P.O. Box 31431
Rio Verde AZ 85263-1431
August S, 19971

Donald A. B. Lindberg, M.D.

Director, National Library of Medicine
National Institutes of Health

Bethesda MD 20894

Dear Don,

Please excuse my delay in responding to your letter
of July 12, with its attachment of “QUESTIONS ON HISTORY OF
RMPS." Serious illness in members of my family, which
culminated in the death of my son-in-law in Morgantown WV
recently, have completely disrupted my regular activities in
the last few weeks. Things now appear to be back to a
reasonable state of normality.

You will find enclosed my "“off-the-top-of—my—head"
responses to your questions. As usual with such inquiries,
the questions are short and simple, but the answers are long
and complex if one takes the time and trouble to think about
them. I hope that I have not indulged in "overkill," and
that what is provided will be of some use to you.

Incidentally, if anybody has tried to contact me by
telephone and has failed to get an answer, the reason is the
one given above. Dorothy and I have been traveling a qreat
deal because of our family problems.

One of your earlier communications asked for
suggestions on persons who might be invited to participate.
Perhaps it is too late naw, but some who should be
considered if they have not already been contacted are:

Dr. Leonard D. Fenninger
Dr. Bland W. Cannon
Dr. Vernon Wilson

I can supply addresses and telephone numbers if you would
like to have them.

If there is anything further I can do, please let
me know.

Sincerely,
(3.02
C. H. William Ruhe, M.D.

Enclosure
QUESTIONS ON HISTORY OF REGIONAL MEDICAL PROGRAMS

1. Why were RMPs established?

In my opinion, the purpose was primarily political.
I do not mean that in a pejorative sense, but rather to
indicate that the medical program was a part of the broader
concept of the New Society. In this sense, it. was deemed
important to present a bold, imaginative program which would
bring about major changes in the way health care was
provided.

It seems clear that President Johnson considered
the matter to be urgent. The time between the President's
health message in February 1964 and the signing of P.L. 89-
239 in October 1965 was amazingly short for such a major
undertaking, and the first planning grants were awarded only
a few months later. One can only assume that the orders were
to “get something going in a hurry." Expedition of the
legislation was aided by the national feeling of guilt and
remorse related to President Kennedy's assassination and the
impression that this would have been part af the Kennedy

agenda.

I do not know whether the plan was "pre-formed" in
somebody’s mind (DeBakey?) but it seems likely that this was
at least partially the case. In any event, it met the
political requirements for boldness, imagination and major
change, and provided the opportunity for a national public
relations and promotion effort (today we would call it
marketing) in an area which affected almost every citizen.
Privileged or under-privileged, everybody was concerned about
Heart Disease, Cancer and Stroke.
2. What were the major accomplishments of RMPs?

I believe that the most important thing
accomplished was the development of cooperative arrangements
among regional organizations, institutions and agencies;
this was the central core of RMP. The degree to which it was
accomplished varied widely from region toa region; and, in
general, the success of RMP was dependent upon how
etfectively the cooperative arrangements were established.
There were some areas in which cooperation and coordination
were minimal (e.g. Chicago) and in these regions, RMP never
really got off the ground. The large cities, where there
were several medical schools and major medical centers which
had never cooperated well in the past, were the most
difficult sites in which to achieve the RMP goals.

It is hard to say to what extent regional
cooperation and coordination of health activities have
endured since the demise of RMP, but it seems clear that
communication was enhanced and subsequent efforts to bring
people and organizations together to solve regional problems
were made easier, at least for a while. Today the
competition among health providers and health institutions
has probably overridden any lasting benefit from RMP in this
area. Your desire to recall the history of events leads me
to suspect that you feel that the earlier cooperative
arrangements have been all but forgotten.

RMP also brought about some improvement in the ways
in which continuing medical education was organized and
delivered. The most significant things were that RMP
recognized the importance of continuing medical education and
provided same funding for innovation in the field. Toa the
extent that the various regions seized on this and taok
advantage of the apportunity, there were improvements and
growth that continued for many years. I think it is fair to
say that RMP gave c.m.e. a substantial boost forward.

Perhaps I am simply ignorant of it, but I was not
impressed that RMP caused any significant difference in the
ways in which medicine was practiced, other than that there
was perhaps a heightened awareness of new technology and
sonefncreased funding for new "centers."
3. Why was RMP terminated?

Just as it was initiated for political purposes, sa
was it discontinued for political purposes; again, I use the
term "political" not in the narrow sense of party politics,
but in the broader sense of changes in the political scene.
RMP had pretty much “run its course" in the sense of
accomplishing its original political purpose. It no longer
captured the imagination or suppart of the public, and it was
time to change to different approaches (e.g. the designation
of a separate National Cancer Institute.)

If one looks at it strictly from the point of view
of whether it accomplished its objectives, it seems clear
that the program was "doomed to failure" from the beginning.
This does not mean that the program was faulty, but simply
that it was vastly oversold, again for political purposes.
President Johnson’s health message presented an overblown
picture of millions of people dying from heart disease,
cancer and stroke, because of “the gap between the research
laboratories and the bedside", and because of poor
organization of the way medicine was practiced and health
care was delivered (and I might add because of the great
shortage of physicians).

While there was some truth in all of these
allegations, they were greatly exaggerated. Furthermore, the
impression was given, when the RMP legislation was passed,
that there would be a great reduction in the numbers of
people dying from heart disease, cancer and stroke. [t
should have been obvious that this was not likely to happen,
and it was really unfair to judge RMP on that basis. Some
did so, probably for their awn political purposes.

Neither Congress nor the public was happy with
providing support for the continuing education of rich
physicians, and there was little enthusiasm for supporting
that aspect of the program. Furthermore, both the new
administration and Congress were looking for ways to cut back
on the cost of health programs and it seemed logical (or was
said to be logical) to merge RMP with the Health Planning and
Hill-Burton legislation. After that, it was inevitable that
funding would be reduced and then eliminated. The Hill-
Burton legislation had really accomplished its purpose, and
there was much less enthusiasm for building more hospitals,
even in rural areas. The Health Planning legislation was
never really understood by the health community, the general
population or the Congress, and it was the kiss of death for
RMP to be merged with it. I am sure that those responsible
for the merger were well aware of that.
4. Other Impresseions and Personal Reactions

One of the problems I had with the RMP legislation
from the beginning, and even more with the Health Planning
legislation, was the difficulty in determining exactly what /
was intended and what was likely to happen if the legislation i
passed. I was one of the AMA staff persons assigned to work
with the AMA Department of Legislation to develop an AMA
position. It was very difficult because the language was
vague, and it was obvious that a great deal would depend oan
how the regulations would be written, or oan subsequent
amendments to the legislation once it had been passed.

Since the legislation was presumably based on
The_Report of the President's Commission_on Heart Disease, _
Cancer and Stroke, we made frequent reference to that
document in an attempt to determine “what was really on their
minds." @s noted in your Chronological Summary, the
Commission Report contained "35 recommendations, including
the development of regional complexes (poorly defined)
medical facilities and resources." Most of the
recommendations were not covered specifically bv the proposed
legislation, but the language was sufficiently vaque in some
areas that it might be extended to include the
recommendations.

Eventually, after staff meetings between AMA reps
(I was not included) and HEW/Commission reps, agreement was
reached on modification of same of the language of the bill.
I don’t recall all of the compromises, but the ones which
stick in my memory were those cited in your chronological
summary: "The Commission concepts of ‘regional medical
complexes’ and ‘coordinated arrangements’ were replaced by
‘regional medical programs’ and ‘cooperative arrangements. ‘"
These were significant changes and virtually dashed the hapes
of those who saw in RMP a means of moving to a nationalized
health plan for the delivery of care.

I am moved to comment philosophically that one of
the problems with this legislation (and with a lot of other
legislation over the years) is that it means different things
to different people; i.e., various people, reading the same
words, have different understanding of what they mean. It
became evident in time that many people‘s expectations were Vi
not fulfilled by the course that RMP eventually followed.

This was abundantly clear in the meetings of the
Review Committee (which George James chaired and I served oan)
Our task was to review the grant applications and make
recommendations to the National Advisory Council. We were
frequently confronted with misunderstandings of applicant
groups, and occasionally by misinterpretations on the part of
RMP staff. It was sometimes necessary for the Review
Committee to reconsider what was really intended by the
legislation, and to make sure that there was no gratuitous
extension of the law and its regulations to satisfy a broader
agenda of some individuals.

The meetings of the Review Committee were long and
sometimes tedious, and each member had a lot of home-work in
reviewing applications. It was a good committee and the
members worked hard, but there was occasionally some
misunderstanding (perhaps only on my part) of what was
intended by the legislation. I guess I was more sensitive to
this than were others because of my position as an AMA staff
member. We received frequent complaints at AMA headquarters
from medical societies and individual physicians that RMP was
everstepping its boundaries in some of its regional
activities. Some of the complaints were valid, some were
not; but there was always a frictional interface with the
practicing profession, usually because of misunderstanding or
misinterpretation of the legislation.