Regl'oii(il il.Llc(t'l'ci,-,Il Piop,]'(Illls W I L I I A M L. K I S S I C K, M.D., Washingion, D. C. On October 6, President Ioiiiison sigi,ed into law expenditures of ipi)roximatel%. $36 billion in 1964 the Heii-t Disease, Cancer, and Stroke Aineiicl- (6 per cent of Gross National Product) and cm- ments of 1965 (Public La%v 8-J-239). This legislation ploved tpproxim;itel,@. 4 million profession], tecii. will support the development of regional metrical rlical, and other ir..ilipo%vei, (5 per cent of the civilian programs of research, training, continuation edilea- labor force.) tioii and demonstration of patient care in the fields Po,,)ulitiort piiss-,d 194 -nillion by the close of of heart disease, cancer, stroke and related diseases. 1964. Of tlies(-, ,-iliiioqt one-half (93 million) were The Committee Report to the Ilouse of Reprcscti- 19 -Sears of age or less or 65 vears of age and over. t,,ttives states the character of the ne,.%, I:i@v as follows: These age groups represent the most frequent con- "The program authorized under this legis- slijitei-s of health services. Population is projectvrl to lation would provide sul)port for cooperative retch 210 million lix, 191-0, 22.5 million bv l@15, arrangements N%,Ilicli .@()Ul(l link medical schools and 245 million by 19SO with pi-ol)o@.onatel%l gre,.tt- and affiliated teachii-ig hospitals t@,ith their or incr(.-ascs a,, the %@u,.Iiigcst and oldest sediments of Itighiv developed capabilities bi diagnosis, traini" rig, and treatment, .N-ith clinical research the spectrum. centers, local cominuiiitv hospitals, and prac- Urbanization aiici persistent geographic mobility ticinLT pli),siciaiis. characterize our .%,.tv of line. Shift of population, "'fhe cooperative arranLet-neTILS be from rural to urban c'e.,iters is %ucli that almost three, plannee, and establisl)ed localiv %%,itli the ari Ca n p quarters of the tutii population ar,! Iccated with,' ticipation of existing institutions and niedi practitioners. These cooperative arrtrigenients the 212 Standard \Ietropol-ltaii Statistical Areas patients and would provide for more effective (S.MSA). would permit the iriterclian!,re of personnel and ']'he economic indicators of Gross National Pro- flow of information concerning the latest ad- -,. c,@s ; i duct, disposable personal income and median familv d;,-,6-ncsis a-.rl t-ICC)IIJU, sigiiiA'N, r@s;ng st.-6ri@4ard of The Itw encourages an alliance of public and living. Educationil attainments are also rising. Ap- private agencies and institutions to enable medical proxi.niatclv one-half of persons 25 years of age or science, education, -and service to join for t c benefit of patients. The regional medical programs .vill aim older in 1950 lead computed high school or college. Bv 1975 tlirce-qtiarters of adults 23 years of a-e and to utilize i-nore fully our e.,cisting facilities and n older will have ac'@iic%,ed this level of education. 'rained minpnwer. The got] is ecaiiomv and effici- 'r, & llese ractois in combination %%jtli LLi, uxf-caurdiLlUt6' encv through improved community planning. The systei-n of communications are features of a sopbis- purpose of the program is to auumetit and enhance, ticated population %%-Iiieli is increasingly. articulate in rather than to supplant or duplicate existing man- power and facilities. expressing its demands for health services. It has been stated that the growth of scientific societal context L-nowled,,e is exponential. We are experiencing iri- As the President's creased specialization within scientific and technical Commission on Heart fields. One can assuiiie that these trcnds will con- Diseise, Cancer, and tinue. The acquisition of ncnv knowledge creates Stroxe began its Work both the need and the deni@irid bv individuals and it had as a frame of ref- communities for Health services. Accordinglv, niedi- erence one of the most eine inct the other heitlth profession ,ire challenged vital cl%,ziainic of to applv acquired kno%,,-Ic(IL-0 in order to -tble contemporary, social cii- translate the achie%,cincnt of research into measure terprises. The health huniiii e)ide(tubr comlirisiti(, It %vas to tlis last concern that the liresicietit's Commission addressed itself-tlie gro%ving cliasrn 4. services, education, re- search, and supporting between the potential and the realized beiltli acti%,itics pertiiiiiiir, to achievements ii otir soci.,.,t%l toclay. Indeed the sci- \[.D. health, represented total (!zitific and teelitiolorical break-tl)rotighs of the last Dr. Kiqsick is Special Assistant to Assistant Secretar@, Presented at the Pack Forest Conference on Regional (Health and Scientific Affairs). Departnient of Health. Medical Proglanis, La Grange, Washington, Saturday. Educattion and Welfare. Noveiiiher 6. 1965. tt-ii %-v.irs ;k)otie c.iii st@ig,lier the imagination. private practice of medicine. The legislation has the )it,;iliiig arts arc c)ial- neither as @iii objL-eti\,e. The ];Lw opts for the plur- )(.Ilg(.(l to iilt-t-t ii(-\%- (I( -irs;iiicls. Sir Ccoffrt,%- \'ickers alisin that seeks to merge public iccouiitabilit), ith w has sititl tij@it I)i(- )iistor%, (if lltl;lltli, might well private initiative in our societv. Thus, as the health I)LI written as a record of sticcessi%,c recicfiiiings of endeavor continues its accelerating and 'relentless the Each achievement presages new aclN,aiice to\\-arcl institutionalization, we continue our inc\-ital)lc becomes to- i.iiiique ;approach to social action described bv Alexis nioi-row's iiitolcr@il)le. de Tocqueville o\,cr a century ago. He visited the lUnitcd States in 1831 to sttid\l our political institu- institutionalization of health services tions. Subsequentl\,, he \vrote his classic Deiiiocracy in America in which he noted: As observers of current trends and social forces have suggested, the gap between knowledge and "Americans of all ages, all conditions, and all application is one of the elements which forciblv dispositions constantly form associations. They have not on]%, commercial and manufacturing argues for the institutionalization (in a functional companies . . . . but associations of a thousand sense) of health services. This connotes movement other kinds . . . wherever at the head of some from independent and isolated personal health ser- nex%, undertakings vou see the Government in vices toward a fabric of health care in which the France or a man of rank in England, in the United States -%,ou will be sure to find an Asso- individual components are interrelated and coor- ciation."3 dinated. In essence, health pro,-rams have and are advancing from the age of tlie@cottage industry to The new complexities of life -,ire beina met more the ?ra of space exploration. In mv opinion, 'this and more bv a spirit of cooperative endeavor of trend will be manifest in health procrams that are varying intensity between the public and private highly consistent Avitli the genius of this nation sectors of our economy. This point was well stated for pragmatic and pluralistic enterprise. by Secretary Gardner while in his former post as The adequacy of health resources must be assured President of the Carnegie Corporation: if high quality health services are to be available "In all fields (with the exception of religion, and accessible. To date, the Federal Government of course) governmental ,tnd private institu- has concentrated its attention on the development form a pa,-tnc4-ship of rare effcct;,k,eness and expansion of the resources of facilities and bi- in serving the public idterest."- omedical knowledge. Federal investments of more The health endeavor is now poised on the thre- than $2.5 billion in hospitals and other health facfli- shold of such a partnership. Its dimensions and in- ties and of $5.6 billion in medical and health re- tensity are unprecedented. The organization and co- lated research during the past two decades has ordination of health services in the public and private definitely strengthened these resources. The third sector of our economv in a manner best suited to the resource, manpower, has become a priorih, concern aspirations and requirements of both the providers as evidenced by the Health Professions Educational and recipients of medical care will require a nesv Assistance Act of 1963, the Nurse Training Act of emphasis upon our national proclivity, for prag- 1964, and the Health Professions Educatinal As- matism and pluralism. sistazice Amendments of 1965. The fourth resource- the effectiveness and efficiency achieved through increased involvement of educational institutions planning and organization-has an intangible char. .teter. This is the next major requirement for the There is now wide-spread recognition of the health endedvor. necessity for increased participation of institutions The concept of regionalization for better health of higher education in the life of society. This trend care has been 'discussed, studied, and tried on a was discussed and analyzed by Clark Kerr, President modest scale in the United States for several dec- of the University of California, in his book, The -Uses of the University. The "multiversity" is his ades. The necessity to coordinate services and to epithet for this emerging institution. He described seek the most effective and efficient use of hedth the stimulus for ei-nergence of the 'multiversity" resources was reaffirmed by the Presidcnt's Commis- as follows: sion. With the passage of Public Law 89-239, the need for regionalization has been acknowledged by "Kno%vledge is now central to society. rt is wanted, even demanded by more people and the Congress, A vehicle for beginning to meet this more institutions than ever before. The univer- need has been provided. sitv, as producer, wholesaler and retailer of Manv critics of the legislation main wled tain that it kno ge cannot escape service.",, seeks to thwart the public responsibilities of official In Health, as in other societal enterprises, the agencies. Others foresee a major assault on the educational experience is moving from one of a pre- Iii(ic to professional life to tliit of a continuum. The the Office of Economic OpporLuiiitv and the Ap- rapiclitnt of scientific and technological change 1).ilacliiati Regional Cominissi'o?i are examples of I)CC(Issi tates continuous educational ictivitv on the iic%%, applications of this technology. It has become part of the professional if )ie or she is to avoid apparent that niaiiv large corporations ivitli these obsolescence. NN'liereas past generations of phvsi- competencies perceive the health endeavor as a cians Avere equipped at graduation for a lifetime promising customer. NVIieii one considers the po- of practice, their counterparts of the 1970's Nvill tential for expanding physiological monitoring; graduate from medical school with a body of know- communications networks for consultation linking ledge sufficient to sustain them for a decade at most. several community hospitals, the university medical The reality of health services for the ftit'ure pro- center, and other health agencies; increased diag- hibits anv further separation of research, education, nostic and therapeutic capacitv through automated and patient care. These ictivities must be related Iiboratories; and enhanced progrims of continuation as never before. They must literally become varia- education utilizing closed circuit television, the op- tions 'on a theme. New patterns of cooperation for portunities in this program are obvious. the delivery of health services are needed to facili- tate this convergence. a new d@mension to ea p nning A successful relationship bet%veen community The most judicious employment of resources re- and university that draxvs financial support from both quires planning and coordination. Planning, how- the private and public sectors of the economy is ever, is still anathema to many elements of the alread found in agriculture. I refer to the arrav o y I f health endeavor, regardless of its scope or the level agricultural experiment stitions, model farms, and on which it is pursued. The attitudes towards extension services which link land grant calicoes to planning in health afftirs are changing, however, individual farming units. It has been suggested that as they have within other components of our society. the regional medical programs represent for the Even among the production and marketing sector health field, a comparable effort toward coopera- of the economy, the advent of planning has been tive endeavor. a recent occurrence. Karl Schriftgiesser notes in his history of the Committee for Economic Develop- applied research and development merit that ac recentlv as 1940, whenever the word planning appeared it was laden with pejorative In addition to planning and effecting the region- connotations." Its adoption bv the business corn- alization of health services, the legislation under discussion would also inaugurate a new dimension munity began during and after World War 11. Its for applied research and development in the health current universal usage is equaled by its acceptance endeavor. The $5.6 billion invested by the Federal as an essential component of informed business Government since the late forties in biomedical practice. research has been concentrated in basic and labor- The probable scope and scale of health planning atory investigations. Efforts to develop extensive in the future is worth a cursory glance. As sug- programs of applied research and large scale de- gested in the above section, the systems and corn- velopment have been lacking-thtis, the gap be- inunication technology can be useful to, the health twcen our scientific capabilities and our medical endeavor. The realization that health services reflect achievements. the inter-related variables of manpower,. facilities, This legislation authorizes $340 million over a equipment, information, communications network, period of three years to assist, " . . . planning, feas- and the like will undoubtedly bring ne%v dimensions ibility studies, and pilot projects.' Accordingly, the and perspectives to the planning of health programs. equivalent t'o developmental engineering in health Adequate planning in the future will require can be undertaken. Herein may lie the greatest op- individuals trained and knowledgeable in the portunity. theorv and function of complex organizations, in- Our economy is rich in the technology essential terpersonal relations, operations research, and other to sophisticated communication and coordination aspects of the cybernetic revolution. It is appropriate of activities. The capacity for automated data pro- to note at this point that both the Senate and House cessing with high speed computers underlies the Committees stipulated that the early emphasis of technique of thorough studv and planning known the program should be on planning. as "systems analysis." A substantial portion of the business done by these firms is on contracts with the hypothetical regional medical program Department of Defense and NASA. The proposals A hypothetical situation can serve to illustrate that military R and D be reduced have stimulated the relevance of the above concepts to the regional an intense search for new markets. Contracts tvith medical programs. Let us assume an urban center %%,itli a population other ictivities essential to the initiation of an of al)l)ri).,jmat(-I%l 600.000 in the core citv and an enterprise of this scope. equal number of people resi(Iiiig in tite surrounding Development of the Regional Medical Program suburban areas and counties. N17itlliii a riditis of 100 miles of the core cit%,, there are three other The regional program Nx-otild evolve on,cr a period cities each with populations over 100,000. The of time ts specific components are added. The total population of the geographic area approaches law authorizes $340 million over three years to 'I.5 million. assist, "iti planning, in conducting feasibility studies Presently Available Medical Resources and in operating pilot projects," leading to the estab. )ishment of regional uiedical programs. Implementa- A medical schot)l and a iiiiiversitv teaching hos- tion in this hypothetical illustration would include pital are situated in the core citv. In addition there the development of a cancer clinical research center are nine voluntary gei)eral hospitals, two of which, in the state chronic disease hospital; a stroke clinical .i childrcns' hospital and a large cotintv hospital, are research center at the 450-bcd hospital in another city affiliated with the medical school. Two of the where a .part-time member of the faculty is pursuing other cities in the region have 450-bed voluntary some promisin- research in the rehabilitation of general hospitals, while the third citv is the site stroke %victims; "arid a heart disease clinical research a f t,.v 300-bed voluiitar%, hospitals. A 300-bed 0 center in the recently affiliated general hospital in chronic disease hospital, operated bv the State the core city. Department of Health, is also located within the The other hospitals located in the region .vould region. This hospital has developed clinical studies be encouraged to participate in the regional medical it, die treatment of cancer. @l'ithin the 100 mile pr ram in a manner consistent @vith their needs radius of the core citv there are also several small @g a,,a resources. In some situations this might mean comniunities that have hospitals of 100 beds or less. the development of an acute coronary care unit Planning the Regional Medical Program with the Yuidance and assistance of the medical The medical school, state health department, center. In others, the affiliation of the medical or hospital association or, ". . . other public or non- surgical service with the teaching program of the profit private agency or institution," would inde- medical school and the .1@@gillIlClIt of L'.in"cal @. rkb pendently or jointly assume the initiative in the or interns %vould be sought. planning and future development of the regional The main ingredient in the regional medical medical program. One of the first steps .vould be program is, of course, people. Success will require the organization of an advisory group. The legisla- a willingness and desire of individual professionals tion requires that membership in this advisory group arid agencies to work together. Only thus can the include: health services of the region benefit,.from a con- vergence of the energies and competencies of prac- sicians, medical center titioners, educators, and research scientists. official inistrators, representatives Facilities and equipment are, of course, import- from a ical societies, institutions, and a encies concerned with activities of the azit. In this liv othetical regional medical program, .P kind to be carried on tinder the program and extensive renovation and installation of equipment mei-nbers of the public familiar With the need %vould be a prerequisite for development of the for the services provided tinder the program." cancer clinical research center in the state chronic This advisory group would assist a staff located disease hospital. To establish the heart disease clin- at the University, health department, or other ap- ical research center at the voluntary general hospi- propriate'iiistitution in the initial planning of the tal %vitliin the core city, new construction related regional mealical pro-ram tnd in the preparation to its planned expansion program would have to of an application for a grant to a:isist its financing. be modified. The initial application would describe the existing The professional arid technical health Workers, institutions, agencies, and programs %vbich would however, will provide the viability. For example, participate in the formation of the regional program. the medical school would create a department of it %vould also describe the geographic area and continuation education and would undertake re- population base to be served, the relationships st)onsibilitv for assisting all the hospitals in the between the institutions necessary for the success- region %vith their educational programs. Some phvsi- ftil operation of the net%vorl-, and other fictors. cians in practice would be asked to assume After review by the National Advisory Council part-time teaching responsibilities, both in the med- on Regional \Iedical Prngrams, approval of the ical school and by serving as preceptors for medical application would result in a grant to assist the students, interns, and residents who would rotate detailed planning, contractual negetiatiotis, and tlll.(,)Iigh tile service programs xvithiii several has- pitals. Although this illustration concentrates on the of the proposed legislation %%,itli some O' the "I's- I relationships bct%veen practitioners and educators conceptions that have appeared in recent discus- in medicine there are obviously extensive possibili- sioiis. The legislation: ties for developing enhanced educational programs Assists family, doctors bv making more resources for nursing, phvsical therapy, social %%.OTk-, and other available; it does not substitute larae specialized health professions. centers for the comprehensive care provided bv The more effective the operational relationships individual practitioners. and communication within the net,%vork-, the more Stimulates efficient use of facilities, manpower, substantial will be the realization of the potential an(] equipment; it does not divert manpower from of the concept of regional medical programs. Mak-- health services to research. ing the latest medical knowlcdac and capactity Promotes local initiative; it does not impose a ractitioner in order to Federallv directed pi-ocram. available to the individual p p Encourages -claiming and establishing of regional benefit his atient, and where necessary, assisting the patient and physician bv providing' a smooth arrangements among medical centers, hospitals, and I practitioners; it does not duplicate or supplant working referral svstem, would enable the patient existing health institutions or acrctic-les. to gain access to the most advanced diagnostic and treatment skills and equipment. NNith the University Promotes cooperation bet%vecii educational and medical center functioning as the nucleus of ahealth service institutions; it does not divide the regional medical program, the major impact will interests of practitioners, teachers and scientists. Provides increased opportunities for continuing no doubt be centrifugal rather than centripetal in el direction. education; it does not replace existing courses or programs. The following is a partial listing of the types Reduces the need for referrals bv providing of resources that could be developed in the region-. highly technical services, consultants, and equip. l.-High-voltage radiotherapy, cobalt units, car- ment to community hospitals; it does not altcr the diac surgical team, cardiac catherization units, and referral s,,Istem among doctors or interfere with radioactive tracer labs. methods of financing patient care. 2.-Automated clinical laboratories. Enhances opportunities for undergraduate and 3.-Intensi@e care units and physiological monitor- postgraduate medical education and training &@v ing. using more hospitals for reaching; it does not coD- 4.-Training program for emergency resuscitation centrate intems and' residents in central medical teams. institutions. 5.-A communication net%vork, to facilitate diag- Each of the component parts of a regional rned. nostic studies (EEG, EKG, frozen sections, etc.). ical program created under the Heart Disease, 6-Emcrgency reference center for adverse drug Cancer, and Stroke Amendments of 1965 would reactions. differ to some degree from those in other regions. 7.-Automated svstems for data processing to Full use of alread), existing facilities and differing serve the community hospitals and medical prac- local needs would insure the diversity, which has titioners throughout the region. been and should continue to be one of the great 8.-A communications network by which con- strengths of American medicine. This legislation sultative resources of the uiiiversitv medical center provides an opportunity to seek the innovation could assist practitioners in their own corfimunities essential if our efforts in he-,dth -.ire to be coi-nmeii- thus obviating the necessity for travel of physicians sitrate vith the present and future challenge. 5 or patients. Dcpt of Health, Editcation and AVelfare (20201) 9.-Increased diagnostic and therapeutic capacity in community hospitals through the installation of ITEF ERE; NC E.S sophisticated equipment that can be electronically I Heart Disease, Cancer, and Stroke Amendments of linked to the medical center and ser'viced b), tcains 1965. Report of the Committee on Interstate and Foreign emanating from it. Commerce oti H. R. 3140, 89th congress. ist session. House Report No. 963, September 8, 1965, Washington, D. C.. P. S. IO.-A year-round program of continiiiiia edu- 2 Vickers, G., What sets the goals of public health, New cation for physicians and other health personnel Eng J Nied 258: 1)89-596 (.March 20) 1953. 3 de Tocqueville. A., Democracy are America 11, pp. 128- utilizing closed circuit television and other corn- I'-)9. Schoken Boolts, New York. 1961. ,,nitnicaliaii techniques as necessary to tdapt the 4 Gardner, J. W., 1964 Annual Report of the Carnegie Corporition of New York, "Private Initiative for the Pub- opportunities for learning to the %vork-iiig schedules lic Good". p. 4. of individuals. 5 Kerr, C., The Uses of the Universtty. p. 114, Harvard University Press. Cambridge, 1963. conclusion 6 Schriftgiesser. K., The impact of the committee for economic development 1942-1960; Business Comes of Age. In summary, I should like to contrast the specifics Harper and BFothers. New York. 1960. frnm Northwest @ledicinc