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.