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Regional Medical Programs -

WILLIAM © KISSICK,M.0., Washingion, D.C.

On October 6, President Johnson signed into law
the Heart Disease, Cancer, and Stroke Amend-
ments of 1965 (Public Law 89-239). This legislation
will support the development of regional medical
programs of research, training, continuation educa-
tion and demonstration of patient care in the fields
of heart disease, cancer, stroke and related diseases.

The Committee Report to the House of Represen-
tatives states the character of the new law as follows:

“The program authorized under this legis-
lation would previde support for cooperative
arrangements which would link medical schools
and affiliated teaching hospitals with their
highly developed capabilities in diagnosis,
training, and treatment, with clinical research
centers, local community hospitals, and prac-
ticing physicians.

“The cooperative arrangements would be
planned. and established locally with. the par-
ticipation of existing institutions and medical
practitioners. These cooperative. arrangements
patients and would provide for more cffective
would permit the interchange of personuel and
flow of information concerning the latest ad-
venecs in diugnesis and trealiuent.”

The law encourages an alliance of public and
private agencies and institutions to enable medical
science, education, and service to join for the benefit
of patients. The regional medical programs will aim
to utilize more fully our existing facilities and
trained mannower. The goal is economy and effici-
ency through improved community planning. The
purpose of the program is to augment and enhance,

rather than to supplant or duplicate existing man-

power and facilities.

societal context

oe A As the President’s
“e-}~=. )& Commission on Heart

‘] Disease, Cancer, and
Stroke began its work

 

 

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: : ae 48" jit had as a frame of ref-
: : | erence one of the most
: _ j vital and dynamic of
DUA ™ ; contemporary social en-

ae i terprises. The health
endeavor comprising
i services, education, re-

% ; search, and supporting
wn vecewisd bustened .... J activities pertaining to

WILLIAM L. KISSICK, oD. health, represented total

 

Dr. Kissick is Special Assistant to Assistant Secretary
(Health and Scientific Affairs), Department of Health,
Education and Welfare.

expenditures of approximately $36 billion in 1964
(6 per cent of Gruss National Product) and em-
ployed approximately 4 million professional, tech-
nical, and other manpower (5 per cent of the civilian
labor foree.)

Population passed 194 million by the close of
1964. Cf these, almost one-half (93 million) were
19 years of age or less or 65 years of age and over.
These age groups represent the most frequent con-
sumers of health services. Population is projected to
reach 210 million by 1970, 225 million by 1975,
and 245 million by 1980 with proportionately great-
cr increases at the youngest and oldest segments of
the spectrum,

Urbanization and persistent geographic mobility
characterize our. wav of life. Shift of populatior
from rural to urban centers is such that almost three:
quarters of the tutal population are Iccated within
the 212 Standard Metropolitan Statistical Areas
(SMSA).

The economic indicators of Gross National Pro-
duct, disposable personal income and median family
income, siguify a continuous! rising standard of
living. Educational attainmeuts are also rising. Ap-
proximately one-half of persons 25 years of age or
older in 1950 had completed high school or college.
By 1975 three-quarters of adults 25 years of age and
older will have achieved this level of education.
These factos in combination with uu extraordinary
system of communications are features of a sophis-
ticated population which is increasingly articulate in
expressing its demands for health services.

It has been stated that the growth of scientific
knowledge is exponential. We are experiencing in-
creased specialization within scientific and technical
fields. One can assume that these trends will con-
tinue. The acquisition of new knowledge creates
both the need and the demand by individuals and
communities for health services. Accordingly, medi-
cine and the other health professions are challenged
to apply newly acquired knowledge in order to
translate the achievement of research into measurable
human welfare.

It was to this last concern that the President's
Commission addressed itsel{f-the growing chasm
between the potential and the realized health
achievements in our society today. Indced the sci-
entific and technological break-throughs of the last

 

Presented at the Pack Forest Conference on Regional
Medical Programs, La Grange, Washington, Saturday.
November 6, 1965.
 

ten years alone ean virtually stagger the imagination.
With each break-through, the healing arts are chal-
Jenged to meet new demands. Sir Geoffrey Vickers
has said that the history of health, “. .. might well
be written as a record of successive redefinings of
the unacceptable”? Each achievement presages new
expectations. Yesterday's inevitable becomes to-
morrow’s intolerable.

institutionalization of health services

As observers of current trends and social forces
have suggested, the gap between knowledge and
application is one of the elements which forcibly
argues for the institutionalization (in a functional
sense} of health services. This connotes movement
from independent and isolated personal health ser-
vices toward a fabric of health care in which the
individual components are interrelated and coor-
dinated. In essence, health programs have and are
advancing from the age of the cottage industry to
the era of space exploration. In my opinion, this
trend will be manifest in health programs that are
highly consistent with the genius of this nation
for pragmatic and pluralistic enterprise.

The adequacy of health resources must be assured
if high quality health services are to be available
and accessible. To date, the Federal Government
has concentrated its attention on the development
and expansion of the resources of facilities and bi-
omedical knowledge. Federal investments of more
than $2.5 billion in hospitals and other health facili-
ties and of 85.6 billion in medical and health te-
lated research during the past two decades has
definitely strengthened these resources. The third
resource, manpower, has become a priority concern
as evidenced by the Health Professions Educational
Assistance Act of 1963, the Nurse Training Act of
1964, and the Health Professions Educatinal As-
sistance Amendments of 1963. The fourth resource—
the effectiveness and efficiency achieved through
planning and organization—has an intangible char-
acter. This is the next major requirement for the
health endeavor.

The concept of regionalization for better health
care has been “discussed, studied, and tried on a
modest scale in the United States for several dec-
ades. The necessity to coordinate services and to
seek the most effective and efficient use of health
resources was reaffirmed by the President’s Commis-
sion, With the passage of Public Law 89-239, the
need for regionalization has been acknowledged by
the Congress. A vehicle for beginning to meet this
need has been provided.

Many critics of the legislation maintain that it
seeks to thwart the public responsibilities of official
agencies, Others foresee a major assault on the

private practice of medicine. The legislation has
neither as an objective. The law opts for the plur-
alism that seeks to merge public accountability with
private initiative in cur society. Thus, as the health
endeavor continues its accelerating and ‘relentless
advance toward institutionalization, we continue our
unique approach to social action described by Alexis
de Tocqueville over a century ago. He visited the
United States in 1831 to study our political institu-
tions, Subsequently, he wrote his classic Democracy
in America in which he noted:

“Americans of all ages, all conditions, and all
dispositions constantly form associations. They
have not only commercial and manufacturin

companies . . . but associations of a thousan

other kinds . . . wherever at the head of some
new undertakings you see the Government in
France or a man of rank in England, in the

United States you will be sure to find an Asso-
ciation.”*

The new complexities of life are being met more
and more by a spirit of cooperative endeavor of
varying intensity between the public and private
sectors of our economy. This point was well stated
by Secretary Gardner while in his former post as
President of the Carnegie Corporation:

“In all fields (with the exception of religion,
of course) governmental and_ private institu-
tious form a partnership of rare effectiveness
in serving the public interest.”*

The health endeavor is now poised on the thre-
shold of such a partnership. Its dimensions and in-
tensity are unprecedented. The organization and co-
ordination of health services in the public and private
sector of our economy in a manner best suited to the
aspirations and requirements of both the providers
and recipients of medical care will require a new
emphasis upon our national proclivity for prag-
matism and pluralism.

increased involvement of educational institutions

There is now wide-spread recognition of the
necessity for increased participation of. institutions
of higher education in the life of society. This trend
was discussed and analyzed by Clark Kerr, President
of the University of California, in his book, The
Uses of the University. The “multiversity” is his
epithet for this emerging institution. He described
the stimulus for emergence of the “multiversity”
as follows:

“Knowledge is now central to society. It is
wanted, even demanded by more people and
more institutions than ever before. The univer-
sity, as producer, wholesaler and retailer of
knowledge cannot escape service.”*

In health, as in other socictal enterprises, the
educational experience is moving from one of a pre-
 

Jude to professional life to that of a continuum. The
rapidity of scientific and technological change
necessitates continuous educational activity on the
part of the professional if he or she is to avoid
obsolescence. Whereas past generations of physi-
cians were. equipped at graduation for a lifetime
of practice, their counterparts of the 1970's will
graduate from medical school with a body of know-
ledge sufficient to sustain them for a decade at most.
The reality of health services for the future pro-
hibits any further separation of research, education,
and patient care. These activities must be related
as never before. They must literally become varia-
tions on a theme. New patterns of cooperation for
the delivery of health services are needed to facili-
tate this convergence.

A successful relationship between community
and university that draws financial support from both
the private and public sectors of the economy is
already found in agriculture. I refer to the array of
. agricultural experiment stations, model farms, and
extension services which link land grant colleges to
individual farming units. It has been suggested that
the regional medical programs represent for the
health field, a comparable effort toward coopera-
tive endeavor.

applied research and development

In addition to plauning and effecting the region-

alization of health services, the legislation under
discussion would also inaugurate a new dimension
for applied research and development in the health
endeacor. The $5.6 billion invested by the Federal
Government since the late forties in biomedical
research has been concentrated in basic and labor-
atory investigations. Efforts to develop extensive
programs of applied research and large scale. de-
velopment have been .Jacking—thus, the gap be-
tween our scientific capabilities and our medical
achievements.

This legislation authorizes $340 million over a
period of three years to assist, “ ... planning, feas-
ibility studies, and pilot projects.” Accordingly, the
equivalent to developmental engineering in health
can be undertaken. Herein may lie the greatest op-
portunity.

Our economy is rich in the technology essential
to sophisticated communication and coordination
of activities. The capacity for automated data pro-
cessing with high speed computers underlies the
technique of thorough study and planning known
as “systems analysis.” A substantial portion of the
business done by these firms is on contracts with the
Department of Defense and NASA. The proposals
that military R and D be reduced have stimulated
an intense search for new markets. Contracts with

»

the Office of Economic Opportunity and the Ap-
palachian Regional Commission are examples of
new applications of this technology. It has become
apparent that many large corporations with these
competencies perceive the health endéavor as a
promising customer. When one considers the po-
tential for expanding physiological monitoring;
communications networks for consultation linking
several community hospitals, the university medical
center, and other health agencies; increased diag-
nostic and therapeutic capacity through automated
Inboratories; and enhanced programs of continuation
education utilizing closed circuit television, the op-
portunities in this program are obvious.

a new dimension to health planning

The most judicious employment of resources re-
quires planning and coordination. Planning, how-
ever, is still anathema to many elements of the
health endeavor, regardless of its scope or the level
on which it is pursued. The attitudes towards
planning in health affairs are changing, however,
as they have within other components of our society.
Even among the production and marketing sector
of the economy, the advent of planning has been
a recent occurrence. Karl Schriftgiesser notes in
his history of the Committee for Economic Develop-
ment that as recently as 1940, whenever the word
planning appeared it was laden with pejorative
connotations.’ Its adoption by the business com-
munity began during and after World War II. Its
current universal usage is equaled by its acceptance
as an essential component of informed business
practice.

The probable scope and scale of health planning
in the future is worth a cursory glance. As sug-
gested in the above section, the systems and com-
munication technology can be useful to. the health
endeavor. The realization that health services reflect
the inter-related variables of manpower, facilities,
equipment, information, communications network,
and the like will undoubtedly bring new dimensions
and perspectives to the planning of health programs.
Adequate planning in the future will require
individuals trained and knowledgeable in the
theory and function of complex organizations, in-
terpersonal relations, operations research, and other
aspects of the cybemetic revolution. It is appropriate
to note at this point that both the Senate and House
Committees stipulated that the carly emphasis of
the program should be on planning.

hypothetical regional medical program

A hypothetical situation can serve to illustrate
the relevance of the above concepts to the regional
medical programs.
 

Let us assume an urban center with a population
of approximately 600.000 in the core city and an
equal number of people residing in the surrounding
suburban areas and countics. Within a radius of
100 miles of the core city, there are thrce other
cities each with populations over 100,000. The
total population of the geographic area approaches
2.5 million.

Presently Available Medical Resources

A medical school and. a university teaching hos-
pital are situated in the core city. In addition there
are nine voluntary gencral hospitals, two of which,
a childrens’ hospital and a large county hospital, are
affiliated with the medical school. Two of the
other cities in the region have 450-bed voluntary
general hospitals, while the third city is the site
of two. 300-bed voluntary hospitals. A 300-bed
chronic disease hospital, operated by the State
Department of Health, is also located within the
region. This hospital has developed clinical studies
in the treatment of cancer. Within the 100 mile
radius of the core city there are also several small
communities that have hospitals of 100 beds or less.

Planning the Regional Medical Program

The medical school, state health department,
hospital association or, “. . . other public or non-
profit private agency or institution,” would inde-
pendently or jointly assume the initiative in the
planning and future development of the regional
medical program. One of the first steps would be
the organization of an advisory group. The legisla-
tion requires that membership in this advisory group
include:

“

. « + practicing physicians, medical center
officials, hospital administrators, representatives
from appropriate medical societies, institutions,
and agencies conceriicd with activities of the
kind to be carried on under the program and
members of the public familiar with the need
for the services provided under the program.”

This. advisory group would assist a staff located
at the university, health department, or other ap-
propriate “institution in the initial planning of the
regional medical program and in the preparation
of an application for a grant to assist its financing.
The initial application would describe the existing
institutions, agencies, and programs which would
participate in the formation of the regional program.
It would also describe the geographic area and
population base to be served, the relationships
between the institutions necessary for the success-
ful operation of the network, and other factors.

After review by the National Advisory Council
on Regional Medical Programs, approval of the
application would result in a grant to assist the
detailed planning, contractual negotiations, and

other activities essential to the initiation of an
enterprise of this scope.

Development of the Regional Medica! Program

The regional program would evolve over a period
of time us specific components are added. The
law authorizes $340 million over three years to
assist, “in planning, in conducting feasibility studies
and in operating pilot projects,” leading to the estab-
lishment of regional medical programs. Implementa-
tion in this hypothetical illustration would include
the development of a cancer clinical research center
in the state chronic disease hospital; a stroke clinical
research center at the 450-bed hospital in another city
where a, part-time member of the faculty is pursuing
some promising research in the rehabilitation of
stroke victims; and a heart disease clinical research -
center in the recently affiliated general hospital in
the core city.

The other hospitals located in the region would
be encouraged to participate in the regional medical
program in a manner consistent with their needs
and resources. In some situations this might mean
the development of an acute coronary care unit
with the guidance and assistance of the medical
center. In others, the affiliation of the medical or
surgical service with the teaching program of the
medical school and the assignment of clinical clerks
or interns would be sought.

The main ingredient in the regional medical
program is, of course, people. Success will require
a willingness and desire of individual professionals
and agencies to work together. Only thus can the
health services of the region benefit. from a con-
vergence of the energies and competencies of prac-
titioners, educators, and research scientists.

Facilities and equipment are, of course, import-
ant. In this hypothetical regional medical program,
extensive renovation and installation of equipment
would be a prerequisite for development of the
cancer clinical research center in the state chronic
disease hospital. To establish the heart disease clin-
ical research center at the voluntary general hospi-
tal within the core city, new construction related
to its planned expansion program would have to
be modified.

The professional and technical health workers,
however, will provide the viability. For example,
the medical school would create a department of
continuation cducation and would undertake re-
sponsibility for assisting all the hospitals in the
region with their educational programs. Some physi-
cians in practice would be asked to assume
part-time teaching responsibilities, both in the med-
ical school and by serving as preceptors for medical
students, interns, and residents who would rotate
through the service programs within several hos-
 

saisnac ibaa acid

 

pitals. Although this illustration concentrates on the
relationships between practitioners and educators
in medicine there are obviously extensive possibili-
ties for developing enhanced educational programs
for nursing, physical therapy, social work, and other
health professions.

The more effective the operational relationships
and communication within the network, the more
substantial will be the realization of the potential
of the concept of regional medical programs. Mak-
ing the latest medical knowledge and capactity
available to the individual practitioner in order to
benefit his patient, and where necessary, assisting
the patient and physician by providing a smooth
working referral system, would enable the patient
to gain access to the most advanced diagnostic and
treatment skills and equipment. With the university
medical center functioning as the nucleus of a
regional medical program, the major impact will
no doubt be centrifugal rather than centripetal in
direction.

‘The following is a partial listing of the types
of resources that could be developed in the region:

1.—High-voltage radiotherapy, cobalt units, car-
diac surgical team, cardiac catherization units, and
radioactive tracer labs.

9.—Automated clinical laboratories.

3,—Intensive care units and physiological monitor-
ing.

4.—Training program for emergency resuscitation
teams,

5.—~A communication network to facilitate diag-
nostic studies (EEG, EKG, frozen sections, etc.).

6—Emergency reference center for adverse drug
reactions.

7.~Automated systems for data processing to
serve the community hospitals and medical prac-
titioners throughout the region.

8.—-A communications network by which con-
sultative resources of the university medical center
could assist practitioners in their own conimunities
thus obviating the necessity for travel of physicians
or patients.

9.—Increased diagnostic and therapeutic capacity
in community hospitals through the installation of
sophisticated equipment that can be electronically
linked to the medical center and serviced by teams
emanating from it.

10.-A year-round program of continuing edu-
cation for physicians and other health personnel
utilizing closed circuit television and other com-
munication techniques as necessary to adapt the
opportunities for learning to the working schedules
of individuals.

conclusion

In summary, I should like to contrast the specifies

of the proposed legislation with some of the mis-
conceptions that have appeared in recent discus-
sions. The legislation:

Assists family doctors by making mere resources
available; it does not substitute large specialized
centers for the comprehensive care provided by
individual practitioners.

Stimulates efficient use of facilities, manpower,
and equipment; it does not divert manpower from
health services to research.

Promotes local initiative; it docs not impose a
Federally directed program.

Encourages planning and establishing of regional
arrangements among medical centers, hospitals, and
practitioners; it does not duplicate or supplant
existing health institutions or agencies.

Promotes cooperation between educational and
health service institutions; it does not divide the
interests of practitioners, teachers and scientists.

Provides increased opportunities for continuing
education; it does not replace existing courses
or programs.

Reduces the necd for referrals by providing
highly technical services, consultants, and equip-
ment to community hospitals, it does not alter the
referral system among doctors or interfere with
methods of financing patient care. ;

Enhances opportunities for undergraduate and
postgraduate medical education and training by
using more hospitals for teaching; it does not con-
centrate interns and residents in central medical
institutions.

Each of the component parts of a regional med-
ical program created under the Heart Disease,
Cancer, and Stroke Amendments of 1965 would
differ to some degree from those in other regions.
Full use of already existing facilities and differing
local needs would insure the diversity, which has
been and should continue to be one of the great
strengths of American medicine. This legislation
provides an opportunity to seek the innovation
essential if our efforts in health are to be commen-
surate with the present and future challenge. #

Dept of Health, Education and Welfare (20201)

REFERENCES

1 Heart Disease, Cancer, and Stroke Amendments of
1965, Report of the Committee on Interstate and Foreign
Commerce on H. R. 3140. goth Congress. Ist Session. House
Report No. 963, September 8, 1965. Washington, D. C.. p. 5.

2 Vickers. G., What sets the goals of public health, New
Eng J Med 258: 589-596 (Mareh 20) 1958.

3 de Tocqueville, A., Democracy in America Il, pp. 128-
129, Schoken Books, New York, 1961.

4 Gardner, J. W., 1964 Annual Report of the Carnegie
Corporation of New York, “Private Initiative for the Pub-
lic Good”, p. 4.

5 Kerr, C., The Uses of the University, Pp. 114, Harvard
University Press. Cambridge, 1963.

6 Schriftgiesser, K. The impact of the committee for
economic development 1942-1960; Business Comes of Age,
Harper and Brothers, New York, 1960.

Ranrintead fram Northwest Medicine