NATIONAL LIBRARY OF MEDICINE REGIONAL MEDICAL PROGRAMS Bethesda, MD December 6, 1991 Session IV Lindberg: We now move into the fourth portion of the considerations of the day--and it looks like today could have been a longer day, but we just couldn't manage it--and that is, What can we learn from the RMP experience? As with the other events, we will start off with an introductory TV. [Video shown] Lindberg: Karl Yordy, if you'll excuse me, I'd like to insert a couple of unscheduled brief remarks here. Bill Butler has arrived late from Baylor. He was attending a meeting downtown. I wonder if we could offer you an opportunity to make a comment or raise a question just so we hear from you before you have to go slipping off to an airplane. Butler: Thank you, Don. I mentioned to Don at the coffee break that I had chaired a meeting this morning downtown at the VA, where I serve as the chairman of the special medical advisory group. This morning we received the official commission report of the Secretary's Commission on the Restructuring and Function of the VA System. When I walked in here at two o'clock, it was almost d j vu. I think the VA is about to recycle again. The fact is that a major thrust of the commission report centered on the division of the VA into functional regions. It's always been regions, but these are geographic service areas, is what they're going to call them, whereby the people in that area will have the total responsibility for the total continuity of their care from the preventive end through hospice care. There is the full integration of the academic medical center with the communities. One must realize, of course, that the VA has 20 percent of their hospitals in non-metropolitan areas, so they are well positioned to form the seed corn of a regional program in their own regions. So I think that we're seeing the regionalization concept. I was pleased to see the persons on the screen all comment on the fact that maybe it was too early when it occurred. I was a young child at the time, practically, and I shouldn't even be speaking to the issue, but in another role as chairman for the Association of American Medical Colleges, I have seen the development over the last ten to fifteen years of a remarkable amount of regional planning at the academic medical center level. I would also suggest that perhaps academic medical centers had not developed sufficient maturity, depth, and breadth to really support the regional system to the extent that it should have been supported. We are seeing really remarkable cooperation among medical schools, among medical centers in regions in trying to meet the needs of those particular regions. I appreciate the opportunity to talk. Lindberg: Thanks for the report from downtown. I also invited Dr. Rice Leach, who is chief of staff of the surgeon general of PHS Tony Novello to join us. Karl Yordy, it's all yours. Yordy: Thank you, Don. I want to join in the comments of all the others who have commended you and the NLM staff for putting this program together, I think not just that you created the occasion, but all of the evident hard work that you've put into it. You know, that's relatively rare. We go to conferences all the time where people are invited and everybody says what they have to say. You have really done some research and work in advance that has made this a particularly useful and valuable occasion. I was a young child when RMP got started, and I'm delighted to have here a very distinguished panel who bring a variety of other kinds of perspectives to this. Monte DuVal, of course, had been in academic surgery, and I think the first time I met him in Bob Marston's office he was still doing that. Then he went off and built a medical school, and in the process of that, he also got involved in the Arizona RMP. Then, getting rewarded for these good deeds, he came to Washington to be assistant secretary and played a role from the other end. Bill Kissick was the head of planning and evaluation for the Public Health Service during a very interesting time of change and ferment in health care. Bill was a person who was a serious student and scholar of health care issues and has remained so through the years. But most pertinent for this purpose, he served as a key staff person for the DeBakey Commission, so he was really there at the birth, before I was even around and involved. I first met Nathan Stark, I think at the door of a University of Missouri DC-3 at the Kansas City airport, or some kind of small plane, maybe smaller than that, where he had taken on the role of being the chairman of the regional advisory group for the Missouri RMP. He came to this from an interesting background of business, his work with Hallmark, and actually got seduced into the health care business and health education world. Later he also came to Washington and served as the under secretary of the department. I want to make just a few comments about this topic at the end of the day about what do we learn, what lessons are there to be learned from RMP. I have the difficulty, as I suspect many others do, which is that this has been a very interesting and provocative day for me, and I have a lot of thoughts about what's been said today, but I'm going to try to confine them to a few observations which are going to intersect with some things that have already been said, as inevitable at the end of the final session. I am also supposed to tell you how I got involved in RMP. It's a fairly simple answer. I was in the office of the director, a young staff person involved with legislative activities of NIH, and I first got involved just that route when, as someone pointed out, Jim Shannon designated Stu Sessems to carry the ball for NIH on the development of RMP, and I was assigned to work with Stu Sessems on that. Then I was (I think it's accurate to say) bequeathed to the RMP program by Jim Shannon. Those of you who recall Jim Shannon, it wasn't quite in his character to ask me if that's what I wanted to do. I actually learned this when I heard him describing it to someone else. That was fine. I thought it was wonderful, but that's the accurate story. I don't know what would have happened if I would have said no. I then had the most exciting experience of my working life. Then in 1968, in this event that's been described already, I went along with Bob Marston over to this new agency, the Health Services and Mental Health Administration, and became the head of planning and evaluation for HSMA and, therefore, had some kind of oversight over all that list of seventeen programs that Vern Wilson gave you a partial account of. So that's the background I bring to this. Since then I've been involved in health policy analysis at the Institute of Medicine. Several things are critical lessons, or some of the lessons, that I think can be brought out of the RMP experience. One is the very positive one of how you can mobilize people for cooperative and voluntary action in a good cause with some concrete incentive provided by the availability of some funding, the sense of those days that it was good to think about lofty goals and to believe that they could be accomplished and that the government could actually play a positive role in doing that. It seems to me it's that flavor and environment which is what led to what's been referred to a number of times today, which in retrospect I find truly amazing, which is how rapidly how things happened. This sense of getting the whole country involved in this program, people throughout various parts of the country, was truly an amazing thing, and I think is still there as a source to be tapped if we could only recapture some of that flavor. The second lesson which sort of intersects with that is the particular model of action that RMP represented. Here I'm going to make a comment about Bob Marston. In the first place, working for Bob Marston, I've been blessed with a marvelous set of bosses in my life, but working for Bob Marston was truly the most enjoyable experience I've ever had. Part of that was his infectious enthusiasm which relates to the previous point I just made. He was the exact person to help bring that flavor to the program. But the crucial point I'm going to make is that I think at the core of his soul, Bob Marston is an educator. The model that was used with RMP in some ways you can describe as an educational model. It's a kind of soft model, as contrasted with a harder maybe regulatory model or some kind of model, where basically you're describing in precise terms what somebody's going to do and then you're enforcing it. This was a model which really had the sense that the true nature of RMP would emerge over time from the work of all the good people that got involved in it out in the country, and that you would emerge from the specific to the general. You wouldn't start off with a general scheme, but you'd start off doing specific things within this broad framework and then you would refine that over time. That was assisted by the fact it was a project grant program and yet intended to cover the whole nation. That's not an immediately obvious thing, but if you think about it a bit, it's interesting. There was a group here in Washington, an advisory council, which was saying yea or nay on proposals, and yet the ultimate intent obviously was that the whole country would get covered. What this created was an interaction between that review process and the extraordinary people who were involved and the applicants, almost, to use the educational analogy, like a thesis advisor, you know, commenting on the first draft of a thesis. We actually invented a new kind of action which I'm sure some of you will recall, called "return for revision." When the group came in from Alabama, it was really the only group in Alabama that was ever going to come in with a proposal, so you couldn't sort of reject it. What you could do is to say, "We have some comments. We can't approve it yet, but we're going to return it for revision. Here is the benefit of our comments and observations." So there was this kind of interaction between the review process and the applicants. Finally, of course, the whole emphasis that was placed in the program on evaluation, the notion that if you were going to have this feedback loop educational model, you needed to have evaluation. And, of course, the necessity for a relatively long time frame for that to emerge. Some other comments about the lessons which are maybe on the more negative side, the difficulty of implementing a long-term strategy for change in the American political climate, especially when other strong incentives and other strong dollar flows are pushing in other directions, maybe competing with the direction of change that you're trying to achieve. Much reference has been made today to the ambitious objectives, the multiple objectives, the fact that it's difficult to measure effect in that situation in any sort of classic evaluation model, the sort of simple evaluation model doesn't fit and therefore it's very difficult to justify the program to skeptics. Another lesson, it seems to me, is the need for a better coordinated strategy about what we're trying to do to improve health care for the American people. There was a tendency in the heady days of the Great Society to push all the buttons at once and without much coherence among them. It seems to me as we think about how these lessons might be applied, we need to give attention to how it's going to relate to other kinds of efforts that are intended to improve health care and to the important forces of financing health care. Finally, the relevance to the current debate over health care reform, which is motivated, I think, largely by issues of access, especially financial access for the uninsured, and cost containment. It seems to me that there's a missing piece in that strategy, and the missing piece is a real focus on how to improve health care, because if you think of those other two things, you can sort of do those without really paying any attention to whether or not health care is actually being improved. It seems to me that that is a void in the current debate about health care reform that needs to be filled by some kind of thinking which could well draw on some of the kinds of lessons that RMP has to bring. The nice thing about that is it can give a positive thrust to some of the thoughts about health care reform, whereas the terrific focus on cost containment is, after all, ultimately in some ways a negative. Its, "What are we going to cut back?" and not, "What are we going to do without?" It seems to me to join that with some notions about what ought to happen in terms of health care would be a useful addition to the health care reform debate. Anyway, those are my personal comments. What I'd like to do now is turn to this panel and ask first Monte DuVal if he would give us the benefits of his observations about what we can learn from RMP. DuVal: Thank you, Karl. I'd also like to express my personal appreciation for the opportunity to be here today. This has been a remarkable experience. I also want to single out not only Don Lindberg and John Parascandola, but Bill Leonard, for the unusually competent job it seems to me they have done in arranging not only the logistics and the background in arranging this meeting, but that remarkable set of tapes. It's been a great pleasure, Don, to have been a part of this. I also would say that my experience sitting in the audience today was to hear my colleagues say all is right with the world as long as we had RMPs and what a shame that the only problem is that it's dead. If I might take just a minute to tell you a cute story that seems to fit to me this day, it had to do with the visit of a young housewife to her obstetrician. She said to him one day in the course of a visit, "I have done everything you've told me to do. I have watched the calendar. I have counted days. I have taken temperatures. I'm still not able to get pregnant, and now I'm uptight, I'm upset, and everything is going wrong in the world." The obstetrician, having heard this story before, said, "Young woman, I've heard this story before and I have this advice for you. Forget everything I've told you and go home and begin to live normally." About eight months went by and she made an appointment to come back and see her physician. When she came back, she said, "Doctor, I'm pregnant and I'd like very much to have you take care of me and deliver my baby." He said, "That's thrilling. Then all is right with the world." And she said, "Well, in a way it is." He said, "Will you tell me what happened?" She said, "Yes. I went home and did everything you suggested. I stopped looking at the calendar. I stopped counting. I stopped measuring. I stopped taking temperatures. One night, nothing special, but one night my husband and I were having a quiet dinner and I dropped my napkin. Apparently he realized it and we both reached down to the floor at the same time and picked up the napkin. When our fingers touched, it sparked. It was just like when we were first married. Right there that evening, under the table, I became pregnant." The doctor said, "Well, I've heard it all, but that's a fabulous story. Then all is indeed right with the world." She said, "Yes. There is, however, only one problem." He said, "What's that?" She said, "We're not welcome to have dinner at the Hyatt Regency." [General laughter] That's sort of the feeling I have from Regional Medical Programs today, that it really did add a great deal to the American scene. When I was asked by Don to summarize what I thought we'd learned, I wrote down five simple statements and I'm going to read them for you and then turn it over to Bill and Nathan. The first thing I think that we learned is that RMPs showed us that it is possible to create a federal and private relationship that, in fact, can be unusually productive, but at the same time is not necessarily to be trusted. I think subsequent history, particularly with respect to Medicare and then prospective pricing and now with resource-based relative value scales and so forth, we are seeing that play out. The second thing I think we learned, as I see it, is that the federal government is quite capable of creating what I would call decentralized authorities that are capable of making subgrants and yet at the same time are independent of any preexisting political jurisdiction. There's a price, however, for this, and I think we've seen that. That is that it permits the entry of a high level of confusion. I remember very, very vigorously some years ago one great colleague and friend of many of us in this room, Ken Endicott, was talking about Regional Medical Programs and I asked Ken, "What is your perception of Regional Medical Programs?" He said, "Monte, my perception is exactly the same as can be illustrated by the story of the child in kindergarten who was drawing a picture one day and the teacher came by, looked over the little girl's shoulder and said, "What's that a picture of?" She said, "It's a picture of God." And the teacher said, "How do you know what God looks like?" She said, "I won't until the picture's finished." [General laughter] I thought that was a very wise bit of perception on Ken's part, but I do think that's something we have learned from Regional Medical Programs. A third thing I think we've learned is that it is very possible to create a process which itself is uncommonly effective and yet at the same time as soon as we've learned that the process is effective, you can count on the fact that it will be used beyond the purposes for which it was created. I think that is, to me, a real lesson from RMPs. Fourth is one that Karl has also mentioned in his opening comments. When it comes to a public good, of which I would submit that quality health care is an example, that a community is very capable of assembling very disparate and diverse interests around a table, who are willing, not always, but to some substantial degree, to put aside their narrow special interests and come to grips with the problems at hand, the convening function, as somebody referred to it this morning. A very, very find lesson from this legislation. Finally, in some measure, and I think this also addresses, at least peripherally, a couple of things that came up earlier today, I have the feeling that RMPs will be seen historically some years from now as having had a similar, if not entirely parallel, impact on academic medical centers that the Morrell Land Grant Act of 1853 had on colleges of agriculture. It precluded their remaining totally isolationist (I'm talking about the academic medical centers) and forced them, in effect, if they were going to be participants, to start looking at what constituted the problems in their community. In the long range, in other words, things that were never visualized, if you want the expression of the law of unintended consequences, I do think these are the kinds of lessons we've learned from the RMP experience. Thank you. Yordy: Bill? Kissick: Thank you very much, Karl, and thank you, Monte. Several of us have offered a metaphor for this gathering of RMP alumni. The examination of a failure or, as I would suggest, we are here to examine a success. For that I would like to compliment colleagues at the National Library of Medicine for organizing it and thank them for including me. For my lead, I borrow from Mike DeBakey. During lunch he recalled that the President's Committee on Heart Disease and Cancer was delivered to the White House the eve of the Bay of Pigs. The next day, before a press conference, President Kennedy said, "Success has a thousand fathers. Failure dies an orphan." As I look around, so many who claim maternity and paternity for RMP, and know of others who couldn't make it, I suspect that RMP was indeed a success, particularly in the context of the United States Supreme Court, where social policy has often evolved through the great dissenting opinions rather than those of the majority. Being a warden professor, I am accustomed to speaking in an hour and twenty minutes' sound bites. Accordingly, I have scripted my remarks to hold them to the assigned five minutes. On the video you heard me state, "Right concept, wrong culture." Health care transcends the biomedical sciences. It is a cultural affair. RMP was born in a context of the culture of the Great Society, one of thirty-five recommendations of the DeBakey Commission, one of two dozen proposals incorporated in the 1965 Health Message, transmitted to Congress on the seventh of January, three days following the State of the Union Address. Wilbur Cohen was the principal architect of the Health Message. Wilbur's superordinant concern was Medicare, which has been the ghost of Hamlet's father in this particular conference. Wilbur's goal was economic security for the elderly. All else was derivative. Medicare was an Herculean political achievement, but limited to the extension of the status quo, Blue Cross and Blue Shield coverage to 10 percent of the population, now called senior citizens. Blue Cross and Blue Shield, of course, enjoyed a three-decade track record. RMP, by contrast, emphasized innovation with the following constraint, "to accomplish these ends without interfering with the patterns of the methods of financing of patient care or professional practice or with the administration of hospitals." The preamble of Medicare actually expressed the same sentiment, but rather more succinctly. For Medicare, promulgation of precedent was not a problem. It was easy to do within existing patterns. My second clip in the video declares, "Much has changed in a quarter of a century. We need RMP more than ever." In 1965, when Regional Medical Programs was enacted, the United States spent 6 percent of gross national product on health, 6 percent on education. In 1990, the United States spent 12 percent of gross national product on health, 6 percent on education. The forecast for the year 2000 is that we will spend between 15 and 18 percent of gross national product on health and medical care, and I am certain 6 percent on education. If that is true, early in the 21st century the United States will have a very well-medicated illiterate labor force busily selling french fries to each other under golden arches. [General laughter] At which time Japan, Inc., and the European Economic Community will dominate world markets and our economic well being. Paul Rogers, who is not with us today, appeared in the final segment, and I would like to expropriate his words. He said, "Costs are out of control. We want to increase access and we will not yield on quality. I call this the dilemma of the iron triangle of health affairs, cost containment, access, and quality, which we address as infinite needs confronting finite resources." This caused me to conclude on Kissick's third law: for every health policy action, there is a reciprocal overreaction. The reciprocal overreaction to Medicare is our attempt to control costs with what I call the Lilliputian scenario: prior authorization, second opinion, utilization review, diagnostic-related groups, resource-based relative value scales, and practice guidelines that will soon become therapeutic protocols. I title this the Lilliputian scenario because I think that Jonathan Swift may have been prescient. Captain Lemuel Gulliver was the ship's surgeon on the Swallow when it was wrecked at sea, and he washed ashore on the land of Lilliput to find himself bound to the beach by an army of Lilliputians. Where do we find the Lilliputians? At Chrysler under the leadership of Lee Iacocca and Joe Califano, in Prudential sitting on a piece of the rock, in HCFA, the temple of doom in Baltimore. These initiatives have radically changed the constraint of RMP and Medicare because, listen: patterns of financing, professional practice, administration of hospitals. Which has not been touched? The culture of health care, like its societal context, has changed. If RMP was ahead of its time in 1965, is RMP an idea whose time will come before the 21st century? As I view health affairs in our society at the threshold of the 21st century, I conclude that what was perceived as a threat to the practice of medicine in 1965 looks to me like a lifeline in the decades ahead. Thank you. Yordy: Thank you very much, Bill. Nathan? Stark: Before I speak, I would like to say that this has been one of the finest programs that I have ever attended. I say that before I speak so it doesn't sound like self-aggrandizement. [General laughter] I have been, for most of my adult life, a public member, albeit a token public member, of many of the health agencies. I'm not going to say, Roger Egeberg, which half that is. As a public member, I am very strongly in favor of what we did with RMP in terms of bringing in the citizen, the voluntary citizen, the lay citizen, and I think that's a lesson that we should learn and carry forward. As a matter of fact, at the time RMP came into being, we were just then starting to recognize that lay people on health organizations could be of some use, and I think the RMP program itself gave more impetus and drive to that notion. I think about the leadership that was mentioned somewhere along the line, the lack of leadership that we have not only in the health field, but also that we have missing in government. I think back to the time after the first year's funding when Bob Marston asked me and also Mike DeBakey to appear before Paul Rogers' committee. Before the session began, every single representative (and there were many of them present) came down to have a photo with Mike DeBakey, and it was that kind of leadership, I think, that inspired them to go ahead with this program. What we need is more of that on a continuing basis, but also what we need is leadership in government--and that's where your constituency is--if you're going to succeed in the future. We've got to work on that. Bill Ruhe remarked that we had oversold the program. Well, I think there was a lot of zeal and enthusiasm, but I think what we need in the future is some balance. After all, you're not going to get a program through Congress unless you do have some zeal and enthusiasm. What we need is a balance so that we don't create expectations which can't be fulfilled in the short term, and I think that was another problem. Each time I read or attended a meeting of the Congress, a committee of Congress talking about RMP, "What have you done for us lately?" Well, this is not the kind of program that you complete within a year, two years, or three years or even ten years. It has to be ongoing. I think in the future when we think about programs such as this, we think about them long term, not build up the expectations for a short term. I think also--and I don't know how you could control this--the spate of legislation, health legislation, that came through all at once, all competing for the same dollar, all competing for notice in the public, Medicare, Medicaid, the Health Professions Act, CHP, HMOs, all of these were in competition for public notice. I think with those kinds of programs it's very difficult to gain the kind of public support and, therefore, constituency to press forward for any kind of program. In the closing statement, I think we could have taken the last session and turned it around and said, "Okay, just do these things that caused our collapse." I think it's true that limited funds have something to do with the decision to terminate RMP, but I also think that there was another reason. I can speak for this on personal experience when I was in the department of HEW. Each time an administration turns over, the new kids on the block want to wipe the slate clean, regardless of whether the program is good or bad. If it's a different administration coming in, a different party coming in, then they're not going to want the former administration to take all the credit for a good program. Therefore, it isn't going to become one of their top priorities. I can only offer this suggestion for the future, and that is get the program into a position where it can become institutionalized. In other words, we had a Democratic president who had eight years in terms of the time in which to continue this program. Let's elect another Democratic president to go another year. [General laughter] I'm sorry, that wasn't political. The other thing that I think we learned from this, and I think this will carry on in the future--I hope it will carry on in the future--academic health centers, in my experience, have been very reluctant to move outside of the ivory tower and into the community. Maybe that wasn't so true in rural areas or with state medical schools, but it was true on the whole for medical schools. They didn't like any kind of interference from outside sources to come in and interfere with whatever they had in mind for programs. I think we have overcome a good deal of that in bringing them out of the shell and into the community, and I think this linkage of the medical schools, the academic health centers of the community is something that is ongoing and should be continually fostered. One other thing. Only four of us are here now of the Missouri Mafia. You might also know that three of us have left Missouri. [General laughter] But in any event, in Missouri we found that what we considered to be a better approach to developing and implementing this program was not to deal exclusively with the medical school, but to form interdisciplinary research groups including talents from engineering, business administration, communications, as well as medicine. I think that's some lesson that we've learned from RMP and would do well to carry on in any future programs. Yordy: Thank you very much, Nate. I'd now like to turn to the four people who have been designated to address questions to the panel. The first is Charlie Flagle. Charlie Flagle was in the Office of the Surgeon General during these interesting times. He has a very distinguished career as one of the leading people concerned with operations research as applied to health care. Therefore, in some of this discussion about rationalization of health services, it perhaps is very appropriate to hear from Charlie. Flagle: Thanks, Karl. I have a question that I'd like to address to the full panel and later on to the audience as a whole. There are at least three of us in the room, those of us who are working with the new Agency for Health Care Policy and Research, who believe that to an important extent the Regional Medical Programs have been reborn and are walking among us today. That agency, in addition to the already existing health services research activities, has been charged with developing a program of medical treatment outcomes research, and on the basis of that research to support the development of clinical practice guidelines and to develop an extensive program in dissemination of those guidelines in collaboration with other agencies like the National Library of Medicine that is in the dissemination field. That work has been under way for about two years. The work is more similar to the original intent of the commission on heart disease, stroke, and cancer in that it concentrates on specific health problems, not only those major problems that began with RMP, but important common problems like pain, urinary incontinence, bedsores. We face the tough problem in that agency of creating and disseminating guidelines. My question to the panel is this. On the basis of our experience with Regional Medical Programs, what kind of advice would you give the new agency in its work? Kissick: Beginning historically, it was about a year after Regional Medical Programs were enacted that we first put pencil to paper to create the National Center for Health Services Research, which has evolved through a number of titles to the agency that you speak to at the present time. We saw two video clips of Paul Sanozaro [phonetic], who was the initial director of the center and sort of the visionary conceptualist of what it might be. I think the most significant feature is that we now have a stronger commitment to research outside of clinical research within tertiary care centers, which has been the priority of much of our research. This, of course, was one of the agendas of Regional Medical Programs. Actually, it was the main agenda of Ed Dempsey, who was probably el primo among the fathers of Regional Medical Programs because he was on the commission and then he was appointed assistant secretary for health and was very much championing the concept of the regional medical complexes, and he, too, was from Missouri. Stark: From the other part. Kissick: The other part of Missouri, and a private institution, Washington University School of Medicine. So I think that you can find, as the many fathers and mothers of success go in different directions, there are elements of the RMP concept which was really so protean and so eclectic that you can see many of these emerging in different kinds of arenas, while at the same time finding some of the other agendas still neglected or untouched or of low priority. Yordy: I have one comment, Charlie, which, in a sense, I've already made in a general way, but I will apply it to your specific matter. That is this question about time perspective. It seems to me that the Agency for Health Care Policy and Research, in its several legislatively mandated agendas, faces the risk that RMP had of trying to be held accountable for early results in what is inherently a long-term strategy. It's interesting. I spent an hour one evening being quizzed by the now director of the Agency for Health Care Policy and Research about my experience with RMP. He was exactly pursuing that. He had made that connection in his own head that here was RMP, that it had this up-and-down experience, and was there anything that could be learned with regard to the experience of the future of AHCPR. So I think that's one of the lessons. DuVal: Let me speak to it also. There is something that can be learned from RMP, and I'm not about to challenge Charlie's posture or suggestion that there is a high level of comparison between the two programs. There may or may not be. I can suggest, for instance, that the parallelism between what his agency is now doing and the PSROs is equally great. But we don't need to get into that. In terms of your specific question, I would suggest that depending, again, upon what your objective is, in other words, if you say, "How can we succeed?" do you mean remain alive or do you mean succeed with your mission? They may not be the same. [General laughter] My own feeling at this moment is that until you achieve buy-in from the practicing physicians, you have no future. If you want to be sure you've achieved buy- in from physicians, you've probably got to use your product as a source of immunity from malpractice. Kissick: A quick comment. Ecclesiastes wrote, "Nothing is new under the sun." Much of the precursor literature to Regional Medical Programs can be found in the Committee of Costs of Medical Care in 1932 and the report of Lord Dawson of _______ in 1923. Yordy: Let me turn now to the second questioner, Priscilla Mayden, who has been at the University of Utah involved in the medical library aspects of the University of Utah, and in that way was involved in the Intermountain Regional Medical Program, which we heard described earlier today as one of the really successful efforts. Mayden: I believe that I am representing the entire medical library profession, which is a very heavy responsibility. I'd like to put in this disclaimer right now that whatever I say is my opinion, and I can't speak for the several hundred medical librarians who lived through what I consider those golden years in which the RML was established and the period of cooperation with the newly emerging Regional Medical Programs. I'd like to pay special tribute to Dr. DeBakey for his foresight and his influence in helping to bring about the establishment of the National Library of Medicine and, ten years later, making certain that the medical libraries, as a base for the information needs in an entirely new undertaking, was included in the report of the Heart, Cancer, and Stroke Commission. The two programs, the RML and the RMP, emerged in parallel. There were many similarities, but many more differences. [Begin Tape 7] Mayden: . . . in a little corner of this basement, and he came for the rest of it. But it brought about a very close relationship. We were neighbors. If you use the same restrooms and wait for the same elevator over a period of years, you find that you're working very closely with a neighboring organization. The Intermountain Regional Medical Program was very generous with us in supporting manpower. Because RML regions did follow state lines and RMP regions did not, that gave us, in working with RMP, which we did before the RML was established, some more flexibility in that we were able to reach out to the institutions' watershed at least in the earlier years. You were all given this booklet which describes in detail, but not complete detail, the programs that have survived that were started under RMPs throughout the country. Unfortunately, many of the most successful are not detailed here because the people who initiated them are no longer with us or were unobtainable. For many of the young medical library directors now, something like the RMP relationship in the mists of the past. But I think that many, many of these programs survived in Utah. A very strong consortium of medical libraries, hospital libraries, has flourished for years and been self-supporting. I think that the reason perhaps--this would be my thought--why the regional medical library program survived the years of cuts, both under President Nixon and later in the early eighties under President Reagan, attempts to cut it back, I think it was because, first of all, we had the superb leadership of the National Library of Medicine, which has been an agent for change in the field of information dissemination. The scope of the RML program overlapped the scope of the Regional Medical Program, but it was much smaller and very focused. It was the dissemination of information to the point of need, and training people to perform that function. Also relatively it didn't cost very much, really. It has never cost very much. Perhaps the fourth reason is that within any given institution and perhaps nationally, libraries are politically neutral. In other words, we don't support them very well, but nobody doesn't love libraries. [General laughter] I think that perhaps what we've learned is that with a great idea and great leadership, with good organization and relatively little money and a lot of human cooperation, you can accomplish a miracle, which I think the presentday regional medical library system and the national medical information network represents. What survived that was the most successful? Certainly the RML network in itself is probably the most outstanding example of what survived, but there were individual projects that had their origin in RMP that were highly successful. One of them was the MIST [Medical Information by Telephone] program in Alabama. Nearly every RMP in the country tried to do this at one time or another, in one form or another, and it languished. In Alabama, MIST not only survived and flourished, but it has grown and has become national in its own right. I would like to know, first, how did this happen? Perhaps you would let someone from Alabama explain this. Secondly, is this one-on-one kind of information transfer the way we should be going in the future? Yordy: I think that's a very useful summary of related experience. My reaction would be that in the context of which we've been talking earlier, that is a piece, but probably not a sufficient piece in terms of renewal of the RMP notion. I think it would have to have some broader kind of impact. DuVal: Let me, however, make one comment that I think might have been missed. I'm sorry it did not come up earlier, because in my judgment it doesn't belong before this panel, but maybe some of you would say that it does. It could have been brought up best perhaps under Stan Olson's panel. Most people today have begun to recognize that the relationship between a patient and a physician has changed, that patients are much better informed today and are much more apt to jointly, as it were, converse with a physician about their problem and the options for treatment than ever before. The days of the physician on a pedestal saying, "This is what I think and this is what you should do," etc., with the patient being totally passive are gone. The turning point for that, in my personal judgment, was Regional Medical Programs. The activation of one-on-one, what happened, for instance, in Alabama (in my judgment, more important what happened in Wisconsin, but there's no reason to be geographically partial), where patients could dial an 800 number and get immediately tapped into a bank of tapes that told them everything they wanted to know about a particular diagnosis was a most important turning point. To me that was a product of RMPs. It is not necessary something we learned from it. Maybe we did. As I said, I'll leave that to your judgment, but I think it should be mentioned for historical purposes. Yordy: In the interest of time, I think I'd better move on to the other questioners, giving credit to Vern Wilson, who used to talk about the activated patients. It sounded a little familiar there. Gus Swanson has had a distinguished career related to academic medicine, both at University of Washington and for recent years as vice president for academic affairs of the AAMC. Gus, would you like to address a question or comment? Swanson: I think I probably will comment. I think today we've heard several commentators say that a major effect of the RMP was to get the academic medical center out of the center and into the community more. One of the residuals of the RMP, although not one nickel's worth of money from RMP went into the program, was the Washington, Alaska, Montana program, often called the WAMY [phonetic] program. That was conceived in September 1969 and was funded just over a year by the Commonwealth Fund. The process of trying to get the University of Washington operators into the three other adjoining states required that we have very close coordination with the intelligence provided us by the coordinators in those states. I can recall going to Alaska at the request of the education committee of the Alaska State Medical Association. At that time the whole state was very paranoid because they thought everyone in the Lower 48 was coming up after the oil money which hadn't yet flowed. I met for half a day with the coordinator of the RMP in Anchorage, and he gave me a historical sketch of every member of that education committee, so when I walked in I was completely briefed as to what to expect. I think if I hadn't had that briefing, we'd been thrown out of Alaska before we really started. Because of the importance of the intelligence, the information, I think WAMY did survive and flourish. I talked to Jack Lynn [phonetic] last night, who is now vice president for health affairs at the University of Washington. I would have liked to have him here. Jack particularly emphasized the importance of the library role. He was at that time dean of continuing medical education. Jack had the privilege of opening that library in Alaska, which I might say was the state that had the least medical library facilities of all the states, and the only thing he could remember about that last night when I talked to him on the phone was the fact that the only comment in his opening speech that the AP [Associated Press] picked up and would up in the Seattle papers was, "I have closed many a bar, but this is the first time I've ever opened a library." [General laughter] Charles Oligard picked that up in the Seattle Times and brought Jack up to what we call the upper campus and gave him hell. In the original concept, as we read it, at least, from the DeBakey Commission, the academic medical center would be the center of excellence. I've heard particularly Bill Kissick today say we need to redo the RMP. What, in your opinion, would be the characteristics of the centers of excellence if we rebirthed the RMP? Kissick: An academic health center can be defined as an institution organized for the provision of primary care in a secondary fashion at tertiary prices. [General laughter] I think that when I said on the tape that culture has changed, we've just heard one comment on the culture, the difference of the patient. If you read the New York Times science section every Tuesday morning, you're ahead of most of the nation's medical school graduates in terms of an understanding of what's happening in science and where things are going. If you want to meet an authority on an inborn error of metabolism, talk with a parent of a child that has that disease. They know the literature. You want to find out what it's like, just ask them. They'll tell you which journal to go to. This is but one dimension of change. Health is an information industry. We collect, collate, interpret, store, retrieve, analyze, and apply information. When I was a medical student, one of my professors taught me his ability to write a prescription in Latin as a secret communication between the physician and the pharmacist. Now if I want to know whether to use glaxo [phonetic] or to use Tagamet, I watch NFL football, because during the huddles, each of them are advancing the strengths of their particular product. What I'm trying to say, humorously and not cynically, is that the changes in medicine at the periphery are far faster than in the academic health centers, that science indeed is complex and the developments are extraordinary, but health care transcends the biomedical sciences as a cultural affair. So the next time around, I think I would reconvene the regional advisory groups, but probably preclude chairmanship to anybody with an academic appointment and to actually pull off what Comprehensive Health Planning was trying to do. We've heard that disparaged today. One of the most exciting RMPs I ever visited was in Tennessee, where the Regional Medical Program and the Comprehensive Health Planning advisory groups were working as one and the same, trying to look at the problem from both ends, the periphery and the center. The problems are there. The iron triangle is ruthless. If we are going to contain costs by most measures we're going to compromise access and we're going to diminish quality. If we want to increase access without changing quality, we're going to drive costs up. They are interrelated. I personally think that the forums, or fora, created by Regional Medical Programs were very appropriate for addressing these kinds of issues. So the means were there. If we could just restructure some of the priorities, I think it would be very valuable. Yordy: Dr. C.E. Smith is a person who is very much involved in the early days of Regional Medical Programs and specifically focusing on the question of evaluation. We've heard that referred to a number of times today, a difficult program to evaluate, given the fact that the objectives were not only multiple, but moving. Dr. Smith, do you want to say a few things? Smith: Thank you. I wanted to say, first, too, that I appreciate being invited here. I did, along with a number of coordinators who are here, Dr. Ingall, Dr. Barrow, and others, work in trying to summarize information about the accomplishments of RMP, and that fed into the suit and it fed into the good efforts of a full-time lobbyist the regional coordinators hired, who is here attending, who did a lot of very good yeoman's work in keeping the RMPs at least funded, if not alive. Perhaps they died before they ran out of funds. We didn't get all that news in Boise. I guess that's why I asked for the opportunity to say something. I'm here kind of as the representative of the last surviving RMP. The mountain states RMP is still at work in Boise, Idaho, and surrounding states. It has been continuously funded from other sources for the last sixteen years at a level that is at least what we had from the RMP grant. So I'm glad to be a volunteer board member on that organization which is still there. We hadn't heard that we're supposed to be dead yet. [General laughter] It seems to me one way of rephrasing a lesson learned that you all have talked about is that the local RMPs did create a kind of missing management element that was effective in directing the efforts of the consortium of interest toward the solution of particular applied problems at that level. They did so in a way that Monte DuVal talks about, that was an effective process that maybe got out of control. It got out of control at the last simply because those of us in the field kind of felt that the insiders in the beltway didn't support the program any longer, and that was obviously true. It was not supported inside the beltway. Therefore, the coordinators organized and brought about this suit and this information and learned, I think, some political constituency skills. Given the insider/outsider views about inside-the-beltway inability to bring about effective change, what do you see the lessons from RMP might be in terms of including those kind of external fora that have been talked about, or creating a decentralized power base for working in the trenches, in the fields, that is still responsive to some set of priorities that's important in the iron triangle that Bill Kissick talks about? Kissick: The iron triangle is implicated. I think the strengths and the promise of RMPs was, and will be, the fact that, as Ed Pellegrino said on the tape, we do not have a comprehensive system of health services in our society. I know a fair amount about the comprehensive health service systems of the Soviet Union, Sweden, United Kingdom, and Canada, and I am convinced none of them would work in the United States because of the characteristics of our society. If you don't believe me, read the first amendment to the Constitution. It's only forty-five words, so you can get it done during a commercial. We have the freedom and are encouraged to worship a god of our own choosing, and if we're not happy with her, we can create another one and worship that god. The same concerns our speech and the press. In a three-decade career--actually, Karl started out younger than I am and now he's older--in a thirty-year career 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've yet to visit two alike. There were no two Regional Medical Programs alike. They were all attempting to solve a variety of problems. Give me back RMPs and let me address the problem of the iron triangle, because there's no right answer. There are many right answers. There aren't many wrong answers. But they have to be developed from within the institutions that are responsible. I think this was the lesson of RMP, the advantage over Comprehensive Health Planning. RMP was clear. Those that implement have to be involved in the planning. Comprehensive Health Planning said, "Let somebody plan and let somebody else implement." I think that was one of the geniuses of RMP. It still is valid. Lindberg: Dr. Leach, do you want to give a questioner some advice? What's the view from the surgeon general's office? Leach: I would rather speak personally, porque no tengo ______ idea que l'id neo, okay? I spent twenty-five years on the line as a health services deliver, and I'm old enough to be a grandfather. I know that most of the people here have got to be grandparents. The reason I mention that is the wisdom that you have, I think needs to be passed on. How are we going to do that, especially to the people who are twenty-five and thirty? I have a couple of ideas that I would like to mention. There are groups of physicians with which I associate, and I'm thinking specifically of the College of Physician Executives, who sometimes hear from some of you, but usually don't hear from you. What you have to offer, I think, is terribly important to that group. There are not very many from the Department of Health and Human Services in that. Military, SIGNA, Kaiser, other groups, yes. But not the Public Health Service and the public policy people. So I would say there's a real audience that has a lot to learn from this group, and I would ask if there would be any interest in that. The other thing I was thinking of is how to link what you're doing to what is going on right now in terms of buzzwords. This "total quality management" issue seems to be one of narrowing the distribution and advancing it toward the positive side, seems to require a certain amount of planning, a certain amount of staging, and a certain amount of rationality to what they're doing. Somebody with far more knowledge than I have would seem to be able to do that, because if the industries that are putting us out of business in the manufacturing world are getting ahead by that technique, and the physicians are starting to talk about that technique, it seems to me that what went on in Regional Medical Programs certainly has an adaptability to this sort of thing. How are we going to pass on to the people twenty and thirty years younger than I am the desire to do what you did as we came from pre-Medicaid through Medicaid to the current situation? It would be nice for them to hear articulated what the loyal opposition had to say along with what the interpretation of what they had to say was. Thank you very much for the opportunity to be here. I've heard your names my whole career. Some of you taught me. Kurt Dushel [phonetic] got me into this business. Arizona got me indoctrinated to this business. It's a pleasure to be here among you. Lindberg: Thank you. Karl, do you have a comment? Yordy: I want to make one comment about that and actually link it to a different aspect of what Dr. Smith was saying. I'll use a fancy term here, and that is one of my observations over the years has been--and Irv Lewis and I have spent the past years talking about this--two words I'll use, there isn't an adequate infrastructure addressing some of the kinds of health care and improvement of health care questions that you want to address at the community level. You've got a bunch of disseminated centers or groups or individuals or institutions that are involved, but there isn't any way of putting them together. The second is the question of accountability. The reason I bring those two together is that I think that they, in fact, are related. That is, if you have an infrastructure that's got some kind of concern for an accountability for what goes on, we might have a structure that could be used to address a number of problems, including some of the basis behind notions of whether to use continuous quality improvement or total quality management, whichever one of those terms are used. If you look at the Demming lingo, it talks as if a management structure exists. In fact, one of his first statements is that you've got to have the commitment of top management. Well, the problem with doing that the way the health care system functions in most places, you haven't got that structure. So that's an issue that we have to think about, too, and we can draw some lessons. DuVal: I also thought the question was superb. Incidentally, I don't pretend to have an answer. I only know that history is destined to be repeated, and while times change and we won't quite reinvent RMPs the same way again, the question of how the experience of those who have gone before and tried can be appropriately transmitted, in my judgment, has rarely, if ever, been successfully addressed. So I think the question is, in its own right, very, very profound. I would also marry something that you said, not only just about total quality management, with the other two big comments that came up today about the possible RMP role in both access quality and cost control, to what Bill Kissick said about his familiarity with certain of the systems that we see in other nations and why, in his judgment, they are not transportable directly to the United States. I would submit that I have an answer that satisfies me, and I would leave it with you for whatever it's worth. That is that if you wish genuinely to pursue quality and you genuinely wish to have universal access and if you genuinely want to control costs, you must then take the next step and acknowledge that you can have any two of those three, but you may not have three. The problem we have in the United States today is we have not decided which of those three we are willing to sacrifice in order to achieve the other two. Lindberg: On the other hand, if what people allege, namely that at least 25 percent of all the bills that G.W. Medical Center, according to Tom Bowles, are an utter total waste of money that are used to practice defensive medicine. If that's 25 percent and another 20 percent is utterly bookkeeping in order to send claims forms, I mean, we could just about double any one of those things you want to double. How about if we get to that problem? Is that true or not true? There are people in town who claim they're going to write new legislation and have new programs. That's wonderful, but is it going to take account of the past? Yordy: TQM evangelists would claim that, in fact, you can get better quality at less cost. It remains to be seen. DuVal: I understand what they mean by that. Some of you here remember Paul O'Neil [phonetic], who is now the chairman at Alcoa. He was the director of domestic affairs for the Office of Management and Budget when some of you and I were in the department. Paul tells a wonderful story that I think touches on this. He tells the story about the day that he was having a staff meeting with the senior vice presidents, and one of them made the observation that a preassembled item that Alcoa purchases from the marketplace in order to convert it to something else that they then turn around and sold was arriving with as many as twenty defects per 100. He said, "I wondered, in view of the reputation that this total quality management program has in Japan is such that we might order that same package from an outfit in Japan." Paul O'Neil, who is an enormously "Buy American First"-oriented person, if I can put it that way, made this suggestion. He said, "I'll tell you what. I'm not inclined philosophically to do that, but I am prepared to let you go ahead and try it for a year or two, but I would insist that if you do it, you ask that there be four defects per 100." The first order was delivered and with it was an accompanying note to the CEO of Alcoa saying, "We have fulfilled your order. We do not understand the four defects, but they are separately packaged." [General laughter] This is to make the point that it is, in fact, a state of mind. Of course total quality can reduce cost. There's no question about that. But the point was made here earlier, especially with respect to the new Agency of Health Policy Research, that you cannot pursue ultimately even guidelines, for that matter, by which clinical medicine will be practiced in a quality manner at the same time that you have the concept of defensive medicine, which is precisely why I answered this question by saying, as the state of Maine has just recently done, that until you provide some opportunity for immunity or relief to the American physician from malpractice as a result of following the guidelines, you will not succeed. Lindberg: A pretty significant factor. Jones: I'm Janet Jones. I was with Maine's Regional Medical Program from its inception in 1967. For the record, Maine's Regional Medical Program was a private, non-profit entity from its inception. It still continues today and is doing many RMP-like activities in addition to those that were started throughout the course of RMP funding. We even thought the concept was so great that we tried to make it work in Tunisia and Haiti and Ouagadougou and some other places that we weren't as successful in the state of Maine. Those are a couple of asides. A couple of things that I think have not been mentioned today or stressed enough is the autonomy that was inherent in the regional advisory group (RAG) decision-making process. The RAG had clout because they had veto power over programs at their own local levels. I think that may be the precursor to the public accountability question that we're going to be facing relative to national health insurance. The other thing that I think has not been stressed is that one of our missions in Regional Medical Programs was to avoid duplication of resources. We were able to do that by being the central entity that got funding from NHLBI and we got state funding to carry out diabetes control programs. We got money from the Department of Education to do educational activities, in addition to the Regional Medical Programs. I think that's one of the keys as to why, particularly in our area, we were able to continue so long. Also we did not have a medical school. Maybe that's an answer. [General laughter] I do have a question for the panel and it's similar to what was just stated, but a little different. With such a distinguished assembly of people, is there any way that we can get across some of these lessons to the people who are currently making policy, writing legislation for health care reform? What can we do right now? Not to impart to people twenty-five years from now what needs to be done, but right now. Every group in the United States is trying to fashion a piece of health care legislation to reform the health care system. Yordy: That is a daunting task for the reasons I implied, given the fact that the focus is so much on the question of financial access and cost containment, which is not where we're really starting. As Bill and Monte have pointed out, the resolving of that is a difficult thing. Nevertheless, I think there is room for getting across a message, how to get the health care debate to pay some attention to how we organize and provide health services, which is a different kind of agenda than is present in most of the health care reform. I think there is some opportunity. The people who are involved in those proposals, many of them have become, in my observation, most sophisticated about health care issues as they have wrestled with some of these issues and, I think, may be getting to the point where you, in fact, could make some of these points. Lindberg: A number of individual elements of RMP live today. One that keeps popping up is community- based research centers. That is now a very important integral part of at least NIH's strategy--I would say the entire PHS strategy against AIDS. That was greeted with a lot of disbelief, but Tony Forshee [phonetic] has made it work, and it's clear now that without that community-based centers, it would be impossible to get even statistical data, let alone actually implement effective treatment programs. So that's come back in. Actually, the intersection with clinical trials was something we never thought of in RMP times, but, in fact, is greatly facilitated by these comprehensive cancer centers and now the community-based AIDS centers. I would imagine that were it alive today, that would be a very lively and interesting interface. So there are a lot of elements, but I don't know any program with either the purity of purpose or the scope that RMP had. Nate? Stark: It's very interesting to me to note that four out of the five speakers, with very good programs being financed independently of government, I think one exception there is Charles Flagle, and I would say that they don't have to be aware, say, of the pressures of the finance system, especially when OMB is driven by budget considerations and not by program content and do, in fact, intrude on programs. I think it would be very helpful if we could put together a true Blue Ribbon Commission that would advise the government on this total problem of health care access, costs, and so on, but I'm afraid that isn't going to come about because OMB and others in government are concerned about what that might cost. Lindberg: We're told that some of the last recent elections were decided on the basis of health stances of the contestants, so perhaps the time has come to look once again broadly. Kissick: I come from the state that had the preeminent election. Harris Warford started forty-four points behind, and he defeated Governor Thornburgh by 58 to 42, I believe it was, in the election, on a sole issue: national health insurance. I think I can speak with authority that the senator doesn't have a clue as to what national health insurance is, but it was a very attractive issue to the electorate. I think that Monte has identified it. They say, "We want access, we want quality. But costs?" Remember, when the rubber meets the road, health policy becomes tax policy. Everybody's approach to tax policy is, "Tax the other person. They have the ability to pay some of it. I don't." So I think that we may have a Blue Ribbon Commission. I hope I'm not invited to serve. [General laughter] Lindberg: I'd like to invite comments from the audience on this topic. Fran Howard? Howard: Dr. Egeberg's big push and contribution was the involvement of a community, the voluntary health organizations in the implementation of health programs. I think it was said so well today that the people who plan have to be involved in the implementation. Those who implement have to be involved in the planning. In the state of Massachusetts, a community voted no taxes and then, of course, they realized that they have to. The teachers, the janitors, everybody has to work to keep the school going. They had to let the janitors go, they had to let all the staff go, so the teachers have to assume all these duties. Well, they really want to make a rerun now and maybe it's a good idea to have some taxes to provide the basic services which a community needs. The community must, according to Roger Egeberg (and I am one of his disciples), be involved in health planning. When I worked with Roger, we thought about the health organization as voluntary, non-profit, non- governmental health agencies working with the government. That was his major theme in his opera, that the voluntary agencies ought to be working in cooperative in the state of California, where he came from. Otherwise, you really wouldn't get community action. I think the RMP began that conceptually and that is one thing that is very applicable now as we face the problem of who makes the choices about what we want in health care. It's involvement of your citizenry from the beginning. Lindberg: Sir? Baum: I'm Ken Baum. I got onto the RMP staff sometime around 1969 or '70. Actually, I was Herb Pahl's jack-of-all-trades special assistant. If he was the undertaker who presided at the funeral of RMP, I guess I was the grave digger who threw the dirt in, because I was the last person who was left on the staff to give out the last $10 million that we had to disseminate in a week--that is literally true--and to box up all the records and ship them off to wherever they were going. As a matter of fact, I brought a last carton of stuff I had in my basement for years over here to the library the other day. A few other people can probably clean out their basements now. It's rare that one has an opportunity to sound brilliant in front of a room that has a higher density of assistant secretaries of health and under secretaries per square inch than has ever before been assembled, and hopefully some of the observations that I'd like to make may have some value for the future, whether it's a program that emulates Regional Medical Programs or not. There are two of us in the room who even date back farther to the old Hill-Burton program, where Dr. Rikli and I first met God knows how many years ago. Rikli: 1842. Baum: It probably was earlier than that. Incidentally, speaking of people who are kids, you're no longer a kid when you were born in a year that ends in the letters B.C., meaning "before computers," and you are no longer a kid when you're too old for anybody to accept your organs for transplant. That probably covers everybody in the room. I would like to suggest that for any other program that starts up from scratch, particularly if it's a government program that's innovative and that's vastly different from anything that's been around before, you need to have some time built into the legislation for it to get off the ground, for somebody to put together a staff, for somebody to put together some goals. You know, hot lunches for poor kids or whatever it happens to be, good medical care for everybody. To think through and to work through with whoever you have to work with on some of the policy and ideological things that have to be done when you're cranking something up brand new. You can't crank up a new industrial giant from nothing, and you can't crank up a new government program from nothing. Karl Yordy, I remember visiting you once when you were the only person on the staff. As I recall, you were sitting in a very small office out here at NIH in the basement somewhere, and I don't think it even had a window in it. It was at the bottom of a flight of steps. You had piles of paper all over the place. I thought, "Gee, this is this big new government program? And there's only one person working on it." Well, it obviously took a lot more people to be assembled, to get it started. The reason I mentioned Hill-Burton was, Harry Truman was president when that passed, and I understand that part of the history of that was that President Truman insisted that in the law there had to be a year for planning before any grants went out to anyone, and that meant that you had to have people on the staff in Washington, you had to have people on the staff in the regional offices. It was a grant-to-states program and gave the states time to line up people on the staff. That program was not only needed, had obvious direction and purpose, but it didn't have to go into full gear before at least the basic administrative machinery was in place. If we've learned any lessons from anything, the Comprehensive Health Planning program that replaced RMP had the same thing. They had to go into full gear, they had deadlines to meet that were in the legislation that were totally unrealistic. Gene Rubell [phonetic] had a six-foot-long pert [phonetic] chart on his wall with the deadlines, and by the time he left fourteen months later, not one of them had been met. Not one. Lindberg: You may be preaching a counsel of perfection, of course. Baum: Okay. But I think that's very important. I'd like to suggest some other things that need some study if you're going to do it. If you're talking about RMP into the general status of chaos and disorganization that accompanied governmental administration during the Watergate period, I think that after Dr. Wilson left, there was a period of four or five months where we had something like six different acting administrators. Bob War [phonetic] was acting administrator for two weeks. Some guy named Buzel [phonetic] came in and he was around for a matter of two or three weeks or a month. I don't recall anybody who ever even saw him, but I'm told he was a real person. Dr. Sensor [phonetic] came in. I'm right, am I not? So that you had a turnover of agency administrators about every two or three weeks. It is impossible to work in any systematic manner that way. That period ought to be looked into from the point of view of what was happening in the department, in the world, and in the government at that time. I will mention one other thing that nobody's mentioned. Section 904 of the act originally provided for something that was called interregional or multi-program services. It allowed adjoining Regional Medical Programs to do joint projects or do areawide projects. At a later time, and I don't remember what year, that was extended so that Section 904, while it had the same title, into Regional Medical Programs, vastly expanded the purview of Regional Medical Programs from heart disease, cancer, and stroke to virtually anything that was within the purview of the Public Health Service Act. At the end of the Regional Medical Programs, the $35 million that was released by the court, the last $10 million that Congress assembled, the general direction in which the projects were taking and the subject area was not so much heart disease, cancer, stroke, training of physicians and medical auxiliaries, but was actually filling in chinks in the local armor and putting money into delivery of health service directly. I don't have statistics to prove that, but I read an awful lot of those applications, and it would seem to me that somebody might want to look at the change in direction that occurred particularly at the end of the program and because Section 904 was revised. Lindberg: I think that's what Paul Rogers was referring to about the broadening. Okay. Any other suggestions on next steps? Vern, how about it? Wilson: It's tempting to just write you a letter. [Laughter] And that still may be the best idea. You know, this has a more pessimistic sound to it than at least I feel the program merits. I think you have what it takes in the way of resources and charge to make the new Regional Medical Programs work. I know all my friends will immediately chuckle, but it's the computer side that is going to solve this. I've been saying that for twenty years or thirty years, and I still believe it. The activated patient will start to work when they can get the information, and the one way they can get it is to put it into computerized form and distribute it properly. The only block in this kind of endeavor is the same block that we had when we changed from apothecary prescriptions to metric systems, and that's us. You can call it any way you want to, but it's the medical profession that is holding the line because they're scared, literally scared, of what the future holds. Some way we have to convert ourselves before we can recreate a Regional Medical Program to work. I'll write you a longer letter with more explicit thoughts. Lindberg: Herb, please? Pahl: I don't think one ought to confuse tactics with strategy. Bill Kissick summed it up very well, as did Ed Pellagrini. In the long run, if we're going to do something about access and quality and insurance and so on, we have to do something about accountability and we have to do something about management structure. One of the key lessons of RMP is in that arena, that there will be, if we decide to do something politically, which is the strategic bit, if we decide to do something politically about access and quality, we will have to do something about structure and accountability, and it's in that context that I would answer the lady from Maine who raised this question. The last thing in the world I would try to do is to bring to the political debate today about health insurance and access the issue of accountability. If they can't at this moment deal with the issue of finance, which is what Bill was saying so wisely, is the tax question. It's the heart of the issue. They don't have the ability as yet to deal with the financial aspects. They surely don't have the political will to deal with the issues of management and structure and accountability. I hope that you would have, at the results of the conference, very carefully and cleverly put together so that the lesson which is to be drawn from the group is clear there for the future, but I certainly wouldn't rush to see that Rockefeller and all the other people who worry about the debate know that they also have to worry about how to organize the whole system. Lindberg: Certainly if you need legislation, you need a legislative champion, but I think Vern Wilson is suggesting the power of the increasingly educated, intelligent public. I must say I think that's underestimated at every level. Just a non-medical issue, Montgomery County is not the first to adopt every improvement, I might say, but they have finally gotten around to dealing with the issue of recycling plastic and paper goods. They've dealt with it typically as if this has to be resolved by some group of gray-beards, gray-heads around the walnut table and everything figured out and so forth, and then sold to the people. That's completely crazy. The people have been way, way, way out ahead of the government. There has been stuff piled up in the streets waiting for weeks for these guys to come around with their blue boxes to put it in, and they don't have to sell anybody on those ideas. They're ready, willing, and able to cooperate. I would imagine they'd be ready, willing, and able to understand and cooperate with a lot of improved health ideas as well, but that is an entirely new approach. Closing suggestion to us? Even a benediction if someone has one handy? Unidentified: May I give the benediction? Lindberg: Sure. Unidentified: I'll begin with right concept, wrong culture. We've been discussing total quality management for total quality improvement, which comes out of the work of Demming. Demming actually pursued his work in Japan and they created Japanese management. Japanese management is the synthesis of American statistical theory with the Japanese culture, and I think the lessons of total quality management, which RMP was about in the beginning in a very interesting way, requires us to understand the concept and the culture, and we will develop our approaches within our culture. Amen. Lindberg: Ladies and gentlemen, thank you so much for your participation.