Interview with Dr. Cecil Sheps
Date: July 27, 1992
Location: University of North Carolina, Chapel Hill, NC
Interviewer: Stephen P. Strickland
Interview with Dr. Cecil Sheps
Strickland: Dr. Sheps you have been a pioneer in various
areas in the medical and health care arena and you have been here
for some time but what I am trying to do is to get a picture of
what Regional Medical Programs amounted to. We know what inspired
them but there were 55 of them and each seems a little different
from the other and when we take the differences along that
spectrum, the question is whether they added up to something
important?
Sheps: What is the national scene now? Have any of them
folded?
Strickland: Well what happened was that after about ten
years, you know they got going in 1966-67 then the Nixon
Administration recommended that they be terminated.
Sheps: He terminated everything, I had several projects,
someone from New York, he was here for two weeks.
Strickland: What we have now are some residual programs but
there are no more Regional Medical Programs. It seems that in
North Carolina that it has evolved to what Regional Medical
Programs had in mind, that is state coverage with a system of
referrals.
Sheps: Well it is a proven part of the structure now, there
is no question about it. The other three medical schools work in
their one area, but UNC does all the rest. And it's on everybody's
agenda, doctoras and other professionals go out to one of the
organized regions. they give seminars, people ask questions and
that sort of thing.
Strickland: The original impulse of President Uohnson and Dr.
DeBakey was that Regional Medical Programs would make sure that the
latest and best reserach in the treatment of cancer, heart disease
and stroke would be available to anybody who lived anywhere.
Sheps: It certainly moved the state in that direction, it
certainly improved the opportunity for people. The clinicians are
out there.
Strickland: Does North Carolina have a problem with physician
shortages still?
Sheps: Others could answer that question more certainly than
I can but I think there is still a problem in the rural areas. It
is a question of two major factors, one is that physicians want
their kids to go to good schools and you can't do that in the small
towns. And two, the modern physician is trained to work with other
people. When I graduated in Canada, quite a few years ago, I was
all alone in my prctice; I couldn't consult anybody, and it was
horrible. That's what it was like in those days and now its much
better. That plus the whole business of the quality or level of
living makes it very difficult. I think they are foolish to keep
seeking that kind of placement of physician in every town, and I
think the answer is regionalization.
Strickland: Yes, Some sore of system like that is one of the
things that Regional Medical Programs envisioned, that somehow you
would have service areas or geographical areas within which people
in need could get good up-to-date care, at least for certain
medical problems.
Sheps: Well, yes and in this state there is some of that.
Strickland: I forgot to ask Jim and Gene Mayer and Harvey
Estes about one of the first things that happend, for example, in
my home state of Alabama, that they were very proud of, their
telephone referral syste. Any doctor, in any part of the state,
could call in and say for example, I have a cardiology problem I
need to discuss and within five minutes, somebody would call him
back. Did north Carolina have something like that?
Sheps: I don't think so. Not as a formal thing, not a
special hotline. I am sure many physicians do such things, but I
am not aware of any formal setup. It seems like a good idea.
Strickland: It seemed to work there, but Alabama is a larger
geographic area than North Carolina.
Were you on the National Advisory Panel of the RMP'S?
Sheps: Yes.
Strickland: What was the feeling about the original emphasis
on heart, cancer and stroke versus some other medical and health
care needs?
Sheps: It was clear to us that we had to provide a much wider
range of services and we did that.
Strickland: The only clear pattern I see is that virtually
every states, particularly states that covered vast areas, such as
in the Northwest and West, developed emergency coronary care units
in hospitals and trained people how to use vertain techniques. But
aside from that, the other programs they undertook were really
quite varied.
Sheps: A lot of the problem in America is the fact that the
regionalization concept has not taken hold and so every hospital
tries to make sure it isn't outdone by "the competition." It is a
problem when there is no agreed specialization.
Strickland: What do you find is the case, these days, in
terms of cooperation, communication and collaboration between
medical center? Here's the context: Everybody says that one good
thing that Regional Medical Programs did was to get people talking
to each other. And Harvey Estes said that the North Carolina RMP
had the advantage that the three medical schools that existed
seemed to work pretty well together.
Sheps: Sure, but the fact is that UNC carried most of the
burden and still does.
Strickland: For example, I was told that UNC manages six of
the nine area health education centers and the others each manage
one. So UNC bears the central burden.
Sheps: To be completely fair about this, you should recognize
that this gives UNC a referral pattern and an advatage over the
other.
Strickland: How long have you been in North Carolin.
Sheps: This is my second coming. I was here from '47-'53,
then went to Boston and New York and came back here in '68.
Strickland: And you came back to do what?
Sheps: I was working in New York. The government had
established a policy of having seven research centers, and so the
people here wanted to have UNC become one and they aske me to help
write the proposal. Then when the proposal was funded, they said
they wanted me to run the program, so I back.
Strickland: It is your opinion that the medical centers are
now stressing the possibility, if not the desirablility of treating
as many patients as possible on an ambulatory or out-patient basis?
Sheps: The hospitals are being force to do it because the
hospitals are only paid so much and therefore they try to reduce
the length of the stay becuse they are paid by the case from
insurance companies and Medicare. Mdicare started it and they are
interested in doing it as economically as possible and the others
are following suit.
Strickland: So they are interested in doing it on an out-
patient basis to cut costs. And this is quite a dramitic shift
from twenty years ago.
Sheps: oh yes. I had used this approach twenty years ago
when I was the directo of one of the hospitals in Boston.
Strickland: So you are saying the balance is shifting in
favor of out- patient and ambulatory care.
Sheps: Oh yes. The cities used to pay on a per them basis.
It was in their interest to keep the patients in the hospital. Now
its in their interest to get the patients out to free up the bed.
Strickland: And sometimes, it;s in the family's financial and
logistical interest to keep the patient in. I am thinking of my 90
year-old aunt who has been in the hospital twice this year with
blood clots. And I am always terrified if she is discharged before
she has her full strength back.
Sheps: We try to use the resources as efficiently as possible
and if patients can be ambulatory, then you should treat them on an
ambulatory basis.
Strickland: What about the emphasis we were begining to
develop in the early '70s on family practice and general practive;
is there still a push?
Sheps: Sure, it's still a problem. Those type of fields
attract approximately 25% of the graduating class in this country
and that is not enough. In Canada, they attract 50%, a big
difference. In Canada the specialists are confined to a referral
role whereas here they are not.
Strickland: But in practicality, how would that work? I am
just thinking that when I ho to my ear, nose and throat doctor for
some general problem, like I can't sleep, he will perscribe
something for me. And my dermatologist will do the same. I guess
my question is is it practical that the medical progession be
dicided in G.Pls and specialists who whould rely only on referrals?
Sheps: I think the ideal organization of medical care is for
the personal physician to be in charge all the time, and he or she
decides if some help is needed. And if that help is needed, the
physician would know what it is and see that it that all the right
things were done.
Strickland: And what kind of payment or insurance plan would
foster that kind of approach?
Sheps: The one we have doesn't foster it; on the other hand,
the HMO's foster it.
Strickland: How would you revise and reform our health care
system? Where would you begin?
Sheps: I would begin by having a single payer, a government
insurance program. We have 1500 health insurers in this country.
It's crazy and it's expensive. Think of the administrative
expense. In Canada, it's only 1%. In this country it's 15-20%. So
all that money we would save would almost pay for the 37 million
who don't have insurance.
Strickland: So it would have to be a government insurer.
Sheps: Yes and it could come out of taxes. It is very simple
though, because you don't have to confirm the individuals
eligibility.
Strickland: It sounds simple but it's complicated
politically. If Governor Clinton called you to Washington and
said, "I recommend what would you do?" and you said, a single
payer, make it the government, "wouldn't the insurance industry
rise up to fight?
Sheps: What I would say to Clinton is, let's have a health
program so the 40 million without health insurance can have it.
You talk to the physicians in Montana who spend time across the
border, they see that the Canadian plan is great, it's simple. All
they need is the patient's number and they get treatment.
Strickland: In the state of Georgia, Dr. J.G. Barrow said
that one of the reasons that contributed to the demise of the
Regional Medical Programs was not, as some others contend, things
like competition with health planning, but because Medicare started
paying doctors to see patients that otherwise they would volunteer
to see in a Regional Medical Program Clinic. In other words, they
got used to being paid to see patients, so they didn't want to
volunteer their time in community hospital programs or for RMP. Are
you suggesting that something like that would happen with national
health insurance plan; that doctors would know that everyone they
saw would pay?
Sheps: You think they wouldn't welcome that? Naturally they
would.
Strickland: I am not sure I understand why physicians...
Sheps: Well, they are afraid that someone would be looking
over their shoulder all the time. But the truth is they have that
now. They can't admit patients on a non-emergency basis without a
committee reviewing it. They have to get permission for various
treatments. In Canada there is nothing like that. It is a
tremendous difference, and its a contradiction, because the
American physician thinks he or she is going to be supervided to
death and in Canada the is none of that.
Strickland: How would HMO's operate under a national system?
If everyone is covered, can I go to either an HMO or a single
practicioner?
Sheps: You could still do that, I think it would simplify the
bookkeeping.
Strickland: Are you optimisitic that we are going to have
some reforms?
Sheps: I am satisfied that we are going to have national
health care coverage in this decade?
Strickland: This has been helpful. And you would have kept
RMP's going?
Sheps: Well we've kept them going here. We went to the
legislature and got the state to keep them going.
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