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     Interview with Professor John Thompson Head, Division of
     Health Policy Yale University School of Medicine and Dr.  George
     Silver, Former Deputy Assistant Secretary of Health the (then)
     Department of Health, Education and Welfare.  
     Date: July 8, 1992
     Location: New Haven, CT 
     Interviewer: Stephen Strickland

           give penicillin every time someone came down with strep
     throat, the rational of that being that it is also preventative of
     heart disease.

           Strickland: Well what about the Maine program aside from the
     connection with the Tufts Medical School?

           Thompson: Well, the guy in charge was working so hard, he was
     an Indian, from India...

           Strickland: Chatterjee?

           Thompson: Something like that.  And to see that man somehow
     whip those damn Yankees into shape!  It was my impression that he
     was situated in Augusta, and that's pretty far off and he was
     trying to do the best he could.  He was trying to involve
     everybody.  There is only one V.A. hospital in all of Maine, and
     that is also in Augusta and he was trying to drag them into it
     somehow.  He was a cardiologist I think.  Chatterjee, how did you
     remember that that was his name?

           Strickland: I remember seeing it or maybe even hearing it at
     the December conference at the Library of Medicine last year.

           Thompson: Was Henry Clarke there?

           Strickland: No I don't think so.  There was all kind of
     speculation, and still is, as to why if the RMP's did such a good
     job they were terminated.  Thompson: Well their weakest point was
     their evaluation; there was simply no way to get a systemmatic
     evaluation of the programs.  That's why we spend so much time on
     this damn Davis System because we could begin better measurement of
     health outcomes.  And a lot of the program was in education --
     public education, physician education and the evaluation of those
     programs was difficult.  First you have the context but then you
     have the practice and that's the thing you're interested in, not
     what is on page six of the hand out.  And the program people were
     not sophisticated educators, so there were problems with that but
     they were done in by public law 93-641.

           Strickland: Which is the..

           Thompson: National Health Planning Board.  See what happened
     was that that was passed shortly after the RMP legislation but it
     had a different constituency, consumer constituency varied somewhat
     between state health department or in some sort of designated
     planning group, but they control a kind of power that RMP never
     had.

           Strickland: RMP was basically convening device or support
     mechanism.  And if institutions didn't want to do it, it did not
     have enough money to pursuade them to.

           Thompson: No, you could buy them.  And then there was of
     course that fact that health planning had a different constituency,
     these were the social planners, and that sort of business, and they
     all screamed that the old medical schools were taking over the RMP;
     that the schools took the money and ran, didn't do anything.
     Meanwhile they said we're out here working in the trenches for
     years, we were a consumer-based organization, Ralph Nader's
     business, involving consumers in health care decisions.  So they
     wiped the RMP right out of action.

           Strickland: And you say that, when RMP's were done away with,
     it was in one of those periodic times when budgets are tight and so
     something has to go.

           Thompson: Yeah, but that's no good because they were
     funneling more and more money into 93-641.  And I think those
     professional planning people just pressed the right buttons and the
     medical schools were probably by this time getting bored with this
     RMP shit anyway.  Besides medical schools are never going to get in
     the arena with a publicly represented body of some kind.  No
     medical school is going to fight national groups of this kind, it
     would be death.  So they didn't.

           Strickland: Now, what kind of planning still goes on.  Is
     there still a particular need for this?

           Thompson: Well there are still GLN's some states have done
     away with them, and in this state it was taken over by the state
     and other states too.  Some formal bureaucratic kind of business.
     Most of the bodies had a consumer interest.  Its not like it was
     with 93- 641 where the majority of the people had to be consumers.
     So that was unworkable.

           Strickland: But in fact weren't there lay people on the
     Regional Medical Program's Advisory Board?

           Thompson: Oh yeah, but there were not consumer advocates,
     they were people who were interested in cancer or heart disease.
     Strickland: Representatives of groups with particular health
     interests like American Heart Association...

           Thompson: Or somebody whose father died, or mother or
     something like that.

           Strickland: They were health oriented rather than consumer
     protection oriented.  For some reason Dr.  Barrow in the state of
     Georgia, thinks that the principal competition to RMP in Georgia
     turned out simply to be Medicare.  That the Georgia program got a
     lot of doctors who were volunteering for community health programs
     and that sort of thing because they weren't getting paid anyway by
     their poorer patients.  That the RMP was a way of systematically
     dealing with a patient population with which they would one was or
     another have to deal with, so they just did it.

           Strickland: In any case, what were some of the main features
     of the Connecticut program?

           Thompson: Well, for one thing, we surveyed and catalogued
     everything.  This school was kind of like an intelligence center.
     If the RMP wanted a certain study done before mounting some
     programs, they would commission this, Yale, school or the new
     medical school at the University of Connecticut, to do it, and we
     would send a block of students out and get a formal report to
     submit to RMP. For example, we did a study about physicians and
     their affiliations with hospitals.  We did a big study on total
     radiation therapy.  We must have done 50 or 60 studies of
     particular problems which helped them because they were very cheap
     because all they had to pay for was travel time.  And It was very
     good for us because we got our students out into the community.

           Strickland: We have been joined by Doctor George Silver, one
     of my old friends.

           Silver: Anyhow, I don't have too much to tell you Steve, I
     told you on the phone is that all I know is from the early part of
     heart, cancer, and stroke stuff.  I was Co-chair of the Commission
     on Heart, Cancer and Stroke along with Debaky but he really ignored
     me.  He really wanted to coordinate the whole thing.  The most
     important thing we were able to do as you probably recall is with
     that same report, they got Medicare.  And the other thing they were
     able to do was change the word "complex" to Program, Regional
     Medical Complex was changed to Regional Medical Program.  An the
     "coordination" function was changed to a cooperative one.  And they
     added a noninterference clause.  All in all, I understand that
     there were twenty A.M.A. amendmentss and it undermined the
     opportunity the RMP had to do something creative.  But the AMA
     objected to some key proposals of the RMP package and it also
     interfered with the medical schools taking over the prgram.  Tommy,
     do you agree?  Thompson: I think that there were selective programs
     that were good.  There were other programs that the medical school
     really didn't have the faintest idea of what they were doing.  And
     if you go to a place like Tennessee, you had University of
     Tennessee, Vanderbilt, and Meharry.

           Silver: Memphis-Baptist Hospital was the most important
     teaching hospital in the United States.

           Thompson: But you had Meharry Medical School.

           Silver: Which was nothing.

           Thompson: Yeah.  Very little came out of there.

           Silver: The thing I was getting at was the Rochester
     experience which had a regionalization base.  It was indicated that
     you could create a way to involve all of the medical institutions
     and personnel provided you didn't sneeze too hard.  That experience
     was ignored and the idea that all of the institutions would want to
     be the regional medical complex was the AMA's position and that was
     the point you make.

           Thompson: I think that we had a look of Rochester business
     here.

           Silver: Yes, I had to mediate between you two giants each
     time.

           Strickland: Most of the discussion I heard in December was
     that the Debaky plan was thwarted by the AMA. What you are saying
     is that if the plan had been simply adopted wholesale and we tried
     to implement it as a national proposition, it might have been a
     failure...

           Silver: I wouldn't exactly say failure but not necessarily a
     success.  What would have happened is that it would have maybe
     accelerated what we see today with medical schools focusing less on
     patient care and becoming more involved with their own
     institutional needs.  They would be driven not by their original
     purpose, which is to take care of sick people, but with
     multiplication of their own internal needs.  That would have
     happened in a half dozen places in the United States.  If you were
     a practicing physician and you wanted something new in techniques
     or technology to compete with other schools and hospitals, the
     patient would be less important.  It's not to different from what
     happened in England before they started leaning hard on the general
     practitioner.  Don't you agree?

           Thompson: Yeah.

           Thompson: So in a sense, having a series of competative
     regional medical complexes would have further distanced the medical
     care system from the patient.

           Strickland: I see.

           Thompson: That's what I meant.

           Strickland: That's very clear.

           Thompson: So 10 or 12 institutions that had the capability
     would dominate the whole field and the rest of them would just be
     sucking hind tit.  There never would have been enough money in the
     government to set up 120 centers.  Strickland: Did Dr.  DeBakey
     actually have that many in mind: Silver: He said that, because that
     was the number of medical schools in the country at the time.  But
     I don't think he meant that.

           Strickland: What should we do to reform the health care
     system?

           Silver: That's not part of your project mission, is it?

           Strickland: Well, one part of the mission is to see whether
     there are any lessons in RMP for revising or remodelling the health
     care system.

           Dr.  Strickland: The RMP experience is only useful when there
     is a structure of reform into which the lessons of RMP can be
     applied.  Do you agree Tommy?

           Thompson: Yes.

           Strickland: Everybody says that the one thing the RMP did
     almost everywhere was to facilitate if not actually encourage, for
     the first time, cooperation among institution.  In a lot of places
     people of one hospital never talked to people of another hospital.

           Thompson: Oh yes.

           Silver: Here in Connecticut, the major contribution that RMP
     made was that it gave some poor hospitals an opportunity to improve
     themselves.

           Thompson: They didn't necessarily do anything different, but
     they tried.  The people in charge of particular medical services
     didn't always try their best to extend those services to more
     people.  By giving them ranks and title they thought this would
     encourage them to do better and that is a false asumption.

           Silver: Yes, but they improved Waterbury; they improved
     Danbury and Greenwich.

           Thompson: Danbury was on its way up anyway.

           Silver: And they did some good things in Bridgeport.

           Thompson: Two of the hospitals, yes.  There are three of
     them.  There is Park City, St.  Vincent's, and Bridgeport.  

           Silver: Bridgeport Hospital is not a bad hospital.

           Thompson: That's true.  In fact, all over the country there
     was a very significant advance as far as medical care is concerned.
     For most people it became more available.

           Strickland: The second thing that it said for Regional
     Medical Programs is that, for better or for worse, they let states
     and communities decide what the priorities were.  I mean, everybody
     was aware of the heart, cancer and stroke emphasis, but beyond
     that, the regions decided their priorities and constructed their
     programs Silver: That was one of the peculiar things about the
     program.  I went out to New Mexico and they said that's not our
     problem.  our problem is alcoholism among the Indians.  You can
     take your heart, stroke and cancer money and to hell with it; there
     is nothing there for us.  They did somehow establish some tenuous
     relationship between alcoholism and hypertension.  But that was a
     pretty weak link.

           Strickland: Well Don Lindberg says that in Missouri they
     didn't pay much attention to the heart, cancer and stroke emphasis
     either.

           Thompson: Yeah, Missouri was a good place.  There is another
     place that became the kind of places we're talking about.

           Strickland: But the variations in programs and activities
     became a concern when the Nixon administration reviewed it.  Eliott
     Richardson asked who ever, "What can we say about what Regional
     Medical Programs have done?"  that I can talk to the budget
     committees about.  It was too scattered: there was nothing that he
     could sum up.  There was too much differentiation among them and
     yet that stemmed in part for the leeway they had to follow their
     own sets of priorities.