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with shifts in norms defining appropriate behaviors; the second involves redefining a deviant role as non-deviant. Normative Change

In the first instance, it is thought that the individual's decision concerning what to do about any symptoms he perceives is guided by norms appropriate to the groups to which he belongs. Thus, if his symptoms are interpreted as inconsequential or as "natural" (i.e., a normal consequence of aging) and appropriate behaviors are defined as ignoring the symptoms or administering self-treatment, that individual will not likely seek out professional care from community resources. It could be hypothesized, however, that one effect of Medicare (conceptualized as an increased ability to pay) will be alter the norms defining the appropriateness of seeking professional care for symptoms that had not previously been defined as illness or illness requiring professional care. If this is the case, the predicted increase in utilization would be expected to occur somewhat later. This, of course, is consistent with a general principle of social change, namely that normative definitions of behavior change more slowly than other elements, say, the acceptance of a technological innovation. Deriant Roles

In a theoretical context, illness is viewed as deviant behavior insofar as the sick person is unable to fulfill his normal role obligations. The concept of the "sick role" has been described as the mechanism by which groups handle the illness behavior of a member of their group (9). The sick role is, of course, a social role in that it has certain rights and obligations and is related to other, complementary roles. An incumbent of the sick role is temporarily excused from normal role activities and is ordinarily seen as “not responsible” for his illness since disease is viewed as a natural phenomenon. At the same time, the sick person is expected to view his state of ill-health as undesirable and to "want to get well.” That is, he should be motivated to return as quickly as possible to a state of being well. In this connection, the sick person is obliged to seek out and cooperate with competent helping agents in the process of recovering good health.

This conceptual framework has, for the most part, adequately explained much of the data collected in research on illness behavior in a group context. Yet there is a growing awareness that the assumptions underlying this conceptual framework are based on the characteristics of acute (and often, communicable) diseases, while an increasingly larger proportion of the diseases found in the population have the characteristics of chronic and degenerative diseases (10). Thus, the present conceptualization of the sick role as a deviant role may be inappropriate, i.e., chronic problems are not always incapacitating, thus the sick person may be able to fulfill most of his normal role obligations, at least part of the time. Moreover, it is unrealistic for the chronically ill person to expect to recover fully a former state of good health, but it is likely that he would require more or less continual medical surveillance and episodic treatments for the chronic condition.

Thus the sick role in the case of acute illness is regarded as deviant and the social system acts to separate temporarily the individual from normal role performances until restorative therapy can be applied. The case of chronic illnesses would require an entirely different set of definitions and responses because chronic illnesses, by definition, are more or less permanent, enduring conditions and, therefore, normative rather than deviant. This would require that the system accept and adapt to the long term limitations imposed by chronic illness of the individual rather than remove him until full capacity is restored ; and that both the individual and medical care organizations become oriented to the types of preventive, rehabilitative and maintenance care which the management of chronic illnesses require. Thus, it could be hypothesized that another consequence of Medicare will be the development of a sick role that is defined as non-deviant and which imposes on the incumbent the obligation to seek periodic (and increasingly frequent) treatments from professional sources. At The same time, however, it allows the individual to participate in usual activities with some limitations of capacity. The implications of this hypothesis for illness behavior by the chronically ill and for patterning of medical care services for them are far-reaching and relatively clear. What is not so clear, but will bear watching is the relationship of the redefined "chronic" sick role to the previous one based upon the characteristics of acute diseases. Perhaps, the former will replace the latter. Perhaps, they will exist concomitantly. In addition, a nondeviant sick role may also have consequences for attitudes toward the aged person on the part of adult children and other family members, health professionals and operators of health care facilities, and on the general population.

PROVISION OF COMMUNITY HEALTH SERVICES From a theoretical perspective, the effects of Medicare on the provision of health services by the community may be viewed in terms of "institutionalization of need" (11). This is a complex process which, at the community level, involves studying the relationships among service agencies or organizations and interest groups in the provision of services and allocation of clients (patients). Although our prediction is that the need for increased services and facilities will occur after the redefinition of the sick role, the fact is that managers of present facilities are acting as if the need will appear immediately due to the increased ability to purchase medical care. That is, they are presently making decisions and plans for the future on the assumption that they are now unprepared to meet an immediate and large demand for their services. Thus, it is appropriate to study these changes in provision now as well as later.

The general question which may be posed is what happens to the community's health resources as a consequence of anticipated increased demand. Initially, it could be expected that communities may seek to (1) increase the types of services offered and extend the scope of present services; (2) shift the focus of present services to cope with the source of increased demand ; (3) reorganize its resources to deal more efficiently with all the health demands of its population; or (4) effect some combination of these modes of adjustment. One hypothesis would be that most communities cannot now (1), expand their services, but will prepare to do (2), shift their present resources to cope with one set of problems at the expense of another. Eventually, however, it is likely that (3), reorganization will occur.

The rationale for this hypothesis is fairly straight-forward. It does not seem likely that any appreciable development of new facilities or expansion of present ones will occur immediately. In part, this is because it takes time (and money) to build facilities and recruit personnel to provide the services. More importantly, many facilities presently available are currently operating at less than optimum capacity. For example, the average hospital has about a 75% occupancy rate, thus could absorb some increase in patient load without expansion of physical facilities. However, many facilities do not provide services appropriate for chronic disease problems, especially hospitals geared for short-term care of acute diseases. Expansion of ancillary services for chronic or rehabilitation care is severely limited because of the shortage of trained personnel (12).

It seems more likely that health care organizations will adjust-at least initially-by becoming capable of shifting their present resources to meet the anticipated increased demand for long-term care services. There is some evidence that small (especially rural), acute hospitals become virtual chronic disease hospitals when their beds become filled with older, long-term patients (13). In any cases, it is expected that available resources will be employed as the need arises, but often at the expense of coordinated and comprehensive care.

Finally, in the long run, it is expected that much of the community's resources will be reorganized and more highly coordinated. In the first place, it is likely that new services will be developed which must be integrated into the pattern of existing services. More importantly, the management of problems of chronic disease requires teamwork by a wide range of expert personnel and demands coordination (and cooperation) if comprehensive care as envisioned under Medicare is to be effective.

Just how or in what order these processes will occur or how long they will take is, of course, an empirical question. It does seem likely, however, that the resources presently available to a community will influence the expected patterns of development. In other words, the size of the community, its present health resources and, perhaps, other attributes will be important factors to consider. In this regard, it seems imperative to study the local medical societies as the key to successful resolution of the allocation of resources. In studying these community processes in terms of social change, the medical profession becomes the key either to rapid and effective adjustment to pressures of demands or to a major block to innovation in the reorganization of medical care services.

EXPLORATION OF OTHER ISSUES

There are a number of issues with both theoretical and applied significance besides utilization and provision which are related to the enactment of Medicare. Limitations on space do not permit their full discussion here, but they can at least be noted.

First, there is the question of whether Medicare will act to increase the level (or quality) of care provided. That is, will patients who formerly sought care from faith-healers, chiropractors, and other sources of nonorthodox medicine now take their problems to physicians who are eligible to receive payment from Medicare vendors for their services? Again, the question relates to shifts in normative definitions of appropriate sources of help for health problems.

Secondly, will Medicare affect the ideological underpinnings of the delivery of health care services? Management of chronic diseases has largely occupied a residual category in priorities of profesional commitment. Will it now begin to assume equal status with the more traditional orientation towards treatment of acute problems? If so, there may be a subsequent redefinition of the objectives of long-term care facilities from custodial to a more therapeutic orientation.

Third, and also related to ideology, can it be expected that our basic philosophy concerning the payment for medical care services will change? Certainly it is unlikely that physicians will give less than their best to patients regardless of how they are paid for their services. Moreover, we are predicting a rational increase in utilization that, with coordination and planning, can be managed by the community. Thus, the major consequence of Medicare should be an increase in availability and accessibility of services for the aged population and it is, therefore, likely that the mechanism of subsidized care may be eventually extended to all population groups.

Finally, but not exhaustively, will Medicare effect an improvement in the physical (and, perhaps, mental) health status of the older age group? If so, the principles of more or less continuous medical surveillance and frequent treatment in the early stages of the disease process may have some impact on the demand for preventive medical care which, if extended to the general population, would benefit the nation as a whole.

NOTES

(1) Anderson, O. W., Collette, P., and Feldman, J. J., Family Expenditure Patterns for Personal Health Services. Chicago: Health Information Foundation, Research Series 14, 1960.

(2) V.S. Department of Health, Education, and Welfare, Age Patterns in Medical Care, Illness and Disability. National Center for Health Statistics, Series 10, #32, Washington, D.C., June 1966.

(3) Koos, E. L., The Health of Regionville, New York: Columbia University Press, 1954.

(4) Suchman, E. A., "Sociomedical Variations Among Ethnic Groups,” American Journal of Sociology, 70 (November, 1961), 319–331.

(5) Freidson, E., Patients' Views of Medical Practice. New York: Russell Sage, 1961.

(6) Straus, A., "Medical Ghettos," Transaction, 4 (May 1967), 7-15, 62.

(7) Mechanic, D., “The Study of Illness Behavior: Some Implications for Medical Practice," Medical Care, 3 (January-March 1965), 30–32.

(8) Suchman, E. A., "Stages of Illness and Medical Care," Journal of Health and Human Behavior, 6 (Fall, 1965), 114-128.

(9) Parsons, T., The Social System, Glencoe : Free Press, 1951, esp. Chapter X.

(10) Zola, I, K., “Needed Problems of Research," National Tuberculosis Conference, Chicago, 1964.

(11) Peterson, W. A. and Zollschan, G., "Social Process in the Metropolitan Community,” in Rose, A. M., (editor), Human Behavior and Social Processes. Boston: Houghton-Mifflin, 1962.

(12) Rice, D. K., “Organizational Patterns of Care for the Chronically Ill," Medical Care Research Center, St Louis, 1963.

(13) Ibid.

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ITEM 4: MATERIAL SUPPLIED BY DR. MILTON I. ROEMER*

A-NEW PATTERNS OF ORGANIZATION FOR PROVIDING HEALTH SERVICES ?

1

(By Milton I. Roemer)

(Reprinted from Bulletin of the New York Academy of Medicine, Second Series,

vol. 42, no. 12, pp. 1226–1238, December 1966, Copyright 1966 by The New York Academy of Medicine)

The economic and legislative foundations of a steadily increasing demand for health service have been reviewed by other speakers at this conference. Even if medical technology had been standing still, the very volume of this mounting demand would compel us to find more efficient ways of meeting it through a given supply of personnel and facilities. But the vast growth of scientific potential has compounded the problem; the galaxy of specialized skills and instrumentation require organization if they are to be delivered at all. On top of this, the enlargement of democratic humanism has put further stresses on our health service system; expectations of more and more sensitive patient care have created-paradoxically to some—still further requirements for social organization of services.

These four sets of pressures-economic, legislative, scientific, and humanistichave induced responses in the social institution of medicine in scores of ways. They can be classified, I think, in terms of five levels of medicosocial structure: 1) individual medical practice, 2) organized ambulatory service, 3) hospital organization, 4) interhospital systems, and 5) state and national governments. There is a stream of increasing social responsibility for health services along these five levels of increasingly collective action. Within each level, furthermore, there is evidence of systematization of health functions to higher degrees.

INDIVIDUAL MEDICAL PRACTICE

Despite the basic trends just outlined, at this point in history the prevailing pattern of personal health service in the United States is still the individual doctor in a private office. This is by no means true on a world scale, and the rate of change in the United States is rapid, but the independent private medical or dental practitioner is still the commonest model in the country. Yet, within this basic model, the evolutionary ferment is clear.

The general physician who practices in true isolation has become a rare bird. In the great majority of offices are medical aides, some of whom are registered nurses. The specialist may have a laboratory or x-ray technician or a physical therapist. Equipment may be elaborate and record systems well developed. The office assistant may take the patient's history through a standardized form, like the Cornell Medical Inder. It is commonplace for several clinical rooms to be in use, so that one patient is being examined while another is disrobing. The telephone is, of course, a powerful channel to the patient at home. These and many other measures are forms of organization of the individual physician, whether in general or specialty practice.

The proportion of individual practitioners who share office suites is continually rising. A recent national survey by Medical Tribune and Medical Neurs reported that 46 percent of doctors have shared office quarters, with higher proportions among the young, among specialists, and in the Western states. In the larger cities, office sharing is getting to be the general rule. Although patients and incomes are quite separate, waiting rooms, clerical files, laboratory or x-ray apparatus may be fully shared. Usually these shared facilities serve two or three specialists in the same field, sometimes in complementary specialties. If one doctor is away, his suite partner may cover for him. At a more elaborate level is the "medical arts building,” where a score or more of independent doctors are served by a private laboratory, and perhaps an optometrist or physical therapist, in the same building. A pharmacy on the ground floor is an obvious convenience for patients. One study of such buildings in Washington, D.C., moreover, found 68 percent of the doctors in them to be in “associated practice," ranging from office sharing to full partnership.

*See statement, p. 80.

1 Presented in a panel discussion, Staffing for the Expanded Health Programs : Problems of Utilization and Supply, as part of the 1966 Health Conference of The New York Academy of Medicine, New Directions in Public Policy for Health Care, held at the Academy, April 21 and 22, 1966.

Aside from these physical forms of coordination of solo practitioners, there are functional relationships through a variety of influences. Attachment of the large majority of practicing physicians to one or more hospitals brings them into frequent contact with others. Channels of specialty referral develop through these connections. The medical society or academy serves a similar purpose. Postgraduate educational programs sponsored by voluntary health agencies or medical schools, as well as hospitals and medical societies, are further antidotes to isolation.

Thousands of individual practitioners spend some hours each week at part-time salaried posts in various organized programs. Medical Economics, the magazine, estimates that 65 per cent of practicing doctors have some such appointments in public health clinics, industrial medicine departments, Veterans Administration facilities, schools of medicine, voluntary hospitals, insurance companies, and the like. Another study of that magazine reports that about half of the 64-hour working week of the average practitioner is spent in activities other than direct patient care in his office. It is interesting to observe in the biographical notes of the Directory of Medical Specialists ? the multitude of connections with organized programs that each diplomate proudly claims. The education of the physician, of course, is almost entirely carried out through such social frameworks. When the private doctor, furthermore, serves a patient with an industrial injury, a crippled child, a home-town veteran, or even a Blue Shield plan beneficiary-even though he holds forth in a single office—he articulates with an organized system of health service.

ORGANIZED AMBULATORY SERVICE The impact of organization on the performance and behavior of the doctor is greater at the next level in our typology. When groups of three or more physicians form a team for coordinated services to the individual patient, the rationalization of medical and surgical specialties can be much greater. There are all degrees of group practice, and much depends on the range of physicians of different specialties involved, as well as the system of income sharing. A medical group can make fuller use of aux personnel and exp sive equipment. When group practice embodies a full sharing of earnings, the dysfunctional incentive to "hold onto" patients is replaced by uninhibited referral, but the opposite evil of excessive and expensive work-ups may result. When it is combined, however, with prepayment by a population, the economic incentive favors both economy and quality of care-as shown in several comparative studies.

The movement to coordinated medical teams for ambulatory patient care takes various forms throughout the world. In the underdeveloped countries it is the standard pattern in larger cities. The Chilean National Health Service provides ambulatory service through health centers staffed by a range of specialists and paramedical personnel. The polyclinics of Germany or the Soviet Union have long embodied this concept, as do similar facilities in Israel, Yugoslavia, or Japan. In Great Britain or Scandinavia, the multispecialty clinics are nearly always attached to hospitals, as in the outpatient departments in this country, but their services are, of course, not confined to the poor.

The growth of private group medical practice has probably been more rapid in the United States in recent years than is generally recognized. The count of organized groups by the U.S. Public Health Service in 1949—using the definition of three or more physicians with some form of shared incomefound only 368 such entities. In 1959 the count was 1,546 such practices. But in 1965, when a national inventory of virtually all physicians was made by the American Medical Association, Chicago, Ill., it was revealed recently that 5,450 group practices were identified with about 26,000 physicians. This is about 15 per cent of all doctors in community practice. In the Western states, where traditions are younger, the growth of group practice is very prominent.

Programs serving special populations have developed teams of physicians for ambulatory care outside of private practice. The Veterans Administration operates free-standing multispecialty clinics in most large cities. Industrial medical care programs, since the pioneering of the Endicott-Johnson Shoe Corporation, Binghamton, N.Y., do likewise, especially in large enterprises such as public utilities or railroads. The ordinary public health clinic for children or mothers, for tuberculosis, venereal disease, or cancer detection is not to be overlooked in an

· Published for the Advisory Board for Medical Specialties, Inc., by Marquis-Who's Who, Inc., Chicago, Ill.

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