A New Era in Medical Care* by Wilbur J. Cohen Under Secretary of Health, Education, and Welfare We are meeting here today to focus on the future structure of regional medical programs. We are seeking advice from those of you who will have to make the programs work. We are continuing to try to improve the formula for bringing all groups together to fuse the contribution of science, education, and service for the benefit of all of our people. Many pressures and trends for change contributed to the health legislation of the 89th Congress, which was the most health- minded Congress in our history. More national health measures or providing the American people with the best possible health care were enacted in the 89th Congress than at any other time in the past century. The Regional Medical Program, Medicare, Medicaid, aid to medical schools, comprehensive health planning, grants, support for training professional and allied health professionals and increased support for medical research are just a few of the developments that aim for the delivery of comprehensive high-quality care. Today., as never before in history, you ate being asked to help create the basic instruments to give people the kind of care they need, when and where they need it. These programs represent a major new thrust, a new momentum in the field of health care. A whole continuum of the most economical and efficient forms of health care is being developed. Medicare, for examiale, has focused attention *Presented to the Conference on Regional Medical Programs, Wa hington, on ways to improve medical care, and the program itself carries major incentives to provide new and improved:,services. The,,,program has high-lighted the need for community planning of all: its health and medical care facilities and manpower resources. Communities, many for the first time, have had to plan for an adequate number of facilities with a full range of needed servides--extended care facilities, home health services, and outpatient clinics. Cooperative arrangements are being developed to assure that community resources are used to promote quality care with the most efficiency and economy. We are entering a new era in health care--an evolutionary, almost revolutionary period. Our chief concern is the achievement of high-quality, comprehensive care for all Americans. We are keenly conscious of not only expanding medical services to many groups who have been without them in the past, but also wit the provision of a higher quality of medical services for all of the population. The achievement of our goal will not be easy because there are serious shortages in the health professions and in health facilities. The inherent nature of quality care rests with the health professions, their ideals, integrity and vigilance. If they are going to meet the demands for high-quality care, 3 improvements in the organization and the delivery of health and related services must be made. The Government can see to it that, in ever increasing numbers, professional competence is ever present in providing patient care. We are going to have to do a lot of rethinking about better ways of utilizing IL-he personnel we have, how to train more personnel, how to rationalize our services and how to create economy and efficiency in the organization and delivery of services. Every community will have to reexamine how available personnel, institutions and equipment can serve to a better advantage. Business, labor, and civic leaders,, under the leadership of the medical profession, can also help to introduce innovations and create new and improved methods of delivery of health care. Every member of the community, has become involved in the organization and delivery of medical care in this country and shares the responsibility for its improvement. Effective community planning, active cooperation between the educational systems, health facilities and medical and other professional organizations are essential ingredients for implementing the new health programs. While the new programs enacted by Congress in the past two years are national in scope, it is up to local groups to 4 provide ideas-and initiative in carrying them7out and making them a success. These programs ar an expression of "creative'federalism.11 In discussing tbis.corfcept recently before a@Congressional Committee, Secretary Gardner pointed out: "There is a great potential for innovation in the scope and variety of the Federal Government's partnership arrangements. Through these the Federal Government taps great sources of strength in American life. @The private economy is the chief source of economic growth and vitality. The universities-'-State, local and private--harbor the bulk of the Nation's intellectual resources. The professions provide'the specialized talent without which no modern society can run. Non- profit or voluntary associations provide a, significant means of harnessing non-governmental resources toward a public purpose." The complexities of the problems we face in providing high-quality care requires the best ideas and efforts of all the Nation's resources. Secretary Gardner noted: "We have a'multiplicity of institutions, public and private (universities, hospitals, etc.1 and we have no intention of submerging their identity in some rigorous master plan. The solution is to be found in new forms of cooperation among institutions." .No program better expresses this concept and approach than the grants for Regional Medical Programs. The very first words of the Act setting up the programs call for "cooperative arrangements" among the interested and affected organizations and agencies. The main purpose of the program is to afford, 5 through such cooperative arrangements, the medical profession and institutions of the Nation opportunities to make available to their patients the latest advances in the diagnosis and treatment of heart disease, cancer, stroke and related diseases. And I would emphasize again--as did the Congress in reporting on the bill and the President in signing it-- that our purposes will not be achieved until all medical practitioners and their patients realize the full benefits that modern science and technology makes possible. So now we reach the real test. After the new legislation authorizing giants for Regional Medical Programs was signed, it was up to youths health leaders of the Nation, private, voluntary and public--to do something about it. In April 1964 when President Johnson met for the first time with members of his Commission on Heart Disease, Cancer and Stroke he outlined their task in the following words: "Unless we do better, two-thirds of all Americans now living will suffer or die from cancer, heart disease or stroke. I expect you to do something about it." The President was talking directly that spring day to a small group in the White House Garden. But, indirectly he was setting a challenge for all persons concerned with the Nation's health. He was calling upon the practicing physicians who 6 bear the heavy responsibility for diagnosis andtreatment- t the physician--the the health workers who assist and supgor enerations--the educators,who train the present and future g research scientists who are extending available knowledge and cal3ability--the health officers who are concerned with preventing disease and disability--the volunteers and staffs of the private health agencies who are devoted to furthering the education of the public and the work of the professionals.. To all of these, the President was also addressing his charge: "I expect you to do something about it.,, Tonight we can tell the President that a good deal has been done about it since April 1964. But while the job has been started well, there is still much to be done. Tomorrow and Tuesday, I hope you will tell us how the job can be done better. Regional Med4ical Programs were designed to fit into the complete spectrum of needed health services and they represent the kind of innovative and experimental approach needed to achieve out goal. The authorizing legislation allowed three years for planning and pilot projects to gain experience. In order to provide an early opportunity for review and evaluation, the Sur ral is required to report to the President and .geon Gene 7 the Congress n6xt summer on what has been accomplished and what changes are indicated. You have been asked to come to Washington to help the Surgeon General prepare this report to the Congress. We need your reports on what has been happening in your localities in planning and developing Regional Medical Programs. We need your advice on what more needs to be done so that we can help you step up the time between the discovery of medical miracles and their availability to the people whose lives may be saved by them. Let us review the path we have traveled since April 1964. The President's Commission, under the Chairmanship of Dr. Michael DeBakey, was convened on April 17, 1964 and made its report on December 9, 1964. The Commission contacted 60 private and professional agencies and organizations and consulted over 175 witnesses. The second National Conference on Cardiovascular Disease was rescheduled so that the Commission could have the advantage of its findings. In looking back on the Commission's findings, we find eloquent testimony to the gains that scientific progress has made possible. But we also have documentation that results of this progress is not being made available to the people who 8 could benefit from it. The Commission, Report pointed out: "The rising tide of biomedical research has already doubled and redoubled our store of knowledge about heart disease, cancer and stroke. Yesterday's hopeless case has become today's miracle cure. We stand on the threshhold of still great breakthroughs in the laboratories and clinical centers of the Nation. Yet for every breakthrough there must be follow-through. Many of our scientific triumphs have been hollow victories for most of the people who could benefit from them." ,. How are we going to close the gap?" the Commission asked. The answer to this question was strikingly similar to the answer found by many others in related social fields 3n recent years. Scientific progress has outpaced changes in human organization. As a society, we have more knowledge than we have know-how. As a result, the benefits of scientific progress are not accessible in equal portions to all the people of the Nation. The Commission found that many agencies and institutions were working on overcoming these problems. However, these efforts were often being performed in isolation--and sometimes at cross-purposes. The Commission found that its concern with the heavy price of fragmentation were shared by many others. Spokesmen of 9 medical groups, medical schools and public health, among others, testified both about the penalties and problems of separated efforts and their willingness to explore new approaches and remedies. On the basis of the extensive expert advice and its own staff studies, the Commission did something about it. It produced a 113-page report containing 35 major recommendations plus a reference document including over 600 pages of documentation and many subsidiary recommendations. The ma3or recommendations covered a wide variety of proposals. Some were concerned with strictly categorical activities; others were aimed at the underlying problems of medical manpower and communications, which the Commission felt had to be met to effectively attack the so-called "killer" diseases. While the Conmission's Report had many facets, there were two central themes. One was that people everywhere, not only those near great medical centers, should have the benefit of the latest medical scientific advances. The second was that this goal could only be accomplished by a fusion of science, education and service. After the Report was issued, it was up to the Department of Health, Education, and Welfare to do something about it. And we did two principal things. First, the Department requested, 10 and the President and the Congress approved, additional funds .to begin to implement several specific recommendations of the Commission. Secondly, the Department, under the leadership of Dr. Edward Dempsey, Dr. Stewart and Dr. Shannon, developed a legislative proposal to carry out that part of the Report which called for a joining of the worlds of scientific research, medical education and medical care. In formulating the legislation, the Department focused on the following recommendation: "The Commission recommends that a broad flexible program of grant support be undertaken to stimulate the formation of medical complexes whereby university medical schools, hospitals and other health care and research agencies and institutions work in concert." Perhaps the best way to recapture what the Department proposed is to quote from the President's message of January -7, 1965 on the legislative proposal: "A plan to improve our attack upon these major causes of death and disability should become a part of the fabric of our regional and community health services. The services provided under this plan will help the practicing. physician keep in touch with the latest medical knowledge by making available to him the latest techniques, specialized knowledge, and the most efficient metho s. To meet these objectives, such complexes should--b6 regional in scope; provide services for a variety of diseases; be affiliated with medical schools, teaching hospitals, and medical centers; provide diagnostic services in community hospitals; provide diagnosis and treatment of patients, together with research and teaching in a coordinated system...Action on this new approach, will provide significant improvements in many fields of medicine." The bill was introduced in Congress in January 1965 and enacted in October. During the intervening months, all interested groups had an opportunity to be heard and to participate once again in considering the best ways to meet the identified needs. Many viewpoints were heard. Testimony was received from representatives of the American Medical Association, American Heart Association, American osteopathic Association, American Public Health Association, American Dental Association, American Cancer Society, American Hospital Association, American Academy of General Practice, as well as many individuals from medical schools, medical practice, hospitals and other concerned citizens. As a result of the views expressed, numerous changes were made in the language of the bill which, I might add, taxed all the ingenuity I had gained from 30 years of legislative experience. As many of you know, the President joined personally in these efforts, in which Dr. Hudson participated to find just the right words and concepts for bringing all the groups 12 involved together in a common.attack against these common enemies of man. The Act that was signed in October 1965 was the result of these combined efforts. The story of what you have done in a little over a year is exciting and auspicious. Under the able leadership of Dr. Robert Marston you have undertaken some of the most significant cooperative planning efforts in all our health history.. Planning grants covering regions in which some 60 percent of the population of our country live have already been awarded. Applications for planning grants for the remaining regions,are well along. Moreover" the proposals for first pilot projects for operational activities have already been received and I trust grants for this purpose will .be made within the coming months. During 1966, innumerable groups of practitioners, educators hospital administrators, health officers, voluntary agency staffs and consumers met together all over the country to be'JtL to,plan Regional Programs. Many of these sessions, 9 I am told, have not been entirely comfortable--for the participants have not been used to working together so closely in the past. But you have begun to work on something that is 13 - full of many problems and difficulties and you are working them out. That,is progress and that is hopeful for the future of all medical care in our Nation. Reports indicate that our faith in the ability of local groups to develop new approaches is proving to be well-founded. We are also looking tQ the regional groups to find the best ways of fitting together the many related programs that touch upon these problems. The key problems of coordination must be solved at the local level. If the Federal Government tried to coordinate all its programs at the Washington level, it would end up imposing a pattern. More important, only State and local leadership has the knowledge of local needs and resources that will enable them to put all the programs together in a way that makes sense. Regional Medical Programs have been described as having an obsession with quality. Nothing is more necessary--or fitting. We are all aware of the tremendous investment that has been made in effort and resources over the last 20 years to advance the frontiers of medical ]Snowledge. The advances of this movement has been one of our great accomplishments as a Nation. We intend to maintain and extend this investment in research. For we realized that only in this way can we achieve our objectives for the control of heart disease, cancer and 14 stroke-and other diseases. Some'have argued that there is an inconsistency, or even conflict,-between high quality and widespread use. They believe that excellence is such a rare and tender flower that it can only bloom in special and carefully protected environments. They have suggested that we can lose everything by trying to mass produce what requires the mIost skilled craftsmanship. This point of view, I believe, is contrary to our national history and commitment. I think we have the capabilities as a society to make the very best available to all our people. This is our national goal. It is this goal that inspires and integrates all the diverse programs for which the Department of Health, Education, and Welfare is responsible. Regional Medical Programs have a unique and extraordinary contribution to make in this movement. Their essential purpose is to speed up the diffusion of knowledge--to bring together science and service for the benefit of all. In the last year or so, the Public Health Service has reorganized itself so that under the leadership of Dr. Stewart, it will be able to make its maximum contribution to this effort. Regional Medical Programs are providing an opportunity and means for health groups all over the Nation to take a somewhat 15 - similar-look at their needs and potentialities. it is important but not enough for governmental agencies, either here in Washington or in State capitals, to examine how they can most effectively carry out their responsibilities. Nor is it enough for educational and research institutions to undertake her, as illustrated by the composition similar examinations. Rat of this conference all those concerned with these disease problems and better health must join in the process. Happily this job has already been started in most parts of the country. We are doing something about it. But I trust you will not be satisfied--for we will not--until the best of health care is not only part of the continuing concern of health leaders and a preoccupation of some but is part of the daily life experience of all our citizens. For the next two days you will be able to concentrate on these problems. We hope that you will give us your ideas and advice on how Regional Medical Programs can best be strengthened and facilitated. After you leave, we will welcome statements of your reactions and proposals as further experience is acquired in the planning and operations of Regional Medical Programs. I can assure you that not only the Surgeon General but 16 also President Johnson and Secretary Gardner, as well as members of the Congress, are looking forward as I am to your reports and recommendations. I am confident you,.,will, once again, meet and exceed their expectations.