A Symposium at the Mid-South Medical Center Council Annual Meeting June 10, 1970 Holiday Inn-Rivermont Memphis, Tenn. Participants Joseph T. English, M.D. Harold Margulies, M.D. Eugene Fowinkle, M.D. Harold R. Sims Bland W. Cannon, M.D. Moderator The difficult task of charting new courses to better health care for citizens of the Mid-South puts the Mid-South Medical Center Council and the Memphis Regional Medical Program side by side in the same battles. In many instances the two agencies work closely together to reach common goals. Publication of these proceedings of the MMCC's 1970 annual meeting is one example of that cooperation. Making health-care professionals and laymen alike more aware of the issues facing the region and the nation, now and in the years to come, is an important job for both MMCC and the Memphis RMP. Leaders of both organizations felt that forthright comments by participants in the symposium of the meeting would provide an excellent definition of the issues and some stimulating insight into them for professionals and laymen. We feel that there are no more knowledgeable or more articulate com- mentators on the present and future crises in health care than the men who accepted invitations to appear on the symposium, Harold Margulies, M. D., now director of the Regional Medical Programs Service, Joseph T. English, M. D., then chief of Health Services and Mental Health Administration, Eugene Fowinkle, M. D., state health commissioner for Tennessee, and Harold R. Sims, deputy executive director of the National Urban League. The symposium was ably moderated by Bland W. Cannon, M. D., Memphis neurosurgeon and a member of the National Advisory Council of the Regional Medical Programs Service. Dr. James W. Culbertson, program coordinator of the Memphis RMP, and Mr. Frank M. Norfleet, president of the MMCC, foresaw the benefit of publishing the proceedings and gave their earnest approval to the effort. Staff members of the Memphis Regional Medical Program and the Mid-South Medical Center Council cooperated in tape recording the proceedings and in preparing the transcript necessary to the production of this finished documentation of that meeting. This publication has been edited only when necessary to achieve brevity and conciseness and to eliminate passages which were garbled electronically or when some stray sound made a speaker's words incomprehensible. Occasionally, when garbling or noise interference left the speaker's meaning unclear, passages were deleted rather than run the risk of altering or obscuring his intent. However, in a few instances, a speaker's exact words and phraseology were left undisturbed, even if the precise meaning were unclear, when they helped maintain continuity of comments. We feel that the end result is a fair and accurate account of the meeting and an important document for the edification of persons interested in health care in the Mid-South and the nation. -The Editors Clayton Braddock Information Officer Memphis Regional Medical Program 1. A. Metz, Jr. Director for Voluntary Health Agencies Mid-South Medical Center Council ne out 'r. Ellglish, M.D. Corp. Joseph earth and Hospital President, New York City H ish chief or 'Na m A@ 'nis- e f this. mpodsi@e @ E-1 ,HErgtat m ,d sy eal It0 Servi es an f "etalt uc e c d on im 6 oep8rtmen 0 t'lt at "ea E e il n in t e 'f t 0 10 tre't fa .A Wel re FOR HEAL EX URES - - ljppLIES AND S A ON s PWS'C'4" SERVICFS his opport nitY to Irea shar th re to state V( 32 to t un determ, e, yo@eed to s going t of these Problem Ise, t@ f utu re Of -3 BILLI@N hing e . . MO e than anyt th in this ountry in me ee probleTs are: thE nt)ower ano (3) some rl' , that we who are I ti gs haveto or th are going to ve int( if we are going to ta do in next decade. 5 any f ney. (Slide slide 1 t ufirst talk about MO Services and Les s for Health complex which is only 141 w to take a very ty, I it very brief The projection is by 1975, s rv to review along the road to the eighties, which reflects half wav s you a slide .h that he@lth and mental health services I ing spent in heart 'it be close to a t t is be .s alone in in this country wl erprise. it now I health service I000,000 ent 1 gross ector of our $100,000 s six percent of the tota the public and private @ r- and private represent- of the wealthiest economy; it is both Put)li is information national product f the world - It source of th I he money. The mi Sion on country in the historv 0 nt behind t ent's Corn s t two perce which -Is the Presld uced a is now abol Health Manpower, which Prod Department of Defense years ago. . lic expenditures report some is loo percent Put) r)ublic-private SP lit n1955 we were you do not have the , in health. Ws is that i do What it sho h and mental health in defense that You fthe or healt. - ertheless,. as a segm?nt 0 cl,v rivaled the spending .f this country a.bout Nev y, we have alrea , d by services I en in 1.965 that econom Department in size an ightly $17,100, 27,300,000,000' Defense ay be equal to it or si n with figure ha $62,000,- 1,975 we M ding on the situat-lo In 1970, than the ahead,depen ooo,ooo get Of al t a few the war. national c the world countries Therefore, one way to look at the money problem-as we are in a period of time when we want to do many things and money is tight-is to see that in this segment of the economy, not doing things for a lack of money is a cop-out, because we are guaranteed growth. Growth in some ways, as we approach the 1980s, is one of the great threats to us in health, for a very simple reason -because our country has been so generous in investing in health. This may not really be enough in terms of the importance of health to the national The thing that is f Tightening about this life of a country to even maintaining projection is the situation that we face domestic tranquility in a country. in 1970. If there are not major changes in the way in which this growth is It has been said by many observers of handled, we could find ourselves in countries in development that if you 1975 worse off in terms of health and do not meet something as fundamental mental health services to the American to life itself as health, that it may be people-the quality of health and impossible to maintain order in a medical care provided to the American country. And therefore, we are not people in 1975, despite nearly doubling first in the percentage of our gross of the investment that the total public- national product in investment in private sector puts in-than we are in health. There are other nations that 1970. 1 do not think that any of us percentagewise invest far more than would look forward to the decade of we do and therefore I do not think that the nineties where, despite the tre- we should fear the growth we are going mendous growth of the sixties and to experience; rather, we should fear seventies, in spite of that growth, the use that is made of that growth people ended up less well served than because that is the problem. they were in mid-1970. 4 Now, to get some understanding of how we can face that dilemma, I would now like to put the bee on the federal government, which shares responsi- bility for this pickle.that we are in. And FEDERAL OUTLAYS FOR HEALTH the next slide (Slide 2-"Federal BILLIONS OF DOLLARS (est.) 18.3 Outlays for Health") concerns the 16.3 3.5 Xv EW OF HEAUH natu re of federa I expend itu res f rom 14.1 3.1 RESOURCES 1964 to 1970. It is a small part of the 2.8 $62,000,000,000 enterprise but a very PROVISIONS F significant part; and my own feeling 14.0 HEALTH SERVICES 12.5 (III MAl.,. S here is that until very significant 5.1 10.8 Mdic.id) changes are made within the federal l@8 PREVENTION AND CONTROL OF expenditures, it is going to be impos- 4 @,6 7 r.8 HEALTH PRWLEMS sible for the total public-private sector 1964 1968 1969 1970 of health in this country to get out of FISICAL YEARS its present pickle. SOURCE: BUREAU OF BUDGET SPECIAL ANALYSIS Slide 2 Now let us first take a look at the way these expenditures have grown, because until very significant changes are made they have grown rapidly between 1964 within the federal expenditures, it is going to and 1970. You can see that the federa I be impossible for the total public-private share in 1964 was about $5, 100,- sector of health in this country to get out of its 000,000 and in 1970 it is up to $18,- present pickle." 300,000,000. There are not many segments of the federal economy, other than the Department of Defense, that can show that kind of growth in a relatively short period of time. So to begin to understand the problem, you have to see where the growth has been. But even more significantly, where the growth has not been. If you have binoculars in the back row, you may just be able to see a little brown line here which represents the investment made for the maintenance of health, the prevention of disease, and the control of health problems. It was .4 billion back in 1964; it is now.8 billion, but you know that is not even a real Number two, if you look up at the yellow measure of growth because when you box, you can see the money that the take into account what a health dollar federal government invests in basic is worth in 1970 as compared to what medical research, in manpower pro- it was worth in 1964@ you can really duction, in developing the capacity of see there has been almost no growth the American health care enterprise at all. I consider that to be one of the to better deliver the excellence of serious problems which, if we do not American medicine and to be able to face it in the seventies, is going to give better deliver health care to the growing us an incredible dilemma for the and pressing demand the 200 million eighties. people are making. 5 Where we are going up in cost to the American public from six to twelve percent per year, it leads to dilution of quality, because a physician has to If you take a look at the growth that take care of five times the number of has occurred between 1964 and our people because there are not as many support for developing the capacity of doctors as there were before. the American health care enterprise, to better serve the needs of 200 million Whenyouconsiderthestrainsthatthe people, again you do not see significant hospitals are under, you begin to see growth there. That is why we have a what happens to the quality of care. manpower shortage of physicians, Then thirdly, most of the resources go nurses, and paramedical people. It is to care of the patient after he needs to Why we do not have the resources for be between the sheets and a very the hundreds of experiments that pittance of our total investment is going medical societies, hospitals, group into the prevention of illness and in the practices, physicians and other maintenance of health. medical purveyors in this country would like to do to make the delivery of But we have not yet seen the federal medical care more effective in this leadership that is going to be required country in places where it is not, without first in the federal sector to reverse necessarily diluting the quality and this absolutely elemental disproportion the excellence of medicine that we in the investment we are making in a have learned how to produce in this rapidly growing segment of the econ- country. omy. And it seems to me that until that begins to occur, it is going to be very If you take a look at the federal invest- diff icult for the private sector of hea ment for the development of health in this country to help with the total resources to better serve the growing problem that we are going to face in health needs and the growing aware- eighties. And I think that is indeed why ness of their health needs of the there is a crisis in medical care. American public, you can see that there has been very I ittle growth at Now let us go to the next slide-man- all, even without taking into account power distribution (Slide 3).* This the inflationary impact on the health begins to get us into the second prob- dollar because the strategy has not lem ... which is manpower. Now I have been correct. Three and a half bill ion chosen an illustration which I do not dollars is not very much for the develop- think will surprise any of you. It shows ment of the American health care what has happened to the mythology enterprise within a $62,000,000,000 of the mainstream of American medi- industry. cine over the last 25 years. So therefore, the question is where has Part of the reason why most of the the growth been? As you can see, the federal investment is trying to buy growth has been largely in those sums people into the mainstream was of money which the federal government because back when that term first was provides to pay for medical services used, there was a mainstream of but which do not necessarily help the American health care. But there have purveyor increase his capacity to meet been dramatic changes in the last 25 a growing demand. This is largely years that present federal policy has Medicare and Medicaid and, in the not yet taken into account. In a 55-block private sector, other third party pay- area in Harlem 25 years ago, for 25,000 ments. It is the money that is putting the people there were 50 practicing physi- pressure on a very limited capacity, a cians attempting to take care of them, capacity that is inadequate to meet the most of them being in the general prac- needs of 200 million people. tice of medicine. Look at the dramatic 6 change that has occurred today where Let us move on to the next slide now twice the number of people are living (Slide 5-"Physician-Population Ratio, in that area, and there are now only 1943") * and just take a couple of min- f ive physicians there. If you look at who utes to try to project a little bit into the those five physicians are, you are going future what may have to happen by to find that they are, in general, older the 1980s if we are not going to see men and there are no younger men ... federal medicine-government coming in to take their place, medicine, whatever that is. Because if there are not basic changes, if we keep You could give countless illustrations investing more and more money in of this in most of the cities of our coun- health, as we are at the present time, try. You could show it in poor rural Without the consumer, without the areas too, but the next slide indicates citizen seeing his medical care or health that it is not just a problem of the poor; care improved as a result of that, the it is a problem of some relatively well- consumer outrage is going to produce to-do areas in rural parts of our coun- a situation in the Congress that is going try as well. It is a problem that goes to convert us very rapidly to a public beyond socioeconomic parameters. utility or to a federal form of direct (Slide 4-"Physician-Population medicalcareas asbeendoneforthe Ratio, 1943")* Indians and for other populations. I think that would be tragic in this This concentrates again on physician- country. population ratio in the urban core of our cities in 1943. Back at that time, the ratio of doctors to patients, potential patients, was 1 to 500 and out in the suburbs in 1943 it wets 1 to 2,000. Take a look at what happened as early as 1968; the change was dramatic. You have a situation now where in the urban core of our major cities that ratio has gone from I to 500 to 1 to 10,000 and you now have a situation in the suburbs where it has gone, in that same period, from 1 to 2,000 to 1 to 500. HOSPITAL PHYSICIAN GROUP PRACTICE Just as the money problem is not &MENTAL HEALTH CENTER @ NEIGHBORHOOD HEALTH CENTER simple, which I think the former illus- Slide 6 trations tried to show, it is very clear that the manpower problem is not simple either. It is not just a question Now what are some of the things that of producing more doctors, more are going to have to occur if we are to nurses, more medical personnel of avoid unfortunate outcomes of this other kinds; it is a question of how, in a crisis? (Slide 6-"Community Puzzle free and democratic society, we get of Hospitals. Group Practice, etc.") those medical personnel and those medical facilities to the places where The f irst thing I think you see evidence they are needed. And I again want to of is a variety of groups, representing emphasize that this problem is not just the purveyor and the consumer and the in poor areas of our country, but in a teachers of medicine and the people great number of relatively well-to-do rural areas where you have the same kinds of changes going on. '@Slides 3, 4 and 5 not reproduced for proceedings. 7 interested in medical research, coming those dollars into better health care for together and recognizing that in one area of a community there may be no the American people. If that does not doctors at all. happen, then I think we are going to be in difficulty. This would be the case right here (re- ferring to slide) and that might be the I would hope that we would begin to see a variety of different ways of coming together at the local level, as we see being done here (on slide diagram) to see how those pieces can f it together more effectively, whether they are through an areawide health planning agency, a Regional Medical Program or cooperation between those two programs and other efforts. This is something which does not yet exist in this country in health: a community trusteeships coming together of the HOSPITAL PHYSICIAN GROUP PRACTICE MENTAL HEALTH CENTER @ NEIGHBORHOOD HEALTH CENTER Slide 7 reason why, through some federal effort or some private effort, something like MUNITY a neighborhood health center is started to try to re-attract physicians back into that area and to put them together with paramedical people that extend the hands of the relatively few physicians. In other parts of the country we may HOSPrrAL PHYSICIAN @@@rROUP PRACTICE have a group practice in a hospital. IMMENRALHEALTH CENTER@ NEIGHBORHOOD HEALTH CENTER Way over here (referring to slide) there may be a mental health center in Slide 8 a hospital and just a few solo practi- tioners. Over here there may be public and private sector at the most something else. But it is very rare, in local of levels where the citizen mandate most parts of the country, that there is there with the community, where all is any public-private institution devel- segments of the community are rep- oped to survey that whole scene and resented-the taxpayer, who supplies to try to figure out how to make the best the money increasingly for these use of the resources that are there, the services, and also all of the purveyors, new resources that need to come in, be too. they public or private. My conviction is that, though the re- We have not yet seen that institutional sponsibility of those in Washington is development in this country and it is great, the real difference is going to really through Comprehensive Health be made by the initiatives you exert Planning and the Regional Medical right here at the local level to do some Programs that we are beginning to of the most elemental things that need see the start. So I would suggest that to be done if we are to be optimistic by the eighties, if these programs are about what we can do in health, perhans given the priority which they should one of the most important dimensions have, in ... what is already a $62,000,- of the quality of life in our society in 000,000 enterprise, this will help turn the 1980s. 8 ost o ervice Vs t e a ue o are Harold R. Sims Acting Executive Director, National Urban League (Mr. Sims was deputy executive director at the time of the symposium) When I attended high school in Mem- phis during those years I mentioned, I became quite fond of an old Chinese proverb which followed me through the years; I am sure you are familiar with I thought as a sub-name I would it: "If you would plant for one year," choose the "Cost of Service Versus said the old quotation, "plant grapes. the Value of Care." I remember it was If you wou'ld plant for ten years, plant said that, "That which is immediate trees. But if you would plant for etern- takes precedence over that which is ity, plant men." important and that which is important only gets attended to when it is urgent, Given the current status of man, woman and then it may be too late." and child in the American world today, our commitment to planting men You know, I am very happy to be here. ratherthanthingsistragicallyin ou t. I feel, sitting here on this stage today, Inthefaceofunprecedentedscieritific that systems have changed, because technology and technological progress, when I finished Booker T. Washington we fail to commit and demonstrate our High School (in Memphis) in :L952, I capacity and resources to the magni- don't think there was any less likeli- tude of the problem which we have hood that a student of the University of here at home. Our cities and rural Tennessee would be sitting here or areas are in an ever-deepeni'ng crisis, anywhere near anybody like me but with both qualitative and quantitative there was no likelihood that I would defects robbing our children and our get in the University of Tennessee youth of the occasional opportunity Medical School or anywhere else. I am needed to facilitate their maximum happy to make that note. growth and development. 9 A housing crisis continues to worsen with blight decaying the slums, breed- ing crime and delinquency in every major urban city. Our living environ- ment is in a crisis, through pollution, poisonous air, dirty water, the rodents rampant and clutter-it is becoming an increasing ... problem. , Of all the crises we face today, none is more critical or urgent than the growing deterioration of health care and serv- ices. For without a healthy body and mind, none of the other crises or op- portunities really matter in the march- ing hierarchy of human needs. Now, this health-care crisis in our age ex- presses itself in many insensitive and ironic ways. Although the statistics are used from a variety of sources during the decade of the sixties, nothing has changed very much to alter the picture. For example, despite spending $62,000,000,000, or 6.7 percent of the United States gross national product on health care in 1969, our life expectancy is still only 18th for -C) males and llth for females in the who e worldwide rankings. Despite the fact that we have the highest level of medi- cal competence and are expending insurance industry which collectively greater resources for health-care serv- took in about II billion dollars worth ices than any other nation in the world, of premiums in 1967, the cost to the our ranking again in the world order medical consumer increased 5.8 per- has consistently declined in the last cent from 1965 to 1968 alone. For twenty years, particularly in the area there was only a 3.3 percent increase of infant mortality, where we went from in other consumer prices without second in 1953-55 to eleventh place comparable income increases. in 1960 to fourteenth in 1967-1969. As of today, we rank below East Germany During the period of deteriorating serv- in this regard. And as for our black ices and World standing in health care, citizens, above all, they rank below despite the critical shortage of doctors Jamaica, Japan, Italy, and Greece- and the necessity to "import" to in 28th place on the world order scale. survive, many of America's medical schools consistently complained and This factor ought to be particularly threatened to close for lack of funds. important to you here in the South. In The other day in California, people 1968, the East-South Central region were so insensitive to this great need which included Kentucky, Tennessee, that they voted down the creation of and Mississippi and, I believe, Alabama, two new medical schools, despite the had the highest infant mortality rate critical need. in America for both races, white and black. Despite the creation and devel- Despite all the rhetoric of the medical opment of a multi-billion-dollar health profession of prevention and mainte- 10 nance, the health-care delivery system "The plight of health care for black America is of this country is still designed to two to four times worse than white America, react rather than preclude, to support although proportionately more black mates socioeconomic classes rather than contribute to Social Security than white mates. all people on the basis of need. At the present rate of United States retrogres- sion in health-care areas and at the present order of United States prior- ities, unless drastic changes are im- mediately undertaken, by the 1980s the United States may very well be first in the race for the conquering and population of barren ... outer space but last in the race for viable lifef ul earth or human space. The black maternal death rate is almost The pi ight of healthcare today for four times the white, in spite of the black America is two to four times drastic reductions in the last three worse than white America, although decades (69.5 compared to 19.5). proportionately more black males Life expectancy is lower for blacks than contribute to Social Security than for Whites of all ages. In the prime of white males. Given the present mor- life, the prime working years, 20-35, tality rate, the average black man at black men and women average five birth cannot expect to live long enough years less life expectancy than white today to collect his Social Security. men and women. The difference begins Most black families without health to taper off in later years and is greater insurance, and many with it, are con- among women than among men. fined to the wards of over-crowded Blacks have a much higher death rate municipal facilities where daily hospital than whites in communicable disease. charges are somewhat less than the Particularly blacks are more than likely voluntary hospitals. About six percent to die more often from tuberculosis, of black mothers-eight percent in the influenza, and pneumonia. South-had no medical care before the birth of their child, compared to only One positive note: suicide is more one percent of white mothers-three prevalent among whites than blacks percent in the South-in a national and is consistently lower among black mortality survey in 1963. women. And someone rationalized this in an article in The New York Times At the same level of income and educa- that talked about the psychic advan- tion, black mothers are more likely than tages of urban life. That may have white mothers to have been seen at something to do with it. I do not want to public medical facilities rather than by simply re-emphasize the horror but to a private physician. Both black and dramatize the opportunity available to white mothers receive little dental care us. I want to differentiate something before the birth of a child, although that ought to be clear to you. I won't pregnancy is known to affect the elaborate on this because of the time, mother's teeth critically. Regardless of but do not get too optimistic about the income, black mothers very seldom see status of white health in this country, a dentist before childbirth, or they see because even the optimum average them much less often than white white health care is still much lower mothers do; over 90 percent of the than in some Communist countries. black mothers-compared to 70 And we turn to the relative improve- percent of the white mothers, according ment the whites have made in the last to a 1963 survey again-did not see a ten years. Really what has happened is dentist at all during the twelve months that the blacks are moving closer to before birth of the child. the inferior level. Since we did not come here to drama- tize the horror that dramatizes the opportunity, let's talk about the plan- We called for an action-oriented health ning. An alternate range of strategic system with a program and a platform planning in all areas may have many which encompasses all employees of controversial meanings, but more health, health maintenance, disease practitioners agree it is to plan for and prevention, medical care delivery, fi- put in place today, which will maximize nancing consumer participation, train- what we want to happen tomorrow. The ing, and education. National Urban League has recently recognized the critical nature of the In this new system-for maximization seventies. No telling what may happen in the eighties, and for maximization in the eighties. now-we called for a complete new organization of the health care system We called for a consumer-oriented of the United States, an organization national health system-a framework that would reflect the national health which addresses itself to designing policy which is responsible for the f ive mechanisms by which health, as a basic assumptions which I hope to right and not as a privilege and we elaborate on during the discussion maintain health as a right-can be period. achieved as a reality for all Americans. We also called for a commitment to a system of public education for all categories of the health profession- doctors, nurses, technicians, with a service commitment which can be utilized to provide a more even distri- bution of health care services. We also called for the re-orientation of the health care system to help add its maintenance rather than only attending disease and illness. If you will carefully examine most of your health policies and all the things you carry, you will find that they are not designed to help you prevent and maintain yourself; they are designed to react and to respond. We are calling for a national health insurance plan, which we will also elaborate on during the discussion period, For the final analysis, we agree with the late Walter Reuther, who said: "We call for, plead for, indeed demand a health care system now that will eliminate the waste and the ineff iciency of the present non-system, a system moreover that will bring the poor into the mainstream of medical care, a system that can, in an organized manner, begin to bring about the effec- tive use of our health manpower, our health facilities, and our economic resources." 12 u IC oncern an ro essiona u ment Eugene Fowinkle, M.D. Tennessee Commissioner of Health Ten years ago I heard Dr. Cannon say, "What this community really needs is an effective planning organization made. This phenomenon was put very that can develop good appropriate plans nicely by a well-known physician: for the future development of this "These are days of deep dissatisfaction. medical and health community." We Cries of dissension and loud demands saw the birth of this idea. We saw it for change f ill the air. Nothing is fair- nurtured through birth and childhood by government, the press, industry, labor, Dr. Cannon, Mr. Norf leet, and many of religion, the educational system, philan- you here in this room and now we have thropy. Nothing! An uneasy concern an effective and mature organization blows across the land and around the and I think we are all justly proud of it. earth, already shaking all the eaves and already some worthwhile mighty Public health, as its name implies, is trees have fallen. Necessarily caught in both public and health. Consequently, the relentless movement is the field of public health is acted upon both by health, with all its various manifesta- public forces and by forces which are tions, its professional schools, its generated from within the health in- established disciplines, its traditional dustry. One important and profound programs, its time-honored approaches public force which is influencing us now to planning, public relations and serv- is that all institutions, agencies, sys- ice." So what he is saying and what tems, traditions, or even individuals, I'm saying is that we are on trial. We are are on trial now by society. We are being tested for our validity. I think being tested continuously for our we will see many aspects of our health validity. The American health system system strengthened by the existing now is certainly on trial and is being testing process because a number of tested for its validity. I think in the those components that are not valid 1970s and on into the 1980s the will fall by the wayside. system will be tested. The various components of the system will be Another public force which has had a contested for validity and some replace- profound effect upon the health system ments and changes will doubtless be is, of course, the social mandate that 13 "Built in and ingrained into our very way of life AM) was referred to by Mr. Sims, that every American citizen receive essential basic is the quality building and quality maintaining health services regardless of his ability private enterprise motive that exists not only to pay. This mandate has been read in our health structure but in our entire out in a number of ways. Some have economic structure." read this to mean that every citizen should have gold-plated health care; others say every citizen should have token health care. I think, in general, what we hear is that every American citizen should have at least essential basic health services. This social mandate has manifested itelf in a variety of ways. One is that it has pro- duced, in the mid-1960s, two of the most profound health legislative acts This, in fact, is the present trend, in American history. The health system Medicare and Medicaid being the two is staggering under the weight of this most profound examples. As you know, socio-political decision now and will they provide buying power to individuals continue to wrestle with it through who can then go to the private market the 1970s and hopefully will find solu- if they so choose, and purchase their tions as we go into the 1980s. health care just as any other individual. So the present trend is federal subsidy Another public force or influence which to the existing health system, both is acting upon the health system of this private and public. I think that we have country and which is a corollary to this to say, however, that there are some red social mandate is involvement of the flags waving. federal government. This was pointed out to you very clearly by Dr. English. Another powerful public force which is The question used to be, "Will the acting upon the health system, espe- federal government involve itself in the cially on public health, is the public health industry?" but the question now demand to stop further deterioration is, "How will the federal government of our environment. During the @en involve itself in the health industry?" years I have been in public health, I have seen a variety of levels of 'public As I see it, there are two major alterna- interest and concern on matters related tives. One is to socialize the system, to to health. However, I have never seen put health providers on federal payrolls any reaction of the public to any matter and develop national health programs related to health as strong and as as some of the European and Asiatic intense, as enthusiastic as the present countries have. I think that few clear- expressions of concern about our en- thinking Americans at this time think vironment that are now being given to that this is the best way to provide us. We have a very strong signal from health care for the citizens of this the pu bl ic that f u rther deterioration of country. Built in and ingrained into our our environment is to stop. Public very way of life is the quality building, demand is here; it has not always been quality maintaining, private enterprise here on the environmental problem. motive that exists not only in our health Ten years ago I heard the surgeon system but in our entire economic general of the Public Health Service structure. The other alternative to warn that this country is headed toward federal involvement in the health in- serious environmental health problems. dustry is federal subsidy to the existing However, at the same time, he pre- health system. dicted that very little would be done 14 years because of the lack of public concern. We have public concern now- but just how adequate to develop adequate environmental quality con- trol. Although public concern and public demand, whether they relate to the environment or to the predicament and the immediate response of 200 of the present health system of this million Americans was to say, "turn country, are important and essential, it around, bring it home." This was an they must be tempered by professional expression of public concern that we judgment. wanted our people back home safely, but it was tempered with professional One of the greatest problems which we judgment, in that the men at the con- are going to encounter in the 1970s is trols in Houston realized that if they dealing with the public clamor that now were to try to turn the ship around exists about our health system and immediately and bring it back, it would about our environment. This is im- be destructive to the people that it portant but yet perhaps it is being served. So with the intent of getting overdone. them back, they used the momentum, the forward motion, that the ship had, Let me i I I ustrate. A few wee ks ago o u r but they guided it on the proper course. Apollo 13 space ship got into trouble They made periodic and f req uent adjustments to it, got it on the right course, and steered it back home safely. Public concern was there, but it was tempered by professional judgment. There are those who say, "Let's com- pletely do away with our existing health system and start over." There are those who sayi "Let's immediately solve our environmental health prob- lems." I think this will have the same effect as trying to turn the space ship around while it is going away from the earth. It would be destructive to the very people that we are trying to serve. I think we must temper these expres- sions of public concern with profes- sional judgment. So in summary, I do think we need public involvement. We need public criticism. We need public participation in policy decisions in the health in- dustry. But yet I hope we can have the ingenuity, the knowledge and the strength to temper this appropriately with professional judgment so that we do produce the best possible product the 1970s and into for our consumer in the 198bs. Comprehensive Health Planning brings together, at interface, the public concern and the professional knowledge and experience and judg- ment. So I think CHP is one of the best tools that we have to achieve the task that lies ahead of us in this decade. 15 A& VW) a in ar 0 oices Harold Marg lies, - - Director, Re ional Medical Programs Service (at the time of the symposium, Dr. Margulies was acting director of PMPS.) You've heard a number of things this afternoon which are pointing toward Because I have only briefly entered what may be our health-care system federal service, I think I can look at it or our health-care problems in the with that kind of a perspective. What 1980s. But because I have to deal with has happened since I finished medicine them in a very direct fashion, I think I at the University of Tennessee? In those am going to have to be a little more years there has been a rapid increase explicit. We have heard problems and in the use of hospitals, a rapid increase I think I can add to them, but I would in specialization, a rapid increase in like to balance up the record very physician concentration and nurse quickly and point to some of the things concentration in certain areas and which I think are going to occur and abandonment of others, a rapid rise make it as clear as possible to you that in the cost of medical education with a the answer to the question of what disappearance of private sources and medicine will be in the 1980s is not at funds to pay for it, and a rapidly in- this table. It is in this audience. And I creased dependence upon allied health don't think you quite begin to recognize manpower, all of which you are familiar that fact. with, none of which was create y federal government or any oth r kind Dr. English told you some things that of government. These were the prod- the federal government has been doing, ucts not only of the medical professions which he thinks it should not have been but of the public. doing, and he pointed to a certain level of inexpertise in the federal government At the present time-and I think Mr. from which I am sure he exempted me Sims' presentation is fairly character- and himself. I feel confident about that. istic o i- -we are still not able to But I would like to point out,, just to narrow our purposes down to what it balance what we are talking about is we really want. We have a whole today, what has gotten us into the kind kaleidoscopic range of interests saying of situation which he described and we want this, and this, and this, and with which you are familiar. this, meaning we want everything all 16 at one time and not really being able going to be a reflection of how success- to settle down on exactly what we will f u I the present efforts are to do some- give up in order to get what we really thing about the health care system. want. We hear the usual range of more physicians, more allied health people, We are lacking certain kinds of basic more hospitals, more acute care, more ingredients. One of the ingredients we chronic care, more preventive care, and are lacking is an understanding of what so forth. What is it that we are really it is that we wish to have as our major willing to bargain for with the six per- priority. And our choices, because this cent or eight or ten percent of the is going to become political, and in- gross national product we are talking creasingly federal and increasingly about? I think this is going to get settled, governmental in the payment system, and I think it is going to be settled our choices are going to be toug er before the 1980s so what occurs then and they are going to be a combination is really the issue of the 1970s. And of political, fiscal, and moral choices. more than that, it is the issue of the What are they going to be? next three years. We are going to have to decide on I believe we must recognize the fact whether we are going to preserve the that, despite the interest of the people life of 85 year olds or preserve the life at this table and the interest of those of eight year olds. We are going to have who are in the audience, concern with to decide whether we are going to put health care in this country is still all of our efforts into acute episodic marked primarily by apathy. This is care for people who may or may not die true of the medical profession and all or put them into the maintenance of levels of health skills. It is true of the health. And we are not going to have public in general Look at any general the opportunity to do both. Because in survey of the major issues which people the next three years the problems which spontaneously bring up and somewhere we have been describing here today, ... they will talk about health issues. which Dr. English laid out for you very This will change. It will change as the effectively, are going to get worse. ur political climate of this country is health manpower shortages are going progressively changing. Because, in to be exaggerated. The costs of medica this decade, the issues are going to care are going to go up. The deteriora- move away, as they already have, from tion of hospitals is going to be accele- those we are familiar with, to those rated. Access to medical care is going with which we are becoming increas- to be unimproved. Medicaid is going ingly familiar. to be as paralyzed as it has been in the past and have very limited benefits They are going to have to do with such for very limited numbers of people. And things as peace, as something we be- the agony will increase progressively lieve in, and for Which young people are u nti I we a re ready to ma ke the ki nds going to prefer candidates. They are of political judgments about w at we going to have to do with education really want out of this health care sys- available to everyone-all colors, all tem and what we want to purchase with areas, all creeds. They are going to our money. have to do with decent housing which is currently not available and which is And then some things are going to disappearing even more rapidly than it occur. If I had more time, I could sketc is appearing. And it is going to have to for you, I think without much difficulty, do with health. And in this decade, the a logical conclusion about where we issue of health is going to rise to a major are going to be very quickly. If I did political issue, and I mean political with that and ran through the range of things a small "p" as well as with a big "P." that have happened these last ten or And what happens as a consequence is twenty years, I would come to this 7 "There is still a reluctance in make the choices, one billion dollars for this next f iscal the hard choices between what is obvious year in health, 83 percent is going for and visible and exciting and what is much less Medicare and Medicaid, merely mean- attractive like preventive medicine, health ing paying more money without any maintenance, and the whole concept of plan- increase in the access or quality of ning for the total community." medical care. This is an uncontrollable cost which at the present time is strangling all other efforts. Now you know that one of the things which has been going on in this country is an attempt at some kind of decen- tralization. The federal government has said to itself, "We really can't handle this. It is too big for us. The problem is out there; the solution should be out there." On the way down here on the plane I read an article by Dwight Ink, who is one of the leading budget managerial theorists in the country and in the federal government. He describe a variety of basic ways in which the political process is going to move toward the solution of problems whic have become too central and must be decentralized. It intrigued me that he did not identify the very special quality conclusion: That the high cost of of the Regional Medical Programs in medical care, which can be increasingly this country. Because of the whole identified as being from federal sources, federal system, they have remained is going to lead to an increasing demand unique. There is no arrangement avail- that We have a measurement of what able to any branch of the federal gov- we are purchasing. And one of the ernment which allows for a federal- rising issues before 1975 is going to private mix to identify problems, to have to do with the quality of medical attack problems, and resolve those care which is being purchased by problems. This is the one option in the federal and private money. And this is health system which remains open as going to produce some profoun an effective mechanism for dealing changes in attitudes. locally with local issues. Public hospitals which currently pro- Now since I have come into the Regional vide miserable medical care for people Medical Programs, and I knew it well because they are indigents are going to before that time, I have been even more have to face the fact that this care is impressed with the very special char- unacceptable. Payment systems are acter of that activity, not only for the going to identify the difference between health field, but as a measure of what good and bad care at levels of sophis- kind of mix we can maintain between tication which none of us feels ready federal and private efforts and skills to take on. Now the government is well and talents to produce a desirable re- aware of this; you are well aware of it. sult. I have to say that what I have seen The federal system is lunging in a num- so far in ... those programs is not ber of directions trying to decide how we very exciting. I have seen a range of are going to cope with this very diff icult activities which continue to reflect con- problem. Of the total increase of over cepts and priorities which are already 18 can reflect federal thrust, can be re- sponsive to consumer interests, unless these two can do it, then clearly they e to be abandoned in favor of will hav something which is much less likely to be successf u 1. Now what disturbs me about it more than anything else is that it is new, it is fragile. It represents, in its essence, the best of the American genius, which is the capacity for people of different kinds to work together toward a com- mon purpose within their own com- munity, But there is still reluctance in making the choices, the hard choices between what is obvious, and visible, and exciting and what is much less at- tractive like preventive medicine, health maintenance, and the whole concept of planning for the total community. Be- cause these choices are ones which people are reluctant to make, I have my own skepticisms. Now I can pledge to you that so long as I have the responsibility for Regional Medical Programs and have the access I have to thinking about Comprehen- sive Health Planning, research and development in the medical area, so long as I have that responsibility, I will do my best to bring these f u nctions together because I am confident that if what we are trying to do now is not successf ul, it will be replaced by some- thing else and in the course of time wil have to start all over again to create what is now Regional Medical Program out of date at the time they are initiated. and Comprehensive Health Planning. I have seen very little real integration of the concept of planning totally for the I also recognize the fact that they are total population on one hand and total young and have had very little time to response and total conflict from the f ind out whether or not they can work. professional side on the other hand. In the same moment I must tell you that there is no time left to be delib- Regional Medical Programs by itself is erate, to be doubtful, to be hesitant. If a totally ineffective instrument. Com- you mean to make this area, the Mid- prehensive Health Planning by itself is South, an area which the whole nation a totally ineffective instrument. They is looking at, one in which people wish are so interdependent upon one another to live because health care is available that the failure to recognize that inter- to them at a good quality level, you will dependence constantly astonishes me. have to work vigorously and effectively And unless there is a way in which these and with a kind of humility which is es- two can serve total community needs, sential to good community activity. 19 QUESTIONS AND ANSWERS DR. ENGLISH: Let me read two of the $62,000,000,000 enterprise which questions that I have just received: health and mental health services now "Who really makes the health decisions is in this country. Regardless of where at HEW? Concurrently, why is health the decisions are made, I do not think receiving the short end of the stick at we are going to see progress in the HEW? Dr. English, you implied that the crisis in health care in this country until, White House should have an advisor in with in the place where the decisions are health. Could Robert Finch fill that role? made, someone is assigned the re- If so, will he be asked to do so?" sponsibility for knowing something about this critical area of the American I think they are very good and pertinent economy. questions and, not necessarily sticking with the tradition of federal bureaucrats, And now the second part of the ques- I will try to be direct, honest and most tion: "Will Mr. Finch's going to the responsive as well as brief in my White House as counselor to the Presi- response. dent help with this?" Who really makes the health decisions I must say that all of us are terribly in HEW? The big decisions are not made optimistic that he may be able to help. in HEW. The big decisions have been Others would point out that if he had made in the White House. Part of the difficulties as Secretary, will it really reason that poses a problem is that the be different as he joins the White House nation's top health off icer is excluded staff itself? I would say that most of us from the decision-making process in retain great optimism, because the the White House. He has publicly la- Secretary understands these problems. mented that fact on numerous occa- We hope that he will be helpful. I doubt sions. Who makes the decision in the that he would become the President's White House is very difficult to deter- health advisor. I think he realizes the mine, except to say that in this situation greater need for expertise. Hopefully, he it is almost without precedent. No one may be able to get the nation's top within the White House is presently health officer into the White House assigned that we know about to the decision-making process where up 20 until this time he has been excluded, ment" of the people. The recommenda- the reason being given that he is a tions come from people who are physician and a physician in those eminently involved in the medical field. councils could not be objective: he And we developed our position on our would be an advocate. thorough examination of the AMA draft bill on health care and health- DR. CANNON: Dr. English, I think I care insurance, the AFL-CIO proposal, should ask you one question for clarifi- the Griffin Bill, the Jackson proposal, cation. Some people might associate the Committee for National Health the White House as meaning President Insurance, the Rockefeller proposal, Nixon. I think you ought to give some and a variety of taxpayers' proposals. clarification to that, because really it I also want to emphasize that we are may be a different ballgame than is not talking here about socialism. I think perceived by your comments. I do not that the Urban League is committed to want to put you on the spot. the democratic process and we have committed to the process a surge o DR. ENGLISH: No, I am delighted to be people, as well as machines and things. on the spot. These are times when a So all that concerns you is delivering public official should be on the spot this kind of thing. and I am delighted to be in that posi- tion. I do not think that this reflects the Perhaps if I can read in full as quickly terrible problem of an president dur- as I can the position of the Urban y ing times when the national crises are League on health care and health in- too numerous to mention, when his surance, I may answer a lot of these attention is focused on many things. questions. We called for this reorgani- With his dependency on the people that zation of the health care system, which both control access to him and advise did not mean so much throwing out as him, I think that the President would be better utilizing. Our aim is not so much ts, a[ far better served if there were someone, to provide for new kinds of cos - recognized by the departments of gov- though we believe it is inadequate cost ernment, by the professions in this effectiveness to the American people, country, by the consumers who are to the consumer, to bring about a interested in health in his own house, in greater value for the current medical the decision-making process, to insure dollar. And the five assumptions we that the President gets the advice of the talked about, in reference to what nation's top health officer. health care, or health care policy, or the health care system ought to contain, MR. SIMS: I have several related ques- a re: tions here: "What are the four major items that you observed during your 1) That we believe a national health talk to be the top items to be considered system should be conceived and func- in health care for the future? How do tion to meet the needs of the consumer you think that compulsory national and provide opportunity for appropri- health insurance should be financed?" ate consumer participation and control of the system that will serve him. More First of all, let me explain something. consumer-oriented than provider- Perhaps I am the consumer up here, oriented system. The current system is in terms of my actual involvement. If mainly oriented toward the provider. you give a little credibility to what I am The consumer should have something saying, I am from a very successful to say about his health and the health family of purveyors. I am from a family care of his children. of doctors and teachers. I have lived around them all my life. Secondly, the 2) The national health system should input through the National Urban be oriented toward health and its main- League is rather unique, in that it brings tenance rather than simply disease. together, if you will, the "establish- This involves prevention and distribu- 21 tion, not simply reaction. For example, based on the premise that all members how many health care policies pay for of society must have equal access to your annual physical, which may be education in the health professions for critical to your survival? We say the fee- which there will be in turn an obligation for-service concept is not acceptable in to that society. We feel that some form a health care system in which the basic of funding for health profession educa- concern is for the health care needs of tion must be an essential criteria of any the consumer. The elimination of a national health insurance program. fee-for-service principle will be useless without the development of interrelated DR. FOWINKLE: "What part should a positions of health professionals, the real group practice play in the 19BOs?" redefinition of roles and tasks, and a reorientation from disease to health Unt@ll the mid-1960s, the major prob- care. lem of entering into the existing health system was the financing. As Dr. 3) And we assume, and we say, that English indicated, the big input into the the health care system must be de- financing of health care has been in the signed to provide an even distribution area of providing service or financing. of comprehensive health care services We have somewhat overcome the f i- in all communities, irrespective of their nancing problem and have overdone it racial and their economic base. A sys- so that now we have put on the health tem of tax-supported public education system such a tremendous demand with a service commitment for all health that it is overwhelmed and is producing professionals is essential to achieve an predictable results. equitable solution for manpower needs. It is inconceivable that America would If you overwhelm any economic sub- value its soldiers more than it values system with an excess demand which the people who make those soldiers has taken the form of some $12- possible. 14,000,000,000 of new buying power within the past half decade, you can 4) The general tax revenue should predict that you will get an increase in be the source of f inancing for universal cost and a decrease in quality, and an health insurance. Economists say, increase in consolidation of bigness or "While the social security mechanism institutionalization. And this has, o . . . can be perhaps modified, a progres- course, occurred in the health care sive taxation method is preferable." We system. So what we have now is not a do not see this costing you about the financing problem but a capability same money for better services for all problem, as Dr. English said. people, irrespective of your age or eco- nomic status. A major concern of ours Group practice fits into this question in or any national health insurance pro- my opinion as being a potential solu- gram is to place a significant emphasis tion to part of our capability problem. on the improvement of the geographical We have a number of capability ex- distribution of health services. We say panders. One is Comprehensive Health that national health insurance must be Planning. Anything that can make our committed to the development 6f a system more efficient in delivery will single health system without social or expand our capability. CHP would be racial discrimination. We oppose reim- one of them. bursement formulas and the utilization of private insurance carriers. Another important capability expander is operations or systems or administra- 5) We support a system of public tive research. I think group practice financing, including stipends, for edu- should be classified at this point in cation in the health professions, Such history as a research endeavor. I would public financing would make inherent hate to see group practice implemented a community service obligation and is totally and widely without an adequate 22 many physicians are using Tne concept without the medical or legal clef initions. There are some question marks around period of testing. I am afraid that we this, but I think through practice we are have run into the same types of unex- developing a trend which will make the pected problems that we did with Medi- legal aspects of it much easier. care and Medicaid. So it is a thing that needs to be totally researched and is DR. MARGULIES: Some of the ques- being researched in many areas. It does tions I received are also on the subject many things to the delivery system. of health manpower. Let me lump them First, it changes the mechanism or together and pick up what has already organizes or systematizes the mech- been said; and then there is another anism of entry into the health care explicit question which I will address in system. Furthermore, it carries the a moment. In order to do that, I think individual in an orderly fashion through the system in accordance with need I should retreat back into the 1980s rather than in accordance with t e per- because I was not specific enough when ceived wants. It changes somewhat the I spoke earlier about the way I think motivation and control of utilization. I things are going to be. For one thing, I consider group practice at this point as believe pre-payment systems probably a very good idea in concept that needs will be fairly universal by that time. to be further tested, applied on a fairly Secondly, I want to remind you that we large scale-and it is, in fact, going to have been addressing certain myths up here and some of those myths are be before it is totally implemented in going to be examined even further. delivering health care in this country. The next question, in short, asks: A myth we did not speak about is that biological research necessarily means "We cannot hope to get enough physi- better health care. We found that was not true. The second myth was that if cians produced in the next few years to you increase the ability to purchase meet our physician manpower needs- 9 care, the system is infinitely expansible consequently, we will have to use'physi- and can respond. We found that is not cian-expanders'of some type. How will true. And the third one, which we are these physician-expanders be accepted gettin intoabetterunderstandingon, by the public and by the medical pro- 9 fession?" is that increasing the number of people available to provide medical services is I think they would be accepted both by the way to overcome the manpower the public and by the medical profes- shortage. That is pre-eminently false. sion, provided certain things can be If you are to trace an investment in the done. education of a physician, relative to an area of need in the middle of Arkansa!§, You know, when you go to a bank, you you will find that the drop off between do not always expect to see the presi- the thousand dollars invested in the dent and do not always need to see the medical school and the point of service president. Your heeds can be taken in the middle of Arkansas is astonish- care of very adequately by another type ing. Now as a consequence, we are of individual. When you go for health facing an interesting dilemma as we go care, the same situation can and prob- into the seventies and eighties. If we ably should exist. However, there are are to maintain expertise in the quality certain medical, legal and technical of medical care and make sure that it is problems that make this very difficult available, what is the role of the physi- and somewhat impractical in many in- cian and what is the role of the people? stances. I think we are moving rapidly I believe the following event will occur now toward surrounding this concept by the eighties: with adequate medical-legal support with standards, licensing, and definition Specialists will continue to be trained@, of specialties. they will be confined forthe most part 23 to hospitals; they will be governed by use of the way in which they spend their the hospitals rather than by other kinds time. This means that responsibilities of systems. The majority of medical for all levels of providers are going to care is going to be provided by other be increased and under supervised individuals under a system of mainte- circumstances. And people are going nance and supervision which will de- to be free to do those th i ngs which need pend upon a different kind of physician. to be done, where they need to be done, Some of this will be in group practice, which is where people are ill. I think but I must say that if there is anything that as a consequence there is going to worse than an incompetent physician be a regulation of the Way in which in solo practice, it is a group of them. hospitals are used. SO we have a few things to learn about Now the other question has to do with how to manage group practice. But, in a much more precise issue, which general, I think we will discover that it sounds rather small after I had been is not necessary to see a physician for operating at that positive level. "Should a very large percentage of those ail- RMP and CHP be combined?" The ments Which are now brought to the answer to that question is unequivo- attention of a physician. And if we look cally "no." They serve a different kind a I ittle f u rther i nto the seventies, I th i n k of a purpose and if I have my prefer- we are going to discover that a signif i- ences, I would say that CHP and RMPs cant portion of the time spent by profes- should operate in such a way that they sional people is spent giving attention have a productive tension between to individuals who do not need to be them, one forcing demands on the into the health-care system at all. other, the other dealing with those de- mands. They should have a basis e- A major input is going to be the use of tween them for an effective negotiation automated techniques and I believe this between what the community needs will include screening methods which with a resolution in capacity, the identi- will have their concentration on health fication of reasonable priorities, and maintenance rather than on the identi- the reaching toward those priorities by fication of acute kinds of illnesses. a common understanding. As a consequence, there will be a dif- DR. ENGLISH: Just to express a ferent use of allied health manpower. slightly different shade of opinion on And although this may startle you a that manpower question, I agree with little, I think our current efforts to (1) Dr. Margulies totally that we are moving increase the output of medical schools, into the area of a new mythology if we associated with our efforts to (2) * re- think that manpower, in terms of pro- organize the way in which health care ducing more of the same, is going to be is being provided, will lead to a discov- the solution to the crisis of health care. ery somewhere along the line that we It obviously is much more complex than are training too many physicians. If that,ashehaspointedoutsowell. ut the latter is successful, the former is even in medical care systems w ere unwise. If the former is pursued and there has been an attempt to utilize the latter is not, we are going to have to physician manpower better, where get around to it at a later date. So all other kinds of present ea t manpower these efforts to vastly increase medical are being utilized better or where new schools, with the illusion that this will kinds of health manpower are being provide medical care, are going to be utilized very effectively, there is much re-examined and, in the course of time, yet to be learned. I think are going to be dropped. I would say there is one example of this The solution lies, not in adding to the that I think you probably know well. It numbers, but in making more effective is becoming increasingly known in this country as the Kaiser Permanente Pro- *Numerals added.@ds. gram. Even there, when you talk with 24 they will tell you that one of their major need some help in trying to pay it so problems in trying to expand is a short- they started working on what was called age of medical manpower. I think the a National T. V. Aid Bill. And it was very problem and the mythology is that just clear that it was a very politically popu- producing more manpower is not the lar measure and it would take a little solution any more than investing in bio- work to get it through the Congress. medical research would solve our But within three years it would get problem. through, and it would provide to every American-some on a 100 percent I think to really deal with the health basis, but others would have to contrib- care crisis, you have to face a whole ute something to the cost of that set- range of strategies without tolerance the purchasing power to put such an for any mythology that begins with the instrument in every American home. new conceptions of how to organize and deliver care. Only when you have If we were back at that time, I think Worked that out with a variety of ex- you could imagine what outfits like perimentation ... can you figure out General Electric, Zenith, RCA, and what your real manpower needs are and Admiralwouldbedoing.itwould e only then can you figure out the pur- my prediction that they would be out chasing power mechanism, the third borrowing money to expand their abil- party payment mechanisms that will ity to produce, even if the interest rates support these new structures. I think were 15 to 20 percent. Why? Because our problem in the past is that we have they were going to be guaranteed a never had united strategy covering f i- tremendous source of purchasing power nancing, manpower production, and when that legislation went through. It the issues of organization and delivery. would compensate them very well for taking that risk, even at very high in- terest rates. I think it is also very pre- This leads, I suppose, to a question that dictable that you and I would be out was asked, and which is, I think, perti- nent to many of the questions that we buying all the stock we could in those received. I will just read it to you. "Why companies, because with that kind of does health care expenditure continue guaranteed purchasing power it would to increase without corresponding not be hard to predict how they Were increase in the quality of care?" going to do. Our problem in health is that we have I think everyone up here has dealt with been misunderstood and thought to be that. I think Dr. Fowinkle in his last like that. First, we kidded ourselves remarks dealt with it with real clarity. into thinking we had the capacity in this country in health to serve the needs Suppose that five years ago the Con- of 200 million people and then we saw stitutional scholars had discovered that that mythology exploded when $14,- the Constitution had a basic human 500,000 of purchasing power was right in it that nobody really ever noticed given to consumers to test. That is the before. And that basic human right was seed of the present crisis, and it seems to have in the living room of every to me that's the reason why, although American family a 23-inch color tele- the money going into health care is vision set with a 14-foot antenna up rising dramatically, the quality on this on the roof and a lifetime maintenance overburdened system-if you can call contract to make sure that it worked it a system-of health care is being ex- terribly well. It was there in the Consti- posed greatly every day. And of course tution all this time but we just never the implications of national health in- paid attention to it. So the Congress surance- which would expand the decided to redress this oversight. And purchasing power almost beyond our it realized that it would cost about $600 present ability to imagine-would dem- a year to provide that television set to onstrate our present inadequacies to every American and that some could respond even more dramatically. 25 That is the critical importance of the Partnership for Health and Regional Medical Program. If we are not given, DR. ENGLISH: I think that when you publicly and privately, the money to consider that it took us nearly two expand, whether it is in manpower or centuries to develop the excellence of new methods of organization and de- American medicine, an excellence in livery, whether it is in the new things this country that is unrivaled anywhere we need to know about how to deliver in the world, maybe you should argue high quality care, the new kind of re- that we should have another century search that is required, we will contin- at least to deal with the next great issue, ually be in this bind, even though the which is "equity"-how to translate total number of dollars grows. I think that excellence into equity and effici- that is what we have got to understand ency and respect for human dignity in and that is what we have got to help the delivery of that excellence to the American people understand and 200,000,000 Americans. that is why the next question is a very pertinent one: "What are the chances But I think the real problem is that we that the private sector will move rapidly are not going to get a century. As a enough and the voters be patient matter of fact, things are changing enough to avoid a government- much too rapidly for that. The con- controlled monolithic system?" su.mer is becoming much too sophisti- cated and he recognizes for the first How do we encourage provider change time that our national resources are and voter patience? On the basis of past limited and there is going to be great performance, the chances that the competition within major segments of private sector will move rapidly enough the society for those resources. I are very slim. Federal leadership has believe that we have about f ive years been very important. We are not seeing to do what needs to be done and I think that federal leadership today neces- that is going to take tremendous initia- sarily in measure to what the crisis is. tive from the private sector in our coun- So therefore I think our dependency try if we are going to make any progress. on the private sector is greater than ever. I do not see suff icient optimistic I think if it is not done in five years- signs that the private sector is going to that is, if we do not increase our capac- move rapidly enough except in such ity to provide care in five years-then in programs as RMP and the Partnership the second half of this decade, we are for Health, medical societies, health de- going to see things like national health partments and hospitals and programs insurance and they are going to abso- like the neighborhood health center. lutely expose our present inadequacy in delivering care ten times as dramatic- But the major hang-up right now is ally as it is being exposed today. We will resources in that area to do all the see our profession, whether it is the things they would like to do. That is practicing physician or the hospitals of why the only thing that is going to help this country or any other segment of us with the voter is the extent to which that profession, thoroughly discredited he sees we are concerned and that we before the consumer will understand are trying, the extent he understands that the money is going up, that the our difficulties and helps us change the costs are going up and the service is way that $93,000,000,000 is going to getting worse. I think that is how a be spent in 1975. country finds itself in government medicine. That is why I think this will DR. CANNON: If the response is not be the most historic decade in medicine adequate, how much time before we in this country rivaled by only that first consider the crisis to have reached the decade back in 1785 when the first point of a burst and something rather medical school, hospital, and mental (W radical happens in the health care hospital were started in this country system? in Philadelphia. 26 SUMMARY STATEMENTS MR. SIMS: People with not as much what he wants and he will do it fortun- experience as Dr. Margulies, their main ately as a voter. Yet I am hoping we can concern was that the distribution of temper this with professional judgment services and the public health profes- and knowledge. The consumer wan s sion's education ought to be major a good product and he wants it at an components of any health care system affordable price and he is burdening it ... We are concerned with all kinds of on our back to produce it. manpower ... Doctors are extremely concerned about consumers taking In summary, I would like to deal pre-eminent roles in what they feel with the question of national health in- ought to be their roles determining what surance. When will we have it? Should medical care ought to be at any given we have it? As an administrator of the point in time. state program for financing medical care to the tune of about $50,000,000 DR. FOWINKLE: On the consumer, -1 would very much like to see national I think it is clear to most of us in the health insurance. It would relieve from health administration business that the state at least part of the burden of the consumer is going to be involved their share of the financing and a tre- more substantially in the determination mendouslyoverwhelminga ministrative of health policy. I think what the con- task of running this thing. We have a sumer really wants is a good product $50,000,000 program superimposed and he wants it at an affordable price. upon a $20,000,000 agency. So we I think he is telling us very clearly what have the tail wagging the dog and this he Wants and is probably telling us that is happening all over the country. States if he does not get it, he is going to try are staggering under the administrative some method of his own to help us and physical load of Medicaid. So I produce it. think from the state standpoint, I would like very much to have national health I think we will have to deal effectively insurance. This would standardize it with the consumer and his demand, and lift the burden somewhat off the but yet I still feel very keenly about the state. need for professional involvement in the policy-making process. I think the Looking at it from the health-system consumer is going to have to tell us standpoint, I think we must emphasize 27 DR. ENGLISH: I would like to share just two dreams. One would be to proceed with confidence and go to the places that it would make a more efficient where we are going to need help before financing mechanism, which would we can do the job in the 1980s. One of have the same effect and adding to the the places I think we need to go, as financing of health care, which would practicing physicians, as hospital ad- simply throw coal on the fire by pro- ministrators, as officials of the states, ducing further inflation and further of the cities, in the whole purveyor decreasing quality. So we have got to system, is to the school of business. change our national, state, and local I would like to see by 1980 two to three priorities for capability expansion rather percent of the graduating class of every than financing, and this includes na- school of business administration in tional health insurance in the foresee- this country producing people who will able future. come and help us with what, by that time, will be a $100,000,000,000 enter- DR. MARGULIES: I would like to prise. I do not think the physicians and answer one question, because it did not health professionals should become the come out of the audience and because major managers in an enterprise of this its deficiency disturbs me. In deciding magnitude, of this size, of this complex- what health care should be like in the ity. There is little in our training and eighties, determining it by what hap- there is little in what brings us into the pened in the seventies, we have to face field of health that equips us for this. one of the most d iff icu It issues, which is the concern more at this point of the So, I think we should welcome help non-professionals than it is the profes- from those institutions which produce sionals. Over the last 25-30 years, the people who have this kind of expertise public has been lured into having ap- but who have not yet come, often be- petites for yellow refrigerators, or cause they have not yet been asked, to whatever it may be, which we must help us in one of the largest segments learn to change into other kinds of of one of the most important segments appetites. of our national life. That, I hope, will occur by the 1980s. The creed now is a transplant in every garage-the exotic, the sophisticated, The second thing that I hope will have in fact, the whole kind of concept the occurred by that time is that we would RMP began with and with which I never be having meetings like this but ex- agreed, even in the early days. If we panded into what one might call, "town are to be effective in RMP and CHP, meetings" in health, around the crisis the problem is a double one. Not only of health care all over the country, that must we be responsive to consumers, health would become the critical issue but we must be able to interpret to that I believe Dr. Margulies and other consumers the difference between an members of the panel have predicted irrational and the rational effort to meet it will increasingly become. their basic needs. And because it is a sophisticated issue and because the The consumer is the best ally we have health care system is complex, it means in the tremendous competition for that the professional efforts of an RMP resources. But rather than Waiting for or any other organization needs the full them to come to us, we will go out to understanding, the full exploitation, and them, gain their understanding, their the most minute interpretation to the help, their partnership. If in the 1980s community so they can appreciate the we see that alliance between the health difference between the visible, the professionals and the consumers in glittering and the glamorous and what this country, I think we can proceed with really is essential for health mainte- great confidence to be sure that we will nance for control of cost and for the serve the national interests as the public basic health of the community. in this country hopes that we will. 28 "Should RMP and CHP be combined? The answer to that question is unequiv- ocably'no.'They serve a different kind of a purpose and if I have my prefer- ences, I would say that CHP and RMPs should operate in such a way that they have a productive tension between them, one forcing demands on the other, the other dealing with those de- mands. They should have a basis be- tween them for an effective negotiation between what the community needs with a resolution in capacity, the identi- fication of reasonable priorities, and the reaching toward those priorities by a common understanding ... "if we are to be effective in RMP and CHP, the problem is a double one. Not only must we be responsive to con- sumers, utwemust ea letointerpret to consumers the difference between an irrational and the rational effort to meet their basic needs. And because it is a sophisticated issue and because the health care system is complex, it means that the professional effort of an RMP or any other organization needs the full understanding, the full exploi- tation, an t e most minute interpreta- tion to the community so they can appreciate the difference between the visible, the glittering and the glamorous and what really is essential for health maintenance for control of cost and for the basic health of the community." -Dr. Harold Margulies