The practitioner urged that I discuss this decision with X.Y. Perhaps I would reconsider my decision. I answered that X.Y. no longer had direct line responsibilities for Medicaid. No one else but me now bore these responsibilities. I said that my decision stood.

The practitioner then asked if I minded his discussing the matter with X.Y. I responded that I wanted there to be no misunderstanding about how strongly I felt about this issue. I would interpret any attempt on the practitioner's part to bring pressure by X.Y. upon me as an act of insubordination.

The practitioner replied that he understood my position. He agreed not to communicate with X.Y. Furthermore, he would take steps to discontinue the practitioner activity that I found objectionable.

About one week later I received a telephone call from X.Y. inviting me to his office. My initial assumption that this call was coincidental was shortly disabused by the subsequent subject for discussion. X.Y. apologized forgetting involved in this matter, but he felt obliged to respond to the current pleas of the practitioner at least to discuss the matter with me. I then reviewed with X.Y. my analysis of the current situation, pointing out how matters had changed since X.Y. my analysis of the current situation, pointing out how matters had changed since X.Y. had granted the original permission. X. Y. could be agreed completely with my decision and recounted an analogous incident where he had only just made a similar policy decision within his own current balliwick of responsibility.

I returned to my Medicaid office. I called in the practitioner. I ordered and received his resignation.

MAINTAINING INTERNAL PURITY

A chronic anxiety that troubled me was that at any time one or more among the 300 or so of the Medicaid staff, constituting practitioner and paraprofessional auditors and their associates, would surreptitiously enter into collusive relationships with Medicaid providers whom they were auditing. Temptation is a feature in a program of such fiscal magnitude. A sense of tension customarily accompanied the daily act of opening the newspaper and skimming the headlines. It was therefore prudent to take all practical precautions to render less likely the corruptive infiltration of staff and the imminence of scandal.

Let the dental auditing program serve as a representative example, not only of our internal protective devices but of our uneasy state of mind that produced these. Morton Fisher, D.D.S., M.P.H. the first Dental Director of Medicaid, and currently Director, Bureau of Dentistry, New York City Department of Health, devised these administrative fall-safe techniques.

Each of the 40 or so auditing dentists of the Medicaid staff was assigned to review the quality of professional work performed by practicing dentists whose family names began with specific letters of the alphabet. For example, Dr. Jones on our staff was assigned dentists whose family names began with A and B; Dr. Smith, assigned dentists whose family names began with C and D; and so on. Should there be any future suspicion of collusion with respect to a specific dentist, we could easily identify any collaborating suspect on the staff. But, more important, the potential for collusion was statistically diminished 5-6 fold because the imposed quarantine to specific letters in the alphabet constrained the probability of collusion deriving from personal friendship. Normally people's friends are randomly distributed throughout the alphabet rather than being concentrated among a few letters.

Dr. Fisher imposed an additional safeguard. As a second level of audit he assigned to a separate dentist altogether, now reporting directly to the Dental Director of Medicaid, the responsibility of continually auditing samples of the Medicaid dental audits performed by the rest of the staff.

But what about the remote possibility of collusion even on this second level, i.e. between the auditor and one or more of the staff dentists on the primary level of auditing? As a third level of audit, Dr. Fisher requested that the New York State regional dental officer periodically review the quality of the work of the second level dental auditor.

All these internal devices should not suggest that we suffered from a brooding lack of trust in the integrity of our staff. Indeed, we had reason to believe that our staff was less corruptible than most. We had chosen them with care. We subjected them to continuous supervision. We tolerated no departure from scrupulously ethnical behavior. But, at the same time, we had to proceed on the assumption that there were a host of enemies who would gleefully discredit our staff if given the opportunity. A program, so controversial as Medicaid, partic

ularly with the unprecedented monitoring and enforcement functions that we were administering, was fair game. The program was compelled to be pure and give the appearance of purity. All these devices against internal corruption and external mockery were designed not only to preserve the intergity of the program but also to protect the reputation of our beleaguered staff of conscientious auditors.

CURIOUS RELATIONSHIPS WITH SUPERIORS OUTSIDE THE AGENCY

The following is the rank of desirability with respect to working relationships between superiordinates outside and above the program and the subordinate program director himself. The increments are arbitrary.

1. Most desirable

Superordinate has a comprehensive understanding of the program. Superordinate has participated with program director in determining objectives and means to achieve these. Superordinate has absolute confidence in the quality of management of the program. Superordinate manifests keen interest in the progress of the program by requesting and analyzing periodic status reports. Superordinate takes the initiative to protect and enhance the program. Superordinate does not permit other valid official responsibilties to divert his attention from the program.

2. Less desirable

Superordinate takes no initiative to protect and enhance the program but responds positively to the initiative taken by the program director to enlist superiordinate's support. Other comments in 1. apply.

3. Even less desirable than 2, but still acceptable and workable

Superordinate neither takes initiative to protect and enhance the program nor responds positively to the initiative taken by the program director to enlist superordinate's support. Superordinate does not interfere, but does not help either. Superordinate possesses other qualities mentioned in 1. but to a lesser degree. The general ambience is one of indifference.

4. Less desirable

Superordinate manifests little understanding or interest in the program and has little confidence in the quality of the management. Superordinate may take active measures to shrink the program or try to run portions of it himself. The tolerance level of the program director determines at which rank order of relationship he is prepared to resign.

What was the rank level of relationship of New York City Medicaid with the office of the Mayor during my tenure in the New York City Department of Health between 1967 and 1972? If the evolutionary relationship between the office of New York City Medicaid within the municipal health department and the office of the Mayor were to be portrayed graphically over time-from 1967 to 1972, it would begin in 1966 between Level 1 and 2, show a perceptible rise during 1968 and 1969 toward Level 1 and plummet abruptly in 1970 toward Level 3. Why this inconstancy?

The onset of Medicaid in New York State and New York City in 1966 was characterized by generosity and optimism. Indeed, as the financial implications and potential of Medicaid became clearer, the relationship with the office of the Mayor improved. For New York City at least, Medicaid represented, if not precisely a bonanza, at least welcome and belated financial assistance from the state and federal government to provide health services to the City's medically indigent citizens. The 1970 decline in relationship seemed less attributable to the municipal administration's disenchantment with the rising Medicaid expenditures (75% of which was reimbursed by State and Federal government for direct services) than to turnover in key personnel in the Mayor's office. We date the decline to a cluster of events shortly after Mayor Lindsay began his second term of office in 1970. New political intimates now gathered about the Mayor. Mr. Werner H. Kramarsky, Special Assistant to the Mayor and our primary liaison to him, resigned.

It is speculative whether the Mayor's 1970 Presidential ambitions contributed to his inattention to local Medicaid matters. The fact was that after Mr. Kramarsky's departure we found no replacement of equivalent intellectual and political stature who enjoyed the confidence of the Mayor and understood Medicaid. There

now seemed to be no adequate substitute within the Mayor's office to worry particularly about what we were doing with a program that was spending over 34 of a billion dollars annually for about 2.5 million Medicaid enrollees. In our view the program deserved more scrutiny and concern than the conventional budgetary reviews we were receiving.

Albert Moncure, Deputy Commissioner of Social Service, was my Medicaid alter ego in his own department with responsibilty for overseeing Medicaid eligibility and payment. Once I asked him whether anyone outside his department was currently talking with him or with his commissioner in any sophisticated depth about the program.

He seemed puzzled. "Not at all. I've assumed they've been talking with you or with your commissioner.'

"They" were talking with neither of us. On one level, we supposed, this noncommunication bespoke trust. On another level, this inattention bespoke neglect presumably due to diversionary activities of greater salience for the public good. The ambience was one of indifference.

The hands off attitude gave Commissioner Moncure and me a free hand, but at the same time precluded the City from seizing major opportunities to restructure publicly funded health services for the City's medically indigent.

One day we thought such an opportunity had arrived. An emissary from the Bureau of the Budget asked me to put together an analysis of alternative ways to spend annual Medicaid moneys to achieve reasonable health care goals. The analysis was needed in a few days. This emissary, I was reliably informed, had the ear of the Budget Director.

I cancelled activities. I put staff immediately to work. I updated my white paper on the subject. I made the deadline.

Then nothing happened. Nothing. There was no acknowledgement. A few months later I followed up and learned that the major attentions of the Bureau of the Budget had been directed to other matters.

In public administration this anecdote is not unique.

THE HEALTH SUPERAGENCY OF NEW YORK CITY

The concept of a health superagency in New York City drew its impetus (1) from the Mayor's decision to coordinate all municipal public health agencies more intensively within a single administrative structure; and (2) from the reluctance of the Mayor to deal separately with individual commissioners of health, hospitals, mental health, and the Office of the Medical Examiner. All relevant commissioners henceforth would report to a single superagency administrator, who in turn would report to the Mayor.

The Health Services Administration (HSA) as the superagency was called, was to concentrate its energies on data collection and analysis that would lead to more intelligent decision-making in health services. The individual agencies within HSA were to continue their traditional responsibilities and line operations as before. For the first few years this division of labor was more or less maintained. But by 1970 with new appointments to HSA marking the Mayor's second term of office, it was evident that the original policy was no longer in force. Instead, the new HSA leadership was moving more and more aggressively into direct line administration of programs of lead poisoning, methadone maintenance, inspection of food establishments, prison health services, etc. These functional incursions did not necessarily imprint themselves in the formal table of organization. Nevertheless program directors soon found themselves compelled to report to two bosses, one within the Health Department and one within HSA. With the passage of time it was clear that much of the reporting within the Health Department had become ceremonial.

This is not the place to discuss the pros and cons of this administrative development, although the literature of public health administration would be enriched by analysis on the part of proponents, opponents, and objective observers of the superagency movement. Whatever such analysis might reveal about the consequences to effectiveness and efficiency of public health administration in New York City, there was certainly no ambiguity in camera about HSA's impact upon the attitude of prominent Health Department staff and Board of Health membership. A non-coincidental exodus of professionals of stature from both agencies occurred.

In the meanwhile within the Health Department office of Medicaid we became increasingly dismayed about this train of events. To be sure we had

been unhappy with our functional isolation from the office of the Mayor. We initially had welcomed the idea of HSA participation as a means to reopen our old conduit to the Mayor's office and to optimize our relationships with the Department of Hospitals (now the Health and Hospitals Corporation). HSA as coordinator and advocate were roles that appealed to us. But HSA as functional assimilator of Medicaid itself was unacceptable. We were jealous of our organizational identity. It is proper to list the reasons:

REASONS FOR ORGANIZATIONAL IDENTITY

(1) We were undefensively possessive of our traditional Medicaid responsibilities and prerogatives that we had wrested from so much opposition. In our view other Medicaid programs in the country had yet to attack the problems of quality and cost control with imagination and vigor.

(2) We had assembled and trained a cadre to promulgate, monitor, and enforce standards of Medicaid health care services. We were certain that many of these would join the dismal exodus of Health Department professional if HSA were to infiltrate Medicaid functional turf as successfully as it had encroached on other areas of the Health Department.

(3) Since 1970 HSA had demonstrated a propensity for behavior and style that we found offensive and amateurish: expansion of expensive public relations activities in the guise of health education, adoption of programs of high political visibility but of statistically meager publc health impact; continued replacement of departing health professionals with inexperienced "managers." According to the argument or the cant, quantification cum hard nosed administration would now supplant the dysfunctional sentimentalism of rigid traditionalists.

In our view technique was supplanting rather than complementing qualification and experience. The once great New York City Department of Health of Stebbins, Mustard, Baumgartner, and James was deteriorating into mediocracy. It was now no longer just a question of preserving Medicaid intact within the Department. We deemed it imperative to preserve every possible enclave as a refuge where competent health administrators might survive in order one day in a more propitious future to emerge and rebuild the Health Department. We concluded that it would be calamitous to Medicaid and to the Health Department if HSA were to take over Medicaid.

It is unimportant whether our analysis was objectively correct. A siege mentality existed and was a factor in our strategy. Perceptions govern the behavior of actors.

Certain factors favored the continuing functional integrity, if no longer the total isolation, of Medicaid from HSA.

(1) The program itself was incredibly complex, encompassing a potpourri of eligibility rules, modifications, modifications of modifications, service benefits, technical issues, interpretations, and in-house history yet to be recorded. Why need HSA go after Medicaid with more vulnerable game in the offing within the Health Department? For the present, HSA obviously viewed restaurant inspection, rat control, etc. as conceptually easier to understand and to administer.

(2) Medicaid required a physician as Executive Medical Director. This was the law. HSA had no available physician on its immediate payroll. HSA had no experienced health administrators. The health professionals in the number 1 and 2 positions in Medicaid originally hired by me reported to me directly. It was not easy for an outside agency to invade a loyal network of peer professionals.

(3) Medicaid was located on 34th Street about 3 miles away from the main building of the Health Department. The geographic separation discouraged casual dropping in from HSA program analysts on scouting expeditions.

(4) New York City Medicaid's activities against provider abuse had enjoyed an excellent press in contradistinction to the journalistic criticism that had been the lot of much of the municipal administration. Medicaid had a reputation of recovering or saving mllions of dollars annually. It would be hard for HSA to classify it as stodgy as some other Health Department programs it had so categorized.

TACTICS

In order to protect the program, we did the following:

(1) We took precautions to assure that there would be no let up in the pace of the program, lest we unwittingly provide some justification to HSA to take over the program.

(2) To the extent possible we exploited every factor favoring the program's functional integrity.

Complexity. We always behaved with formal correctness. Whenever HSA asked for status reports or programmatic analyses of any kind, we were detailed and meticulously so. Rather than pursuing a policy of withholding information (Knowledge is power. Lack of knowledge means less power), we took precisely the opposite tack, and provided comprehensive information. We would give HSA no grounds to accuse us of insubordination, uncooperative attitude, or insufficient grasp of our own programmatic responsibilities. Our immediately goal was to overwhelm HSA with the obvious complexity of the program in order to give the superagency pause about pursuing incursive tactics.

(3) Physician.-Here we could rely open HSA's evident distaste for public health physicians. Although the Health Department, Health and Hospitals Corporation and other municipal health agencies used non-MD as well as MD health administrators in important posts, HSA tended to downgrade the participation of public health physicians. HSA's policies reflected a view that possession itself of the medical degree probably meant a trained incapacity to administer, even if the physician (a) held the Master of Public Health degree, (b) had majored in health administration, and (c) had years of successful experience in increasingly responsible administrative posts. Indeed, experience was suspect and tended to be equated with rigidity, i.e. resistance to the new administrative style. M.D.'s would be tapped consultatively by HSA on strictly technical problems in health, but otherwise the influence of Health Department physicians in substantive formulation of health policies diminished perceptibly from month to month. Whatever the formal table of organization seemed to show, there was an irrational shift of MD's from line to staff functions, and programs analysis people from staff to line functions. But the law resolutely required a physician at the head of Medicaid. At the head of Medicaid was David Lieberman, M.D., M.P.H. as Executive Medical Director, formerly director of State Medicaid Program in Pennsylvania; his immediate subordinate, the Director of Operations was Morton Fisher, D.D.S., M.P.H., who had already acquired a national reputation for setting up the New York City Medicaid dental quality control program. The Executive Medical Director reported to Florence Kavaler, M.D., M.P.H., M.S. (in biostatistics), who was Assistant Commissioner for Institutional Review and Evaluation in the Health Department and whose biostatistics degree protected her presumably from the conventional accusation of inadequate analytical ability. She reported directly to me in my position as First Deputy Commissioner.

There was thus a solid phalanx of experienced health professionals each of whom, promoted by me, was personally loyal to me.

(4) Geography.-Here we could stand pat. There was inadequate space at the main Health Department building on Worth Street to accommodate a transfer of a Medicaid staff of over 300 from our West 34th Street operations. Moreover, our West 34th Street office was conveniently adjacent to the Medicaid office of the New York City Department of Social Services who would unquestionably have opposed any contemplated move.

(5) Press relations.-The Health Department had received orders that all stories henceforth were to be funneled through the public relations office of HSA, the superagency. We were told quite explicitly that the public relations staff within HSA saw as their major responsibility the enhancement of the HSA public image. At the same time there was conspicous atrophy of effort to present the Health Department's story. The public relations staff of HSA was ordinarily too busy to attend Health Department meetings that produced newsworthy policies and programs.

For example, restaurant inspections, a traditional Health Department responsibility, were now being publicized as an HSA program. In the weekly announcement to the press, HSA, rather than the Health Department, would now list those eating establishments that had persisted in their violations of the sanitary code. It had hitherto been customary for any program status reports to emanate from the office of the pertinent Assistant Commissioner of Health or Program Director Mary C. McLaughlin, M.D., M.P.H., the Health Commissioner, regarded this as sound administrative policy to acquaint the public with the people in charge of the Health Department operations impinging directly upon them. She believed, moreover, that it was good for the morale of the programs and their directors to receive such individual recognition. HSA now supplanted the