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HEALTH / PAC Health BULLETIN Policy Advisory Center 1 Editorial: The CHC Experience Volume 12, Number 1 HPCBAR 1-40 ISSN 0017-9051 SUBURBAN SUBURBAN FOLK'S S HOSPITAL 3 Vital Signs 6 Community Health Centers After Fifteen Years BACK TO THE HOSPITALS: When they were first begun, neighborhood health centers saw community involvement as an effective means of providing appropriate care to people. Under new management now, its priorities may be undergoing change. 15 The Unkindest Cut of Al Plans to economize Detroit's health care system hit the poor and the minorities hardest while increasing the size and power of the largest hospitals. Can real savings or better care actually result? 17 Columns URBAN: Fighting for Our Hospitals WORK ENVIRON / : The Supreme Court's Benzene Decision FIFTH COLUMN: Consumers Union Grows in the Bronx 39 Peer Review = Crt [ } ] ned ABUN CFA & o PARKING oy CELSI MEM LX X X off a " Z ZB v1 Editorial Community health centers were born in the atmosphere of hope and possibility prevailing in the mid 1960s - . Today, the legislation is near- ly 15 years old. With this issue, the Health / PAC Bulletin begins a series of articles ad- dressing the evolution of federal community health center policy and the current dilemmas and future prospects faced by these no longer - fledgling endeavors. As the articles in the next two issues will make clear, the dilemmas are of no small magnitude and the future is- as has seemed all too often true in the past - - up for grabs. Community health centers were not only a product of social reform, they were also to be an agent of it. They were designed to address the unmet health care needs of America's poor; equally important, however, they were to do so in a manner so different and superior that, if successful, this alternative model might revolutionize the delivery of all primary care. Thus community health centers brought with them a political agenda for the health system. Instead of rigidly professional and institu- tional dominance, they offered community con- trol; instead of narrowly medical, illness- oriented services, they proposed a wholistic and preventive approach to the health prob- lems of individuals, fragmented, specialized munities; instead of fragmented, specialized and depersonalized outpatient clinic services, they touted comprehensive and integrated care in single setting; instead of care delivered by a rotating cast of doctors training - in - , community health centers offered a full time - personal physician as well as a staff of culturally and linguistically compatible community residents. Community health centers seemed to offer the ideal blend of personal health services and public health. Several articles in financial liabilities which could no longer be supported. Whether the CHC experience failed to demonstrate to the unbelieving the success of this particular alternative model, or whether the lagging social movement from which CHCs sprung failed to impress policy makers and funders with the urgency of trying alternatives, the undermining of CHCs was accompanied by a shift in policy. Through a variety of measures detailed in the articles that follow, both HEW and private foundations have clearly decided that hospitals are the more auspicious sponsors of ambulatory care. Not surprisingly hospitals, sniffing clearly " where the money is, " are undergoing a renaissance of interest in am- bulatory care. Thus the power and resources which flowed away from established institutions during the social turbulence of the 1960s and early 1970s are flowing back to them during the quiescence of the late 1970s and early 1980s. These developments this series recount, with refreshing specificity, the fate of this alterna- tive model whose eco- nomic feasibility in a hostile environment Community health centers were not only a product of social reform, they were also to be an agent of it. They were designed are described in the general and in the con- crete in the articles that follow. The questions they raise, however (or occasionally fail to raise) waxed and waned in toaddress the unmet health care are more difficult. one one - to - proportion to the strength of the social movement which needs of America's poor re Among the more impor- tant questions still to be answered out of the 15- spawned it. Since the inception of community year experience with CHCs are: health centers in 1965, their history has been one in which the federal government has pro- gressively undermined and thrown up obstacles to implementing that original vision of community - controlled, change oriented - , comprehensive care. The following articles describe how first the base of political support for community health centers was circumscribed and the model tar- Is the traditional " them us - " polarization bet- ween communities and institutions with regard to ambulatory care still a valid or useful one, particularly in light of the " back- to institutions - the -" flow of federal policy? Can this flow be reversed in the near future with the forces now on hand? If it can, does this struggle warrant the effort and red with the brush of " poor people's medicine " when OEO and HEW limited the clientele of resources? If not, what political agenda should activists purse with regard to institu- CHCs to the poor. The articles describe in painful terms the results of the Nixon Ad- ministration decision that, if they were to con- tinue, CHCs would have to prove their sur- vivability according to the same reimburse- ment imperatives that created the very system to which they were to offer an alternative / tions? Is the CHC model of care completely incompatible with institutional sponsorship and delivery of services? If not, what aspects are compatible? Are the unique features worth the struggle necessary to win them? * Activists have, over the last two decades, come to apppreciate the importance of ad- Without the strength of a social movement to dressing not only the form of health service give viability to alternative models, the in- novative and unique features of the CHC model 2 were quietly transformed into luxuries and delivery, but the content of those services as well. What conclusions can be drawn from Continued on Page 6 " 7 Signs Vital AGENT ORANGE UPDATE The Carter Administration's efforts to retain control over scientific studies of those expos- ed to Agent Orange have suf- fered several setbacks in recent months. In early May, the Na- tional Academy of Sciences published a sharply critical analysis of a plan by the US Air Force to study " Ranchhand " spray personnel. The Academy concluded that the proposed study was too small both in numbers to be studied and dura- tion. Further, it questioned whether the Air Force study would enjoy any credibility - no matter what conclusions it reached. The Pentagon has given no indication of what it will do, but the study seems unlikely to go ahead in the face of such powerful opposition. Meanwhile, an epidemio- logical study of veterans being designed by the Veterans Ad- ministration " house in -" has also been gathering opponents as its details have become public. Several epidemiologists have criticized this study for its scope and design, concluding that considerations of cost prevailed over scientific integrity. Voices as diverse as Senator Alan Cranston (Calif D -) and the American Legion have begun demanding that the VA's control over such studies be ended. Even stockholders of Dow Chemical are beginning to feel the heat for that company's role in manufacturing most of the dioxin - laden 2,4,5 - T that was sprayed on Vietnam. A group of stockholders, led by the National Council of Churches, pushed a resolution at Dow's annual meeting in May 1980, calling for an investigation of Dow's hand- ling of potential hazards associated with 2,4,5 - T. Dr. Samuel Epstein, well known - scientist / activist and author of The The Politics Politics of of Cancer Cancer,, joined joined their effort, demanding that Dow release the results of studies the company has conducted on the reproductive histories of women married to some 300 dioxin- exposed Dow workers. Predic- tably, the resolutions were re- jected, but not before Dow had received some unwanted pub- licity for its deceptive and ar- rogant practices. Meanwhile, Citizen Soldier recently began the arduous pro- cess of hand coding - data from each of the 4,200 medical ques- tionnaires which have been returned to the organization in response to its canvas of ailing veterans. Anyone who can volunteer a few hours for this im- portant work can contact Citizen Soldier at (212) 777-3470. Citizen Soldier, a relatively tiny non profit - group, may represent the only serious attempt to see correlated health data on Viet- nam veterans published within the next few years. -Tod Ensign (Tod Ensign is co director - of Citizen Soldier and co author - of GI Guinea Pigs, published by Playboy Press.) MEDICAL MARKETS The stock market can sometimes tell the astute observer more about the direc- tion of the health care than either patients or workers. The proprietary portion of the US health system, of course, places market success higher on its list of priorities than satisfy patients ' or workers'needs. Some bellweather trends in recent market events include: * Glasrock Products, Inc., has seen its stock shoot up to $ 40 per share from a low of almost $ 5 a share in 1979 because the The home health care industry may end up where much of the medical industrial - complex has been for some time: highly monopolized by a few giant corporations ceramic products company is buying up small home health care companies. National Medical Enterprises, Inc. and National Medical Care, Inc. are two other companies currently gobbling up small home health enterprises as well. The home health care industry may be rapidly moving from cottage in- dustry to major corporate con- trol, and perhaps will end up where much of the rest of the medical industrial - complex has been for some time: highly monopolized by a few giant cor- porations. * Merck and Company, maker of Aldomet for high blood pressure and Indocin for ar- thritis, is being touted as another strong growth prospect. Merck's 3 new products and growing foreign business are expected to offset the predicted recession- induced drop in doctor's visits in this country. Merck's $ 227 million in research and develop- ment expenditures over the cur- rent year - - up 21 percent from 1979, and marking Merck's 25th consecutive year of escalating R & D expenditures - is the source of market optimism about its future growth potential. * Emerson Radio is being recommended as a medical growth stock because of its re- cent introduction of an FDA ap- proved, portable, battery- powered automatic resuscitator for emergency use on heart at- tack victims. Stock analysts estimate that Emerson has to sell 250 units to break even. But they are predicting that more than 2,000 Heart - Aids will be sold in fiscal year 1983. Each costs $ 6,275, about half of which is gross profit. The market in- cludes any place where large numbers of people congregate: industrial plants, offices, buses, planes, transportation terminals, sports stadiums, and auditoriums. Of course, even home sales cannot be ruled out. " Be the first on your block... ". -George Lowrey Sources: Barron's, 4/28/80; Business Week, 7/7/80; and Op- penheimer & Co., Inc. WHILE SOCIAL CHANGE IS NEGLECTED William Shockley - who, with his Nobel prize in physics, of- fers living evidence that " regression " is a social social phenomenon, in this case, of the Nobel Foundation - appears to have initiated a new offensive 4 to popularize his " new Health / PAC Bulletin Tony Bale Pamela Brier Robb Burlage Michael E. Clark Jaime Inclan Board of Editors Hal Strelnick Glenn Jenkins David Kotelchuck Ronda Kotelchuck Arthur Levin David Rosner Des Callan Madge Cohen Kathy Conway Doug Dornan Cindy Driver Dan Feshbach Marsha Hurst Louanne Kennedy Mark Kleiman Thomas Leventhal Alan Levine Associates Richard Younge Joanne Lukomnik Peter Medoff Robin Omata Doreen Rappaport Susan Reverby Len Rodberg Alex Rosen Ken Rosenberg Gel Stevenson Rick Surpin Ann Umemoto Managing Editor: Marilynn Norinsky Staff: Kate Pfordresher, Loretta Wavra MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR should be addressed to Health / PAC, 17 Murray Street, New York, N.Y. 10007. Subscription rates are $ 14 for individuals, $ 11.20 for students and $ 28 for institutions. Subscription orders should be addressed to the Publisher: Human Sciences Press, 72 Fifth Avenue, New York, N.Y. 10011. Health / PAC Bulletin is published bimonthly by Human Sciences Press. Second - class postage paid at New York, N.Y. and at additional mailing offices. 1980 Human Sciences Press Illustrations by David Celsi (pp. 1, 15, 36) and Mel Rosenthal (7, 10, 11). eugenics " based on racial genetic inferiority and superiority. In the August issue of Playboy, the Stanford pro- fessor reveals that he has con- tributed sperm in an attempt to produce superior children. Superior according to whom, one may ask? It appears that Shockley's proposed ideas - such as the of- fering of financial rewards to Black welfare mothers who would get sterilized to prevent " dysgenics " - have not been enthusiastically embraced by enough of the people in power positions to implement them. Shockley evidently does not question the wisdom of these ideas in the face of social and ethical condemnation, however, but proposes a strategy consistent with his own thinking: " Through genetics, create the'right'people who will think like I do and adopt and implement my proposals! " Fortunately, it just doesn't work that way as Shockley himself suggests in the Playboy article. In it he claims that his children " represent a very significant regression " since they have not reached the academic distinc- tion that he has and one son is a college dropout! Shockley's new " contribu- tions " to the creation of a superior stock of people will un- doubtedly follow the same course that his existing children did. As they become exposed to other than Shockley - like in- fluences they will develop their own world views, values and social positions. Shockley meanwhile, true to the spirit of racism and eugenics, remains fixed in his positions. As to why his own children are " regres- sions ", he scientifically ex- plains, " my first wife their - mother - had not as high an academic achievement stan- ding as I had. " Now if this " genius " can only find a way to procreate without Blacks, Latins or women, what a Shock - ley world we may all look forward to! -Jaime Inclan Source: Playboy = Magazine, August, 1980. Health / PAC Bulletin Renew your subscription today! Individual $ 14.00 Institution $ 28.00 Student $ 11.20 THE HEALTH CARE HIERARCHY Volume 12: 1980-1981 (six issues). Health / PAC Bulletin is published bimonthly on a volume year basis from the September - October issue to the July August - issue. 5 Editorial Continued from Page 2 the content of the health services delivery at- tempted in the CHC model? If we had the ex- perience to repeat in light of this new ap- preciation, would we structure the content of those services any differently? If so, how? * Similarly, early community - control activists hoped that community residents would espouse a fundamentally different set of values about health and medicine than did health professionals. Put in control of medical resources, the community would allocate things differently, e.g., prevention, education and counselling instead of technology and specialization. To what ex- tent has this proved to be the case? What has this 15 year - CHC history taught us about that assumption? Are community control or con- sumerism a sufficient basis for a radically dif- ferent health system? Is comprehensive care always preferable? In the 1960s and early 1970s, it was assumed anyone who knew better would prefer " com- prehensive health care. " Comprehensive services, however, often seemed to make more sense to the providers than to their pa- tients who, in an era of fast food, fast media and rapid transit, were often impatient with visits requiring long, extensive medical histories, thorough diagnostic work - ups, and extensive patient counselling. Moreover, poor health consumers like their more af- fluent counterparts, proved to be more selec- tive in shopping for their health care than was anticipated - seeking hospital OPDS, health centers, health department clinics and Medicaid mills depending upon the pro- blem and the circumstances. * What is necessary to overcome the image of CHCs as " poor people's medicine " and the frequent equation of quality health care with complex technology and prestigious names? If indeed the CHC model of care is superior, what measures are necessary to educate health care consumers? The editors are convinced that these and similarly major, if knotty, questions underlie the CHC experience. Moreover, whatever else is possible, future activists must have access to, understand and learn lessons from the rich CHC history. The answers to the kind of ques- tions raised here can only result from a process of candid and continuing discussion. We hope the next two issues of the BULLETIN will initiate this discussion. We invite our readers to join in. Community Health Centers after Fifteen Years BACK TTHOE Federally Federally funded " Neighborhood Health HOSPITAL Centers " began as demonstration projects within the Office of Economic Opportunity (OEO), the lead agency in the Johnson ad- ministration's " War on Poverty. " In some way they have been among the most remarkable survivors of that war. But today, the innovation and reform they symbolized in the 1960s has been largely eroded and their future is unclear. In 1965 the War on Poverty job training pro- grams were finding then surprising levels of ill- ness and disability among their participants and paying large sums of money to private physicians for their treatment. Sargent Shriver, then director of OEO, found the Public Health Service's existing programs inadequate to this challenge and called for more innovative ap- proaches (1). The health centers which 6 emerged received a broad mandate from OEO to attack the cycle of poverty and interrelated ill health as they saw fit. As a result, the centers often developed innovations that many obser- vers believed were uniquely successful in in- tegrating preventive and primary care and making both kinds of services more appropri- ate to the health needs of the poor. The centers had five initial defining prin- ciples: (a) service to and location in a com- munity with a high concentration of poverty; (b) integration of and coordination with ex- isting health and human service agencies; (c) provision of high quality health care; (d) com- munity involvement through participation in governance (i.e., advisory boards and boards of trustees, OEO's mandated " maximum fea- sible participation "); and (e) employment op- portunities and training for community residents (2). Neighborhood Health Centers, some 150 in number, grew to provide a wide range of A Team Approach to Organizing Primary Care family oriented - health services to approximate- ly 1.5 million residents of low income com- munities by 1976 (3). With the expansion of the National Health Service Corps and its Rural Patients visiting many of the pioneer centers related not to just a single physician, but to a team made up of physicians, nurses, technical and Urban Health Initiatives (which combine workers, and paraprofessionals. The team was ! operating grants with federal personnel) in intended to reduce the traditional professional 1977 approximately 420 centers were serving 3.3 million people. At the same time many have become the focus for social and political action. hierarchy providing care, while emphasizing a more continuous and comprehensive approach to patient and family. in their surrounding communities, both rural and urban. Among the unique features of these centers with their wide individual variation were the following: Community Involvement in Policymaking Employment and Training of Local Residents as Health Professionals Perhaps the best known type of paraprofes- sional " invented " by the centers is the " Family Health Worker " (or " Community Health Workers "). In many centers the function of the Family Health Worker combined the skills of the more traditional medical assistant inside the center with the public health nurse's preventive outreach and follow - up outside the center, while integrating social work into both spheres. The original OEO centers were started by hospitals or medical schools, or at least had strong ties to such institutions. Each also developed advisory boards that were to pro- mote and gauge the appropriateness of the ser- vices provided to their communities. Although there were serious battles over how best to ac- complish this aim - some arguing that com- munity control was necessary, others maintain- ing that advisory functions were sufficient - the consensus which emerged secured channels for maintaining community involvement in and / or control of center policy making - . N The original neighborhood health centers were started by hospitals or medical schools but they all evolved channels for maintaining community involvement in policy making - An Emphasis on Prevention The native wisdom of community boards and _ local residents working as paraprofessionals, catalyzed by OEO's financial support for re- form, contributed to shifting the emphasis from routine medical practice toward interventions which would prevent some of the death and disability associated with poverty. Nutrition, jobs and income, housing, lead paint, and drug and alcohol abuse. - - what communities knew first hand - was making them sick - became the targets for the centers'intervention. All of these features, of course, emerged in the social and political context of the late 1960s and early 1970s - a context created by several broad, popular movements raising demands for civil rights, for community control, for ser- vice to " the community, " and for increased relevance of services from large institutions. As the 1970s progressed, many of these demands were either co opted - by institutionalizing " community involvement " (and thereby remov- ing it from the community) or dampened with the ebbing of social protest in general. In 1967 the " Partnership for Health " Act had directed the Department of Health, Education, and Welfare (HEW) to expand the neighbor- hood health center idea. As a result, a steady growth in " Community Health Centers " -the new official name for the centers progressed - , and within the following eight years, the total number of community health centers CHCs ( ) reached 157, of which 75 percent were in urban areas. With the growth of Medicare and Medicaid programs that offered third party - revenues for services to the poor, the CHCs ' future seemed bright. But the CHCs'troubles were only beginning. Major battles had raged since the beginning and continue today- today- over the uneasy rela- tionship between the centers and the hospitals and medical centers affiliated with them. The shift of federal responsibility from OEO to HEW and the growth of Medicaid funding only in- creased these tensions. HEW has long been closer to the established medical model in outlook than was the more experimental OEO. 8 HEW was also much closer to the hospitals and medical schools. The social reform aspects of the centers could have been predicted to face a troubled future the day HEW took over. The Case of Boston Boston offers a unique case study in such conflicts, precisely because of the large numbers of centers that have been developed in the shadows of several powerful teaching hospitals with their own large outpatient ser- vices. In 1965 OEO opened its first neighborhood health center in Boston- the Columbia Point Health Center. Ten years later Boston - with its population of about 640,000 - supported 26 neighborhood health centers within the city. That resulted in the unusually high ratio of one health center for every 25,000 residents. Vir- tually every neighborhood in the city, and more recently some suburban towns, claimed its own health center (see Table 1). This proliferation of health centers occurred in the context of a creative use of multiple fund- ing sources. The Economic Opportunity Act of 1964 (the source of OEO funding), the Mater- nal and Child Health Amendments to the Social Security Act of 1965, and the Demonstration Cities and Metropolitan Development Act of 1965 (Model Cities) all provided federal sup- port for health center development in Boston. In addition, the city's Department of Health and Hospitals provided " outreach " funds to seven neighborhood health centers and later offered " matching program " funds to several others. Several of the large teaching hospitals and community hospitals extended services and support to neighborhood health centers which affiliated with or were licensed as part of these hospitals. The availability of so many independent funding sources in Boston generated health centers within blocks of each other in some neighborhoods. Roxbury - North Dorchester, for example, with a 1970 Census population of 145,000, is served by 11 CHCs, a ratio of one health center for every 13,000 residents. Such unplanned growth set the stage for competition for limited resources later, when general Table 1 Boston Community Health Centers, 1975 Name Allston Brighton - Neighborhood Health Center Bowdoin St. Health Center Brookside Park Family Life Center Bunker Hill Health Center Charles Drew Family Life Center Chelsea Community Health Center Columbia Point Health Center Dimock Community Health Center Dorchester House Health Center East Boston Neighborhood Health Center Fenway Community Health Center Harvard St. Neighborhood Health Center Little House Health Center Martha Eliot Health Center Mattapan Community Health Center Neponset Health Center North End Community Health Center Roslindale Health Center Roxbury Comprehensive Community Health Center Roxbury Dental and Medical Group South Boston Community Health Center South Cove Community Health Center South End Community Health Center Southern Jamaica Plain Health Center Uphams Corner Health Center Whittier St. Health Center Total Source: Massachusetts Department of Public Health, Health Data Annual 1976 Visits / Year 8,905 7,463 34,054 53,949 17,434 17,434 23,460 32,245 32,329 not reported 53,562 5,000 5,000 41,923 41,923 7,681 32,556 3,213 13,107 13,107 23,404 4,730 not reported 12,532 15,685 9,312 9,312 41,594 41,594 4,657 4,657 18,483 8,817 506,095 operating funds dwindled and funding agen- cies took other priorities. Despite their numbers, however, Boston's CHCs accounted for little more than half a million visits, only eight percent of the city's total outpatient facility visits, excluding physi- cian encounters in private offices (see Table 2). Since 1975, for which the most recent data is available, many of these CHCs have expanded and moved into new facilities. More recent data would probably show some increase in patient visits. This utilization pattern reflects a national trend. During the same decade of growth for CHCs, nationally hospital outpatient visits doubled to a high of 250 million in 1975, generating 12 percent of all hospital revenues (4). In 1965 visits to hospital outpatient depart- ments accounted for 14 percent of all physician visits in the country. In 1973, 21 percent of all physician encounters occurred in hospital out- patient settings (5) and by 1979 that proportion had reached about 25 percent. Teaching hospitals which represent only five percent of all hospitals - accounted for one quarter - of all hospital - based ambulatory care (6). Hospitals in Boston have traditionally operated large outpatient services, organized as independent specialty clinics for training of residents and conducting research. Faced with the competition offered by group practices and health maintenance organizations as well as by CHCs, the hospitals began to respond to inter- nal and external pressures to improve the quality of primary care in the city. As early as 1970, Mayor Kevin White had suggested that the tax exempt - status of the city's hospitals might be jeopardized by their failure to help meet the health needs of the local population. The state's Determination of Need Program and local health planning agencies repeatedly proposed limitations on hospital ex- pansion. Community groups, meanwhile, be- came increasingly sophisticated in using the 9 federal funding sources for CHCs began tightening. With the expiration of OEO in 1974, its remaining health programs were transferred to HEW. HEW guidelines for CHCs began to reflect concerns with documentation, cost effectiveness - , maximizing third party revenues, and fiscal self sufficiency rather than with community participation in shaping health services or innovative health care delivery. Moreover, the growth of Medicare and Medi- caid led federal policy makers - to anticipate some form of national health insurance. Universal coverage would allow patients to purchase their health services from any source they chose, so the days of direct subsidy of CHCs by the public sector were thought to be numbered. Under such a vision of national health insurance the marketplace would attend to the health needs of the poor. This, of course, never materialized, but rather Medicaid and Medicare eligibility and coverage were cut back. Finally, despite the availability of CHCS, poor people had all along continued to use hospital outpatient facilities for primary care. Determination of Need process to block hospi- One year ago, the Massachusetts Department tal expansion that occurred at the expense of of Public Welfare generated utilization profiles low income - housing. In order to win approval for sample Medicaid recipients who receive for their expansion plans, several hospitals care at several CHCs. The profiles revealed a made new commitments to primary care ser- consistent pattern. Medicaid recipients used vices in their surrounding inner - city com- their health center for about one third - of their munities. ambulatory care and went elsewhere for the Moreover, the hospitals finally began to ex- rest, most often to a hospital. Health center staff : amine and reorganize their own outpatients confirm this impression. Patients use different departments, long the focus of criticism for health centers and hospitals for different ser- fragmentation, long waits, poor record- vices, or at different times of the day or night. keeping, and inefficiency. With funding from (7) private foundations such as the Robert Wood Many community residents assume the Johnson Foundation and later from the federal health center is second - rate just because of its government, several Boston hospitals location. " If he were a good doctor, he wouldn't established separate primary care centers. be working in the ghetto. " The best doctors, Beth Israel Hospital opened the Beth Israel Am- after all, must be at the big medical centers. In- bulatory Care Center in 1974. Boston City deed, many physicians and the general public Hospital opened a modern ambulatory care may share this perception of " poor people's facility in 1977. Both the Massachusetts medicine " on the one hand and " Medical General and the new Affiliated Hospitals (a Center " on the other. Massachusetts General merger of the Peter Bent Brigham, Robert Hospital, for example, operates two health Breck Brigham, and Boston Hospital for centers in Chelsea and Charlestown but does Women) have built million multi - dollar am- not allow the centers'doctors to admit their pa- bulatory care centers. Most recently, New tients to the hospital, thus perpetuating two England Medical Center was named as a recip- classes of care. ient of a large Robert Wood Johnson grant to One reason patients " shop around " may well replace its medical clinics with a group prac- be their perception that CHCs face unstable tice. financial conditions. Community residents At the same time that hospitals were ex- hear of such internal struggles because friends, 10 hibiting renewed interest in primary care, neighbors, and relatives work at the local center. Such news travels quickly on the grapevine and may be exaggerated in the pro- cess. At other times the information may be quite public - a health center goes into receivership or is taken over by an affiliated hospital. CHCs do reflect the economic instability of the low- and middle income - communities they serve. Many continue to struggle for economic survival long past initial start - up stages, caught between a community with high health care needs and a reimbursement system that does not cover full preventive and ambulatory care services. Public medical coverage- Medicaid and Medicare covers hospital costs for similar ser- vices at rates that allow the hospitals to recover a greater proportion of their costs than health centers. For example, at the Roxbury Dental and Medical Group, Inc., where the author is Executive Director, a primary care physician who sees a Medicare patient will generate a reimbursement of $ 10.44. At a hospital outpa- tient clinic nearby, the institution receives $ 35 for the same services. At a large private clinic support for medical schools to training for in Boston, a physician performing the same ser- primary care, mandating that an increasing vice would generate a $ 70 consultation. Private health insurance often disallows routine or proportion of medical postgraduate training positions be devoted to primary care special- preventive health care altogether, and most ties. The teaching of primary care requires pa- health center patients are not covered by tients who need primary care and the settings private plans. in which to provide it. The Act also offers fur- As a result, CHCs serving low and moderate ther incentives for teaching hospitals and income families have never been able to medical centers to become more involved in 1 generate sufficient patient reimbursements to primary care. The legislation authorizes cover costs. Annual grant support to subsidize special project grants to medical schools and operating deficits has continued to be essential hospitals to develop family medicine depart- long after HEW policy makers - expected it to ments and residencies and general internal " wither away " with the self sufficiency - derived medicine and pediatric residency programs from third party reimbursements. (8). Meanwhile, actual federal grant support has become increasingly limited. Federal funds that were initially designated for community health programs have shifted since the 1960s toward other priorities. Scarce private philan- For the first time in the 1980 Federal Budget, Public Health Service funding was designated for ten Hospital Affiliated Primary Care Centers. In the January 1981 budget request sent to Congress, more than $ 30 million would thropy is being tapped by many other fields of be allocated to these centers and other com- human services. The major national sources of munity hospitals for primary care services. The primary care funding - the federal government and the Robert Wood Johnson Foundation- have shifted more and more of their CHC fund- ing from independent community organiza- tions to hospitals. revised budget (March 1981) calls for a $ 10.1 million reduction for CHCs from the original $ 374 million requested in January. The Johnson Foundation, largest single source of health care dollars outside the federal Incentives for Hospitals The Health Professions Education Assistance Act of 1976 (PL 94-484) tied federal capitation government, has concluded from their ex- perience in funding several autonomous urban and rural health centers that independent CHCs cannot survive without ongoing opera- tional subsidy. Because the Foundation is in- 11 terested in planting seed money, not indefinite subsidization, they have created an alliance with HEW to identify and jointly fund hospitals to develop community ambulatory care pro- grams. In addition, the Johnson Foundation is funding 15 teaching hospitals to develop group practices within re organized - outpatient departments to provide primary care. Hospitals need clinical sites for their growing numbers of primary care residents in order to provide patient care experience and respond to increasing demands upon their outpatient facilities. As one alternative they could, of course, send these residents to the health centers under supervision by senior physi- cians. For their part, health centers can utilize affiliation with teaching hospitals for economic support and to attract well trained - young physicians. But, rather than create and strengthen links between community - based health centers and the hospitals, the new fun- ding incentives are mainly leading to a reorganization of hospital - based ambulatory care. Thus, the delivery of primary care is becom- ing consolidated within the hospital sector, both by virtue of patient utilization patterns and the incentives of funding. What difference does this make? Why should primary care not be delivered by hospitals, rather than community- based facilities? Community Advantages The differences are important. First, com- munity participation in the organization and delivery of services will be all but lost. Par- ticipation of consumers in local, community- based health services has often increased their responsiveness and acceptibility to the com- munity. Although certainly no panacea, at their best the community boards have facili- tated a dynamic collaboration between medical professionals and consumers that is rarely repeated in the hospital hierarchy. The pro- viders in a health center are not dependent upon individual patients for their income, as in private practice, but they are dependent upon patient approval. One dentist was dismissed from a health center because, in the director's words, " my Board members told me he hurt when fixing their teeth. " Second, CHCs have been able to document superior performance in providing certain kinds of care, better than either hospital - based or private practice physicians. CHCs, for ex- ample, secured better patient compliance in controlling hypertension and ensuring im- munization (9). CHCs have reduced infant mortality rates through earlier, more com- prehensive prenatal care and reduced the in- cidence of rheumatic fever through prompt identification and treatment of streptococcal infections in separate studies (10, 11). Table 2 Outpatient Visits by Type of Facility, 1975 * Boston Hospitals Free Standing Clinics Community Health Centers Total No. facilities 24 38 26 88 No. visits 4,280,603 1,211,353 1,211,353 1,211,353 506,095 5,998,051 Massachusetts Hospitals Free Standing Clinics Community Health Centers Total 109 6,626,247 281 2,690,660 48 1,029,352 438 10,346,259 % of Total 71% 20% 8% 99% 64% 26% 10% 100% * Total outpatient visits, including Emergency Room Source: Massachusetts Department of Public Health, Health Data Annual 1976. 1976. Massachusetts Massachusetts Office Office Office of of State State Health Health Plan- Plan- 12 ning, Primary Ambulatory Care Component of the State Health Plan, October 10, 1978. The reasons for success in treating condi- tions that require behavior change may well rest on the health center's employment of com- munity residents. The social and personal net- work of relationships between staff and patients provides information and support that is relatively scarce in hospital settings. One Boston health center administrator recently recounted the story of a 14 year old pregnant teenager who came with her mother to the family planning counselor. The girl wanted to keep her baby, while the mother in- sisted that she have an abortion. " Our recep- tionist knew the family as friends and neigh- bors, " the administrator said. " She confided in the family planning counselor that the mother had her first child at age 14 and wanted desperately to avoid that situation for her daughter. With that history in mind, the coun- selor could help reconcile mother and daughter in a mutually understanding and sup- portive relationship, whatever the outcome of the pregnancy. " " Third, primary care delivered in a hospital is likely to cost more and use more complex ancil- lary services than if provided in a community setting. Research has indicated a strikingly higher frequency of diagnostic tests on outpa- tients in teaching hospitals, even when dif- ferences in case mix are taken into account (12). The presence of interns and residents results in both increased use of ancillary ser- vices and lower productivity, both of which add to the cost of delivering care. Even those hospitals which have reorganized outpatient services into primary care groups apparently have not reached the productivity or efficiency goals set by HEW for federally - funded CHCs. A recent report on the Community Hospital Program funded by the Johnson Foundation of- fers data indicating high costs and low produc- tivity in hospital - based programs (13). The average cost per visit in the second grant year of the program was $ 47.27; the average charge per visit was $ 19.32. Medical visits at these primary care centers were heavily subsidized - costs were too high to be borne by patient reimbursement alone. The average visits per full time - physician in those hospitals with the longest running programs (25-36 months ' operation) was 4,055, still short of the 4200 visits per full time - physician standard set by HEW for CHCs. More broadly, all levels of patient care- even primary care - in a teaching hospital are likely to be guided by teaching and research goals. Continuity of care cannot be achieved if the availability of any one physician depends upon his or her training rotation. Poor people have traditionally paid their way in such in- stitutions by serving as subjects for teaching and research. A hospital's priority to keep its beds filled, too, would affect the nature of the primary care it provides. Finally, CHCs have a real track record in in- novation and responsiveness to broad en- vironmental and public health issues as oppos- ed to the more medically - oriented hospitals. After all, health centers rose as alternatives to the indignities of the hospital outpatient depart- ments. Health centers have pioneered such in- novative approaches as case management, the use of family health workers and other paraprofessionals, and the primary care team When the Department of Health, Education and Welfare began taking over centers from the Office of Economic Opportunity, the social reform aspects of the centers were threatened. The new concerns became cost effectiveness - , maximiz- ing revenues and fiscal self- sufficiency approach to patient care. They have also often linked health care with other social and human services. Many have stimulated community organizing to respond to social and political sources of disease in a community. One Boston health center, for example, has just added a staff position of Environmental Health Worker. In others, Family Health Workers have sought out high risk patients and residents who would not ordinarily receive health care at all and provided follow - up for those who would other- wise be forgotten or lost by traditional outpa- tient care. Because they are relatively small and tightly knit, CHCs may be more responsive and in- novative than hospitals. If innovation is defined as the ability to respond to a changing environ- ment, then small organizations invariably make " course mid - " corrections more easily than large institutions. For example, emergency room personnel in a large hospital in Massachusetts became 13 When the Department of Health, Education and Welfare began taking over centers from the Office of Economic Opportunity, the social reform aspects of the centers were threatened. The new concerns became cost effectiveness - , maximizing revenues and fiscal self sufficiency - a, aware that increased community capabilities in cardio pulmonary - resuscitation could improve the condition of presenting cardiac patients. Yet, the ER personnel, knowing they would have to transmit this information to the ap- propriate management level at the appropriate meeting for the request to be assessed, evaluated, and compared in light of the other demands on organizational resources, never pursued it. A good idea has a poorer chance of becoming reality in a larger, complex, highly differentiated environment than in a small cohesive unit where people naturally come into contact with one another. By the same token, bad ideas can be discarded more easily in a small organization before they become institu- tionalized. CHCs offer more than superior primary care services to inner - city neighborhoods, impor- tant though that role is. They also continue to serve as testing grounds for innovation in the delivery of ambulatory health care and for im- plementation of progressive public health pro- grams. Currently, teaching hospitals have developed a sudden interest in the limited primary care funding, awakened by the carrot and stick of federal dollars and aided by sym- pathetic HEW and private philanthropic policy makers - . If these trends in federal policy become more pronounced, then more and more primary care resources will shift away from community organizations toward the hospital. The result will be a delivery system that is more technologically sophisticated, more expensive, less innovative, less respon- sive to community needs, and less moved by larger environmental and public health issues. In Boston, where each year the hospitals. assume a greater share of the responsibility for delivering primary care, the trend may be only a harbinger of national trends. If so, in the na- tion's poor neighborhoods, it is the community- based health centers themselves that are at risk. -Rita D. Berkson (Rita D. Berkson is the executive director of the Roxburg Dental and Medical Group, Inc., a community health center in Boston.) References 1. May, J.T., Parry, K.K., Durham, M.L., and New, P.K., " Institutional Structure and Process in Health Services Innovation: The Reform Strategy of the Neighborhood Health Center Program, " in Brenner, M.H., Mooney, A., and Nagy, T., eds., Assessing the Contributions of the Social Sciences to Health. Boulder, Colorado: Westview Press, 1979. 2. May, J.T., Durham, M.L., and New, P.K., " Profes- sional Control and Innovation: The Neighborhood Health Center Experience, " in Roth, Julius, ed., Research in the Sociology of Health Care. Greenwich, CT: JAI Press, 1979. 3. Davis, Karen, and Schoen, Cathy, Health and the War on Poverty: A Ten - Year Appraisal. Washington, D.C.: The Brookings Institution, 1978. 4. Piore, Nora, " Ambulatory Care Issues in the U.S. To- day, " in Bryant et al., eds., Community Hospitals and the Challenge of Primary Care. Cambridge, MA: Ball- inger, 1976. 5. Massachusetts Department of Public Health, " The Out- patient Department Ambulatory - Care at the Hospital, " New England J Med 293: 775, October 9, 1975. 6. Teaching " Hospitals Get Grants to Establish Group Practice Programs, " American Medical News 23: 12, 14 May 2, 1980. 7. Crespo, E., Hightower, L., and Martin, C., " Attitudes About and Utilization of Health Services in a Com- munity Served by a Neighborhood Health Center, " Germinal Ideas 5: 49-76, April 1, 1976. 8. USDHEW, Fact Sheet: Health Professions Educational Assistance Act of 1976 (PL 94-484), Washington, D.C.: Government Printing Office, January 24, 1977. 9. Engelland, , et al., " Blood Pressure Control in Private Practice: A Case Report, " Am J. Public Health 69: 25-29, January 1979; Gorry,, et al., " Care for Hypertension in a Neighborhood Clinic and a Hospital Outpatient Department: A Comparison, " JAmbulatory Care Management: 41-51, April 1978. 10. Anderson, R.E., and Morgan, S., Comprehensive Health Care: A Southern View. Atlanta: Southern Regional Council, 1973. 11. Gordis, Leon, " Effectiveness of Comprehensive - Care Programs in Preventing Rheumatic Fever, " New England J Med 289: 331-335, August 16, 1973. 12. Knapp, Richard M., and Butler, P.W., " Financing Graduate Medical Education, " New England] Med 301: 749-755, October 4, 1979. 13. Block, James A., et al., " Sponsored Hospital - Primary Care: The Community Hospital Program, "] Am- bulatory Care Management, February 1980. INNER CITY HOSPITAL 7 iy y/ SUBURBAN FOLK'S. HOSPITAL 000 ABUN Peassgt PARKING CELSI MOM LXXX The Unkindest Cut of All Health Health planners across the country strug- gle with the mandate to close hospital beds, but without the authority. In Michigan, a unique and powerful business, labor and health indus- try coalition has united to put teeth into bed reduction efforts. Concern over mounting health care costs led the Big Three automakers, the United Auto Workers and Michigan Blue Cross / Blue Shield to win passage of landmark legislation in 1978. It specified a quota of beds to be closed in each HSA region, required HSAs within seven months to develop hospital- specific plans for these reductions and created power to enforce these cuts through the Certifi- cate of Need process (2). A plan for the Detroit area, which bore two- thirds of the state's bed reduction quota, was completed in late 1979. It calls for closing over 2500 of Detroit's hospital beds for a projected annual savings of $ 40,000,000. Although many providers and consumers alike regard it as a progressive and serious attempt to address a grave problem, reaction now threatens to stall the entire statewide effort. Local activists pro- test that the plan will close many inner city hospitals which are the main source of care for Detroit's Blacks, and will throw nearly 9000 mostly Black hospital workers out of jobs in an area already plagued by over 26 percent minority unemployment. Meanwhile, small 15 a Although they are no panacea, at their best community boards have facilitated a dynamic collaboration between medical professionals and consumers that is quite rare a hospitals are incensed that they have been slated to bear the brunt of the cuts and have mobilized their communities to bring the bed reduction effort to at least a temporary halt. Across the country planners, community advo- cates, union and corporate leaders and civil rights activists are watching the outcome close- ly for portents of future health cutback plans in their own regions. Background The bed reduction effort can only be understood in light of rapidly rising Michigan health costs which have become a major political issue. The Detroit area alone has 77 hospitals, ten of which have more than 500 beds, including four " Galactica Memorials " in the 900-1,100 bed range. Fueled by over- building and overinvestment in expensive technology, the use rate of 1,153 patient days per 1,000 residents is among the highest in the nation, and 2.5 times that of many health maintenance organizations (3). Blue Cross rate hikes exploded into a labor issue in 1976 when the UAW struck Ford Motors for six weeks, primarily to resist demands that the union give up its dollar first - coverage and institute a several hundred - dollar deductible in its insurance plans (4). UAW members now pay more than $ 1 per hour for health insurance, limiting potential salary or other fringe benefits. With over 300,000 unemployed members, the UAW has become increasingly sensitive to the financial problems of its employers. In 1975, alarm over the state Medicaid budget led to drastic cuts in such " optional " Medicaid services as optometry and dentistry. A broad based - consumer coalition marched on the Statehouse and successfully restored Medicaid coverage. Medicaid costs have now risen to nearly 10 percent of the entire state budget, cutting into other needed services and increasing tax burdens on the public and to industry. As a result of these events, state health offi- cials met with business, labor and Blue Cross / Blue Shield representatives to draft a plan that 16 would cut health costs while avoiding labor strikes over private coverage and politically troublesome turmoil over Medicaid cuts. The collective clout of business and labor led the Greater Detroit Area Hospital Council (GDAHC) to throw its weight behind a statewide bed reduction plan, which was enacted into law in 1978. In accordance with the plan, Michigan's Of- fice of Health and Medical Affairs (OMHA- Michigan's SHPDA) assigned reduction quotas to each health service area it deemed over- bedded. Once OMHA's criteria were approved by the Statewide Health Coordinating Commit- tee (SHCC) and a joint committee of the legi- slature, HSAs were given seven months to prepare a bed reduction plan. Then, when these specific HSA plans were approved by the SHCC, no certificates of need would be ap- proved unless they were consistent with the reduction plan. Hospitals targeted for major cuts would be unable to replace major equip- ment or make repairs needed to comply with licensing requirements. Thus a war of attrition would force targeted hospitals to consider clos- ing, merging or consolidation. The Commission Over two thirds - of the state's bed reduction quota fell to the Detroit - based Comprehensive Health Planning Council of Southeastern Michigan (CPHC - SEM). Instead of acting on its own, CHPC - SEM chose to establish a " Bed Reduction Commission " to carry out the state's mandate. HSAs and all their committees are re- quired by law to have consumer majorities and to broadly represent their communities. The Commission, however, was hardly a cross- section of Detroit life. It sported a 62 percent provider majority. Five of the 11 consumer members represented auto manufacturers. One represented a bank and one was a local Assistant District Attorney. Three were union representatives (including a UAW staff member who reported to the UAW national of- fice - not to any of the locals) and only one representative from a community - based con- sumer group (5). The Commission assumed an 11 percent Continued on Page 25 issue on as many fronts as possible: URBAN * HSA staff were contacted by coalition leaders and educated about the effects of and San Antonio. Equally the closure on the communi- serious, large cutbacks in ser- ty. vices as well as transfers and Public hearings were plann- outright sales of public ed and held concerning the | facilities to corporate manage- ment firms have also become common Although. many of these attacks on the public sec- tor have been accompanied by closure. These were well at- tended by local physicians, consumers and hospital workers, largely due to ad- vance work by coalition claims of supposed benefit by organizers. FIGHTING FOR OUR HOSPITALS local government or public hospital management, the negative impact on access and quality of care for poor com- * The Office of Civil Rights was brought in and the hospital management was threatened with a lawsuit over the Public hospitals have been suffering a slow death for the last twenty years. Some see our present economic crisis as threatening their existence altogether. An active and increasingly coordinated resistance to these trends is now emerging, however. During the week of June 16, 1980, representatives from public hospital workers ' unions, community groups, consumer health activists, lawyers representing the poor community, health planners, physicians and public health academics from around the country met in Frederick, Maryland to discuss the plight of these financially troubled public hospitals. The con- ference was sponsored by the National Health Law Program and the Physicians National Housestaff Association. At the close of the conference, par- ticipants formed a new coali- tion _ the National Coalition to Save Public Hospitals. There was consensus among the conference participants that the future they face is pret- ty bleak. In the last several years, major public hospitals have been shut down in New York, Philadelphia, St. Louis munities has been real. But, despite serious challenges by local groups, the severity of the deepening recession and fiscal crises of local governments seem to have conspired to assure that such protests fall on deaf ears. There were examples of local victories cited at the con- ference, however. Ironically, one of the major examples in- volved not a public hospital at all, but a small, inner - city voluntary hospital in East St. Louis, Illinois. There, a broad- based coalition of religious groups, local politicians, legal service and legal aid lawyers, poor people and hospital workers unions successfully fought the planned closure of Christian Welfare Hospital, a voluntary institution serving a primarily Black inner city population. The hospital management in this case had built a second hospital in the suburbs, allow- ing the facilities at Christian Welfare to deteriorate. In 1978, management applied to the local HSA to close Chris- tian Welfare claiming that it was no longer financially viable. The community re- sponded with a well coor- dinated effort to bring up the disparate impact that closing Christian Welfare would have on the Black communi- ty. (The suburban hospital's patient population was entire- ly white; Christian Welfare's population was almost ex- clusively Black.) The resolution came when management agreed to give the hospital to a group of Black, community physicians and paid $ 300,000 in damages for civil rights violations. The money has been used to upgrade the facilities and to transfer management. Another example of suc- cessful resistance cited at the conference did involve a public institution -- the City of Memphis Hospital (CMH). There, the city had a long- standing affiliation agreement with the University of Ten- nessee Medical School to staff CMH, which serves Memphis's inner city. Over the years, the hospital had been chronically underfunded and under- staffed. By 1977, the hospital had so deteriorated that the University demanded the city build a new hospital for the University. If Memphis did not agree with this plan, the University threatened to pull 17 out of the contract altogether, leaving CMH without a medical staff. Again, a concerted effort was brought to bear on both ci- ty and county officials and on the University by a coalition of health and civil rights groups, religious leaders and labor unions. The coalition's efforts were timed to peak during the process of contract renewal of the affiliation agreement. Recognizing the University's interest in maintaining its ac- cess to a public hospital (source of much of the research and teaching cases it required), coalition represen- tatives on the hospital's board of trustees worked to write a model contract which would assure the continued existence of the hospital at its present location, staffing by the University and accountability by faculty doctors to their public hospital patients. Provi- sions of the contract included: The University was removed from the management of CMH. Invoicing procedures were implemented that would re- quire faculty doctors to directly supervise their public hospital patients'care. before receiving payment for the services. (While it is hoped that this arrangement will improve the quality of care provided, it also essen- tially reestablished a fee for- - service arrangement between doctor and patient. The coali- tion fought to require a specific time commitment from the faculty but in the end was forced to compromise on this issue.) * Transfer procedures were in- stituted which limit the ability of teaching faculty to move their private - paying patients from CMH to the private 18 University Hospital. At the same time, city and county officials were lobbied intensively to provide in- creased funds for the renova- tion of CMH. With the excep- tion of the invoicing pro- cedures, the coalition won virtually all of its demands. As the conference discussed the above and other possible resistance strategies, several points of agreement emerged. Community coalitions must be broadly based and pursue a wide range of strategies in the political, health planning and legal arenas. Communities struggling to hold on to their hospitals must not depend sole- ly on the courts or HSAs to save the day, but should creatively use every opportunity for publicly airing the testimony of individuals from the affected neighborhoods and work force. The National Coalition to Save Public Hospitals will meet with US Department of Health and Human Services Under- secretary Nathan Stark to sub- mit testimony for the DHHS Task Force Report on Finan- cially Troubled Hospitals. The following principles were pro- posed by the Coalition: " 1. That the federal govern- ment take steps to insure the survival of public hospitals and private hospitals which serve the needs of the poor and minorities. " 2. That as part of insuring that survival, there will be an infu- sion of federal dollars into public hospitals and private hospitals which serve the needs of the poor and minorities. " 3. That the United States Department of Health and Human Services not adopt any policy regarding federal assistance to public hospitals and private hospitals which serve the needs of the poor and minorities until after it holds regional public hearings to get national consumer input. " 4. That there be a moratorium on the closure of public hospitals and private hospitals which serve the needs of the poor and minorities until such closures can be demonstrated conclusively to have no detrimental impact. " The Coalition is working to form a network of activists around the country to share in- formation and strategies, and to create access for local com- munities to lobby federal of- ficials. For more information, readers should contact Dorothy Lang at the National Health Law Program, 2639 South La Cienenga Blvd., Los Angeles, California 90034 (213-394-4811). Perhaps due to the always superior perspective of hind- sight, the one issue that seemed not to have been suffi- ciently explored at the con- ference was the scope of the Coalition's concern itself. The Coalition's title suggests that its only concern is with public hospitals. Yet, as the East St. Louis case demonstrates - and the Coalition's proposed prin- ciples for federal action con- firm -t he plight of inner city and rural public and small voluntary hospitals are more alike than different. A " Na- tional Coalition to Save Hospitals Which Serve the Poor and Minorities " is a strategy whose time is overdue. The approach would indicate both broadening the focus of concern and reaching out to voluntary hospitals'consti- tuents, workers and unions. Considering the magnitude of the problem and the lateness of the hour, such an opportunity to widen the base of support for those struggling for poor peo- ple's health care ought to be a welcome one. -Kate Pfordresher WORK ENVIRON Pf THE SUPREME COURT'S BENZENE DECISION: A TERRIBLE DUTY IS BORNE The U.S. Supreme Court has rewritten the Occupa- tional Safety and Health Act, inserting the words " signifi- cant risk " into the Act where nowhere in the law's 30 pages of fine text did they previously appear. The Supreme Court's action came as part of its recent land- mark decision overturning the new benzene standard set by the Occupational Safety and Health Adminstration (OSHA) of 1 part per million in air, returning American workers to the old, less protective stan- dard of 10 parts per million (ppm). In so doing the Court has ironically engaged in the sort of judicial activism- i.e., rewriting the law from the court bench - which in the earlier, more liberal Warren Supreme Court often set many Reagan and Birchite critics ' teeth on edge. Because of the Court's own attempt to play down the im- plications of its actions, and possibly also because of their own more liberal political leanings, most media com- mentators have emphasized the sunny side of the decision. Several commentators, for ex- ample, noted that the Court didn't rule on cost benefit - con- siderations as they relate to standards. But the results of this decision, unfortunately, are far worse than the media have portrayed. To be sure, the Supreme Court's main decision on benzene was actually signed by only a plurality of four of the nine Justices (Stevens- who wrote the decision- Burger, Stewart and Powell), with the fifth and decisive vote cast in support of the plurality's action by Justice Rehnquist. (Living as he does on his own legal moonscape, Rehnquist chose to write his own decision, declaring as a minority of one that the entire Section of the OSHA Act at issue was unconstitutional.) De The Results of This Decision Are Far Worse Than at First Thought Nevertheless, I believe that this decision to rewrite the standards - setting sections of the Act, while trying to hide from workers and the public the sweeping nature of the change, was a legal and political compromise by the Court which will be with us for many years to come. Thus, for those of us who are actively in- volved in trying to protect the health and safety of U.S. Workers, the decision and its implications deserve careful attention. Significant Risk - Give Us Some Bodies The Secretary of Labor's broad authority to promulgate health and safety standards and the criteria which these standards must satisfy are suc- cinctly stated in Section 6 b () (5) of the Act: " The Secretary, in promulgating standards dealing with toxic materials or harmful physical agents under this subsection, shall set the standard which most adequately ensures, to the extent feasible, on the basis of the best available evidence, that no employee will suffer material impairment of health or functional capacity even if such employee has regular exposure to the hazard dealt with by such stan- dard for the period of his working life. " (My em- phasis). This section sets a high standard for worker health protection. OSHA, through its standards, not only should protect each worker from disease but from loss of func- tional capacity (such as lung function or kidney function), without necessarily being re- quired to show that the loss of functional capacity represents the onset of a disease or will lead to a disease. OSHA's use of these standard - setting powers is restrained by the requirement in this Section that the regulated impairment be " material. " (The original ver- sion of this Section of the OSHA Act said that a standard should protect against " any impairment, " but after much debate Congress changed this 19 to protection against " material impairment. "? It is noteworthly, particularly in light of this Supreme Court decision, that Congress in debating this phrase chose the broader, more ment and places of employment ', the Secretary must make a finding that the workplaces in question are not safe. But'safe'is encompassing term " material impairment, " rather than any of the large number of ob- vious, but more explicitly. value laden - alternatives such as " significant " or " serious. " But the chief restraint on not the equivalent of ' free risk -. There are many activities that we engage in every day- such as driving a car or even breathing city air- that entail some risk of OSHA in this Section is that the standard must be " feasi- ble. " This word is not specifically defined anywhere accident or material health impairment; nevertheless, few people would consider these ac- in the Act, so its use obviously leaves OSHA free to consider technical feasibility, economic feasibility or both tivities'unsafe.'Similar- ly, a workplace can hardly be considered ' unsafe'unless it with setting a standard. threatens the workers This broad requirement of feasibility, which OSHA has with a significant risk of harm. been interpreting in ways unsatisfactory to industry in recent years, must be recon- ciled, the Supreme Court says, with the definition of a standard given in Section 3 8 (): Therefore, before he can promulgate any per- manent health or safety standard, the Secretary is required to make a threshhold finding that a place of employment is " The term'occupa- tional safety and health standard'means a stan- dard which requires conditions, or the adop- tion of practices, means, methods, operations, or unsafe in the sense that significant risks are pre- sent and can be eliminated or lessened by a change in practices. " (Emphasis in original). processes, reasonably necessary or appropri- ate to provide safe or healthful employment and places of employ- ment. " (My emphasis.) This was bad enough - but then, in an act unusual in any US court, the Supreme Court delved into the scientific record presented by OSHA and argued that OSHA didn't prove The new means of recon- that the original benzene ciliation are to be found in the threshold of 10 ppm presented a Supreme Court's guideline " significant risk ": significant risk. The Court specifically criticized OSHA's cancer policy, especially its " By empowering the " assumption " that human Secretary to promulgate standards that are cancer agents have no threshold below which ex- ' reasonably necessary or posure to them is safe. appropriate to provide The Court went on, phrasing 20 safe or healthful employ- its argument in " Nixonesque " terms, " In this case the record makes it perfectly clear that the Secretary. relied squarely on a special policy for car- cinogens that imposed a burden on industry of proving the existence of a safe level of exposure, thereby avoiding the 1 Secretary's threshold responsibility of establishing the need for more stringent stan- dards. In so interpreting his statutory authority, the Secretary exceeded. his power. " Since the Secretary of Labor did not show that the old stan- dard presented a " significant risk, " the Court was able to avoid the necessity of ruling on the standard's cost benefit - im- plications. " Extraordinarily Arrogant and Unfair " Justice Marshall's minority Rockefeller M Medicine and Capita by E. Richard Send orders to: Health / PAC 17 Murray Street New York, N.Y. 10007 " This book tells us really all about... It's an eloquent, we historical marriage impact on shaping 1 today. " i Originally $ 12.95. No Price includes postange and handling. A delivery. opinion, joined by Justices Brennan, White and Blackman, criticizes the Court's decision in unusually harsh and personal terms: " The plurality's discussion of the record in this case is both ex- traordinarily arrogant and extraordinarily un- fair. It is arrogant. because the plurality presumes to make its own factual findings with respect to a variety of disputed issues relating to the carcinogen regulation..... It should not be necessary to remind Members of this Court that they were not appointed to under- take review of adequate- ly supported scientific. findings made by a technically expert agen- cy. And the plurality's discussion is unfair because its characteriza- tion of the Secretary's report bears practically edicine Men alism in America Brown what health care in the United States is . No one can or should ignore this book. Il documented - damning appraisal of the between medicine and capitalism and its the kind of health - care system we have Washington Post ' w Only $ 10.45! llow at least six weeks for no resemblance to what the Secretary actually did in this case. " Marshall argues that the plurality's decision in reviewing the scientific record ignores ex- tensive evidence in the hearing record of chromosomal dam- age, aplastic anemia, and other non cancerous - blood disorders at levels of 10 ppm or less, evidence that these changes are early precursors of leukemia, and evidence regarding leukemia incidence itself. In any case, Marshall argues, the Court is not asked to judge whether or not the evidence is true, but whether, in the words of the judicial review of provi- sions of the Act, they constitute " substantial evidence (of harm) in the record considered as a whole. " They obviously do, he concludes. Marshall is also contemp- tuous of the plurality's legal scholarship: " According to the plurality of the definition of occupational safety and health standards as those'reasonably necessary or appropriate to assure safe or healthful working condi- tions'requires the Secretary to show'more. likely than not'that the risk he seeks to regulate is a'significant'one. The plurality does not show. how this requirement can plausibly be derived from the'reasonably necessary or appropri ate'clause. Indeed the plurality's reasoning is refuted by the Act's language, structure, and legislative history, and it is foreclosed by every applicable guide to statutory construction. In short, the plurality standard is a fabrication bearing no connection with the acts or inten- tions of Congress.'The significant risk ap- proach'is particularly embarrassing in this case, for it is con- tradicted by the plain language of the Act. " Marshall then goes on to show that the Secretary indeed con- sidered and satisfied the re- quirements of the Act that the standard be necessary or ap- propriate, the harm material and the remedy feasible. Why would the Court rewrite the standards - setting section of the Act and then stumblingly try to judge the scientific issues raised in this standard? In part, one suspects, the Court took the unusual action of getting into the scientific issues because it wished to avoid grappling later with the even thornier problems raised by the cost benefit - issues surrounding the standard. Mar- shall and his colleagues suggest an even broader motive: " The plurality ignores the plain meaning of the Occupational Safety and Health Act of 1970 in order to bring the authority of the Secretary of Labor in line with the plurality's own views of proper regulatory policy. " And these views in turn are " based only on the plurality's solicitude for the welfare of regulated in- dustries. " (My emphasis) These are strong and per- sonal judgements by the four minority Justices - and they ring true. For public health people, of course, the decision also represents a sharp break with preventive aspects of oc- cupational safety and health. A standard effectively can not be set until a count of dead or wounded bodies can be made- that is, until after the fact of harm to at least some workers. 21 Scientists and professionals, in alliance with workers and their unions, can helpe shape events in health and safety and to a letter extent in other social and economic areas There's a Power There's a Power... Where does this decision leave us? First of all, despite the sharp words and solid argumentation of Marshall and associates, the benzene ruling stands. Further, on the basis of the new significant - risk test for standards, we can expect at- tempts by various industries to re open - appeals contesting earlier OSHA standards, as well as new legal tests of OSHA's authority. OSHA's Cancer Standard, one of the agency's main advances in re- cent years (see BULLETIN No. 79), appears to be struck down by the Supreme Court even before it has met its first legal test. This legal defeat can be ex- pected even further to weaken Congressional resolve on worker health issues - a weakness reflected in signifi- cant new Congressional sup- port for the Schweiker Amend- ment. The Schweiker Amend- ment guts the OSHA standards- enforcement process, in com- plement to the benzene deci- sion which guts the standards- setting process (see BULLETIN, Vol. 11, No. 4). Let us not forget, while discussing the very real impact of the courts and Congress on health and safety, that the driv- ing force behind the actions in both these arenas is industry's onslaught against OSHA. This is not new. What is new is the in- tensity with which industry is now peddling its case to the courts, the Congress and the general public - as if OSHA 22 and government regulation in general were the cause of America's economic crisis rather than the cumulative ef- fects of the U.S. industry's pur- suit of short - term profits and its weakening grip on the economies of other, smaller countries. But workers and the labor unions that represent them are not powerless in the face of in- dustry's drive against health and safety (and against what ever else impedes their short- term profitability). By virtue of their organization and _ their roles in production and in everyday life, workers can and do shape local and _ national policies to some extent, al- though more by responding to industry initiatives than by in- itiating programs of their own. A measure of this power is the relative strength of the ad- ministering agencies, OSHA and NIOSH, in contrast to the agencies administering the Toxic Substances Control Act and other environmental legis- lation. The environmental movement, with its very large base of support among middle class publics, is not well organized as a movement and hence has a hard time, after getting good laws passed, forc- ing Congress to appropriate funds to administer these laws. OSHA, on the other hand, has the organized labor move- ment and its local affiliates to lobby legislators and (success- fully, so far) fight against cut- backs in the agency's annual Congressional appropriations. And, as those who have contact with working people on health and safety issues know, workers are quite concerned about their health and safety on the job and will not take serious attacks on OSHA lying down. For exam- ple, workers in many shops were and are quite angry at at- tempts to pass the Schweiker bill. The reason for the bill's defeat so far has been the ex- pression of that anger at demon- strative public meetings and Congressional hearings, which has apparently surprised the so- called Congressional moderates who initially sup- ported it. Scientists and professionals who work with workers on health and safety (and other social and economic issues) are not doomed to defeat as are, un- fortunately, many who work with equally deserving, but weaker and less well organized groups. Despite adverse Supreme Court decisions and weak willed - Congressional allies, workers are capable of defending their interests in health and safety against at- tacks by Democratic or Repub- lican administrations. Many professionals like myself who are working with workers and their unions are beginning to understand this more clearly than in the past. We know that in alliance with workers we can help shape events in health and safety and to a lesser extent in other social and economic areas. This of course involves hard, long term - struggles. And success is not assured, although the odds for success are at least reasonable. Then again, who ever said change would come easily? David Kotelchuck hospital by facilitating the grass roots building of a consumers union. Our belief was that the THE FIFTH ing a declining census and the people who rely on BMHC for vital health services should have a dominant voice in deter- COLUMN inevitable decrease in approp- riations for the following year's operating expenses. Thus loom- mining the nature of the ser- vices they receive. If organiz- ed, the users of hospital ser- ed a vicious cycle of poor con- ditions generating its own next round of problems. vices could be an extremely ef- fective political force for demanding change. Erosion of hospital services As a political organization, a also affected relations among consumer union could focus on staff groups at the hospital. As the multiple systems transpor- - overwork progressed, each tation, welfare, hospital, WJ eee overworked groups resisted out title - of - labor assignments, which bounced from nurses, to It became apparent that housestaff, to social workers, to if the Bronx Municipal CONSUMERS UNION GROWS IN THE BRONX ancillary services in an ever- widening spiral of resentment. It became apparent how crucially interdependent all health worker roles are and Hospital Center was to maintain its high stan- dards of service, the support of the communi- In the fall of 1979 a diverse group of health care workers at the Bronx Municipal Hospital Center joined together over the ongoing issue of real and threatened cutbacks of services how, when any one service was restricted, all services suffered. Combined with the fact that, as further cutbacks occurred, the anonymous anger of patients towards the health care system ty of users would be essential ee Medicare Medicaid / - which practically affect the actual at the hospital. Over the past few years health care workers in the Bronx have witnessed a dramatic decline in health care became more manifest, we were forced to contemplate that the cutbacks and restrictions would mean in terms of our own work day day - to - quality of health care services. Through a con- sumers union, not only would the interests of the users of the services for the elderly, the working poor and the un- employed. It appeared that functioning community health services were being systema- tically dismantled, and that staff and funds for remaining facil- ities were becoming im- poverished, crowded and mar- ginally effective in meeting the health needs of the Bronx. General staff reductions at the BMHC created problems at all levels in the hospital, but were particularly felt by the nursing staff. Working condi- tions had so deteriorated that and our ability to provide high quality health care to our patients. It also became apparent that if the BMHC was to maintain its high standards of service and remain an excellent city hospital, the support of the com- munity of users would be essen- tial. There was a need for a new kind of organized political effort to protest changes and restric- tions in hospital services. Past efforts by health care workers to effect the financing of health care services in New York City had met with little success. health care system be represented, the hospital would also, in some cases, gain an ally in protecting vital health care services for the people of the Bronx. With the goal of building a BMHC Health Consumers Union, the Consumers Union Support Alliance (CUSA) was formed to raise funds and facilitate the initial develop- ment of a consumers union. Membership in the support alliance was drawn from all levels of health care workers at the hospital as well as from recruitment of nursing person- nel was even more difficult than As health care workers at BMHC, we thought we might faculty and students of the Albert Einstein College of usual. Nursing shortages led to closing of ward beds, produc- best meet the problems of declining services at the Medicine (the medical school af- filiate of BMHO). Funds were 23 a As a political organization, a consumer union could focus on the multiple systems which affect the day day - to - quality of health care services raised, and, in December 1979, the support alliance hired Joyce Dattner, an experienced com- munity organizer working full time for the Association of Bet- ter Communities (ABC), to begin the task of organizing a BMHC Consumers Union. With the support of CUSA, Joyce began a Consumers Union membership drive in February 1980. Leafletting, knocking on doors, follow - up phone calls and visits, meetings in churches, community health centers and other community settings have all met with en- couraging responses. To date, 76 families have joined the union and paid the 10 $ family membership fee ($ 1 for senior citizens). A goal of 150 family memberships has been set for August of this year. The first meeting of the Bronx Health Consumers Union (BHCU) was held May 17, 1980, at the Sound - View Presbyterian Church. An organizing com- mittee was formed to take special responsibility for building BHCU by signing up new members, meeting with other organizations and making decisions regarding fund- raising. Major health care issues which individual hospital users and community groups have ex- pressed an interest in confron- ting so far include transporta- tion services to and from the hospital, ambulance service in the community, and _ hospital waiting times. When the union reaches this goal of 150 members, it will begin actively negotiating for changes in these areas. The union has the help of 24 Fran Costa, a full time profes- sional advocate at City Hall employed by ABC, who has begun to explore the political terrain in which the union will be struggling. The Advocate's Office of ABC will help the union in its campaign for recognition and economic representation by pressing politicians to represent the health care interests of the union membership who live in their districts. One of the im- mediate issues to be taken up involves the possibility of re- routing the bus services in the Bronx to facilitate travel to the hospital. This issue is now being studied with the help of staff from the Bronx Legal Aid Society. Other union activities in- clude the organization of a package of specific benefits for union members such as dental benefits and discounts at local stores. Joyce has also met with the Patient Relations Office at BMHC in order to clarify the mechanics of patient advocacy as a union benefit. Another area of benefits concerns the ex- citing possibility of courses in various areas of health care and health sciences offered to BHCU members by CUSA members and supporters. The support alliance at BMHC has been growing in step with the union, gathering new people, ideas and resources. To date CUSA has raised over $ 3,000 for the financing of the initial develop- ment of the Consumers Union. Fundraising parties, softball games, films and _ individual pledges have all contributed to this base of support. Currently there are approximately 100 people who have contributed to and / or joined the Support Alliance. This summer, in conjunction with the Department of Com- munity Medicine at Albert Einstein College of Medicine, the Support Alliance is offering a summer elective course for freshman medical students. The students will work with Joyce Dattner in community organiz- ing activities, while also engag- ing in research on health care policy making - as it affects con- sumers and providers in the Bronx. Four students have sign- ed up for the elective, and the medical school has agreed to provide funds for their support. CUSA has also contacted a number of public and private interests with regard to future help in fundraising and media work. The Committee of Interns and Residents (CIR) has given its support to the union and is considering doing joint work with CUSA and the union. The building of the BHCU provides an opportunity for health care workers and the consumers of health care ser- vices to exchange ideas about what is important in health care and to work together to see that the right to good health care for all is maintained. The ex- perience has been rewarding for the individuals who have participated, and we look for- ward with optimism to the con- tinued building of the BHCU. If you would like further informa- tion the Consumers Union con- tact Bette Braun at 250 West 104th Street, New York, New York 10025 (212-663-5056). -Susan Massad, M.D. (Susan Massad is Director of the Medical Clinic at BMHC.) The Unkindest Cut of All Continued from Page 16 reduction in the hospital use rate, down from 1,153 to 1,000 patient days per 1,000 residents. It then made adjustments to account for higher use rates in poor neighborhoods and calcu- lated the number of beds needed by each subarea of the CHPC - SEM region. The Commission then developed a complex rating system, giving hospitals either positive or negative points depending on how well they scored on over 50 different criteria. Hospitals in each subarea were then assigned to three categories depending on their total score. Each category was assigned a specific percentage of its beds which had to be cut. Some hospitals were assigned reductions of nearly 90 percent, virtually guaranteeing their closure. Other hospitals were assigned reductions of 15-30 percent (which might still force closure in a small hospital). The most successful hospitals SICK FOR JUSTICE Health Care and Unhealthy Conditions The South has two histories. One, steeped in self reliance - , today enables us : to try bold, pioneering experiments in community - controlled health care delivery. The other has left the region underserved, making the South a target for exploitation by burgeoning health care corporations and a growing medical / industrial complex. In articles a : ranging from profiles of community clinics and herbal medicine of the early South to a\y Soy 4 analysis of for profit - hospitals and the first documentation of the textile industry's S cover - up of brown lung disease, Sick for Justice unveils both traditions and provides a guide for citizens and health care workers to take back control over our bodies, our environ- ment and the health care institutions which should serve us. An - " indispensable resource for health care activists and professionals everywhere. " -Robb Burlage Southern Exposure $ 3 each or FREE with a one year subscription (4 issues / $ 10) to SOUTHERN EXPOSURE Write: Sick for Justice / PO Box 531 Durham / , NC 27702 25 Craziness: The irony is that this massive and disruptive effort may not reduce hospital costs but actually increase them. Consolidating health care in larger institutions never saves money but usually creates more inefficiencies were slated for token reductions of five percent. By using these very large and small reductions, planners hoped to force hospitals to bargain with one another for consolidations, mergers and shared services. Reduction Criteria: The Book of Numbers The fight over review criteria became the first test of power on the Bed Reduction Com- mission. Consumers initially suggested an en- tirely different approach, based on hospital oc- cupancy rates. They reasoned that facilities with many empty beds could be cut or closed with the least disruption in services. Moreover, they argued, these hospitals were also the least cost effective - because of the excess capacity they had to support. This approach would have worked against many of the large, politically powerful hospitals which had low occupancy rates, however. Thus the GDAHC and business representatives opposed this strategy and it was dropped. The Commission instead opted for a scoring system which would target hospitals for cuts. The system used over fifty review criteria to measure hospital performance. Categories of criteria and their relative importance are shown in Table 1 below. Table 1 Relative Weighting of Measures of Hospital Performance Category Percentage of Points on CPHC - SEM's Rating Scale Utilization (6) Hospital Size and Physical Plant Financial Management and Operations Medical Staff Qualifications and 25.29 16.95 12.93 12.93 Supervision Comprehensive Planning and Services Hospital Heavily Used by HMO Access for Poor and Minorities 5.75 4.60 4.60 Majority of Medical Staff is Black Governing Board Community - Based Training Program Geographical Access Accreditation 26 3.45 3.16 2.87 2.30 1.72 Although any such scoring system will be. controversial, the source of anger among poor and minority groups and small hospitals is im- mediately apparent upon closer examination of what was included, and excluded, from the hospital performance criteria. Information key to directly assessing the quality and efficiency of hospital care was omitted from the criteria. Thus the Commission could have demanded outcome (mortality and morbidity) data by casemix, either from the hospitals or from the PSRO. It could have sought other internal measures of quality such as proceedings from hospital tissue, morbidity and mortality and infection control committees. It could have looked at malpractice suits or hospital disciplinary actions against careless or incompetent physicians. Instead, the Commis- sion opted to use a variety of size and utilization measures as surrogates for quality and efficiency. Similarly the Commission worked without the benefit of patient origin data broken out by race or source of payment, upon which any serious examination of accessibility must be predicated. This could have been obtained from hospitals or from discharge abstracting services which regularly compile it. When the hospitals adamantly opposed releasing such direct data on quality, efficien- cy and accessibility, the Commission refused to challenge their resistance. Planners com- plained they could not handle such compli- cated issues in the short time allowed them to develop the bed reduction plan. " We're cap- tives of the data, " said one leading advocate, voicing the planners'universal plaint. Although lack of data may prove to be the most serious flaw, biases in many of the hospital performance criteria used support the critics ' case. Utilization Although a chief objective was achieving an 11 percent decline in patient days, the plan weighted a short average length of stay (15 points) worth less than, for instance, a large parking lot (20 points). Downplaying the length of stay aided the large hospitals with longer average stays (and more complex cases) at the expense of community hospitals with simpler or more beds, complying with licensing re- cases. The criteria set minimum utilization stan- quirements, and having a sound physical plant. Planners also defend these criteria by dards for different services within the hospital pointing to economies of scale which allow such as obstetrics (1500 births per year) and large hospitals to deliver care more efficiently. open heart surgery (200 procedures per year). Community advocates point to other studies These were generally weighted in favor of high suggesting that economies of scale disappear volumes and large services, assuming that size for hospitals larger than 500 beds because of in- could be used as a proxy measure for high creased administrative inefficiency. They bit- quality and cost efficiency. Not only do large terly note that the flagship hospitals in the services not assure quality or cost efficiency, 900-1,100 bed range were not penalized for however, but this assumption ignores such im- their size. portant issues as the contribution of nursing to quality care, the appropriateness of the setting Fiscal Management and Operations to the condition being treated and the institu- tion's actual track record in contrast to its level Hospitals received credit for having written. conflict interest - of - policies for their directors, of medical capability. Without considering these, the effect is to increasingly consolidate for having audited financial statements, and having costs comparable to other hospitals of all care into larger, more intense and expen- the same size. Community hospitals objected to sive medical settings. this last criteria, pointing out that they received There are other serious problems with util- ization standards. CHPC - SEM uses the federal no credit for having costs substantially lower than those of the giant tertiary care facilities. standard of 200 or more open heart surgeries per year. This standard is based on the belief The larger hospitals were burdened with more expensive technology, higher staff patient - that a lesser number of surgeries is insufficient ratios, and greater debt services, making them to maintain a high level of care, and is also not far more costly for even simple care. cost efficient. Recent reports of death rates for coronary bypass surgery in Chicago highlight Medical Staff the problems with this approach. Although all Hospitals were rewarded if they could show. six hospitals reporting more than 200 proce- approval by the Joint Commission on the Accre- dures per year reported an " acceptable " death ditation of Hospitals of their utilization review ef- rate in the 3-5 percent range, five of the ten forts and that the PSRO had delegated utiliza- hospitals performing fewer than 92 annual 1 tion reviews to the hospital. Yet the goal of an 11 bypasses also had acceptable death rates (7). percent reduction in patient days suggests the Although many high volume - open heart units inadequacy of current review efforts certified - are relatively safe, the smaller units can be just or not - in preventing needless admissions and as safe. Reliance upon federal dicta is no surgeries. Rewarding ineffective review efforts substitute for specific information about mor- seems pointless and contradictory. tality rates at each hospital information - information that CHPC - SEM should have demanded from the The criteria awarded 50 points for each director of a clinical service who is board cer- local PSRO. tified, a measure by which large hospitals with Finally, the manner in which the Commis- more services piled up many additional points. sion rated utilization permits no distinction be- Because some " directors " provide no supervi- tween hospitals which barely fail to meet minimum standards and those far below them. sion whatsoever, there is no proven relation- ship between this criterion and quality of care. Thus a 195 bed - hospital is penalized as heavily In fact, there is no proven relationship between as a 90 bed - facility for failing to meet the stan- many such " input measures " and the quality or dard of 200 beds. A hospital with 1350 births outcome of care. Yet, as cited above, the Com- (90 percent of the obstetrical standard of 1,500 mission was unwilling to wage the battles births per year) is treated identically with a necessary to truly assess outcome - the only hospital with 400 annual births. true measure of quality. Hospital Size and Physical Plant Some small community hospitals provide ex- cellent care and may be best suited for treating Hospitals received credit for having more simpler conditions. Others have alarmingly than 200 beds, for having pediatric units of 30 high death rates, frequent malpractice inci- 27 L Health / PAC Publications r Double Indemnity: The Poverty and Mythology of Affirmative Action in the Health Professional Schools An examination of the forces, developments and policy changes which are closing a door on women and minorities that was all too briefly and cautiously opened by affirmative action programs... $ 5.00 The Myth of Reverse Discrimination: Declining Minority Enrollment in New York City's Medical Schools A Health / PAC expose showing that minority enrollment in NYC's six medical schools lags sadly behind that in the rest of the nation and is falling. 0.0... eee eee. $ 2.00 Prognosis Negative An anthology combining many of the best articles from the Health / PAC BULLETIN with important articles from other publications. 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A look at the impact on hospital ambulatory care, neighborhood health centers and the New York City Department of Health.. $ 13.50 Closing the Doors on the Poor: The Dismantling of California's County Hospitals A detailed look at health policy toward the poor, the trends that spell doom for public hospitals and how they have forced the closing or private take over - of 40 percent of California's public hospitals....... oe $ 7.50 Also Available: A Collection of Drawings by Bill Plympton The health system as captured and satirized in the drawings of Bill Plympton in the Health / PAC BULLETIN. $ 5.00 Coney Island Hospital: A Case Study in the Politics of Health Case study of how a hospital is governed and how it relates to the health needs of the community surrounding it $.75 . Available from the Health Policy Advisory Center, 17 Murray Street, New York, New York, 10007. Add 15 percent to the total charge for postage and handling. All orders must be prepaid. L dents and permissive standards for high- volume surgeons. The Commission could have used the quality issue to educate the public and put low quality - hospitals on the defensive. It had an invaluable chance to garner community support as the defender of the public's right to 28 decent care - and discarded it. Health Maintenance Organizations Hospitals heavily used by an HMO were given eighty points- as much credit as hospitals could get for being totally accessible to the poor. The only hospital eligible for these points was one sponsored by the UAW and the auto industry. Double Indemnity The Poverty and Mythology of Affirmative Action in the Health Professional Schools by Hal Strelnick and Richard Young DR. MARTTIN LUTHER KING. HEALTH CENTER *D I ON UD NOQMN BE NOQMN L M E NOQMN I == T == Y > Double Indemnity is " Exciting and will make a major contribution. " -Professor Sam Wolfe of Columbia University School of Public Health " The most comprehensive study of affirmative ac- tion in the health professions to date. " -Dr. Dean Curtis, Associate Dean at Cornell University Medical College and author of the book Blacks, Medical Schools and Society. - - A Health / PAC Special Report. $ 5.00 each. Now available from the Health Policy Advis- sory Center, 17 Murray Street, New York, New York 10007 1 Access for the Poor and Minorities Accessibility was given little weight in com- parison to other criteria. The planners also ac- cepted whatever claims hospitals made at face value, even though they knew many hospitals were not accessible to the poor. Accessibility for the poor and responsiveness to community needs, a discrimination non - policy, a policy to treat patients regardless of ability to pay, and having a reasonable mix of women, minorities, and neighborhood residents on the hospital's board ranked only as important or slightly more important than the size of a hospital's parking lot! A nondiscrimination policy is already re- quired for hospitals to receive Medicaid or Medicare, and is often a meaningless docu- ment because of its weak means of enforce- ment. Commission members freely admitted. that hospitals discriminate despite such prom- ises but claimed they could not investigate real compliance (8). The business - labor interests backing the plan made it difficult to raise access issues. The orientation was so strongly focused on cutbacks that shortly before the plan's completion, the subcommittee dealing with access problems had only barely grasped the concept that some areas were medically undeserved. Two weeks before the final public hearing, one Commis- sioner earnestly asked, " How do we have so many medically underserved areas in Detroit if we have so many doctors? " (9). Even the access criteria favored the large hospitals. Hospitals received points if at least 30 percent of their admissions were Medicaid or county funded - patients. Yet they could also receive points merely by being in the top 25 29 percent of their subarea for total Medicaid ad- missions. Thus behemoth hospitals with thousands of admissions could admit a high ab- solute number of Medicaid patients while keep- ing their percentage of such admissions at a minimum. The five largest central Detroit hospitals averaged 552 beds and 15 183, admis- sions. The next five hospitals averaged 199 beds and 6,400 admissions. If the largest hospitals admitted one Medicaid patient for every four privately insured patients, the smaller hospitals would have to treat one Medicaid patient for each privately insured pa- tient to receive any points in the rating scheme. The remaining criteria related to unique treatment programs, presence of Black physi- cians on medical staff, health professional training programs, accreditation, and geographical accessibility of rural hospitals in the region. The net effect of the criteria was to severely squeeze small and medium - sized hospitals while assigning only token reduction requirements to tertiary facilities, as can be seen in Table 2. A Small Circle of Friends The reduction plan was written with the guiding hands and steady pressure of Ford, the UAW, and the GDAHC. Of these, the GDAHC certainly faced the most difficult task of all. Although local hospitals accepted the necessity of bed reductions in the abstract, Hospital Council staff members had to work hard to keep facilities from breaking ranks as the plan became more specific. The GDAHC issued its own report on bed reductions in 1977, a report remarkable in its scope and detailed analysis of the political implications of health cuts (3). Although GDAHC's own efforts are unique in the field of private sector planning, its priorities are not. Despite rhetorical flourishes about access, quality of care, and displaced workers, the report is primarily concerned with money. Only two percent of the document is devoted to access, one percent to job rights and none of it to quality of care. Forty - three percent of the Hospital Council's reduction plan is devoted to finance, the problem of retiring TABLE 2 Reduction Responsibility by Hospital Size for Central Detroit Group III II I Number of Hospitals 5 12 3 % Reduction Required 5% 30 90 Mean Beds Median Beds 582 419 191 168 125 128 Resource The Carcinogen Information Program, a project of the Center for the Biology Natural Systems, is dedicated to bridging the gap between scientific journals and the public. You can receive The CIP Bulletin, the program's monthly fact sheet, at no cost by sending a long, self addressed - , stamped envelope to: The Center for the Biology of Natural Systems Washington University Campus Box 1126 St. Louis, Missouri 63130 30 The standards used to measure hospital care and effectiveness took no note of which institutions had high death rates or quite frequent malpractice incidents long term - debt and concern over the impact closures may have on future hospital bonding practices. The Council's commitment to money is equalled only by its commitment to mammoth, technology - intensive hospitals. The Hospital Council's 1977 report announced its own im- plicit hit list two and a half years prior to the Commission's effort: " As a purely hypothetical example, therefore, if it were assumed that all twenty - six hospitals with less than 200 beds were closed within a single year... " (Emphasis in the original) (3). This " example " ceased to be hypothetical as the reduction plan developed. GDAHC Asssi- tant Director Mike Elliott would comment at Commission meetings that " We all know which hospitals should be closed. " When CHPC - SEM adopted review criteria closely mirroring GDAHC's bias in favor of larger facilities, several community hospitals felt the deck had been stacked against them. Those who hoped for countervailing. pressure from the UAW were disappointed. Commission insiders report that UAW health chief Mel Glasser never directly involved himself in the Commission and relied on GDAHC Director Sy Gottlieb for progress reports. Glasser was represented on the Com- mission by a UAW staff member who opposed any real consideration of access problems. Despite expressed personal misgivings, she pressed the UAW's demands for cost contain- ment. Although the UAW's resolve around cut- backs never wavered in the face of access con- siderations, reductions did take a backseat to the union's desire to protect Metropolitan Hospital, site of the UAW - auto industry- sponsored HMO. As the Commission con- sidered the final reduction plan, the UAW join- ed the chorus of advocates from dozens of hospitals crying, " The plan is great... but ex- empt our hospital! " The UAW ultimately threatened to oppose the plan before the SHCC unless Metropolitan were exempted (10). Small Is Beautiful Small hospitals opposed the plan when they found themselves to be the prey. Among these are many osteopathic hospitals which tend to be smaller and which are slated for a 19 percent net reduction compared with a 14 percent for allopathic hospitals. One consumer bitterly defined " community hospitals " as " any... hospital which didn't like its reduction respon- sibility. " Some community hospitals are ineffi- cient, provide poor care, and are no more ac- cessible than other facilities. Others provide a safe, low cost - alternative to the Star Wars medical technology used at tertiary hospitals. Because the plan failed to adequately consider cost, quality or access, the consumers and area politicians cannot distinguish between them. Several hospitals quickly mobilized neighborhood groups in their defense. Because so much of the bed reduction effort relied on powerful corporate and union elites, CHPC - SEM failed to build community support for the reductions. This failure may prove fatal. Under tremendous community pressure, both houses of the Michigan legislature recently voted to suspend the reduction plan until an in- vestigation is completed. Black is Beautiful: Mayor Young in the Middle Looming over the entire bed reduction ef- fort, although not directly involved in it, was Detroit Mayor Coleman Young. Young has fought to establish a pro business - climate without jeopardizing his political base in the Black community. The cutbacks caught him squarely between corporate demands for reductions and Black physicians who feared they would not get attending privileges at sur- viving hospitals if their hospitals are closed. The planners needed federal aid to help pay off the long term - debts of hospitals targeted for closure and they needed Mayor Young to help them get it. Young's influence within the Democratic party and the Carter Adminstra- tion put even more pressure on him to take a role in the reduction plan. 31 INNER CITY HOSPITAL 7 7 Young used his leverage to win de facto ex- emptions from the cutbacks for " historically Black " hospitals. Under his influence the Com- mission decided that hospitals with a majority of Black directors be considered for exemp- tions if they merge or affiliate with other hospitals. Moreover, if an institution is con- sidered to be " historically Black " by the (Black) Detroit Medical Society, and the NAACP, Ur- ban League and the Southern Leadership Con- ference, it will be offered a de facto exemption. This move mollified many of the Black profes- sionals and put community groups in Mayor Young's debt. It did not, however, solve the access prob- lem. Only two hospitals might be saved by this scheme and they account for only a small pro- portion of organized outpatient visits. Worse yet, the overtly political tone of the exemptions has triggered a backlash from suburban com- munities which will bear additional reductions as a result of the redistribution. Access: Ford Has A Better Idea Planners argue that Central Detroit is receiv- ing less than its share of cuts because of the ex- emption of the Black hospitals and the allowances the plan made for greater use of in- patient care in poor communities. Nonetheless, activists and union officials who acknowledge the need for reductions are uneasy about the plan. They insist that the question is not whether beds should be closed, but whose. They point out that empty beds in hospitals with 32 discriminatory admissions policies will do them little good. Doubts about the reduction plan are hard to dispel. In addition to the plan's uninterest in access related - criteria, the plan suffers from a total absence of patient origin data broken down by race and source of payment. Without such information, those concerned with the problems of minorities, especially uninsured minorities, fear the worst. These grave ques- tions have led some advocates to urge that no reductions take place until more is known about this problem. All of these concerns prompted HEW's Of- fice for Civil Rights to begin monitoring the ef- fort in the fall of 1979. OCR officials worked with CHPC - SEM to resolve potential access problems. OCR's involvement was partially motivated by CHPC - SEM's refusal to demand that the hospitals release existing patient origin data. OCR hoped to use such information to identify those hospitals used most heavily by minorities and uninsured patients. Civil rights advocates sought to correct some of the plan's deficiencies by including strict ac- cess criteria in all certificate of need reviews, extracting specific binding commitments from surviving hospitals applying for certificates of need to ensure that minorities and poor patients would be able to get medical care. CHPC - SEM staff, strongly backed by the UAW, objected to this approach, fearing that strict access criteria would interfere with the cutbacks by giving hospitals an excuse to resist access criteria as going " too far. " Entry of OCR onto the Detroit bed reduction scene strengthened the demands of local advocates concerned about the impact of the cuts on minority communities. Their hopes were quickly shattered, however, when Ford VIP Jack Shelton met privately with HEW Undersecretary Nathan Stark and asked him to interfere with OCR efforts to protect minorities. When Shelton returned to Detroit crowing that Stark had disparaged the civil rights effort, CHPC - SEM cooled its efforts to appease OCR. Although CHPC - SEM refused to make access issues into criteria, they at least agreed to collect a small portion of the data OCR had requested. Clearly CHPC - SEM could be pressured to go much further, but OCR has been relatively silent since Ford's Jack Shelton went to Washington. Labor's Love Lost The Bed Reduction Commission attempted to provide safeguards to another major group af- fected by its plan hospital - workers. The plan L states that no closures will occur until retrain- ing and placement programs are in place and that surviving hospitals must agree to give top priority to workers laid off by the closing of other facilities. Hospital unions disparage the safeguards. UNITED VAN LINES The provision giving priority to hiring dis- placed workers is not binding on the hospitals. Retraining and placement programs will be a cruel joke for many entry level workers in Michigan's depressed economy. Meanwhile, in Washington, as federal aid for reducing bed capacity was being written into the 1979 Health Planning Amendments (11), the American Federation of State, County and Municipal Employees (AFSCME) which represents 100,000 hospital workers won cer- tain safeguards for displaced hospital workers. Hospitals using federal funds would be re- Trouble Ahead, Trouble Behind quired to supplement unemployment insur- ance benefits and subsidize health insurance The vagaries of politics make it difficult to predict the final outcome of Detroit's bed while their workers undergo retraining and job placement. This requirement poses a potential reduction effort. Even as the original legisla- tion was under consideration and a hospital obstacle to the Detroit plan whose advocates are construction moratorium was in effect, the reluctant to make such a commitment. University of Michigan pushed through appro- CHPC - SEM, OHMA and GDAHC, seeking federal aid to pay off the debts of targeted hospitals, conducted a high level - meeting with val of an 1,100 bed replacement facility for the UM Medical Center. CHPC - SEM opposed the plan but OHMA collapsed under severe HEW which was virtually chaired by Ford of- ficial Jack Shelton. Ford and GDAHC officials pressure from UM alumni in the legislature. Such political interference bodes ill for the objected that pending federal requirements future. Legislators who initially supported protecting the rights of displaced hospital reductions have backed away in the face of workers would make the closures too costly. community pressure, suspending the plan until ! Although the Detroit Central Labor Council an investigation by both houses of the Michigan testified that it would oppose any reductions oc- legislature is completed. curring until a job placement program was in full swing, that commitment has not been translated into action. Neither the UAW nor the Should the plan be implemented, broad outlines of its impact are nevertheless clear: Detroit AFL CIO - officials present at the HEW meeting objected. The fight over employee protection will be a major test of the UAW's commitment to social justice and progressive domestic policies. It would be ironic for the UAW, whose members enjoy a negotiated plan which supplements their own unemployment insurance benefits, to oppose such protection for hospital workers earning less than half the automakers'salaries. In the meantime, these standards have be- come mysteriously stalled. Insiders at Detroit City Hall doubt that a Carter Administration Labor Department would withdraw its promise to the hospital workers without Mayor Young's approval. They speculate that Young may have demanded exemptions for the Black hospitals. in exchange for his intervention with HEW. COSTS: The superb irony is that this massive and disruptive effort may not reduce hospital costs; it may well increase them. Conventional planning wisdom favors consolidating care into regional systems based in large tertiary institu- tions, where it is assumed the highest quality, most cost efficient - care is available. There is lit- tle evidence supporting these assumptions. Some community advocates cite studies which argue that these " economies " disappear in giant, inefficient bureaucracies. Large tertiary care hospitals, with residency programs or direct ties to a medical school, moreover perform more poorly on a wide range of " efficiency " measures. They are more likely to have a greater debt structure because of overinvestment in expensive technology. Large hospitals also have a higher ratio of full- 33 Table 3 Diagnosis 1978 Average Room and Board Charges by Hospital Group (13) Type of Hospital Normal Delivery Medical School / Teaching Intensive Intern and New Jersey Philadelphia Intern and / or or Residency Teaching Area Residency Hospitals Hospitals Community Program (14) Hospitals Other New Jersey Hospitals $ 196.04 $ 149.49 $ 124.69 $ 94.01 $ 94.25 $ 119.01 Chronic Ischemic Heart Disease 234.53 177.38 146.30 124.89 142.61 130.29 Inguinal Hernia 193.80 148.30 126.06 111.54 118.77 117.98 Female Non malignant - Genito urinary - 195.38 149.57 125.92 104.27 107.09 114.98 time employees per patient (12), perform a greater number of tests, and charge more for them (13). Large hospitals answer that they treat more complicated cases and sicker patients who need more services but their defense does not stand up to scrutiny. When Blue Cross of Greater Philadelphia analyzed the paid claims tapes for 314,000 employees and their depen- dents for 1978, they found that hospital per diem charges and ancillary charges are often twice as great in tertiary hospitals as they are in community facilities (13). Walter McClure, an authoritative figure in nn ee-SSCSCSs Table 4 1978 Average Ancillary Charges per Admission (13) Diagnosis Normal Delivery Chronic Ishemic Heart Disease Medical School / Teaching Type of Hospital Intensive Intern and / New Jersey Intern and / or or Residency Teaching Residency Hospitals Program (14) $ 1,129.99 $ 811.32 $ 667.29 $ 680.68 4,740.77 2,116.80 1,006.94 2,094.13 $ 621.96 829.44 Inguinal Hernia 1,111.42 Female Non malignant - 34 Genito urinary - 1,113.28 670.01 672.33 663.72 581.50 680.70 753.47 575.01 538.46 Other New Jersey Hospitals $ 641.36 1,393.45 613.60 684.02 ne Standards used for closing facilities made no note of those most accessible to the poor and minorities. In fact, accessibility ranked just above the size of a hospital's parking lot excess bed discussions, recently compared metropolitan hospital systems. His findings suggest that: " Direct capacity reduction could force out the wrong hospitals... the most effi- cient metropolitan hospital system (may be) comprised of mainly moderate - sized ' front - line'hospitals backed up by a very few'full service'medical centers offering the more specialized tertiary ser- vices... This guideline suggests that, from the standpoint of efficiency consis- tent with high quality, we should con- strain the number and growth of'full- service'tertiary institutions and em- phasize more moderate - sized'front - line ' hospitals " (15). These two studies raise the troubling thought that after creating access problems for inner city residents and displacing 9,000 hospital workers, the net effect of the reductions may be ~ the opposite of that intended. ACCESS: There is a real threat of serious ac- cess problems. Some of the same crises leading to the reduction plan also make health cuts risky. The closure of city owned - Detroit General Hospital and the threatened sale of the city's Detroit Receiving Hospital to a consor- tium of private hospitals may deprive Detroit's poor of their most certain sources of care. The most disturbing hint of potential access problems is the disdain planners had for the issue until they were criticized by civil rights groups and community organizations. Four months after promising to study access prob- lems, CHPC - SEM still has not obtained or analyzed patient origin data. The reduction plan has also ignored the effect closures will have on primary care sites such as outpatient departments, emergency room treatments, or the location of physicians'offices. CHPC - SEM Director Terence Carroll went so far as to tell HEW officials that the reductions are solely for inpatient activity, and that " Hospitals don't ad- mit patients... doctors admit patients. This plan has nothing to do with doctors'offices. " Inpatient cuts may also overload long term - care facilities. Some hospitals will react to a limited bed supply by controlling unnecessary admissions and surgeries. Others will work to reduce the present length of stay. There is already a strong financial incentive to discharge patients early since the latter days of a patient's stay generate little revenue beyond the hospital's per diem charge. This encour- ages rapid discharge of postoperative patients to make room for new, more lucrative surgical patients. Because Medicaid pays less for care than does Medicare or private insurance, Medicaid patients will be discharged most quickly of all. Detroit's long term - care industry is not in a position to care for many postoperative patients. The shortage of long- term care beds is already so severe that some areas nursing homes are illegally demanding substantial private " payments " before admit- ting Medicaid patients. As in every other arena, minorities and Medicaid patients will face the greatest bar- riers in obtaining nursing home care. A recent survey in Philadelphia revealed tremendous discrimination against Blacks and Medicaid patients in nursing homes (16). Similarly, Memphis activists are suing hospitals whose discharge workers regularly refer white pa- tients to skilled nursing facilities while steering Black patients to board and care facilities with little nursing supervision (17). As one activist summed it up, " The planners behaved as though hospitals existed in a vacuum. They ignored ambulatory care and long term - care. Somewhere, the'comprehen- sive'got left out of'planning health '.- " JOBS: Uncertainty about how many (and which) hospitals will close also complicates projections about unemployment. AFSCME points out that planners'projections of attrition based on historically high turnover among hospital workers may be meaningless in the midst of Depression - like conditions. Hospital workers may well cling to their jobs, leaving displaced employees out in the cold with thousands of other jobless Detroit residents. Planning and the Dilemma of Community Support Hospital administrators who support reduc- tions in the abstract become less public- spirited when their own facilities are targeted. 35 / BEKING UNITED VAN LINES -~ CELSI MOMCAK Michigan hospital administrators have sudden- ly embraced community - based planning. They have not become born again - populists. Their conversion to democratic planning reflects their political judgement that the reduction plan has failed to gain community support. Community participation has long been the " soft underbelly " of health planning. HSAs have allowed questions of community values to become mystified by a series of abstract guidelines and formulae. Because few HSAs are seen as champions of the public good, it is relatively easy for hospital administrators to portray planners as hearted cold - number- crunchers with no respect for community values. Although it may be too late in Detroit, several lessons can be drawn for the future. As agents of cost control, HSAs are in a dif- ficult position. Consumers complain about the cost of care, but they are also concerned about accessibility, quality and patients'rights. Because few HSAs have worked on these prob- lems, they have failed to garner the support that would see them through controversial reduction plans. Had CHPC - SEM earned a reputation as a champion of the consumer, it might be harder now for the hospitals to rally consumers against its cost cutting - efforts. Planners who fail to earn the trust of community groups do so at their own peril, for given a choice between a CAT scan- ner and a planner, many underserved areas will opt for the former however marginal its ser- 36 vices may be. It is equally important that HSAs become champions of quality. The popular sympathy for nursing home reformers, women's health activists, and other consumer advocates sug- gests this tack will be richly rewarded with in- creased public support. CHPC - SEM failed on all of these counts. In this respect it is probably no worse than most HSAs. Yet their failure to address access and quality of care, and to marshall community support may well doom their bed reductions ef- forts. Ironically, the words of the Hospital Council in its own bed reduction report may frame the issue best should an epitaph be needed: " attainment... of the cost containment objective without equivalent concern for other health systems objectives revolving around quality, accessibility, organiza- tion, management, and comprehen- siveness of health services is likely to prove self defeating - in the long run " (3). Disaster Planning: Advocate - Planners in a Shrinking System As the medical industry's lobbying thwarts cost containment legislation, mounting fiscal pressures are steadily driving federal, state, and local governments to cut costs however they can. New York City, Chicago, St. Louis, and Philadelphia are " solving " this problem with a frontal attack on health care for the poor and through the forced closures of public hospitals. Hoping that private hospitals will questions of resource reallocation. Residents of begin treating the uninsured poor, these cities underserved areas, senior citizens, women's operate on what Cook County Hospital's Medical Director Quentin Young calls the " Marie Antoinette " theory of health care health groups, and others become a natural constituency for such programs. Gainsharing approachs are also attractive to reform. It is absurd, Young charges, to believe that the poor who have had to scramble for the crumbs of underfunded public medicine will suddenly be allowed to feast on the cake of hospital workers because the plans concentrate on labor intensive - primary care and public health activities which create jobs for displaced hospital workers. Where planners shirk their private sector largesse. In addition to the direct assault on the poor, HCFA is grimly proceeding with its " omnibus bankruptcy method " of controlling its budget. Unable or unwilling to constrain the massive costs of unnecessary hospitalizations, obligation to ensure fair treatment for hospitals workers, they are inviting a firestorm of opposi- tion. If unions decide that planning is a code- word for cutbacks, speedups, and lay offs -, trade union support for the planning program will evaporate. surgeries, diagnostic tests and drugs, HCFA tries to tighten the screws on the amount Despite the high potential of gainsharing, advocates should proceed with caution. One Medicare and Medicaid pay for various pro- cedures. These policies have led to a new syn- drome of financially distressed hospitals. These hospitals are not facing bankruptcy because of mismanagement or overbuilding. Tragically, their troubles stem from their refusal or inabili- ty to close the doors on the poor. Of the twenty- planning expert observed that " Promises to substitute free standing - ambulatory centers have proven unreliable in many cases " (19). Even the highest - level HEW official respon- sible for the planning program has cautioned, " Promises of clinics appearing at some point in the indefinite future or undocumented asser- four private hospitals which closed in New York tions that there will be no unemployment City between 1974 and 1978, 86 percent were among hospital workers are not enough " (21). in or on the border of medically underserved poverty communities (18). A study of health systems changes in eighteen large cities from A gainsharing program in Detroit would re- quire commitments from HCFA, the Michigan Department of Public Health, Blue Cross / Blue 1937 to 1977 found that hospitals in Black Shield, the UAW, and the auto manufacturers. neighborhoods were three times more likely to The plan would require that half of the prom- close or relocate than were hospitals in white ised $ 40 million annual savings would be used neighborhoods (19). to establish a comprehensive network of The planning arena may offer the least of primary care, home health, environmental 1 three evils. The Detroit bed reduction plan was health and similar programs. Although such a dominated by corporate and political elites in- program would be hard to implement, the different to the poor. Nonetheless, the planning rewards of broad based - political consensus process is more public than private budgetary decisions. This offers advocates freedom to around capacity reduction would be well worth the effort. wrest concessions from those planning the cuts. Because advocate planners must prepare for It may well be too late for Detroit, but reduc- tion efforts in other areas will fare better if they defensive involvement in HSAs, they would do include the following steps: well to develop positive, offensive strategies which seek to translate the pressure to contain costs into efforts to reallocate resources. 1. Steadily build community support around access, patients'rights, and other issues One approach is to unite community and which will give planning agencies high labor interests around plans which would visibility. reduce tertiary care capacity and reinvest the 2. As the agency's credibility builds, begin to savings into primary care, prevention and home health efforts. Advocates of such " gain- sharing " programs assert that there is enough examine the quality of care. Identify and ex- pose hospitals and physicians practicing dangerous medicine. Concentrate on those fat in the system for consumers to benefit from hospitals most likely to oppose efforts to controlled costs and service improvements (20). The important political element in gain- reduce tertiary capacity. HSAs must convey to consumers that they are championing the sharing approaches is that it shifts the debate public's right to good health care. from fights over proposed public sector cuts to 3. Use public support to win approval of a 37 Sa The net effect of the criteria measuring hospital care was to severely squeeze small and medium - sized facilities while favoring the large institutions a regionalization program based on a strengthened network of high caliber - com- munity hospitals and a few large tertiary facilities. Ensure that the savings derived from such a plan will be used to meet health needs of the underserved, provide jobs for displaced hospital workers and emphasize ambulatory care and community treatment of long term - illnesses. Such a prescription foretells a turbulent future for health planning. Yet there is no way planning agencies can avoid such a role, as fiscal crises, public hospital closures and Medicaid cuts force HSAs to address these problems. Ironically, planning approaches are becoming more attractive at the very moment when the planning program itself may be on the chopping block. The Office for Management and Budget has recommeded a 30 percent cut for HSA funding in fiscal year 1981, preferring to strengthen the hands of state planning agen- cies which are well insulated from community pressures. Planners seeking to build a consti- tuency strong enough to pull HSAs through the budget storm and guarantee their survival would do well to consider these proposals. Planning is down at the crossroads. It's time to flag a ride. -Mark Allen Kleiman (Mark Kleiman is executive director of The Consumer Coalition for Health, a national alliance of labor, civil rights, senior citizens, women's, religious and community organiza- tions dedicated to greater consumer control over the health system.) References 1. The author is indebted to Milt Camhi, Karen Glenn, Ronda Kotelchuck, Susan Rourke, Cathy Schoen and Herbert Semmel for their close and patient readings of this paper. 32.. GMoitcthliiegba,n SPyumbolndi,c EHlelailottth, CMoidceh%a el2 2T1.5,4 .H ellstern, Robert F., and Bulter, Frederick W., Reduction of Excess Hospital Capacity: A Suggested Strategy for Action. Greater Detroit Area Hospital Council, Detroit, Michigan, 1977. 4. Shaheen - Paul, Pamela, " The Michigan Hospital Bed Reduction Act. " State Health Notes, National Con- ference of State Legislatures, January, 1980. 5. Comprehensive Health Planning Council of Southeastern Michigan, Commission on the Reduction of Excess Hospital Capacity, Plan for the Reduction of Excess Hospital Capacity in Southeastern Michigan. Detroit, Michigan, 1979. 6. Although utilization became the most heavily weighted factor, this does not reflect an emphasis on occupancy rates. Most of the utilization criteria were based on rates for specialized services found only in larger hospitals. Although the small hospitals could not lose points for not having these services, they could not gain points either. The percentage of points given to overall use standards therefore overestimates the importance of this factor. 7. " Warning: Open Heart Surgery Ahead. " Consumer Health Action Newsletter. 5, 3, May June - 1980, p.4. 8. Tape recording of the January 17, 1980 meeting of " Sub- committee A " of the Commission on the Reduction of Ex- cess Hospital Capacity, Comprehensive Health Plan- ning Council of Southeastern Michigan, Detroit, Michigan. 9. Tape recording of the January 30, 1980 meeting of " Sub- committee A " of the Commission on the Reduction of Ex- cess Hospital Capacity, Comprehensive Health Plan- ning Council of Southeastern Michigan, Detroit, Michigan. 38 10. Metropolitan was ultimately exempted because the 1979 health planning amendments exempted HMOs or hospitals heavily used by them from the CON process. 11. 1621 (b) (1) (C). 12. American Hospital Association, Hospital Statistics, 1978. 13. Joint Health Care Cost Containment Program, Hospital Utilization Report. Blue Cross of Greater Philadelphia, Philadelphia, Pennsylvania, 1979. 14. Among hospitals providing house staff training pro- grams, the degree of teaching intensity has been measured by dividing the number of full time - house staff by the average daily census per hospital. These ratios were listed in descending order and divided into two groups. Hospitals directly affiliated with medical schools, and hospitals which had ratios at or above the mean for all teaching hospitals, were rated as having " in- tensive " programs. 15. McClure, Walter, Comprehensive Market and Regulatory Strategies for Medical Care. Interstudy, Ex- celsior, Minnesota. HRA Contract No. 230-77-0033. 16. Lawrence, Vanessa J., and Duson Mirach, Jill, " Racial Discrimination in Nursing Home Admissions in the Greater Philadelphia Area. " Health Law Project Library Bulletin, 4,1, January, 1979, pp. 20-27. 17. Hickman vs. Fowinkle. Civil Action No. 80-214, Western District of Tennessee, filed January 11, 1980. 18. Kreskey, Beatrice, and Clark, Michael E., " The Evolu- tion of the Fiscal Crisis and the Organization of Personal and Public Health Services. " 107th Annual Meeting, American Public Health Association, New York, New York, 1979. 19. Sager, Alan, " Urban Hospital Closings in the Face of Racial Change. " Health Law Project Library Bulletin, 5,6, June 1979, pp. 169-181. 20. Brownstein, Alan, " Reducing Beds: A Gainsharing Op- tion. " Consumer Health Perspectives, 6,3, April 1979, pp. 5-11. 21. 21. 21. Letter from Dr. Henry A. Foley, Health Resources Ad- ministration to all HSA and SHPDA Directors, November 2, 1979. Peer Review Justice for All? Dear Health / PAC Bulletin: On Saturday, November 3, five anti Klan - demonstrators were killed and two others seri- In Plain English ously wounded by avowed members of the Ku Klux Klan Dear Health / PAC Bulletin: I can understand what you're saying about the exploitation of FNGS (Foreign Nursing Graduates). I understand that many FNGs have problems with English rather than with nurs- ing per se. (Evidence of the fact is that of all four women in my graduating class at UCSF '79 who did not pass the state Board spoke English as a a second language - one at least I know to be a very good nurse.) ; But here's the problem. Some measure of English has to be a requisite for licensure. I've worked in mad house - hospitals where I've sat through reports not understanding one half of what was being reported to me, where patients (English speaking) were furious because they couldn't make FNGs understand their requests, and where FNGs couldn't under- stand verbal orders from doc- tors. It's dangerous when English speaking - practitioners and Nazi Party. Among those murdered were physicians James Waller and Michael Nathan. Paul Bermanzohn, an- other medical doctor, was seri- ously injured. An American Public Health Association resolution passed that same weekend condemned the killings in North Carolina and demanded justice in the full prosecution of the murderers. The resolution went on to state that the APHA " encourages its membership and friends to sup- port in whatever ways possible activities activities in in opposition opposition to to the the Klan and similar groups. " ' The Greensboro Justice Fund has recently been formed to finance a major civil rights suit against the Klan and Nazis and to fight for the widows'right to a private prosecutor. The direc- tors of the Fund include Philip Berrigan, Reverent Ben Chavis of the Wilmington 10, and Dr. Michio Kaku, physicist and anti nuclear - activist. Dr. Michael Nathan was a in this country practice medicine or nursing without be- ing able to understand foreign born patients. It's also dedicated pediatrician at the Lincoln Community Health Center and was co founder - of the Committee for Medical Aid dangerous when FNGs and to Southern Africa. Dr. James FMGs can't understand Waller had worked as a pedia- English. trician at New York's Lincoln Sincerely, Hospital, and was active in Cathie Colwell, RN community organizing there. In North Carolina, Drs. Waller, Nathan, and Bermanzohn all helped to organize screening clinics for respiratory diseases among textile and rubber work- ers. In the words of the APHA resolution, " these three physi- cians felt that opposing the Klan was part of their responsibility in serving the interests of the people. " The ambush of the anti Klan - demonstration and the murders are all recorded on TV video- tape. Yet eight of the nine cars in the caravan which attacked the rally were never stopped and their occupants have never There is a clear and growing danger that most of those responsible for the killings will go free.... It would give a green light to all kinds of hate groups and set a frightening precedent for the 1980s been apprehended. Recently, conspiracy charges against all of those who were " accused of the murders were dropped and all but one of the 13 accused murderers are free on extreme- ly low bail, ranging from $ 4,000 to $ 50,000. One month ago, Dr. Waller's widow was denied her request for a private prosecutor in the case. The legal cases in Greens- boro have now become a focal point for all those who oppose Klan violence. With the funds for this legal effort, there is a clear and growing danger that 39 US POSTAGE most of those responsible for the killings will go free. The acquittal of any of the MD murderers would give a green light to all kinds of hate groups GARR and set a frightening precedent for the 1980s. The ideology of those killed matters not. Not to 20. SUNITED STATES fully prosecute the Klan, Nazis and others responsible for the murders both criminally and civilly will cost all progressive people dearly in the years ahead. The legal cases in Greens- boro will cost a tremendous amount of money -- more than $ 250,000 in the first year. We are asking you to make a con- tribution to the Greensboro Justice Fund to help finance the cases. Your contribution will be used for expenses like deposi- tions, expert witnesses, equip- ment, xeroxing, and part will be used for attorney, secretarial, investigator, and research fees. Please donate now to the Greensboro Justice Fund, P.O. Box 2861, Grand Central Sta- tion, New York, N.Y. 10017. Sincerely, Daniel H. Barco, M.D. Jill Blacharsh, M.D. Jean S. Chapman, M.D. Richard David, M.D. Barbara Donadio, R.N. W. LaDell Douglas, M.D. Joan Drake, M.P.H. Delores W. Esthes, R.N. Robert Ettinger, M.D. Arthur Finn, M.D. Michael Freemark, M.D. Mary Kane Goldstein, M.D. Yonkel Goldstein, PhD Dr. John Hatch Henry S. Kahn, M.D. Michio Kaku, PhD Robert Konrad, Phd Frank Black Miller, M.D. Thomas G. Mitchell, PhD Peter Moyer, M.D. Martha Nathan, M.D. Harold Osborne, M.D. Salvatore Pizzo, M.D. Neil S. Prose, M.D. Juanita Saulters, ALPN Jessica Schorr, M.D. Michael Schwartz, M.D. Christiane E. Stahl, M.D. Alan Woolf, M.D. a Human Sciences Press 72 Fifth Avenue New York, New York 10011 1