ee 3
IN THE 1980s

 

A Symposium
at the
Mid-South
Medical Center Council
Annual Meeting
June 10, 1970

Holiday Inn-Rivermont
Memphis, Tenn.

Participants

Joseph T. English, M.D.

Harold Margulies, M.D.

Eugene Fowinkle, M.D.
Harold R. Sims

Bland W. Cannon, M.D.
Moderator

 

 

 
The difficult task of charting new courses to better health care for
citizens of the Mid-South puts the Mid-South Medical Center Council
and the Memphis Regional Medical Program side by side in the same
battles. In many instances the two agencies work closely together to
reach common goals. Publication of these proceedings of the MMCC’s
1970 annual meeting is one example of that cooperation.

Making health-care professionals and laymen alike more aware of the
issues facing the region and the nation, now and in the years to come,
is an important job for both MMCC and the Memphis RMP. Leaders
of both organizations felt that forthright comments by participants in
the symposium of the meeting would provide an excellent definition
of the issues and some stimulating insight into them for professionals

and laymen.

We feel that there are no more knowledgeable or more articulate com-
mentators on the present and future crises in health care than the
men who accepted invitations to appear on the symposium, Harold
Margulies, M. D., now director of the Regional Medical Programs
Service, Joseph T. English, M. D., then chief of Health Services and
Mental Health Administration, Eugene Fowinkle, M. D., state health
commissioner for Tennessee, and Harold R. Sims, deputy executive
director of the National Urban League. The symposium was ably
moderated by Bland W. Cannon, M. D., Memphis neurosurgeon anda
member of the National Advisory Council of the Regional Medical
Programs Service.

Dr. James W. Culbertson, program co-ordinator of the Memphis RMP,
and Mr. Frank M. Norfleet, president of the MMCC, foresaw the
benefit of publishing the proceedings and gave their earnest approval

to the effort.

Staff members of the Memphis Regional Medical Program and the
Mid-South Medical Center Council cooperated in tape recording the
proceedings and in preparing the transcript necessary to the
production of this finished documentation of that meeting.

This publication has been edited only when necessary to achieve
brevity and conciseness and to eliminate passages which were garbled
electronically or when some stray sound made a speaker’s words
incomprehensible. Occasionally, when garbling or noise interference
left the speaker’s meaning unclear, passages were deleted rather
than run the risk of altering or obscuring his intent. However, in a few
instances, a speaker’s exact words and phraseology were left
undisturbed, even if the precise meaning were unclear, when they
helped maintain continuity of comments.

We feel that the end result is a fair and accurate account of the
meeting and an important document for the edification of persons
interested in health care in the Mid-South and the nation.

—tThe Editors

Clayton Braddock
Information Officer
Memphis Regional Medical Progra

|. A. Metz, Jr.
Director for Voluntary Health Agencies
Mid-South Medical Center Council

 

 

 
 

ms
‘t

 

\ really treasure this opportunity to
share some reflections with you about

more than anything else, the future of
medicine and health in this country in
the 1980s. The three problems are:

(1) money (2) manpower and (3) some
organizational things, that we who are
interested in health are going to have to

do in this decade if we are going to have
any future in the next decade.

Let us first talk about money. (Slide 1—
“Expenditures for Health Services and
Supplies’’) Now, to take a very complex
subject and try to review it very briefly,

| want to show you 4 slide which reflects
the money that is being spent in health
and mental health services alone in

the public and private sector of our
economy: it is both public and private
money. The source of this information
is the President's Commission on
Health Manpower, which produced a
report some years ago.

What it shows js that in 1955 we were
spending for health and mental health
services in this country about
$17,100,000,009- Then in 1965 that
figure had grown to $27, 300,000,009.
in 1970, -- _the figure is $62,000,-
000,000, which is larger than the
national budget of all but a few
countries of the world.

“Let's Talk
About Money

Joseph T. English, M.D.
President, New York City Health and Hospital Corp.

(at the time of this symposium, Dr. English was chief
of the Health Services and Mental Health Adminis:
tration in the Department of Health, Education an

Welfare.)

hI

EXPENDITURES FOR HEALTH
SERVICES AND SUPPLIES

 
  
  
   
    
    
  

PHYSICIANS’
SERVICES

GENERAL
HOSPITAL,
SERVICES

SERVICES OF
OTHER HOSPITALS

DENTAL SERVICES

pRUGS AND
DRUG SUNDRIES

OTHER

The projection is by 1975, which is only
half way along the road to the eighties,
that health and mental health services

$100,000,000,000 enterprise. It now
represents six percent of the total gross
national product of the wealthiest
country in the history of the world. It

is NOW about two percent behind the

in defense that you do in health.
Nevertheless, as a segment of the
economy, WE have already rivaled the
Defense Department in size and by
1975 we may be equal to itor slightly
ahead, depending on the situation with
the war.
Therefore, one way to look at the money
problem—as we are in a period of time
when we want to do many things and
money is tight—is to see that in this
segment of the economy, not doing
things for a lack of money is a cop-out,
because we are guaranteed growth.
Growth in some ways, as we approach
the 1980s, is one of the great threats
to us in health, for a very simple reason
—because our country has been so
generous in investing in health. This
may not really be enough in terms of
the importance of health to the national
life of a country to even maintaining
domestic tranquility in a country.

It has been said by many observers of
countries in development that if you

do not meet something as fundamental
to life itself as health, that it may be
impossible to maintain order ina
country. And therefore, we are not
first in the percentage of our gross
national product in investment in
health. There are other nations that
percentagewise invest far more than
we do. and therefore ! do not think that
we should fear the growth we are going
to experience; rather, we should fear
the use that is made of that growth
because that is the problem.

 

The thing that is frightening about this
projection is the situation that we face
in 1970. If there are not major changes
in the way in which this growth is
handled, we could find ourselves in
1975 worse off in terms of health and
mental health services to the American
people——the quality of health and
medical care provided to the American
people in 1975, despite nearly doubling
of the investment that the total public-
private sector puts in—than we are in
1970. I do not think that any of us
would look forward to the decade of
the nineties where, despite the tre-
mendous growth of the sixties and
seventies, in spite of that growth,
people ended up less well served than
they were in mid-1970.

= ey

 

 
 

Now, to get some understanding of how
we can face that dilemma, | would
now like to put the bee on the federal
government, which shares responsi-
bility for this pickle that we are in. And
the next slide (Slide 2——-‘'Federal
Outlays for Health’’) concerns the
nature of federal expenditures from
1964 to 1970. It is a small part of the
$62,000,000,000 enterprise but a very
significant part; and my own feeling
here is that until very significant
changes are made within the federal
expenditures, it is going to be impos-
sible for the total public-private sector
of health in this country to get out of
its present pickle.

Now let us first take a look at the way
these expenditures have grown, because
they have grown rapidly between 1964
and 1970. You can see that the federal
share in 1964 was about $5,100,-
000,000 and in 1970 it is up to $18,-
300,000,000. There are not many
segments of the federal economy, other
than the Department of Defense, that
can show that kind of growth ina
relatively short period of time. So to
begin to understand the problem, you
have to see where the growth has been.
But even more significantly, where
the growth has not been. If you have
binoculars in the back row, you may
just be able to see a little brown line
here which represents the investment
made for the maintenance of health,
the prevention of disease, and the
control of health problems. It was .4
billion back in 1964; it is now .8 billion,
but you know that is not even a real
measure of growth because when you
take into account what a health dollar
is worth in 1970 as compared to what
it was worth in 1964, you can really
see there has been almost no growth
at all. | consider that to be one of the
serious problems which, if we do not
face it in the seventies, is going to give
us an incredible dilemma for the
eighties.

FEDERAL OUTLAYS FOR HEALTH

BILLIONS OF DOLLARS (est.)
18.3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.3 35 Pa
RESOURCES
14.1 3.4
28
PROVISIONS OF
140 HEALTH SERVICES
12.5 Uncl. Medicare &
5.4 10.8 Medicaid)
1.8
29 CONTROL OF
4-4 1-6 47 1-8 HEALTH PROBLEMS
1964 IS68 1969 1970

FISICAL YEARS

SOURCE: BUREAU OF BUDGET SPECIAL ANALYSIS

Slide 2

“|, . until very significant changes are made
within the federal expenditures, it is going to
be impossible for the total public-private
sector of health in this country to get out of its
present pickle."

 

Number two, if you look up at the yellow
box, you can see the money that the
federal government invests in basic
medical research, in manpower pro-
duction, in developing the capacity of
the American health care enterprise

to better deliver the excellence of
American medicine and to be able to
better deliver health care to the growing
and pressing demand the 200 million
people are making.
If you take a look at the growth that
has occurred between 1964 and our
support for developing the capacity of
the American health care enterprise,
to better serve the needs of 200 million
people, again you do not see significant
growth there. That is why we have a
manpower shortage of physicians,
nurses, and paramedical people. It is
why we do not have the resources for
the hundreds of experiments that
medical societies, hospitals, group
practices, physicians and other
medical purveyors in this country would
like to do to make the delivery of
medical care more effective in this
country in places where it is not, without
necessarily diluting the quality and

the excellence of medicine that we
have learned how to produce in this
country.

if you take a look at the federal invest-
ment for the development of health
resources to better serve the growing
health needs and the growing aware-
ness of their health needs of the
American public, you can see that
there has been very little growth at
all, even without taking into account
the inflationary impact on the health
dollar because the strategy has not
been correct. Three and a half billion
dollars is not very much for the develop-
ment of the American health care
enterprise within a $62,000,000,000
industry.

So therefore, the question is where has
the growth been? As you can see, the
growth has been largely in those sums
of money which the federal government
provides to pay for medical services
but which do not necessarily help the
purveyor increase his capacity to meet
a growing demand. This is largely
Medicare and Medicaid and, in the
private sector, other third party pay-
ments. It is the money that is putting the
pressure on a very limited capacity, a
capacity that is inadequate to meet the
needs of 200 million people.

Where we are going up in cost to the
American public from six to twelve
percent per year, it leads to dilution of
quality, because a physician has to
take care of five times the number of
people because there are not as many
doctors as there were before.

When you consider the strains that the
hospitals are under, you begin to see
what happens to the quality of care.
Then thirdly, most of the resources go
to care of the patient after he needs to
be between the sheets and a very
pittance of our total investment is going
into the prevention of illness and in the
maintenance of health.

But we have not yet seen the federal
leadership that is going to be required
first in the federal sector to reverse
this absolutely elemental disproportion
in the investment we are making ina
rapidly growing segment of the econ-
omy. And it seems to me that until that
begins to occur, it is going to be very
difficult for the private sector of health
in this country to help with the total
problem that we are going to face in the
eighties. And | think that is indeed why
there is a crisis in medical care.

Now let us go to the next slide——man-
power distribution (Slide 3).* This
begins to get us into the second prob-
lem... which is manpower. Now | have
chosen an illustration which | do not
think will surprise any of you. It shows
what has happened to the mythology
of the mainstream of American medi-
cine over the last 25 years.

Part of the reason why most of the
federal investment is trying to buy
people into the mainstream was
because back when that term first was
used, there was a mainstream of
American health care. But there have
been dramatic changes in the last 25
years that present federal policy has
not yet taken into account. In a 55-block
area in Harlem 25 years ago, for 25,000
people there were 50 practicing physi-
cians attempting to take care of them,
most of them being in the general prac-
tice of medicine. Look at the dramatic

 

 

 
 

change that has occurred today where
twice the number of people are living
in that area, and there are now only
five physicians there. If you look at who
those five physicians are, you are going
to find that they are, in general, older
men and there are no younger men
coming in to take their place.

You could give countless illustrations
of this in most of the cities of our coun-
try. You could show it in poor rural
areas too, but the next slide indicates
that it is not just a problem of the poor;
it is a problem of some relatively well-
to-do areas in rural parts of our coun-
try as well. It is a problem that goes
beyond socio-economic parameters.
(Slide 4—''Physician—Population
Ratio, 1943’")*

This concentrates again on physician-
population ratio in the urban core of ©
our cities in 1943. Back at that time,
the ratio of doctors to patients, potential
patients, was 1 to 500 and out in the
suburbs in 1943 it was 1 to 2,000. Take
a look at what happened as early as
1968; the change was dramatic. You
have a situation now where in the urban
core of our major cities that ratio has
gone from 1 to 500 to 1 to 10,000 and
you now have a situation in the suburbs
where it has gone, in that same period,
from 1 to 2,000 to 1 to 500.

Just as the money problem is not
simple, which | think the former illus-
trations tried to show, it is very clear
that the manpower problem is not
simple either. It is not just a question
of producing more doctors, more
nurses, more medical personnel of
other kinds; it is a question of how, ina
free and democratic society, we get
those medical personnel and those
medical facilities to the places where
they are needed. And | again want to
emphasize that this problem is not just
in poor areas of our country, butina
great number of relatively well-to-do
rural areas where you have the same
kinds of changes going on.

Let us move on to the next slide now
(Slide 5—''Physician-Population Ratio,
1943"')* and just take a couple of min-
utes to try to project a little bit into the
future what may have to happen by
the 1980s if we are not going to see

... federal medicine—government
medicine, whatever that is. Because if
there are not basic changes, if we keep
investing more and more money in
health, as we are at the present time,
without the consumer, without the
citizen seeing his medical care or health
care improved as a result of that, the
consumer outrage is going to produce
a situation in the Congress that is going
to convert us very rapidly to a public
utility or to a federal form of direct
medical care as has been done for the
Indians and for other populations. |
think that would be tragic in this
country.

  

Ge
(Pr Hospi, ==} Prysician Hoe GROUP PRACTICE

Bi venta Heact centER a NEIGHBORHOOD HEALTH CENTER
Slide 6

  

Now what are some of the things that
are going to have to occur if we are to
avoid unfortunate outcomes of this
crisis? (Slide 6—‘‘Community Puzzle
of Hospitals. Group Practice, etc."’)

The first thing | think you see evidence
of is a variety of groups, representing
the purveyor and the consumer and the
teachers of medicine and the people

 

*Slides 3, 4 and 5 not reproduced for proceedings.
interested in medical research, coming
together and recognizing that in one
area of a community there may be no
doctors at all.

This would be the case right here (re-
ferring to slide) and that might be the

  

Ce
a HOSPITAL Q PHYSICIAN be p GROUP PRACTICE
a MENTAL HEALTH CENTER a NEIGHBORHOOD HEALTH CENTER

Slide 7

reason why, through some federal effort
or some private effort, something like
a neighborhood health center is started
to try to re-attract physicians back into
that area and to put them together with
paramedical people that extend the
hands of the relatively few physicians.
In other parts of the country we may
have a group practice in a hospital.

Way over here (referring to slide)

there may be a mental health center in
a hospital and just a few solo practi-
tioners. Over here there may be
something else. But it is very rare, in
most parts of the country, that there

is any public-private institution devel-
oped to survey that whole scene and

to try to figure out how to make the best
use of the resources that are there, the
new resources that need to come in, be
they public or private.

We have not yet seen that institutional
development in this country and it is
really through Comprehensive Health
Planning and the Regional Medical
Programs that we are beginning to

see the start. So I would suggest that
by the eighties, if these programs are
given the priority which they should
have, in... what is already a $62,000,-
000,000 enterprise, this will help turn

‘happen, then | think we are going to be

those dollars into better health care for
the American people. If that does not

in difficulty.

 

! would hope that we would begin to see
a variety of different ways of coming
together at the local level, as we see
being done here (on slide diagram) to
see how those pieces can fit together
more effectively, whether they are
through an areawide health planning
agency, a Regional Medical Program
or cooperation between those two
programs and other efforts. This is
something which does not yet exist in
this country in health: a community
trusteeship—a coming together of the

  

(Fy Hosea, ff} PHYSICIAN GP crour practice
MB ventac vate cenTER (CD) NEIGHBORHOOD HEALTH CENTER
Slide 8

public and private sector at the most
local of levels where the citizen mandate
is there with the community, where all
segments of the community are rep-
resented—the taxpayer, who supplies
the money increasingly for these
services, and also all of the purveyors,
too.

My conviction is that, though the re-
sponsibility of those in Washington is
great, the real difference is going to
be made by the initiatives you exert
right here at the local level to do some
of the most elemental things that need
to be done if we are to be optimistic
about what we can do in health, perhaps
one of the most important dimensions
of the quality of life in our society in
the 1980s.

 
 

| thought as a sub-name | would
choose the ‘'Cost of Service Versus
the Value of Care.’’ | remember it was
said that, ‘That which is immediate
takes precedence over that which is
important and that which is important
only gets attended to when it is urgent,
and then it may be too late."

You know, | am very happy to be here.
1 feel, sitting here on this stage today,
that systems have changed, because
when | finished Booker T. Washington
High School (in Memphis) in 1952, |
don’t think there was any less likeli-
hood that a student of the University of
Tennessee would be sitting here or
anywhere near anybody like me but
there was no likelihood that | would
get in the University of Tennessee
Medical School or anywhere else. | am
happy to make that note.

Cost of Service
vs the
Value of Care”

Harold R. Sims

Acting Executive Director, National Urban League

(Mr. Sims was deputy executive director at
the time of the symposium)

When | attended high school in Mem-
phis during those years | mentioned,

| became quite fond of an old Chinese
proverb which followed me through the
years; | am sure you are familiar with
it: “If you would plant for one year,”’
said the old quotation, ‘‘plant grapes.
If you would plant for ten years, plant
trees. But if you would plant for etern-
ity, plant men.”

Given the current status of man, woman
and child in the American world today,
our commitment to planting men

rather than things is tragically in doubt.
In the face of unprecedented scientific
technology and technological progress,
we fail to commit and demonstrate our
capacity and resources to the magni-
tude of the problem which we have
here at home. Our cities and rural
areas are in an ever-deepening crisis,
with both qualitative and quantitative
defects robbing our children and our
youth of the occasional opportunity
needed to facilitate their maximum
growth and development.
10

A housing crisis continues to worsen
with blight decaying the slums, breed-
ing crime and delinquency in every
major urban city. Our living environ-
ment is in a crisis, through pollution,
poisonous air, dirty water, the rodents
rampant and clutter—it is becoming
an increasing... problem. |

Of all the crises we face today, none is
more critical or urgent than the growing
deterioration of health care and serv-
ices. For without a healthy body and
mind, none of the other crises or op-
portunities really matter in the march-
ing hierarchy of human needs. Now,
this health-care crisis in our age ex-
presses itself in many insensitive and
ironic ways.

Although the statistics are used from

a variety of sources during the decade
of the sixties, nothing has changed very
much to alter the picture. For example,
despite spending $62,000,000,000, or
6.7 percent of the United States gross
national product on health care in 1969,
our life expectancy is still only 18th for
males and 11th for females in the whole
worldwide rankings. Despite the fact
that we have the highest level of medi-
cal competence and are expending
greater resources for health-care serv-
ices than any other nation in the world,
our ranking again in the world order
has consistently declined in the last
twenty years, particularly in the area

of infant mortality, where we went from
second in 1953-55 to eleventh place

in 1960 to fourteenth in 1967-1969. As
of today, we rank below East Germany
in this regard. And as for our black
citizens, above all, they rank below
Jamaica, Japan, Italy, and Greece—

in 28th place on the world order scale.

This factor ought to be particularly
important to you here in the South. In
1968, the East-South Central region
which included Kentucky, Tennessee,
and Mississippi and, | believe, Alabama,
had the highest infant mortality rate

in America for both races, white and
black. Despite the creation and devel-
opment of a multi-billion-dollar health

 

insurance industry which collectively
took in about L1 billion dollars worth
of premiums in 1967, the cost to the
medical consumer increased 5.8 per-
cent from 1965 to 1968 alone. For
there was only a 3.3 percent increase
in other consumer prices without
comparable income increases.

During the period of deteriorating serv-
ices and world standing in health care,
despite the critical shortage of doctors
and the necessity to ‘‘import"’ to
survive, many of America’s medical
schools consistently complained and
threatened to close for lack of funds.
The other day in California, people
were so insensitive to this great need
that they voted down the creation of
two new medical schools, despite the
critical need.

Despite all the rhetoric of the medical
profession of prevention and mainte-

 

 

 
 

- 3g

nance, the health-care delivery system
of this country is still designed to
react rather than preclude, to support
socio-economic classes rather than

all people on the basis of need. At the
present rate of United States retrogres-
sion in health-care areas and at the
present order of United States prior-
ities, unless drastic changes are im-
mediately undertaken, by the 1980s
the United States may very well be
first in the race for the conquering and
population of barren... outer space
but last in the race for viable lifeful
earth or human space.

The plight of health care today for
black America is two to four times
worse than white America, although
proportionately more black males
contribute to Social Security than
white males. Given the present mor-
tality rate, the average black man at
birth cannot expect to live long enough
today to collect his Social Security.
Most black families without health
insurance, and many with it, are con-
fined to the wards of over-crowded
municipal facilities where daily hospital
charges are somewhat less than the
voluntary hospitals. About six percent
of black mothers—eight percent in the
South——had no medical care before
the birth of their child, compared to only
one percent of white mothers—three
percent in the South—in a national
mortality survey in 1963.

At the same level of income and educa-
tion, black mothers are more likely than
white mothers to have been seen at
public medical facilities rather than by
a private physician. Both black and
white mothers receive little dental care
before the birth of a child, although
pregnancy is known to affect the
mother’s teeth critically. Regardless of
income, black mothers very seldom see
a dentist before childbirth, or they see
them much less often than white
mothers do; over 90 percent of the
black mothers—-compared to 70
percent of the white mothers, according
to a 1963 survey again—did not see a
dentist at all during the twelve months
before birth of the child.

“The plight of health care for black America is
two to four times worse than white America,
although proportionately more black males
contribute to Social Security than white males.”

 

The black maternal death rate is almost
four times the white, in spite of the
drastic reductions in the last three
decades (69.5 compared to 19.5).

Life expectancy is lower for blacks than
for whites of all ages. In the prime of
life, the prime working years, 20-35,
black men and women average five
years less life expectancy than white
men and women. The difference begins
to taper off in later years and is greater
among women than among men.
Blacks have a much higher death rate
than whites in communicable disease.
Particularly blacks are more than likely
to die more often from tuberculosis,
influenza, and pneumonia.

One positive note: suicide is more
prevalent among whites than blacks
and is consistently lower among black
women. And someone rationalized this
in an article in The New York Times
that talked about the psychic advan-
tages of urban life. That may have
something to do with it. | do not want to
simply re-emphasize the horror but to
dramatize the opportunity available to
us. | want to differentiate something
that ought to be clear to you. | won't
elaborate on this because of the time,
but do not get too optimistic about the
status of white health in this country,
because even the optimum. average
white health care is still much lower
than in some Communist countries.
And we turn to the relative improve-
ment the whites have made in the last
ten years. Really what has happened is
that the blacks are moving closer to
the inferior level.

11
12

Since we did not come here to drama-
tize the horror that dramatizes the
opportunity, let's talk about the plan-
ning. An alternate range of strategic
planning in all areas may have many
controversial meanings, but more
practitioners agree it is to plan for and
put in place today, which will maximize
what we want to happen tomorrow. The
National Urban League has recently
recognized the critical nature of the
seventies. No telling what may happen
in the eighties.

We called for a consumer-oriented
national health system—a framework
which addresses itself to designing
mechanisms by which health, as a
right and not as a privilege—and we
maintain health as a right—can be
achieved as a reality for all Americans.

 

We called for an action-oriented health
system with a program and a platform
which encompasses all employees of
health, health maintenance, disease
prevention, medical care delivery, fi-
nancing consumer participation, train-
ing, and education.

In this new system—for maximization
in the eighties, and for maximization
now-—we called for a complete new
organization of the health care system
of the United States, an organization
that would reflect the national health
policy which is responsible for the five
basic assumptions which | hope to
elaborate on during the discussion
period.

We also called for a commitment to a
system of public education for all
categories of the health profession—
doctors, nurses, technicians, witha
service commitment which can be
utilized to provide a more even distri-
bution of health care services.

We also called for the re-orientation of
the health care system to help add its
maintenance rather than only attending
disease and illness. If you will carefully
examine most of your health policies
and all the things you carry, you will
find that they are not designed to help
you prevent and maintain yourself;
they are designed to react and to
respond.

We are calling for a national health
insurance plan, which we will also
elaborate on during the discussion
period. For the final analysis, we agree
with the late Walter Reuther, who said:
“We call for, plead for, indeed demand
a health care system now that will
eliminate the waste and the inefficiency
of the present non-system, a system
moreover that will bring the poor into
the mainstream of medical care, a
system that can, in an organized
manner, begin to bring about the effec-
tive use of our health manpower, our
health facilities, and our economic
resources.”

 

 

 
Public Concern
and
Professional
Judgment

Eugene Fowinkle, M.D.

Tennessee Commissioner of Health

 

 

Ten years ago | heard Dr. Cannon

say, ‘‘What this community really needs
is an effective planning organization
that can develop good appropriate plans
for the future development of this
medical and health community.”’ We
saw the birth of this idea. We saw it
nurtured through birth and childhood by
Dr. Cannon, Mr. Norfleet, and many of
you here in this room and now we have
an effective and mature organization
and | think we are all justly proud of it.

Public health, as its name implies, is
both public and health. Consequently,
public health is acted upon both by
public forces and by forces which are
generated from within the health in-
dustry. One important and profound
public force which is influencing us now
is that all institutions, agencies, sys-
tems, traditions, or even individuals,
are on trial now by society. We are
being tested continuously for our
validity. The American health system
now is certainly on trial and is being
tested for its validity. | think in the
1970s and on into the 1980s the
system will be tested. The various
components of the system will be
contested for validity and some replace-
ments and changes will doubtless be

made. This phenomenon was put very
nicely by a well-known physician:
‘‘These are days of deep dissatisfaction.
Cries of dissension and loud demands
for change fill the air. Nothing is fair—
government, the press, industry, labor,
religion, the educational system, philan-
thropy. Nothing! An uneasy concern
blows across the land and around the
earth, already shaking all the leaves
and already some worthwhile mighty
trees have fallen. Necessarily caught in
the relentless movement is the field of
health, with all its various manifesta-
tions, its professional schools, its
established disciplines, its traditional
programs, its time-honored approaches
to planning, public relations and serv-
ice.’’ So what he is saying and what

I'm saying is that we are on trial. We are
being tested for our validity. | think

we will see many aspects of our health
system strengthened by the existing
testing process because a number of
those components that are not valid
will fall by the wayside.

Another public force which has had a
profound effect upon the health system
is, of course, the social mandate that

13
14

was referred to by Mr. Sims, that every
American citizen receive essential basic
health services regardless of his ability
to pay. This mandate has been read
out ina number of ways. Some have
read this to mean that every citizen
should have gold-plated health care;
others say every citizen should have
token health care. | think, in general,
what we hear is that every American
citizen should have at least essential
basic health services. This social
mandate has manifested itelf ina
variety of ways. One is that it has pro-
duced, in the mid-1960s, two of the
most profound health legislative acts
in American history. The health system
is staggering under the weight of this
socio-political decision now and will
continue to wrestle with it through

the 1970s and hopefully will find solu-
tions as we go into the 1980s.

Another public force or influence which
is acting upon the health system of this
country and which is a corollary to this
social mandate is involvement of the
federal government. This was pointed
out to you very clearly by Dr. English.
The question used to be, ‘‘Will the
federal government involve itself in the
health industry?”’ but the question now
is, ‘‘How will the federal government
involve itself in the health industry?”

As | see it, there are two major alterna-
tives. One is to socialize the system, to
put health providers on federal payrolls
and develop national health programs
as some of the European and Asiatic
countries have. | think that few clear-
thinking Americans at this time think
that this is the best way to provide
health care for the citizens of this
country. Built in and ingrained into our
very way of life is the quality building,
quality maintaining, private enterprise
motive that exists not only in our health
system but in our entire economic
structure. The other alternative to
federal involvement in the health in-
dustry is federal subsidy to the existing
health system.

“Built in and ingrained into our very way of life
is the quality building and quality maintaining
private enterprise motive that exists not only
in our health structure but in our entire
economic structure.”

 

This, in fact, is the present trend,
Medicare and Medicaid being the two
most profound examples. As you know,
they provide buying power to individuals
who can then go to the private market
if they so choose, and purchase their
health care just as any other individual.
So the present trend is federal subsidy
to the existing health system, both
private and public. | think that we have
to say, however, that there are some red
flags waving.

Another powerful public force which is
acting upon the health system, espe-
cially on public health, is the public
demand to stop further deterioration
of our environment. During the fen
years | have been in public heajth, |
have seen a variety of levels of ‘public
interest and concern on matters related
to health. However, | have never seen
any reaction of the public to any matter
related to health as strong and as
intense, as enthusiastic as the present
expressions of concern about our en-
vironment that are now being given to
us. We have a very strong signal from
the public that further deterioration of
our environment is to stop. Public
demand is here; it has not always been
here on the environmental problem.
Ten years ago | heard the surgeon
general of the Public Health Service
warn that this country is headed toward
serious environmental health problems.
However, at the same time, he pre-
dicted that very little would be done

 

 

 
 

>,
ck
&
F
ord

5 ot
“s. “4
Sanatanal

years because of the lack of public
concern. We have public concern now—
but just how adequate to develop
adequate environmental quality con-
trol. Although public concern and
public demand, whether they relate to
the environment or to the predicament
of the present health system of this
country, are important and essential,
they must be tempered by professional
judgment.

One of the greatest problems which we
are going to encounter in the 1970s is
dealing with the public clamor that now
exists about our health system and
about our environment. This is im-
portant but yet perhaps it is being
overdone.

Let me illustrate. A few weeks ago our
Apollo 13 space ship got into trouble

 

and the immediate response of 200
million Americans was to say, ‘“‘turn

it around, bring it home.’’ This was an
expression of public concern that we
wanted our people back home safely,
but it was tempered with professional
judgment, in that the men at the con-
trols in Houston realized that if they
were to try to turn the ship around
immediately and bring it back, it would
be destructive to the people that it
served. So with the intent of getting
them back, they used the momentum,
the forward motion, that the ship had,
but they guided it on the proper course.
They made periodic and frequent
adjustments to it, got it on the right
course, and steered it back home safely.
Public concern was there, but it was
tempered by professional judgment.

There are those who say, ‘‘Let’s com-
pletely do away with our existing health
system and start over.”’ There are
those who Say, ‘‘Let’s immediately
solve our environmental health prob-
lems.” [ think this will have the same
effect as trying to turn the space ship
around while it is going away from the
earth. It would be destructive to the
very people that we are trying to serve.
1 think we must temper these expres-
sions of public concern with profes-
sional judgment.

So in summary, | do think we need
public involvement. We need public
criticism. We need public participation
in policy decisions in the health in-
dustry. But yet | hope we can have the
ingenuity, the knowledge and the
strength to temper this appropriately
with professional judgment so that we
do produce the best possible product
for our consumer in the 1970s and into
the 1980s. Comprehensive Health
Planning brings together, at interface,
the public concern and the professional
knowledge and experience and judg-
ment. So | think CHP is one of the best
tools that we have to achieve the task
that lies ahead of us in this decade.

15
16

 

You've heard a number of things this
afternoon which are pointing toward
what may be our health-care system
or our health-care problems in the
1980s. But because | have to deal with
them in a very direct fashion, | think |
am going to have to be a little more
explicit. We have heard problems and

I think | can add to them, but | would
like to balance up the record very
quickly and point to some of the things
which | think are going to occur and
make it as clear as possible to you that
the answer to the question of what
medicine will be in the 1980s is not at
this table. It is in this audience. And |
don’t think you quite begin to recognize
that fact.

Dr. English told you some things that
the federal government has been doing,
which he thinks it should not have been
doing, and he pointed to a certain level
of inexpertise in the federal government
from which | am sure he exempted me
and himself. | feel confident about that.
But | would like to point out, just to
balance what we are talking about
today, what has gotten us into the kind
of situation which he described and
with which you are familiar.

Making Hard

Choices

Harold Margulies, M.D.

Director, Regional Medical Programs Service

(at the time of the symposium, Dr. Margulies
was acting director of RMPS.)

Because | have only briefly entered
federal service, | think | can look at it
with that kind of a perspective. What
has happened since | finished medicine
at the University of Tennessee? In those
years there has been a rapid increase
in the use of hospitals, a rapid increase
in specialization, a rapid increase in
physician concentration and nurse
concentration in certain areas and
abandonment of others, a rapid rise

in the cost of medica! education with a
disappearance of private sources and
funds to pay for it, and a rapidly in-
creased dependence upon allied health
manpower, all of which you are familiar
with, none of which was created by
federal government or any other kind
of government. These were the prod-
ucts not only of the medical professions
but of the public.

At the present time—and | think Mr.
Sims’ presentation is fairly character-
istic of it—we are still not able to
narrow our purposes down to what it
is we really want. We have a whole
kaleidoscopic range of interests saying
we want this, and this, and this, and
this, meaning we want everything all

 

 

 
 

vy

at one time and not really being able

to settle down on exactly what we will
give up in order to get what we really
want. We hear the usual range of more
physicians, more allied health people,
more hospitals, more acute care, more
chronic care, more preventive care, and
so forth. What is it that we are really
willing to bargain for with the six per-
cent or eight or ten percent of the
gross national product we are talking
about? | think this is going to get settled,
and | think it is going to be settled
before the 1980s so what occurs then
is really the issue of the 1970s. And
more than that, it is the issue of the
next three years.

| believe we must recognize the fact
that, despite the interest of the people
at this table and the interest of those
who are in the audience, concern with
health care in this country is still
marked primarily by apathy. This is
true of the medical profession and all
levels of health skills. It is true of the
public in general. Look at any general
survey of the major issues which people
spontaneously bring up and somewhere
... they will talk about health issues.
This will change. It will change as the
political climate of this country is
progressively changing. Because, in
this decade, the issues are going to
move away, as they already have, from
those we are familiar with, to those
with which we are becoming increas-
ingly familiar.

They are going to have to do with such
things as peace, as something we be-
lieve in, and for which young people are
going to prefer candidates. They are
going to have to do with education
available to everyone—all colors, all
areas, all creeds. They are going to
have to do with decent housing which
is currently not available and which is
disappearing even more rapidly than it
is appearing. And it is going to have to
do with health. And in this decade, the
issue of health is going to rise to a major
political issue, and | mean political with
asmall‘‘p” as well as with a big "'P.”’
And what happens as a consequence is

going to be a reflection of how success-
ful the present efforts are to do some-
thing about the health care system.

We are lacking certain kinds of basic
ingredients. One of the ingredients we
are lacking is an understanding of what
it is that we wish to have as our major
priority. And our choices, because this
is going to become political, and in-
creasingly federal and increasingly
governmental in the payment system,
our choices are going to be tougher
and they are going to be a combination
of political, fiscal, and moral choices.
What are they going to be?

We are going to have to decide on
whether we are going to preserve the
life of 85 year olds or preserve the life
of eight year olds. We are going to have
to decide whether we are going to put
all of our efforts into acute episodic
care for people who may or may not die
or put them into the maintenance of
health. And we are not going to have
the opportunity to do both. Because in
the next three years the problems which
we have been describing here today,
which Dr. English faid out for you very
effectively, are going to get worse. Our
health manpower shortages are going
to be exaggerated. The costs of medical
care are going to go up. The deteriora-
tion of hospitals is going to be accele-
rated. Access to medical care is going
to be unimproved. Medicaid is going

to be as paralyzed as it has been in the
past and have very limited benefits

for very limited numbers of people. And
the agony will increase progressively
until we are ready to make the kinds

of political judgments about what we
really want out of this health. care sys-
tem and what we want to purchase with
our money.

And then some things are going to
occur. If | had more time, | could sketch
for you, | think without much difficulty,
a logical conclusion about where we

are going to be very quickly. If I did

that and ran through the range of things
that have happened these last ten or
twenty years, | would come to this

17
18

“There is still a reluctance in make the choices,
the hard choices between what is obvious
and visible and exciting and what is much less
attractive like preventive medicine, health
maintenance, and the whole concept of plan-
ning for the total community.”

 

conclusion: That the high cost of
medical care, which can be increasingly
identified as being from federal sources,
is going to lead to an increasing demand
that we have a measurement of what
we are purchasing. And one of the
rising issues before 1975 is going to
have to do with the quality of medical
care which is being purchased by
federal and private money. And this is
going to produce some profound
changes in attitudes.

Public hospitals which currently pro-
vide miserable medical care for people
because they are indigents are going to
have to face the fact that this care is
unacceptable. Payment systems are
going to identify the difference between
good and bad care at levels of sophis-
tication which none of us feels ready

to take on. Now the government is well
aware of this; you are well aware of it.
The federal system is lunging in a num-
ber of directions trying to decide how we
are going to cope with this very difficult
problem. Of the total increase of over

one billion dollars for this next fiscal
year in health, 83 percent is going for
Medicare and Medicaid, merely mean-
ing paying more money without any
increase in the access or quality of
medical care. This is an uncontrollable
cost which at the present time is
strangling ail other efforts.

Now you know that one of the things
which has been going on in this country
is an attempt at some kind of decen-
tralization. The federal government has
said to itself, '‘We really can’t handle
this. It is too big for us. The problem

is out there; the solution should be out

there.”

On the way down here on the plane |
read an article by Dwight Ink, who is
one of the leading budget managerial
theorists in the country and in the
federal government. He described a
variety of basic ways in which the
political process is going to move
toward the solution of problems which
have become too central and must be
decentralized. It intrigued me that he
did not identify the very special quality
of the Regional Medical Programs in
this country. Because of the whole
federal system, they have remained
unique. There is no arrangement avail-
able to any branch of the federal gov-
ernment which allows for a federal-
private mix to identify problems, to
attack problems, and resolve those
problems. This is the one option in the
health system which remains open as
an effective mechanism for dealing
locally with focal issues.

Now since | have come into the Regional
Medical Programs, and | knew it well
before that time, | have been even more
impressed with the very special char-
acter of that activity, not only for the
health field, but as a measure of what
kind of mix we can maintain between
federal and private efforts and skills
and talents to produce a desirable re-
sult. | have to say that what | have seen
so far in... those programs is not

very exciting. | have seen a range of
activities which continue to reflect con-
cepts and priorities which are already

 

 

 
 

 

 

out of date at the time they are initiated.
| have seen very little real integration of
the concept of planning totally for the
total population on one hand and total
response and total conflict from the
professional side on the other hand.

Regional Medical Programs by itself is
a totally ineffective instrument. Com-
prehensive Health Planning by itself is

a totally ineffective instrument. They
are so interdependent upon one another
that the failure to recognize that inter-
dependence constantly astonishes me.
And unless there is a way in which these
two can serve total community needs,

can reflect federal thrust, can be re-
sponsive to consumer interests, unless
these two can do it, then clearly they
will have to be abandoned in favor of
something which is much less likely to
be successful.

Now what disturbs me about it more
than anything else is that it is new, it is
fragile. It represents, in its essence, the
best of the American genius, which is
the capacity for people of different
kinds to work together toward a com-
mon purpose within their own com-
munity, But there is still reluctance in
making the choices, the hard choices
between what is obvious, and visible,
and exciting and what is much less at-
tractive like preventive medicine, health
maintenance, and the whole concept of
planning for the total community. Be-
cause these choices are ones which
people are reluctant to make, | have my
own skepticisms.

Now | can pledge to you that so long as
| have the responsibility for Regional
Medical Programs and have the access
| have to thinking about Comprehen-
sive Health Planning, research and
development in the medical area, so
long as | have that responsibility, | will
do my best to bring these functions
together because | am confident that if
what we are trying to do now is not
successful, it will be replaced by some-
thing else and in the course of time will
have to start all over again to create
what is now Regional Medical Program
and Comprehensive Health Planning.

| also recognize the fact that they are
young and have had very little time to
find out whether or not they can work.
In the same moment | must tell you
that there is no time left to be delib-
erate, to be doubtful, to be hesitant. If
you mean to make this area, the Mid-
South, an area which the whole nation
is looking at, one in which people wish
to live because health care is available
to them at a good quality level, you will
have to work vigorously and effectively
and with a kind of humility which is es-
sential to good community activity.

19
20

 

QUESTIONS AND ANSWERS

DR. ENGLISH: Let me read two of the
questions that | have just received:
“Who really makes the health decisions
at HEW? Concurrently, why is health
receiving the short end of the stick at
HEW? Dr. English, you implied that the
White House should have an advisor in
health. Could Robert Finch fill that role?
If so, will he be asked to do so?”’

| think they are very good and pertinent
questions and, not necessarily sticking
with the tradition of federal bureaucrats,
| will try to be direct, honest and most
responsive as well as brief in my
response.

Who really makes the health decisions
in HEW? The big decisions are not made
in HEW. The big decisions have been
made in the White House. Part of the
reason that poses a problem is that the
nation’s top health officer is excluded
from the decision-making process in
the White House. He has publicly la-
mented that fact on numerous occa-
sions. Who makes the decision in the
White House is very difficult to deter-
mine, except to say that in this situation

~ it is almost without precedent. No one

within the White House is presently
assigned that we know about to the

$62,000,000,000 enterprise which
health and mental health services now
is in this country. Regardless of where
the decisions are made, | do not think
we are going to see progress in the
crisis in health care in this country until,
within the place where the decisions are
made, someone is assigned the re-
sponsibility for knowing something
about this critical area of the American
economy.

And now the second part of the ques-
tion: “Will Mr. Finch’s going to the
White House as counselor to the Presi-
dent help with this?”

| must say that all of us are terribly
optimistic that he may be able to help.
Others would point out that if he had
difficulties as Secretary, will it really

be different as he joins the White House
staff itself? | would say that most of us
retain great optimism, because the
Secretary understands these problems.
We hope that he will be helpful. | doubt
that he would become the President’s
health advisor. | think he realizes the
greater need for expertise. Hopefully, he
may be able to get the nation’s top
health officer into the White House
decision-making process where up

 

 

 
 

until this time he has been exciuded,
the reason being given that he is a
physician and a physician in those
councils could not be objective: he
would be an advocate.

DR. CANNON: Dr. English, | think |
should ask you one question for clarifi-
cation. Some people might associate
the White House as meaning President
Nixon. | think you ought to give some
clarification to that, because really it
may be a different ballgame than is
perceived by your comments. | do not
want to put you on the spot.

DR. ENGLISH: No, | am delighted to be
on the spot. These are times when a
public official should be on the spot
and | am delighted to be in that posi-
tion. | do not think that this reflects the
terrible problem of any president dur-
ing times when the national crises are
too numerous to mention, when his
attention is focused on many things.
With his dependency on the people that
both control access to him and advise
him, | think that the President would be
far better served if there were someone,
recognized by the departments of gov-
ernment, by the professions in this
country, by the consumers who are
interested in health in his own house, in
the decision-making process, to insure
that the President gets the advice of the
nation’s top health officer.

MR. SIMS: | have several related ques-
tions here: ‘‘What are the four major
items that you observed during your
talk to be the top items to be considered
in health care for the future? How do
you think that compulsory national
health insurance should be financed?”

First of all, let me explain something.
Perhaps | am the consumer up here,

in terms of my actual involvement. If
you give a little credibility to what | am
saying, | am from a very successful
family of purveyors. | am from a family
of doctors and teachers. | have lived
around them all my life. Secondly, the
input through the National Urban
League is rather unique, in that it brings
together, if you will, the “‘establish-

ment” of the people. The recommenda-
tions come from people who are
eminently involved in the medical field.
And we developed our position on our
thorough examination of the AMA
draft bill on health care and health-
care insurance, the AFL-CIO proposal,
the Griffin Bill, the Jackson proposal,
the Committee for National Health
insurance, the Rockefeller proposal,
and a variety of taxpayers’ proposals.

| also want to emphasize that we are
not talking here about socialism. | think
that the Urban League is committed to
the democratic process and we have
committed to the process a surge of
people, as well as machines and things.
So all that concerns you is delivering
this kind of thing.

Perhaps if | can read in full as quickly
as | can the position of the Urban
League on health care and health in-
surance, | may answer a lot of these
questions. We called for this reorgani-
zation of the health care system, which
did not mean so much throwing out as
better utilizing. Our aim is not so much
to provide for new kinds of costs, al-
though we believe it is inadequate cost
effectiveness to the American people,
to the consumer, to bring abouta
greater value for the current medical
dollar. And the five assumptions we
talked about, in reference to what
health care, or health care policy, or
the health care system ought to contain,

are:

1) That we believe a national health
system should be conceived and func-
tion to meet the needs of the consumer
and provide opportunity for appropri-
ate consumer participation and control
of the system that will serve him. More
consumer-oriented than provider-
oriented system. The current system is
mainly oriented toward the provider.
The consumer should have something
to say about his health and the health
care of his children.

2) The national health system should
be oriented toward health and its main-
tenance rather than simply disease.
This involves prevention and distribu-

21
22

tion, not simply reaction. For example,
how many health care policies pay for
your annual physical, which may be
critical to your survival? We say the fee-
for-service concept is not acceptable in
a health care system in which the basic
concern is for the health care needs of
the consumer. The elimination of a
fee-for-service principle will be useless
without the development of interrelated
positions of health professionals, the
redefinition of roles and tasks, and a
reorientation from disease to health
care.

3) And we assume, and we say, that
the health care systern must be de-
signed to provide an even distribution
of comprehensive health care services
in all communities, irrespective of their
racial and their economic base. A sys-
tem of tax-supported public education
with a service commitment for all health
professionals is essential to achieve an
equitable solution for manpower needs.
It is inconceivable that America would
value its soldiers more than it values
the people who make those soldiers
possible.

4) The general tax revenue should
be the source of financing for universal
health insurance. Economists say,
“While the social security mechanism
... can be perhaps modified, a progres-
sive taxation method is preferable.’’ We
do not see this costing you about the
same money for better services for all
people, irrespective of your age or eco-
nomic status. A major concern of ours
or any national health insurance pro-
gram is to place a significant emphasis
on the improvement of the geographical
distribution of health services. We say
that national health insurance must be
committed to the development of a
single health system without social or
racial discrimination. We oppose reim-
bursement formulas and the utilization
of private insurance carriers.

5) We support a system of public
financing, including stipends, for edu-
cation in the health professions. Such
public financing would make inherent
a community service obligation and is

based on the premise that all members
of society must have equal access to
education in the health professions for
which there will be in turn an obligation
to that society. We feel that some form
of funding for health profession educa-
tion must be an essential criteria of any
national health insurance program.

DR. FOWINKLE: “What part should a
real group practice play in the 1980s?”

Until the mid-1960s, the major prob-
lem of entering into the existing health
system was the financing. As Dr.
English indicated, the big input into the
financing of health care has been in the
area of providing service or financing.
We have somewhat overcome the fi-
nancing problem and have overdone it
so that now we have put on the health
system such a tremendous demand
that it is overwhelmed and is producing
predictable results.

If you overwhelm any economic sub-
system with an excess demand which
has taken the form of some $12-
14,000,000,000 of new buying power
within the past half decade, you can
predict that you will get an increase in
cost and a decrease in quality, and an
increase in consolidation of bigness or
institutionalization. And this has, of
course, occurred in the health care
system. So what we have now is nota
financing problem but a capability
problem, as Dr. English said.

Group practice fits into this question in
my opinion as being a potential solu-
tion to part of our capability problem.
We have a number of capability ex-
panders. One is Comprehensive Health
Planning. Anything that can make our
system more efficient in delivery will
expand our capability. CHP would be
one of them.

Another important capability expander
is operations or systems or administra-
tive research. | think group practice
should be classified at this point in
history as a research endeavor. | would
hate to see group practice implemented
totally and widely without an adequate

 

 

 
 

- Be

period of testing. | am afraid that we
have run into the same types of unex-
pected problems that we did with Medi-
care and Medicaid. So it is a thing that
needs to be totally researched and is
being researched in many areas. It does
many things to the delivery system.
First, it changes the mechanism or
organizes or systematizes the mech-
anism of entry into the health care
system. Furthermore, it carries the
individual in an orderly fashion through
the system in accordance with need
rather than in accordance with the per-
ceived wants. It changes somewhat the
motivation and control of utilization. |
consider group practice at this point as
a very good idea in concept that needs
to be further tested, applied on a fairly
large scale—and it is, in fact, going to
be—before it is totally implemented in
delivering health care in this country.

The next question, in short, asks:

“We cannot hope to get enough physi-
cians produced in the next few years to
meet our physician manpower needs;
consequently, we will have to use ‘physi-
cian-expanders’ of some type. How will
these physician-expanders be accepted
by the public and by the medical pro-
fession?”’

| think they would be accepted both by
the public and by the medical profes-
sion, provided certain things can be
done.

You know, when you go to a bank, you
do not always expect to see the presi-
dent and do not always need to see the
president. Your needs can be taken
care of very adequately by another type
of individual. When you go for health
care, the same situation can and prob-
ably should exist. However, there are
certain medical, legal and technical
problems that make this very difficult
and somewhat impractical in many in-
stances. | think we are moving rapidly
now toward surrounding this concept
with adequate medical-legal support
with standards, licensing, and definition
of. specialties.

Many physicians are using tne concept
without the medical or legal definitions.
There are some question marks around
this, but | think through practice we are
developing a trend which will make the
legal aspects of it much easier.

DR. MARGULIES: Some of the ques-
tions | received are also on the subject
of health manpower. Let me lump them
together and pick up what has already
been said; and then there is another
explicit question which | will address in
a moment. In order to do that, | think

| should retreat back into the 1980s
because | was not specific enough when
| spoke earlier about the way I think
things are going to be. For one thing, |
believe pre-payment systems probably
will be fairly universal by that time.
Secondly, | want to remind you that we
have been addressing certain myths up
here and some of those myths are
going to be examined even further.

A myth we did not speak about is that
biological research necessarily means
better health care. We found that was
not true. The second myth was that if
you increase the ability to purchase
care, the system is infinitely expansible
and can respond. We found that is not
true. And the third one, which we are
getting into a better understanding on,
is that increasing the number of people
available to provide medical services is
the way to overcome the manpower
shortage. That is pre-eminently false.
If you are to trace an investment in the
education of a physician, relative to an
area of need in the middle of Arkansas,
you will find that the drop off between
the thousand dollars invested in the
medical school and the point of service
in the middle of Arkansas is. astonish-
ing. Now as a consequence, we are
facing an interesting dilemma as we go
into the seventies and eighties. If we
are to maintain expertise in the quality
of medical care and make sure that it is
available, what is the role of the physi-
cian and what is the role of the people?
| believe the following event will occur
by the eighties:

Specialists will continue to be trained;
they will be confined for the most part

23
24

to hospitals; they will be governed by
the hospitals rather than by other kinds
of systems. The majority of medical
care is going to be provided by other
individuals under a system of mainte-
nance and supervision which will de-
pend upon a different kind of physician.
Some of this will be in group practice,
but | must say that if there is anything
worse than an incompetent physician
in solo practice, it is a group of them.

So we have a few things to learn about
how to manage group practice. But, in
general, | think we will discover that it
is not necessary to see a physician for
a very large percentage of those ail-
ments which are now brought to the
attention of a physician. And if we look
a little further into the seventies, | think
we are going to discover that a signifi-
cant portion of the time spent by profes-
sional people is spent giving attention
to individuals who do not need to be
into the health-care system at all.

A major input is going to be the use of
automated techniques and | believe this
will include screening methods which
will have their concentration on health
maintenance rather than on the identi-
fication of acute kinds of illnesses.

As a consequence, there will be a dif-
ferent use of allied health manpower.
And although this may startle you a
little, | think our current efforts to (1)*
increase the output of medical schools,
associated with our efforts to (2)* re-
organize the way in which health care
is being provided, will lead to a discov-
ery somewhere along the line that we
are training too many physicians. If
the latter is successful, the former is
unwise. If the former is pursued and
the latter is not, we are going to have to
get around to it at a later date. So all
these efforts to vastly increase medical
schools, with the illusion that this will
provide medical care, are going to be
re-examined and, in the course of time,
i think are going to be dropped.

The solution lies, not in adding to the
numbers, but in making more effective

*Numerals added.—eds.

use of the way in which they spend their
time. This means that responsibilities
for all levels of providers are going to
be increased and under supervised
circumstances. And people are going
to be free to do those things which need
to be done, where they need to be done,
which is where people are ill. | think
that as a consequence there is going to
be a regulation of the way in which
hospitals are used.

Now the other question has to do with
a much more precise issue, which
sounds rather small after | had been
operating at that positive level. ‘Should
RMP and CHP be combined?" The
answer to that question is unequivo-
cally ‘‘no.”’ They serve a different kind
of a purpose and if | have my prefer-
ences, | would say that CHP and RMPs
should operate in such a way that they
have a productive tension between
them, one forcing demands on the
other, the other dealing with those de-
mands. They should have a basis be-
tween them for an effective negotiation
between what the community needs
with a resolution in capacity, the identi-
fication of reasonable priorities, and
the reaching toward those priorities by
a common understanding.

DR. ENGLISH: Just to express a
slightly different shade of opinion on
that manpower question, | agree with
Dr. Margulies totally that we are moving
into the area of a new mythology if we
think that manpower, in terms of pro-
ducing more of the same, is going to be
the solution to the crisis of health care.
it obviously is much more complex than
that, as he has pointed out so well. But
even in medical care systems where
there has been an attempt to utilize
physician manpower better, where
other kinds of present health manpower
are being utilized better or where new
kinds of health manpower are being
utilized very effectively, there is much
yet to be learned.

i would say there is one example of this
that I think you probably know well. It
is becoming increasingly known in this
country as the Kaiser Permanente Pro-
gram. Even there, when you talk with

 

 

 
 

* of
aie

they will tell you that one of their major
problems in trying to expand is a short-
age of medical manpower. | think the
problem and the mythology is that just
producing more manpower is not the
solution any more than investing in bio-
medical research would solve our
problem.

| think to really deal with the health
care crisis, you have to face a whole
range of strategies without tolerance
for any mythology that begins with the
new conceptions of how to organize and
deliver care. Only when you have

worked that out with a variety of ex-
perimentation ...can you figure out
what your real manpower needs are and
only then can you figure out the pur-
chasing power mechanism, the third
party payment mechanisms that will
support these new structures. | think
our problem in the past is that we have
never had united strategy covering fi-
nancing, manpower production, and
the issues of organization and delivery.

This leads, | suppose, to a question that
was asked, and which is, { think, perti-
nent to many of the questions that we
received. | will just read it to you. ‘Why
does health care expenditure continue
to increase without corresponding
increase in the quality of care?’’

| think everyone up here has deait with
that. | think Dr. Fowinkle in his last
remarks dealt with it with real clarity.

Suppose that five years ago the Con-
stitutional scholars had discovered that
the Constitution had a basic human —
right in it that nobody really ever noticed
before. And that basic human right was
to have in the living room of every
American family a 23-inch color tele-
vision set with a 14-foot antenna up

on the roof and a lifetime maintenance
contract to make sure that it worked
terribly well. It was there in the Consti-
tution all this time but we just never
paid attention to it. So the Congress
decided to redress this oversight. And
it realized that it would cost about $600
a year to provide that television set to
every American and that some could

need some help in trying to pay it so
they started working on what was called
a National T. V. Aid Bill. And it was very
clear that it was a very politically popu-
lar measure and it would take a little
work to get it through the Congress.
But within three years it would get
through, and it would provide to every
American——some on a 100 percent
basis, but others would have to contrib-
ute something to the cost of that set—
the purchasing power to put such an
instrument in every American home.

If we were back at that time, | think
you could imagine what outfits like
General Electric, Zenith, RCA, and
Admiral would be doing. It would be
my prediction that they would be out
borrowing money to expand their abil-
ity to produce, even if the interest rates
were 15 to 20 percent. Why? Because
they were going to be guaranteed a
tremendous source of purchasing power
when that legislation went through. It
would compensate them very well for
taking that risk, even at very high in-
terest rates. | think it is also very pre-
dictable that you and | would be out
buying all the stock we could in those
companies, because with that kind of
guaranteed purchasing power it would
not be hard to predict how they were
going to do.

Our problem in heaith is that we have
been misunderstood and thought to be
like that. First, we kidded ourselves
into thinking we had the capacity in
this country in health to serve the needs
of 200 million people and then we saw
that mythology exploded when $14,-
500,000 of purchasing power was
given to consumers to test. That is the
seed of the present crisis, and it seems
to me that’s the reason why, although
the money going into health care is
rising dramatically, the quality on this
overburdened system—f you can call
ita system—of health care is being ex-
posed greatly every day. And of course
the implications of national health in-
surance—— which would expand the
purchasing power almost beyond our
present ability to imagine—-would dem-
onstrate our present inadequacies to
respond even more dramatically.

25
26

That is the critical importance of the
Partnership for Health and Regional
Medical Program. If we are not given,
publicly and privately, the money to
expand, whether it is in manpower or
new methods of organization and de-
livery, whether it is in the new things
we need to know about how to deliver
high quality care, the new kind of re-
search that is required, we will contin-
ually be in this bind, even though the
total number of dollars grows. | think
that is what we have got to understand
and that is what we have got to help
the American people understand and
that is why the next question is a very
pertinent one: ‘‘What are the chances
that the private sector will move rapidly
enough and the voters be patient
enough to avoid a government-
controlled monolithic system?”

How do we encourage provider change
and voter patience? On the basis of past
performance, the chances that the
private sector will move rapidly enough
are very slim. Federal leadership has
been very important. We are not seeing
that federal leadership today neces-
sarily in measure to what the crisis is.
So therefore | think our dependency

on the private sector is greater than
ever. | do not see sufficient optimistic
signs that the private sector is going to
move rapidly enough except in such
programs as RMP and the Partnership
for Health, medical societies, health de-
partments and hospitals and programs
like the neighborhood health center.

But the major hang-up right now is
resources in that area to do all the
things they would like to do. That is

why the only thing that is going to help
us with the voter is the extent to which
he sees we are concerned and that we
are trying, the extent he understands
our difficulties and helps us change the
way that $93,000,000,000 is going to
be spent in 1975.

DR. CANNON: If the response is not
adequate, how much time before we
consider the crisis to have reached the
point of a burst and something rather
radical happens in the health care
system?

DR. ENGLISH: | think that when you
consider that it took us nearly two
centuries to develop the excellence of
American medicine, an excellence in
this country that is unrivaled anywhere
in the world, maybe you should argue
that we should have another century
at least to deal with the next great issue,
which is ‘‘equity’’——how to translate
that excellence into equity and effici-
ency and respect for human dignity in
the delivery of that excellence to
200,000,000 Americans.

But | think the real problem is that we
are not going to get a century. Asa
matter of fact, things are changing
much too rapidly for that. The con-
sumer is becoming much too sophisti-
cated and he recognizes for the first
time that our national resources are
limited and there is going to be great
competition within major segments of
the society for those resources. |
believe that we have about five years

to do what needs to be done and | think
that is going to take tremendous initia-
tive from the private sector in our coun-
try if we are going to make any progress.

| think if it is not done in five years—
that is, if we do not increase our capac-
ity to provide care in five years—then in
the second half of this decade, we are
going to see things like national health
insurance and they are going to abso-
lutely expose our present inadequacy

in delivering care ten times as dramatic-
ally as it is being exposed today. We will
see our profession, whether it is the
practicing physician or the hospitals of
this country or any other segment of
that profession, thoroughly discredited
before the consumer will understand
that the money is going up, that the
costs are going up and the service is
getting worse. | think that is howa
country finds itself in government
medicine. That is why | think this will

be the most historic decade in medicine
in this country rivaled by only that first
decade back in 1785 when the first
medical school, hospital, and mental

- hospital were started in this country

in Philadelphia.

 

 

 
 

 

SUMMARY STATEMENTS

MR. SIMS: People with not as much
experience as Dr. Margulies, their main
concern was that the distribution of
services and the public health profes-
sion’s education ought to be major
components of any health care system
. .. We are concerned with all kinds of
manpower... Doctors are extremely
concerned about consumers taking
pre-eminent roles in what they feel
ought to be their roles determining what
medical care ought to be at any given
point in time.

DR. FOWINKLE: On the consumer,

| think it is clear to most of us in the
health administration business that
the consumer is going to be involved
more substantially in the determination
of health policy. | think what the con-
sumer really wants is a good product
and he wants it at an affordable price.

| think he is telling us very clearly what
he wants and is probably telling us that
if he does not get it, he is going to try
some method of his own to help us
produce it.

| think we will have to deal effectively
with the consumer and his demand,
but yet | still feel very keenly about the
need for professional involvement in
the policy-making process. | think the
consumer is going to have to tell us

what he wants and he will do it fortun-
ately as a voter. Yet | am hoping we can
temper this with professional judgment
and knowledge. The consumer wants

a good product and he wants it at an
affordable price and he is burdening it
on our back to produce it.

In summary, | would like to deal

with the question of national health in-
surance. When will we have it? Should
we have it? As an administrator of the
state program for financing medical
care to the tune of about $50,000,000
— | would very much like to see national
health insurance. It would relieve from
the state at least part of the burden of
their share of the financing and a tre-
mendously overwhelming administrative
task of running this thing. We have a
$50,000,000 program superimposed
upon a $20,000,000 agency. So we
have the tail wagging the dog and this
is happening all over the country. States
are staggering under the administrative
and physical load of Medicaid. So |
think from the state standpoint, | would
like very much to have national health
insurance. This would standardize it

and lift the burden somewhat off the
state.

Looking at it from the health-system
standpoint, I think we must emphasize

27
28

that it would make a more efficient
financing mechanism, which would
have the same effect and adding to the
financing of health care, which would
simply throw coal on the fire by pro-
ducing further inflation and further
decreasing quality. So we have got to
change our national, state, and local
priorities for capability expansion rather
than financing, and this includes na-
tional health insurance in the foresee-
able future.

DR. MARGULIES: | would like to
answer one question, because it did not
come out of the audience and because
its deficiency disturbs me. In deciding
what health care should be like in the
eighties, determining it by what hap-
pened in the seventies, we have to face
one of the most difficult issues, which
is the concern more at this point of the
non-professionals than it is the profes-
sionals. Over the last 25-30 years, the
public has been lured into having ap-
petites for yellow refrigerators, or
whatever it may be, which we must
learn to change into other kinds of
appetites.

The creed now is a transplant in every
garage—the exotic, the sophisticated,
in- fact, the whole kind of concept the
RMP began with and with which | never
agreed, even in the early days. If we
are to be effective in RMP and CHP,
the problem is a double one. Not only
must we be responsive to consumers,
but we must be able to interpret to
consumers the difference between an
irrational and the rational effort to meet
their basic needs. And because it is a
sophisticated issue and because the
health care system is complex, it means
that the professional efforts of an RMP
or any other organization needs the full
understanding, the full exploitation, and
the most minute interpretation to the
community so they can appreciate the
difference between the visible, the
glittering and the glamorous and what
really is essential for health mainte-
nance for control of cost and for the
basic health of the community.

DR. ENGLISH: | would like to share just
two dreams. One would be to proceed
with confidence and go to the places
where we are going to need help before
we can do the job in the 1980s. One of
the places | think we need to go, as
practicing physicians, as hospital ad-
ministrators, as officials of the states,
of the cities, in the whole purveyor
system, is to the school of business.

| would like to see by 1980 two to three
percent of the graduating class of every
school of business administration in
this country producing people who will
come and help us with what, by that
time, will be a $100,000,000,000 enter-
prise. | do not think the physicians and
health professionals should become the
major managers in an enterprise of this
magnitude, of this size, of this complex-
ity. There is little in our training and
there is little in what brings us into the
field of health that equips us for this.

So, | think we should welcome help
from those institutions which produce
people who have this kind of expertise
but who have not yet come, often be-
cause they have not yet been asked, to
help us in one of the largest segments
of one of the most important segments
of our national life. That, | hope, will
occur by the 1980s.

The second thing that | hope will have
occurred by that time is that we would
be having meetings like this but ex-
panded into what one might call, ‘‘town
meetings” in health, around the crisis
of health care all over the country, that
health would become the critical issue
that | believe Dr. Margulies and other
members of the panel have predicted

it will increasingly become.

The consumer is the best ally we have
in the tremendous competition for
resources. But rather than waiting for
them to come to us, we will go out to
them, gain their understanding, their
help, their partnership. If in the 1980s
we see that alliance between the health
professionals and the consumers in

this country, | think we can proceed with
great confidence to be sure that we will
serve the national interests as the public
in this country hopes that we will.

 

 

 
 

my
}
od

Nee

“Should RMP and CHP be combined?
The answer to that question is unequiv-
ocably ‘no.’ They serve a different kind
of a purpose and if | have my prefer-
ences, | would say that CHP and RMPs
should operate in such a way that they
have a productive tension between
them, one forcing demands on the
other, the other dealing with those de-
mands. They should have a basis be-
tween them for an effective negotiation
between what the community needs
with a resolution in capacity, the identi-
fication of reasonable priorities, and
the reaching toward those priorities by
acommon understanding...

“If we are to be effective in RMP and
CHP, the problem is a double one. Not
only must we be responsive to con-
sumers, but we must be able to interpret
to consumers the difference between
an irrational and the rational effort to
meet their basic needs. And because

it is a sophisticated issue and because
the health care system is complex, it
means that the professional effort of an
RMP or any other organization needs
the full understanding, the full exploi-
tation, and the most minute interpreta-
tion to the community so they can
appreciate the difference between the
visible, the glittering and the glamorous
and what really is essential for health
maintenance for control of cost and

for the basic health of the community.”

— Dr. Harold Margulies