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lies for a healthier, happier population, future economies, and a partial solution to the manpower problem. The developers of the objectives for RMP in California have put great stress on multiphasic screening. Since it is a practical impossibility for every citizen to receive an annual physical examination by a physician, multiphasic screening must be extended in coverage and expanded in comprehensiveness for the discovery of early disease or, even better, precursor signs or symptoms. To date, in California, RMP has not financed multiphasic programs of significant comprehensiveness. One small project of limited scope is a part of the Roseville program. However, it is my feeling that multiphasic screening, broad in scope and coverage, along with other preventive medical programs has great promise and should be a prime RMP objective.
Finally, there has come to my attention the enclosed clipping from the San Francisco Chronicle describing the Hunters Point--Bayview Community Health Service. It brings to mind another subject which has received little attention until recently, that is the inability to understand, and therefore to effectively utilize. existing systems of medical care on the part of the elderly and culturally deprived citizens of our nation. Under the "mainstream" and "free choice” concepts of the public medical care programs of Medicare and Medicaid, government employees have been strickly prohibited from directing, or advising beneficiaries, to seek appropriate sources of care for their problems. These programs have been billpaying mechanisms only. The result has been hapless shopping around, referral and counter referral, outright solicitation on the part of some questionable providers, some provision of unnecessary services, significant waste of valuable professional time, and often deleterious fragmentation of care for many persons. This San Francisco experiment is an attempt to provide what has just recently appeared in the jargon of health as a “patient advocate" or "health ombudsman."
Plans for the Northeast Medcial Center in San Francisco's Chinatown are being developed very much along the lines of the Hunters Point project, but are in a far more embryonic stage. A decision has not yet been made, for example, whether funding should be sought through DHEW or OEO channels. The main intent of the center, once in operation, will be to find and encourage individuals of all ages who are not now operly cared for in the basically Chinese and Italian population of the area to see doctors reguarly and, in the fashionable phrase, get them back in “the mainstream of medicine."
RMP is currently developing many programs to provide superlative care for the seriously ill person. However, the first line of defense against serious illness and disability rests on the capability of the system to provide elementary general health services. It is there, when the patient presents himself for relatively less significant problems, that the first elevated blood pressure can be detected, that cigarette smoking habits can be noted and discussed, or that early increased blood or urine sugar levels can be found. Hence, it appears to me that programs such as Hunter's Point in San Francisco have as much implication for RMP as the highly skilled services of a speech therapist working with a man who has had his larynx removed. If a full scale attack is to be mounted on heart disease, cancer and stroke, people must be assisted in utilizing appropriately the first line medical services already available.
This has been a somewhat lengthy reply to your letter. If I had to reduce it to one statement I think I would say that the elderly are only one segment of complex of groups in our population that are medically underprivileged and that a great deal more vision has to be exercised in a total attack on the health care problems of our entire population than that shown to date, progressive and visionary as it has been. Sincerely,
PAUL D. WARD, Executive Director.
EXHIBIT A: ARTICLE FROM THE SAN FRANCISCO CHRONICLE, "SPREADING THE
MEDICAL WORD IN HUNTERS POINT"
(From the San Francisco Chronicle, Oct. 9, 1968]
SPREADING THE MEDICAL WORD IN HUNTERS POINT
(By David Perlman, science correspondent) Somewhere out in the Hunters Point-Bayview part of town there's an old man, handicapped by a stroke, who sits in his room alone—more a psychological cripple than a physical one.
There are kids out there with decaying teeth—not because their parents don't care, but because they are too unsophisticated to know where to find dental help.
Infants are being born prematurely to malnourished mothers—not because food is so scarce, but because the pathway to adequate prenatal medical care and diet instruction is an unfamiliar one. The fact that public funds exist to pay the bills may even be unknown. Attack
These are the sorts of problems that will be attacked from now on by a new federally financed program designed to change the basic life-style—and with it the health-of thousands of low-income families.
The program, which begins this month, is called the Hunters Point-Bayview Community Health Service. It is armed with a $700,000 grant from the Public Health Service, and it is projected to continue for the next five years at a total cost of $5 million.
Details of the project were discussed yesterday by Dr. Arthur H. Coleman, its director, at a press conference at the service's new headquarters at 5815 Third street. Impediments
As Dr. Coleman noted, the problem for people in the project area is not that medical care is poor—it's excellent, in fact. But far too many potential patientsparticularly black patients--have profound psychological and social impediments to seeking care at all.
So the new community service will not actually provide medical treatment. Rather, it will deploy four health teams of public health nurses, social workers and “social health technicians” to encourage families to use private medical and dental offices in the traditional "free choice” manner of more affluent families. Job
Where patients are eligible for Medi-Cal or Medicare or welfare services, the health teams will show them how to qualify. The health teams also will offer psychological help and nutrition instruction. In many cases the community service will help pay bills that aren't covered by insurance or Medi-Cal.
Of interest to the Public Health Service will be an evaluation of the program year by year. For it actually represents a major departure from other medical projects in low-income areas.
In San Francisco, for example, the Poverty Program is now financing a Mission Neighborhood Health Center, where salaried physicians actually provide comprehensive care in a full-fledged medical facility. Dual
“It is our feeling,” said Dr. Coleman, “that the neighborhood center or clinic is a dual system of medical care a special center for poor people. We hope to show that we can provide first-class care for our patients through the same kind of private medicine that all other sections of the population receive."
EXHIBIT B: RELATIONSHIP OF THE HEALTH POWER STRUCTURE TO REGIONAL
(By Paul D. Ward, delivered at RMP Coordinators' Conference, Arlington, Va.,
Sept. 30, 1968) When I accepted this assignment to speak to you on this subject, I did so with some trepidation. To many of my associates in this program the need to acknowledge the existence of “pressure groups," "power blocks," "special interest groups," or whatever you may desire to call them is in itself a deplorable factor. One sometimes gets the feeling that those who do engage in the art of obtaining consensus from various pressure groups for any given goal are indeed practicing some form of Satanism. It is like being the father of Rosemary's baby without ever having known Rosemary. The only solace I take in all of this is to note that when the connotation of evil is applied to any grouping, it is always the other man's organization that is evil. We only belong to good groups to protect ourselves from the advances of those other groups. Anyone who admits seeing some good in the vast majority of the groups, and who tries to mold portions of their efforts together in order to obtain a working consensus in which progress toward a given goal can be made, becomes contaminated with the "other man's" evil. Further, to openly admit that you are a broker in pressure groups is to admit that you are a member of none in effect isolated-and sitting as if naked atop a beehive, not knowing whether you're about to be seduced by the queen bee or attacked by her suitors. That is why there is some danger, at least to me, in this topic of discussion, "and I must add I feel must as Lincoln must have felt as he was being ridden out of a small southern town on a rail after the Emancipation Proclamation : “If it wasn't for the honor of it all, I'd just as soon walk.”
To those of you who would practice the art of obtaining consensus and keep quiet about it, there is little danger. In fact, at times it can be quite rewarding if you can find a way to silently give yourself credit for that which has been accomplished in the names of others. I fear, however, that like all voluntary collective efforts in the social field, observable progress toward a given humane goal is all, and should be all, the reward we should expect. The legislative framework, the Congressional committee imperatives and the guidelines offer a unique opportunity to determine on a broad national scale whether or not the components of the health power structure can work together voluntarily for the general good of the public. It may not be virgin territory upon which we are treading, but at least it is wild enough to make life interesting.
What are the specific mandates set forth by the law and Congress that we are obligated to observe insofar as the health power structure is concerned ? It seems to me that there are at least three main postulations that we must be aware of. The first is the wording of the law itself. Sec. 903 states that grants under this section may be made only if the advisory group includes "practicing physicians, hospital administrators, representatives from appropriate medical societies, voluntary health agencies and representatives of other organizations." Secondly, Sec. 904 which covers operational grants states that they may be made only if "recommended by the advisory group” as described in Sec. 903. This type of language gave virtually unique recognition in the legislation itself to the regional health power structure. This recognition in effect took the form of the right to veto.
Thirdly, Congress went even further in its subsequent reports on the program. It used the term "voluntary partnership” when referring to research centers, practicing physicians and community hospitals, indicating a co-equal status. Hearings this year brought out the very deep concern on the part of Congress that components of the health power structure may not be involved uniformly in all regions to the degree Congress intended. Some sentiment on the part of the national health power structure tended to support this position although it was pointed out that the problems were sporadic in nature.
At this point in time, Congress seems determined that there be a co-equal involvement of components of the health power structure, not only in the design of the program but in its operational surveillance as well.
How does one determine what constitutes the health power structure? In this case the law is unusually clear. It identifies medical center officials, hospital administrators, practicing physicians, representatives from “appropriate” medical societies, "appropriate” voluntary health agencies, and other organizations, institutions and agencies concerned with activities in RMP plus informed public members. The statute uses key modifiers, in effect, to identify the power structure that legally must be involved in the decision making processes of the program.
Unlike the typical legislation which establishes citizens advisory committees, this act specifies that certain specific kinds of representatives must, not may, be included on the advisory committee. It generally follows that at least Congress looked upon these classifications as the primary power structure involved.
From a practical point of view there may be others, but they are not legally specified. As an example, at least one governor unofficially proclaimed his state a region and apparently his remarks carried some weight. At least one state legislature caused a shotgun marriage between RMP and Community Health Planning and seemingly those involved took note of this act. Whether the marriage has been consummated only the principals can attest.
Although these extra-legal forces are important, time does not permit their discussion here except to mention the fact that eventually we will have to deal with public health power blocks such as those interested in 0.E.O. facilities, model cities programs, Medi-Care and Medicaid, Crippled Children programs, health planning councils and Community Health Planning, among others.
INTENT OF CONGRESS
Some interesting conclusions can be drawn from the unique language used by Congress to establish RMP. First, the program was described as a “partnership” implying an equal role in the decision making process by the partners involved. The only mechanism provided in the act for exercising this role was the advisory group which must advise on and approve the actions of the region. Later, Congress used the term “oversee.”
Secondly, the term “medical center official" was used in place of a “representative of medical centers." An official is one with the authority to commit his organization or institution to a given course of action.
Thirdly, it spoke specifically of "hospital administrators,” not representatives of hospitals. This again implied a specific level of authority and function within the hospital world. If further implies that this person or persons would have the authority to speak for others in his category.
Fourthly, the act specifies both “practicing physicians” and representatives of “appropriate medical societies.” The modifier "practicing” would simply differentiate this physician from those who might be in administrative or other capacities. But the modifier "appropriate” would seem to have more specific connotations. From the legislative history we must assume that this was to be a person with the authority to speak for organized medicine in the region. Even without the benefit of the legislative history, “appropriate” logically would refer to the organization that historically has had the greatest policy impact on medical practice, the most significant legal impact, and geographically covers the area concerned. In the vast majority of the cases, “appropriate” could only mean the state medical society. There are situations when in multi-state regions more than one state society must be represented and there is at least one instance in which the state society may be described as slightly bifurcated but there can be little doubt as to the general appropriateness of state societies.
Fifthly, the same modifier, "appropriate," is used to describe voluntary health agency representatives, as members of the legal advisory group. Again, the structure, function, and coverage of each voluntary health agency would determine the appropriateness—that is, whether it should be the statewide organization that is involved, or some other level.
But, from a practical point of view, it would seem that RMP would want to associate itself with the voluntary health agencies at the point in the agency's structure where the major policy decisions are made. This point differs to some extent among the voluntary agencies from state to state. It is evident that to take full advantage of the relationship with the voluntary agency, RMP has to be plugged in at the decision making point, the point at which new programs are designed, objectives set, data accumulated and stored, financial determinations made and general organizational policy established and executed.
In most cases, this appears to be the state-wide organization. Not to involve the voluntary associations at the policy making point will result in much duplicative effort and the lack of ability to fully utilize all of their existing resources on a coordinated basis. More important, perhaps, is the difficulty in obtaining a definite commitment for support of RMP objectives if this relationship does not exist at the policy making and management level. Agreement on issues without the authority to commit support, funds or resources is as worthless as pursuing the vote of citizens of Washington, D.C. for a Virginia election.
Even though representatives may be chosen from the “appropriate" bodythat is, chosen from the level within organized medicine, the hospital association and the voluntary health agencies where the vital decisions are made and the policy is set—there is more that must be done if progress is to be made. It amounts to giving the partners a sense of confidence that their role in the program will not be subverted. This is especially difficult because the relationships that have existed in the past between these partners have been extremely limited and even then, some were viewed with suspicion.
Some times those of us who live with the programs tend to forget that a massive amount of planning activity has been thrust upon the health leadership. This activity seldom is based on long established, firm relationships; thus, there is bound to be some uncertainty. This uncertainty requires a profuse amount of reassurance and reconciliation to keep the new partnership intact. Let us recognize that this partnership is voluntary, something even less secure than a commonlaw marriage, and until there are abundant children in the form of successful operational projects, it may be hard to keep the faith.
ROLE OF REGIONAL COORDINATOR
Because of this, I believe it is the Regional Coordinator's role to know intimately the decision making mechanisms of the health power groups primarily involved in his region. Not only must he understand the mechanics of their decision process, but he has to have a fairly good knowledge of the people involved and what causes them to take the positions that they do. He has to have some assurances that the representatives of the various power groups have the authority to speak for the decision making apparatus within their own organization. He has to have some assurance that the power group's organizational framework will back up their representative in controversial matters. If the representative's authority is limited, as it is almost certain to be, the Coordinator should know these limits and compensate for them.
The Coordinator is further obligated to back up the representative with his own group by personally providing information and assurances to the decision making bodies within the representative's group on matters of controversy. In most cases, this will mean routine appearances before the executive councils of the state hospital association, the state medical society, the various voluntary health organizations and medical center groups. It means, above all, that he has to be prepared to pegotiate differences in as amicable an environment as passion will allow.
There are other problems within the health power structure that face the more complex region. Although they may not directly affect each of us, at least to the same degree, they nevertheless may have a very profound effect upon the reaction that Congress has to the program. To date, Congress has indicated an unusually favorable reaction, but this reaction could reverse itself if these problems are not dealt with propertly and soon. In my own self defense, I have not mentioned California, and I do not intend to, but let me quote from an article written by a man for whom I have the greatest respect, George James, M.D., Dean of Mt. Sinai School of Medicine, New York. It appeared in “New York Medicine," April 1968. I quote without his permission:
REGIONAL MEDICAL PROGRAMS
“What problems are associated with Regional Medical Programs and how is New York City going about resolving them? New York City has a particularly difficult problem. Those of you have been associated with the review process of the heart, stroke and cancer program in Washington have noticed that it is very easy for a state with a single state medical school, a single state health department, and relatively few really vital agencies to organize for a regional program. This is true for some of our Midwestern states where the entire process is very simple with a single state governor, a single state legislature, a single state health department, a single state university with most of the doctors in the state being alumni of the state university. All of this makes for a very simple arrangement.
“In New York City we bave seven medical schools; we have a large number of additional sophisticated agencies and institutions. This makes for quite a bit of trouble. It creates major problems for intercommunication among groups which have not been notable for their ability to communicate before. Now, in addition to this, New York City has very great needs, and they are very visible needs. If there are any of you who feel incapable of adequately recognizing these needs, there are at least three dozen agencies in the state that will be very happy to point them out. There is great citizen demand for services."
Dr. James stated the problem of the complex community clearly and briefly. It is not as easy to isolate, understand describe the decision making process in the areas where the most people are, where the most voters are, where the most Congressmen come from. This poses a far greater problem than most of us realize if you stop to think where the mass of our health problems exist and who votes the dollars in support of the program.
As Coordinators and as individuals interested in the health of this nation, we face our greatest challenge during the next two years. We are faced with marshalling the health resources of the metropolitan areas which contain our most