B&B ImPoRmikriom ImAmE MAKNAMEMIE@ 300 @oftoc D=ot=Vn SOUL" Ulsoncot ZD'772 0 us^ 0 C301) 24@l 10 10/26/70@. SIZIMAP.Y OF ADL-OSTI REPL)RT The ADL contract has been extended for one mont4 (to November 20) without additional funds. This extension was made in order to allow them to (1) more fully and adequately reflect in their final report the extension comments, criticisms, and suggestions received from those selected coordinators, RMPS staff, and others who reviewed their draft report, and (2) prepare a summary of the larger report. A short staff summary (8-10 pages) of the draft ADL-OSTI report will be available at the time of the Council meeting. Copies of the final report paper and a summary version of it will be sent to Council members as soon as it has been received and reproduced in quantity. Enclosed are copies of two papers that may be of interest to you. (1) "Regional Medical Programs: Improving Health Care Through Voluntary Regional Cooperative Programs," by Dr. Donham. This brief paper not only draws upon the contract effect of ADL-OSTI, but in a sense is a highly selective and incomplete summary of that study. (2) "An Approach to Evaluation for the Regional Medical Program," by Dr. Schon. This paper very nearly mirrors the substantive evaluation chapter found in the draft ADL-OSTI report. it also reflects some of the major themes, such as systems trans- formation, of that larger report. Enclosures REGIONAL liEDICAL PROGRAMS IMPROVING HEALTH CARE THROUGH VOLUNTARY REGIONAL COOPERATIVE PROGRAMS PHILIP DONHAM, D.C.S. Arthur D. Little, Inc. Cambridge, Massachusetts Eastern Regional Conference on Scienc6 and Technology for Public Programs Boston, Massachusetts April 2, 1970 Workshop Session I: Case Reports Section G: Health Services REGIONAL MEDICAL PROGRAMS IMPROVING HEALTH CARE THROUGH VOLUNTARY REGIONAL COOPERATIVE PROGRAMS EASTERN REGIONAL CONFERENCE ON SCIENCE AND 'TECHNOLOGY FOR PUBLIC PROGRAMS April 2, 1970 ARTHUR D. LITTLE, INC. This paper is.written for the Eastern Regional Conference on Science and Technology for Public Programs. My assigned subject, "Regional Medical Programs," is heavily weighted with science and technology; and it most certainly is a public program. Now it would be very satisfying to be in a position to show you how advanced medical technology was expedited throughout the medical system 3 a result of a public program, but that is not'what really happened. When -aedical discoveries of great import are made, they become widely known in a very short time. And if they have significant potential for affecting primary care, they spread through the system as if by magic: witness pen- icillin and the Salk vaccine. Regional Medical Programs started as a vehicle for accelerating the dissemination of the latest advances in technology to where they could reach the patient. This paper tells why this turned out to be an inappropriate target and what took its place when it did. I rather think that the new target may turn out to have more significance to public officials in the future than the original one would have had. -0- REGIONAL MEDICAL PROGRAMS PHILIP DON@L ARTIIUR D. LITTLE, INC. Precis Regional Medical Programs was.one of several Federal programs that were initiated in the eighty-ninth Congress in 1965 to respond to the growing health problem in the United States. Its contribution was expect- ed to be to unlobk the vast storehouse of medical research that had accumu- lated over a decade or more and make it available to victims of the killer diseases: heart disease, cancer, stroke, and related diseases. As the Congress finally passed the Law (P.L. 89-239) it conceived of regional voluntary cooperative programs as the most effective vehicle for facilitating the movement of advanced technology through the medical sys- tem. When the Reg ions began to operate, several unexpected conditions slowly emerged: (1) To the extent that new technology had real applicability to primary health care, it was already very widely known throughout the system. (2) Obstacles to the application of the latest technology to patients were either economic or institutional for the most part. (3) 14hen economic, they were usually beyond the anticipated financial resources of 'RMP to deal with beyond a token level. (And other agencies usually had a more direct responsibility for them, as with renal disease.) (4) RMP was ideally situated to work on the problem of institutional barriers because of its charter to build on cooperative arrange- -ments among all those participating in or closely related to the medical system. Regional Medical Programs has found itself able to turn in the direc- tion of facilitating closer relationships and improving communications across institutional barriers without having to abandon the professional orientation it started with. Regional Medical Programs has thus become a significant practical ex- ample of how a public program can learn and evolve as it develops, so that it can be responsive to reality while pursuing its valid social objectives. [E ORIGINAL GOAL: I@TR%OVED N'@TIO'@\AJ, HEPLTH CARE As long ago as 1965, the Congress of the United States actpd nn the emerg- ing awareness that the state of the Nation's health was unacceptably poor even after billions had been spent on medical research. That was the year that the Congress established Medicare and Medicaid to help old people and poor people meet their medical bills. In the same year, two laws designed to improve the capability of the medical provider system were put on the statute books. (1) The Regional Medical Programs (P.L. 89-239) dealt with improving health care for victims of heart disease, cancer, stroke, and related diseases through voluntary cooperative arrangements among those directly concerned with medicine. The' other, Comprehensive Health Planning (P.L. 89-749), dealt with state- and area-wide-planning of health resources to optimize their effective application. Let us look for a moment at the condition of health in the Nation that led to the concern of those in positions of public responsibility. As told to an audience at Airlie House by Joseph T. English, M.D., administrator, Health Services and Mental Health Administration, on September 28, 1969: "We are 15th now among the nations of the world in infant mortality." "We are 22nd among the nations of the world in life expectancy for adult males." And in another vein he said: "In 1955 the total public-private expenditures for health care in the United States was about $17.1 billion. In 1965'it had grown to $37.3 billion. Today, in.1969, it has grown to better than $60 billion. A conservative projection of what that total will be in 1975 is that it will approach $100 billion." In 1965, the relationship of these numbers was not already evident. What was evident was that billions had been spent on health research with- out a corresponding improvement in health statistics. President Johnson, in 1964, established a Commission on Heart Disease, Cancer and Stroke, the three leading killers, to investigate what might be done to reduce morbidity and delay mortality from these diseases. The DeBakey Commission, as it was named after its Chairman, Michael E. ' DeBakey, M.D., of Baylor University, submitted its report in December, 1964. The re- port, which became the basis for an Administration bill recommended a detailed Federal blueprint for action. 'It proposed the building of a number of "re- gional medical complexes" around the United States for research and training and for demonstrations of patient care in the fields of heart disease, cancer, stroke, and other major diseases. Implicit in the Report were two beliefs that have since under@one careful scrutiny and, at least in some quarters, strong challenge: (1) Effort spent directly on the leading killer diseases is the most promising way to improve health statistics quickly, and (2) Regionally organized medical complexes could force-feed the en- tire medical system with knowledge that had built up in the great medical research centers. The administration bill had very hard sledding in the Congress. There was wide resentment in the profession at the suggestion that excellence and the latest medical knowledge were attributes confined largely to research centers. There was also widespread fear that this was a first step toward a Federal medical system directed from Washington. The Act as passed (P.L. 89-239) turned away from the idea of a detailed Federal blueprint for action. Specifically, the network of "regional medical complexes" was replaced by a concept of "regional cooperative arrangements" among existing health resources. It recognized geographical and societal diversities. It established a system of grants to enable representatives of health resources to exercise initiative in identifying and meeting local needs within the area of categorical diseases. "Other major diseases" became lim- ited to "related diseases." How well local health resources can take the in- itiative and work together to improve patient care for heart disease, cancer, stroke, and related diseases became a measure of the degree to which the vari- ous RMP's would be perceived as meeting the objectives of the Act. The Act was intended, as was the Administration bill, to provide the means for disseminating to medical institutions and professions the.latest advances in medical science for prevention, diagnosis, treatment, and rehabilitation of certain categorical diseases. But the dissemination, instead of being directed from regional centers, was to be implemented through grants which would be used among other things to encourage cooperative arrangements. RMP AS A VEIIICLE FOR DISSEMINATING THE LATEST MEDICAL ADVANCES TO THE PATIENT By the time the Regional Medical Programs came into being, its objectives had been spelled out in the Law as follows:* The program was expected to encourage research and training (including continuing education) and related,demonstrations of patient care in the Condensed and paraphrased. -2- fields of heart disease, cancer, stroke, and related diseases. the program was expected to afford the opportunity to the medical pro- fession and medical institutions of making available to their patients the latest advances in the diagnosis and treatment of these diseases. The program was expected to improve generally the health manpower and facilities available to the Nation. RMP, it would seem, was given responsibility to seek out the latest medical advances and find ways to disseminate them for the purpose, so far as possible, of wiping out heart disease, cancer, stroke, and related diseases. Regions were approved by the Surgeon General and issued planning grants as follows: 1966 34 1967 19 1968 2 55 With approval of the 55, every part of the United States became included. While each Region went about organizing and planning in its own way, they all turned almost immediately to the medical schools for access to the latest -aedical technology that they were expected to help disseminate. The medical schools, by and large, were ready and waiting. Hopes and expectations ran high in some quarters. There had been;con- siderable publicity given to the truly marvelous medical research being car- ried out in medical schools and research centers across the country. This brilliant research had resulted in exciting -- even dramatic -- advances in dealing with what had previously been obscure or untreatable diseases. As the Regional Medical Programs turned to these institutions for the latest advances to be disseminated, the astonishing thing was that virtually no new technology appeared in their grant proposals. Their ideas were al- most universally confined to ways of using @IP funds to make already widely known technology more readily available to local physicians and community hospitals; e.g., coronary care units, audio-visual teaching tools, assistance in multi-phasic screening, and a broad spectrum of continuing education pro- grams, from conventional to creatively new. But the expectation that there was a storehouse of unrecognized advancds in medical technology, ready to be applied by the medical profession as fast as they could be made aware of them, proved to be a myth. There could be no quarrel with the kinds of projects that were approved. Clearly they dealt directly with the objective of making what was known more readily available to the patient. -3- Recognition of the fact that dissemination of nexrtechnoloc,v must, in i:he face of reality, drop back from a position of top priority came slowly. It is the nature of things that professionals in medical schools are better positioned to take the time to prepare grant applications than those more immediately tied to patient care. As might be expected, applications from medical schools dominated the scene in the early years of the Program.. To some degree this seemed to support the notion that @IP was a tool of the medical schools to disseminate their "superior knowledge," and it concealed from general notice for awhile the fact that little of this knowledge was really an advance in the state of the art. There are still those in medicine who find it difficult to accept the reality that has emerged. @IP AS A FACILITATOR OF PROCESSES TO IlrPROVE PATIENT ACCESS TO HEALTH CARE As technology transfer dropped from a position of top priority, those concerned with the establishment of policy and program in the Regional Medical Programs began to look at the Law with a new perspective. They rec- ognized that the Law put initiative in the Regions, and with it responsibility to set new priorities. Public Law 89-239 made it clear that RMP was to focus its energies on making quality care available to the victims of heart disease, cancer, stroke, and related diseases. It placed the profession in the forefront of the Program.* A very significant emphasis on voluntary cooperative arrangements had been added before MIP became law. While Medical centers and clinical re- search centers were to play an important role, hospitals, practicing phy- sicions,'and other persons and institutions related to medicine, as well as laymen familiar with the need for services, were to be included as active voluntary participants. Regionalization began to take on new meaning. *Whereas the comprehensive Health Planning Councils under P.L. 89-749 were required to have more than 50% public members, PlfP Regional Advisory Groups had to have merely an unspecified proportion of public members. The Regional Advisory Groups were to be themselves constituted in such a way as to bring together all those interested in health in the region. By law, membership of an individual Regional Advisory Group would have to include: 4 practicing physicians *medical center officials #hospital administrators representatives of appropriate medical societies *voluntary health agencies representatives of other organizations, institutions, and agencies con- cerned with activities of the kind to be carried out under the program *members of the public familiar with the need for the services provided under the program -4- If lack of general knowledge of new medical technology was not a prime iuse of the poor health statistics of the Country, then "Where is the gap Detween our obviously superior medical knowledge and the observable level of delivered health care?" It was at this point that the wisdom of the Congress in insist ing on regional cooperative arrangements finally became clear. In the process of trying to get all interested parties to cooperate, the IUIP's quickly dis- covered that the medical system is the victim of its own institutional bar- riers: mutual tou-n/gow-n distrust, "guild warfare," defensive referrals, neighboring community hospital rivalries, and other serious interferences in the free flow of the most appropriate care to the patient. The concept of mutual confrontation of common problems was essentially a new one, only just approaching a level of acceptability under the enormous pressures that had begun to beset everyone connected with medicine. And only; P,IFP, of all the public proarams in being, offered a charter to the medical profession to voluntarily address itself to lowering those institutional barriers '. Here, then, began to emerge a new sense ofmission in the most advanced PIiP's. This new mission led naturally to a need to learn where the system of delivery of health care was failing to reach people. Almost immediately. attention was drawn to the poor, both urban and rural. Whereas the middle income and well-to-do are suffering the effects of the institutional barriers' referred to earlier, the poor are really cut off from the mainstreamof the system even when covered by Medicare and Medicaid. Dr. English, at the meeting referred earlier in this paper, presented some facts that point up the significance of the desperately bad health con- dition of the poor:* "A poor child in this country in 1969 has twice the risk of dying before reaching his first birthday as your child would have, and four times the risk of dying before reaching the age of 35 than your child would have." "The dif ference in incidence of chronic disease per 1,000 population...- [is) in orthopedic impairments... 32 to 15; in heart conditions of 30 to 12; arthritis and rheumatism of 27 to 8.7 ... in high blood pressure... of 17.3 to 4.2." Dr. English also called attention to the disparity in age-adjusted death rates in 1966 per 100,OOC population between whites and non-whites. For heart disease, cancer, and stroke his data compared as follows: Heart-Disease Cancer Stroke Whites 270.5 125.9 Non-Whites 324.3 152.7 125.5 Poor is defined as under $2,700 annual family income. -5- Now the significance of these figures for R.NIP is inescapable. A program @hose ultimate objective is, as the Surgeon General said, "...[to] permit the best in modern medical care for heart disease, cancer, stroke and other re- lated diseases to be available to all" cannot ignore them. Indeed, if the medical profession is intent on raising U.S. li;alth statistics to a level equal to the best in the world, they cannot do it without directly confronting the problems of the poor and the non-whites. And the Regional @ledical Programs is the only ready vehicle through which all medical professionals can join forces in that confrontation. Let it be said that the various branches of the medical profession cannot. do the job by themselves. Until other equally severe problems of the poor and underpriviledged -- unemployment, inadequate housing, limited education, and , malnutrition -- are dealt with effectively, no amount of the best quality care will bring the health of these people up to the national average. SPECULATIONS ABOUT RMP @IP will almost certainly shift its center of gravity toward the outreach of the medical system away from the medical centers. Indeed, this has already begun in most Regions. As was mentioned earlier, medical schools assumed a position of dominance at first in most @IP's. In a much smaller number of cases regional medical societies took the lead at the start. However, individual Regions were required to engage a broad spectrum of participation both as to occupational background ind as to geographical spread. The interaction of many professional subgroupings and many diverse geo- graphical interests resulted in tensions and conflicts which were destined to bring about change. The required cooperation led to the thrashing out of issues. There was an awakening awareness that interaction among diverse groups, under- taken in a spirit of cooperation, could lead to creati-ie solutions to health problems. Region after Region discovered that a balancing of interests was more attractive and productive than submission to the dominance of any one group. Reorganizations of boards of trustees, executive committees, and even of Re- gional Advisory Groups became commonplace after a year or two of experience; and interest in subre-ionalization began to mushroom around the country. 0 As new groups of people began to pick up interest, formerly dominant ones moved back to a relatively less active role. All this has resulted in a clari- fication in each RMP of its program objectives. Within the last year there has been a considerable move in this direction. RMP will come to believe in and rely more on the quality of local doctors and the capacity of associated medical personnel to take on greater responsi- bilities.* It came as a surprise to most to discover that excellence is not *The shortage of doctors will force this in any event. -6- imply a quantitative accumulation o' technical medical knowledge. First Lne doctors, it turns out, know some things about patients that the teach- ing hospital specialists get little exposure to. The "whole man" concept of the local M.D. and some of the paramedical professions has a lot to do with the sense people 'have of how good their health care is. On the other hand, the repetitive experience of those who specialize in the larger insti- tutions sharpens their skills in diagnosis and treatment of the particular diseases that they have chosen to focus on. Local doctors usually find themselves treating patients; teaching hospital specialists most often find themselves managing difficult diseases. Both are needed; both call for trained skills. Neither one is by definition more excellent than the other. RMP includes them both. RMP is unlikely to become a powerful force in the economics of medicine. In any foreseeable future, RMP funding is unlikely to exceed 1/2 of one per- cent of the total expenditures for health care. At best its role will be facilitative and catalytic. The significance of project grants will continue a change that has already begun: it will be just as important that a project contribute to a strategy of building improved medical system relationships as that it be professionally sound. The medical system of the United States is on a collision course. Soon, Crom one source or another, nearly everyone will have money to pay for ade- uate health care. But there is a severe and growing shortage of doctors, nurses, and other auxiliary medical personnel even without the new patients who will come to expect care. Even if we were to double the enrollment of our medical schools and train other medical personnel at a significantly increased rate over what is now being done, in ten years we would no more than hold our own in a posi- tion of short resources. There can be no doubt among thinking men but that public pressures will force some degree of rationalization of our medical system starting in the near future. Since what we are now doing, even if accelerated, will not meet the need, it is clear that new concepts, new relationships, new definitions of professional responsibility will come into being under this public pressure. If the medical system is to be as radically changed as this suggests, the profession would be well advised to-prepare itself to participate in the design of what will take the place of the present system. Medicine is highly technical, and professional participation in the design of the system is imperative if the design is to provide adequate safeguards of quality. A system designed by ad- ministrative men or money managers would be likely to exert pressures in favor of the quantitative rather than the qualitative aspects of health care. Incen- tives would likely be conceived of in these terms, and personal advancement with- in the system would almost inevitably become responsive to these quantitative ,easures at the expense of quality. Medicine-could easily be the victim of a -7- kind of Gresham's law, reducing everything to the lowest common denominator. All elements of the profession should be involved in any systems redesi-n, if what comes out of it is not to be warped all out of shape by special interests. Consumers, too, must participate in deciding what is needed.,. Regional Medical Programs is at the present time the only insti- tutionalized-arrangement for bringing all of these elements together. And it does so in a climate of cooperation and voluntarism that will prove invaluable when it comes to destroying old prejudices and building anew. APPENDIX In June, 1968, Arthur D. Little, Inc., and the Organization for Social and Technological Innovation (OSTI), both of Cambridge, Massachusetts, commenced a two-year study of the Regional Medical Programs for the Division of Regional Medical Programs (DRMP) of HEW. In essence we were asked what are the Regional Medical Programs as they are developing out there in the country. We are now about two-thirds'of the way through our study. We have spent. upwards of 60 man-days in each of three regions and will shortly have done' the same in a fourth. In addition, we have spent from two to ten man-days' in each of about a dozen more. We have attended several regional group meet- ings and all national meetings that have been held to discuss RMP matters., In Bethesda, our study had included many discussions with senior offiiI cials in HEW, the National Institutes of Health (under which PMP commenced its existence), the Health Services &Mental Health 'Administration '