorical approach,
but that tension in the program, I think, was an important factor
and probably ended up losing some support from certain people in
Congress when it became much more interested in looking at all
the health care needs of the people that were to be served by the
RMPs.

Lindberg:  Another question that's been discussed I'd like to put
to you and that was the role of the AMA, which initially, we
realize, was to essentially to deflect some of the direct impact
of the Heart Disease, Cancer and Stroke Commission report, to
translate that into a legislative language that was more
acceptable.  Did you have any contact with AMA on that?

Hinman:  Not on that, but there was always someone active in the
AMA hierarchy who was on the advisory council or one of the study 
sections.

Lindberg:  Well, it was interesting to me that here just a few
days ago Dr. Robert Marston, who was the first RMP Director, say
that he found AMA to be tremendously helpful to him in running
the program once they got used to the idea.  So I wondered on
that side, did you have any help, either from AMA or from the
state medical association in Maryland?

Hinman:  I think that the universal experience from the staff of
the RMP program was that the AMA officers and the local officers
were very supportive.  There was the initial hostility and worry,
but by the time I came along there was good support from the AMA.

Lindberg:  That's very interesting.  Personally, what was the
most gratifying accomplishment in RMP for you?

Hinman:  There were a number of things that we enjoyed, but I
think the one I felt was the greatest achievement, in a sense,
was a conference we put on in St. Louis, I believe in 1972.  And
it was on the issue of methodology for quality care assessment
and quality assurance activities.  And at that time we brought
together the leaders who were doing investigative work and
writing on the subject with the RMP coordinators and other RMP
staff and put out a monograph that still stands as a good
reference source, and that was personally, I think, one of the
high points for me.

Lindberg:  So you're directing the question at something you
considered fundamental.  

Hinman:  Absolutely.

Lindberg:  Yes.

Hinman:  Absolutely.

Lindberg:  But it might be hard to explain that to a patient, I
suppose.

Hinman:  Well, possibly, if they could see the things the quality
of care activities are centered around, many of them would feel
much more comfortable that somebody was looking out for them.  

Lindberg:  Yes.  Well, you know, Ed, one of the things that RMP
was sort of criticized for, I don't know whether you'll think
it's fair or not, but in the oversight hearings it was said that
Comprehensive Health Planning was a program in which there was a
kind of domination by consumers and RMP was a program which was
dominated by providers, namely the doctors.  That, in my
experience, didn't seem like a fair criticism, but it may well
have been and I wonder how you would respond to that.

Hinman:  The focus of the two programs was different.  The
Comprehensive Health Planning program was structured so that
consumers would be the majority in the decision-making role, at
least numerically.  They were often intimidated by physicians,
but numerically they were in the majority and they did not have
the same level of visibility or the same input in the RMP
program.  I think it would be fair to say that RMP was more
provider-oriented because there was an emphasis to include allied
health professionals beyond physicians.

Lindberg:  Oh, yes.

Hinman:  The consumer input was there, but it was much less
visible, so in a sense that is, I think, a fair statement.  The
sad thing is that they didn't get together and capitalize upon
the strengths of the two programs.  They sort of went their own
merry way very often and ended up being in conflict with each
other at times.  

Lindberg:  Did you see any of that conflict?  

Hinman:  Not directly.  But when you were looking at funding
priorities, for instance, the Comprehensive Health Planning
program would be much more interested in funding neighborhood
health centers, activities of that nature.  But that was not what
RMP would be funding, so there was tension over the fact that the
RMP activities were more esoteric, if you will, or more
technology driven than the CHP activities.  

Lindberg:  Well, they certainly ended up competing for the same
dollars because in the end the administration took the position
that RMP wasn't needed partly because of the wonders of the
Comprehensive Health Planning programs.  It's interesting,
though, you saw some merit in the argument and so I guess it must
be there.  I personally saw more consumer input in health care
planning in RMP that I'd ever seen before or since.  Under any
circumstances.

Hinman:  But you didn't ask me that question.  [Chuckles] 
Because the health planning that went on in some of the RMPs far
exceeded the health planning that went on in the Comprehensive
Health Planning programs.  Because they got into a lot of
political debate.  By political, I mean political amongst the
individuals in communities, as to where resources were going to
be placed and how it was going to be accessed.  This was an era
in which the feeling was the primary services should be available
essentially on every street corner.  And the CHPs had tremendous
battles dealing with that kind of an issue.  And, fortunately, in
the Regional Medical Programs Service we didn't have that.  

Lindberg:  Ed, in the end, good, bad or indifferent, RMP came to
an end.  Could you say if you remember any of that and if you
have any explanation for its termination?  

Hinman:  Well, as budget cycles go, we were in a period when the
president determined that it was necessary to cut back on many of
the Great Society programs and RMP looked like a pretty easy
target, I think.  That was one of the things that was driving the
Office of Management and Budget.  It was a period in which there
was a cutback in federal employment and other budgetary devices. 
So I think we just happened to be one that looked very easy under
the meat ax, but as it turned out it wasn't that easy because the
suit that was filed by the coordinators tended to slow it down a
good bit.  

Lindberg:  How did this come to your attention?  Did you find a
blue slip on your desk?  Did you read it in the Washington Post? 
I guess the president didn't ring you up on the phone, did he? 

Hinman:  No, no, but when the budget message came out, it was
clear that things were not looking well and then the marks
started coming down on how the budget was going to be implemented
and we were told that so many staff had to be gone by date
certain and the division directors were given the opportunity to
decide which staff went when, so I wrote my own pink slip, so to
speak.  

Lindberg:  [Chuckle]  You were by then in the federal government?

Hinman:  Well, I had been in the federal government for a number
of years at that time.  I was a commissioned officer in the
Public Health Service.  

Lindberg:  Yes.  So you saluted and moved on?

Hinman:  That's right.  

Lindberg:  There's talk even nowadays about legislation to look
again at some of these major problems that RMP was aimed at. 
What do you think are the lessons one can take from this older
program?  

Hinman:  It's hard to view any legislation right now that is
going to have money with it because of the tremendous national
budgetary difficulties.   We still haven't learned the lesson of
regionalization appropriately. Even in spite of the best efforts,
we see too many institutions trying to do things for which there
is inadequate demand to support the investment.   The issue of
the capacity of many hospitals have developed in medium and high
tech areas far exceeds any conceivable demand that is going to
come along.  So I think we still have failed to accept that
regionalization has merit to the extent that we should.  That's
most evident in things like world health care problems, migrant
worker health care problems, and some of the urban city problems. 
Because I mean here they are in the shadow of institutions where
they can get excellent tertiary care and there's no primary care
available to many of our residents.  
     So I would hope that if I could write the legislation, I
would try to put some more muscle back into trying to have better
regionalization of some of our very expensive resources.  In
cities like New York and Philadelphia and Washington we have far
too much duplication and inadequate utilization of certain kinds
of things, particularly transplant activities, some of the high-
tech chemotherapy and cancer work with the attendant bone marrow
transplants.  Those are very big-ticket items and I just don't
think we are getting the best use of our dollars.

Lindberg:  Well, I don't guess this is the right occasion to
debate that.  [Laughter]

Hinman:  Yes, I don't think there's going to be legislation
putting more money into anything like the old RMP.

Lindberg:  Ed, we've discussed some of the good things that RMP
did.  You undoubtedly saw some of its failures as well.  Would
you draw attention to those for us, please?

Hinman:  I guess some of the worst things were the activities
that didn't get to be completed.  One that I had mentioned to you
before we started was in the kidney arena.  The RMP staff and the
leadership in the RMPs had felt that we should be put some
emphasis in supporting home dialysis programs, improving
peritoneal dialysis programs, and strengthening the developing
kidney transplant activities.  We were at the point of beginning
to pull that off when circumstances passed us by, by the passage
of the amendments to the Medicare Act that established the
National Instage Renal Disease Program.  I think it was a failure
that we weren't able to get that out, because if we could have
had a couple of years we might have been able to have shifted the
emphasis so money wouldn't have gone into dialysis centers and
gone into improving transplant for the patients that needed them
and home dialysis programs.  So I think that was a failure.

Lindberg:  You were a nephrologist, so you must have felt badly
about all that.

Hinman:  It bothered me a great deal.  

Lindberg:  What's the situation at the moment?  How did it come
down?  

Hinman:  It's a very expensive part of our health care program. 
Patients are being treated.  There still is much more
institutional-based dialysis than needs to be.  We still are
having problems with some of the organ procurement and transplant
activities.  So I think we are behind where we could have been if
that had been allowed to come to fruition because that was twenty
years ago.

Lindberg:  Yes.  Well, those were government programs that
meshed, but they broke a few teeth in the course of meshing.

Hinman:  Well, we had to stop our initiative when the legislation
was passed.  The money was not made available for that
initiative.  Several of the programs were really quite weak in
the individual areas, so I don't think that they--

Lindberg:  RMPs in particular locations.  Oh, I'm sure that must
be so.  

Hinman:  Specific.  As happens with any type of national program. 
If you look at the state of Washington, the WAMI program, the
Washington, Alaska, Montana, Idaho program for medical education
was largely supported in its inception through RMP and that's
still a model of how to do certain things.  In North Carolina, 
their Health Education Center program, which is still in
existence, was started with RMP money.  So those are successes
that have remained in communities supported by other methods.  I
guess the failure is that we didn't solve problems of that nature
in some of the states, particularly some of the more rural
states.  We just didn't make much progress in helping many of our
rural citizens.

Lindberg:  But do you think it did better in cities or rural?

Hinman:  Probably generally in cities.  

Lindberg:  Do you?  I had the opposite impression, but I guess
that's an unquantitative question.

Hinman:  But you were seeing it from the other side than I was.

Lindberg:  That's right.  I was out in the sticks. 

Hinman:  Well, Missouri is certainly not the sticks.

Lindberg:  Well, that's true.  The AHEC question, I wonder if
you'd discuss that a little more.  Our listeners may not remember
that AHEC is Area Health Education Center--AHEC.  Those do still
exist in many areas.  But it was a separate program.  How did it
seem to you at RMP headquarters?  

Hinman: Well, from a staff standpoint it was a major competitive
program.  There were three agencies that were vying to be the
lead agencies in this area--the Bureau of Health Manpower of the
National Institutes of Health, the Veterans Administration
central office, and the Regional Medical Programs--all had their
version of what Area Health Education Centers should be.   

Lindberg:  It would be interesting to hear what the differences
are.  

Hinman:  There was a lot of lively debate.  There were two kinds
of differences.  One, which was a professional difference of
where the emphasis would be, and the other, which was pretty much
of a turf battle as to who was going to have the dollars and who
was going to direct the program.  To be very blunt about it,
there was a concern about which agency would run it.

Lindberg:  Conceptually, what were the differences?  

Hinman:  The Area Health Education Centers proposed by the
Regional Medical Program Service was more oriented around using
educational funds to improve the capacity to deliver care within
the region.  That is to say, there was planning to see what the
needs were for various types of health manpower and then to try
to put money to help satisfy those needs.  An example would be
looking at the needs for physical therapists, occupational
therapists, in an area and then trying to either subsidize or
start training programs to help get them into the--

Lindberg:  What was the Bureau of Health Manpower concept?

Hinman:  The Bureau of Health Manpower was a little more oriented
around continuing medical education for health professionals and
using the resources of the medical schools to try to improve CME
activities out in the individual communities.  And, of course,
that's the program that eventually was where the money went and
was the emphasis of the Area Health Education Program.

Lindberg:  They both sound like worthy objectives.  What's the
third one?  We have the VA.  How does that fit in?  

Hinman:  I don't remember as many of the professional details of
the VA proposal.  It was much more the Bureau of Health Manpower
approach than it was the RMP program, and I just don't recall any
specific elements of that program.  

Lindberg:  But you do remember there was a difference in point of
view.

Hinman:  That is correct.  

Lindberg:  There were really in that era a wealth of federal
legislation.  I guess you've mentioned the major issues.  Have we
skipped any?  

Hinman:  We haven't really.

Lindberg:  Medicare, of course, is a big one.

Hinman:  Right.  The Emergency Medical Services Program arose out
of this period and there were a fair number of dollars that went
into that, that came through the National Center for Health
Services research after the RMP program had been cut back a great
deal.  That's one that we hadn't gone into in any depth.  There
were a number of the Health Services and Mental Health
Administration programs that were involved in various pieces of
Emergency Medical Services.  Vern Wilson, of course, was a major
supporter of that initiative.

Lindberg:  Did mental health, drug abuse, all those things, did
they occupy RMP at all?

Hinman:  Not that I recall.

Lindberg: And, happily, we didn't have AIDS at the time to
compete for interest and dollars.

Hinman:  That certainly is a program that would respond to the
regionalization approach quite well.

Lindberg:  It would have.  In fact, a number of persons we've
interviewed have suggested that in some respects RMP could have
been, or perhaps was, a conduit for shipping new technology into
the communities, getting communities ready for it.  

Hinman:  Many of us felt that was the real justification for
having an RMP program as opposed to a categorical emphasis on
developing new knowledge, and I think that was part of what was
behind the transfer of the RMP program out of NIH over to the
Health Services and Mental Health Administration.  

Lindberg:  Is there a simple sentence for you that sums up what
RMP was trying to do?  What did it mean to you?  What were you
trying to do when you were in it?  What was the objective of it
all?

Hinman:  Taking information from the centers of research and
translating it out to where people could receive better care.  

Lindberg:  I'll buy into that.  Okay.  Thanks so much for being
with us.

Hinman:  Thank you.

[End of Interview]