Document QJp7yZKK21bkBab8deBoY6VE4

HEALTH & PAC HEALTH POLICY ADVISORY CENTER Bulletin ## 11 July August - 1969 Editorial... THE GREAT PLANNING SCANDAL THE HEALTH PLANNING " MOVEMENT, " THE MOST RECENT ATTEMPT TO BRING REASON AND LIGHT TO AMERICA'S 19TH CENTURY MEDICAL MARKETPLACE, IS ALREADY SHOWING SIGNS OF AGE AND DISILLUSIONMENT. AS HOSPITAL COSTS SPIRAL AND MEDICAL RESOURCES DRY UP, THE ONCE REVOLUTIONARY CONCEPTS OF PLANNING AND REGIONALIZA- TION HAVE SETTLED DOWN AS HARMLESS CLICHES. The need to " rationalize " laissez faire medicine, even at the cost of long dreaded - government intervention, is now a com- monplace theme for medical school graduation oratory. Government " intrusions " resulting from Kennedy / Johnson Health New Deal legislation have calmed the fears of all but the most rear guard - national health forces: The movement for plan- ning and regionalization does not threaten to truly rationalize health services. The need for planning became especially acute to many Federal policy makers - after the passage of two financing bills- Medicaid and Medicare. Liberal medical advisors thought it would be prudent to follow up the Federal dollars with some sense about health care organization. The results were the Comprehensive Health Planning Act (CHPA) and the Regional Medical Program (RMP). Both laws looked to the medical establishment - medical schools, voluntary hospitals and private insurance companies - for leadership towards the Brave New World of planned care. Both are failing fast. The New York City scene exemplifies the national crisis in planning: OE Bed occupancy in the City's voluntary hospitals is 92 percent, which means that doors are often closed even to the seriously ill. One New York doctor has dropped his Blue Cross policy, explaining that if he had a heart attack he wouldn't be able to get into a hospital for three or four days anyway. OE Nursing home bed shortage is so severe that elderly patients linger on in expensive hospital beds while waiting for nursing home openings. M@ With the present City budget cuts, ambulatory ser- vices will evaporate to the point where hospital admissions Brave New World? will be necessary for patients who stopped vital medica- tions which were not obtainable in the outpatient clinics. OE Some sections of New York City have so few medical resources and such difficulty with access to medical facil- ities that they have developed " rural " health care delivery syndromes. In New York, as in many other cities, CHPA and RMP are being destroyed by local nonfeasance and misfeasance. But right from the start, the programs had such serious " congenital defects " that there was little hope they could survive local institutional selfishness. Both are based on the long standing - tenets of American health policy volun- - tarism and elitism - which add up to the naive hope that, if you give the most respectable elements of the private sector enough rope, they will eventually knit together a ra- THE BRAVE NEW WORLD of health planning - with the black bag of technological and scientific advances - is far from reality in New York or the Nation. In this issue you will read about: @ The New York Regional Medical Program - the $ 2 million misunderstanding. [See " Anatomy, " Page 3.] @ The decline and fall of the City's Health and Hospital Planning Council empire. [See " Death of a Salesman, " Page 6.] OE The public health planning agencies breakdown as the agents of change for designing health care de- livery systems. [See " The Blueprints, " Page 8.] OE Community groups seek a piece of the health planning pie. [See Deaf " Ear, " Page 9.] tional health system. All such hopes for elite, voluntary leadership have been dashed by the New York City experience. The New York Regional Medical Program debacle is a case study of what happens to frail Federal legislation in the hands of local medical barons. [See RMP story, Page 3.] The elitist as- sumption that medical schools would take leadership in reorganizing medicine ignored the existing role conflicts among the " medical empires. " Some were too busy build- ing their own private regional empires to bother with the regional service networks RMP envisioned. (See April, 1969 BULLETIN). Others were afraid to tarnish their academic research and educational excellence through involvement in regional schemes. Thus New York RMP " failed to thrive " through neglect and avoidance by the medical schools. The story of the local Comprehensive Health Planning effort is no less sordid. The potential failures of the Comprehensive Health Planning Act have been exposed by the bankruptcy of the model on which it was based, the New York Health and Hospital Planning Council. (See [ (Continued Page 2) Editorial ......... related story, Page 6.] New York City has been hailed as the medical planning model for the nation. Yet all the problems that planning was designed to solve (maldistribution of facili- ties, bed shortages, etc.) have become worse in New York City despite (and sometimes because of) the 30 year - - old Health and Hospital Planning Council. It would take a miracle of retroactive planning to salvage the City's health system from chaos. But the only improvement comprehensive plan- ning is likely to bring, if it ever gets off the ground, is a cosmetic smattering of " consumer " representation in the planning process something - the Planning Council never felt worth bothering with. There are clues that the designers of these self stopping - programs (RMP and CHPA) were not very serious about plan- ning and regionalization in the first place. In the Health New Deal of the mid 60's -, financial reforms (Medicare and Med- icaid) are carefully segregated from organizational reforms (RMP and CHPA). This separation automatically renders any form of planning impotent. Without the financial clout to change existing patterns of service, no new organizational forms (such as team practice) can be encouraged. This amounts to making planning a process of changing relation- ships between given institutions without significantly altering the services offered by those institutions. Reorganization of American medicine through RMP and CHPA has or will clearly fail. But Federal sanction of regional- ization and planning has resulted in two major changes. First, planning has been elevated to the status of a new " science " in the armentarium of health skills. Previously, planning was not only considered unnecessary, it was counter to the spirit of a free society. Some may still look with apprehension on the 1984 - ish vision of health planners actually using the " science " of planning as a basis for decision - making. But there is little substance to this fear. The actual health plan- ners (hospital directors, deans of medical schools, insurance executives, etc.) are not about to surrender any of their power to the new health " planning " technicians. The real danger is that health planning as a science will become a new mask for the current elite health planning, shielding real decision making still further from the public view behind a fog of jargon and professionalism. Second, the Federal sanction of regionalization and planning is another symptom of the decline of the entrepeneurial doctor dominated - forces in medicine and the rise of the new corporate managers (hospital directors, deans of medical schools, insurance executives, etc.). RMP and CHPA have done little so far by way of direct subsidy, but they have provided a flutter of Federal flag waving - for the corporate consolidation efforts. " Regionalization " is a nicer word than " empire building; " and " planning " sounds less arbitrary than " decid- ing. " In fact, from Washington, D.C., a tightly - run medical empire probably looks much more " rational " than an open market of private practitioners - just because there are fewer actors on the scene. But these more consolidated enterprises are no more rational in the delivery of health services than the fee seeking - solo practitioner. The corporate forces have Published by the Health Policy Advisory Center, Inc., 17 Murray Street, New York, N.Y. 10007. (212) 227-2919. Staff: Robb Burlage, Vicki Cooper, Barbara Ehrenreich, Oliver Fein, M.D., Ruth Glick and Maxine Kenny. 1969. Subscription rates per year $ 5 student, $ 7 other. their own narrow institutional priorities, which seldom include the delivery of comprehensive personal health care to the patient. Both regionalization and planning have become tools in the hands of these corporate forces for further mystification of the decision - making process. But it is clear, that in its misguided and hesitant way, the Federal government is inviting somebody to do something about the chaotic health industry. The invitations are still out on the table. Nobody has picked up the challenge. RMP and CHPA have shown there is an absolute vacuum of concern for improving health services for all the people. It is time for the new consumer and health worker forces to take leadership that no one else seems to want. Planning and regionalization must serve as technical adjuncts for the consumer to reorgan- ize the system from the bottom up. Y' Heal Thyself.. FOR PERHAPS THE FIRST TIME, this June medical students handed the Deans a document in exchange for their di- plomas at several medical school graduations. Following is the statement given to the Deans by students concerned about their profession and its future: " As we enter the medical profession, we look ahead to working within a health care system primarily consist- ing of private physicians, private hospitals, drug companies, and health insurance companies governed by the profit motive in a society that makes disease, itself, a commodity. We ask ourselves whether we can work meaningfully within a society whose health system has low social priority and dehumanizes members of all classes. Where can we work so that the medical care we provide is not just a series of Band - Aids on immense social ills? Seventy billion dollars of our public tax money supports private industry and the military in its production of weapons for war. Health, education, and welfare (the pur- pose of taxes?) are allotted less than 10% of the national budget. These figures articulate our national priorities. Will the priorities shift without basic social change? We must turn our attention not only toward the " health system, " but also toward the system that maintains peo- ple in poor health, psychologically as well as physically. But our union, the AMA, fights for doctors, not for better health. It has helped maintain control of the number of physicians, of the class from which they come (one third from the upper 3%), and of medical knowledge, which must be spread, not preserved behind the status screen of " professionalism. " We five recognize that we do not represent the majority of our colleagues. But our numbers are increasing, and we are beginning to reach out to other health workers and to politically radical organizations. We will take our knowledge and skills out to the people, so that they may better challenge the society as a whole. In a country where the provision and availability of so- cial services are still a political instrument, medicine is also used politically: in Vietnam to support the destruction of a country struggling for its very existence, and at home to pacify the colonized poor. We therefore conclude that medical service must relate to a political movement to elim- inate the causes of ill hea-l tpho o-r housing, poor nutrition, poor schooling, and the political impotence of poor peo- ple. Only then can we physicians practice meaningful medicine for all people. " (2) Regional Medical Program THE ANATOMY OF A MUDDLE THE REGIONAL MEDICAL PROGRAM in New York City has been a disaster. There is almost nothing to show for the $ 2 million dollars that the medical schools have spent for " planning " in the past two years. The record of the New York Metropolitan Regional Medical Program (RMP NYM -) at a glance reveals: M@ Only two projects have been approved and funded. One, the pediatric pulmonary center at Babies Hospital at Colum- bia is a failure. The other, the Mobile Coronary Care Unit at Of the various agencies other than medical schools that ex- pressed interest in becoming trustees of the corporation, only the prestigious New York Academy of Medicine had enough political clout to get a seat. Health and Hospital Planning Council [See Council story, Page 6.] and the City's Health Ser- vices Administration were relegated to the back seats. They were only given representation on the advisory committee along with the medical societies. St. Vincent's is a poorly conceived demonstration. OE No plan or set of priorities has been established for the " Closed Shop " metropolitan region. What data have been collected on the Under the national RMP Guidelines this advisory committee needs of the region are meager and superficial. was supposed to be a broadly representative group with con- ' OE During the last year, almost all the central staff has siderable power to prevent the Program from neglecting the left the program. The Associate Director was the first to go. consumer and provider interests of the region. It was to have He was soon followed by the Director, the Director of Program had the responsibility for approving all applications for oper- Development, the Director of Administration and Organization, ational grants. But the Deans made it a subservient group. and finally by the Director of Research and Evaluation. As a recent Federal audit declared, the Deans " were in a posi- In New York City, the attitude of the medical schools tion to dictate the decisions and evaluations required of the doomed RMP from the start. For openers, the Deans of the advisory committee. " New York City medical schools met and decided that they were As of 1968, 17 members of the 45 member - advisory com- not going to participate in the Program. RMP did not really mittee were connected to medical schools or to their affiliates. offer them much: There were no funds for new construction; The remainder of the committee was hardly representative of nor was there any opportunity to take over and staff hospitals. the community. The " public " representatives were mostly Wall Instead, they were supposed to strengthen community hos- Street businessmen and philanthropists. Also listed as a " pub- pitals by cooperating with them. In many cases, the hospitals, lic representative " was the vice president of the Health and that they were supposed to aid were in competition with the Hospital Planning Council. Medicine's own out groups - were medical schools for staff, research money and new facilities. excluded from membership. There were no unaffiliated phy- Now the medical schools were to associate not only with strong sicians on the committee and there were no representatives hospitals but also with the weak hospitals and the lowest level from the smaller voluntary hospitals or the proprietaries. As if of practitioners - groups which they had systematically ex- all these safeguard's against unwelcome " advice " were not cluded in their drive to build " centers of excellence. " enough, the Deans kept for themselves the powers of choosing a Turf Fighting - Curiously enough, it was the isolationist Cornell Medical College which was one of the first medical schools in the city to change its mind and apply to plan a Regional Medical Pro- gram. Part of the reason was that Memorial Hospital for Cancer, which is closely affiliated with Cornell, felt that it could get some money from RMP for some if its already exist- ing programs. It looked to nearby Cornell as the medical school with which to form a Regional Medical Program. Down- state Medical School also applied to organize a Regional Med- ical Program at the urging of some of its affiliated hospitals. Subsequently several other medical schools also began writing applications for their own RMP. Washington, however, insisted that in keeping with Congres- sional intent, " there should not be a region for each medical school. " [See Box, Page 4.] This decision was made in part to avoid the fragmentation of a natural region, New York City, and in part to avoid the political problem of deciding how to parcel Manhattan among its five medical schools. So the medical schools and the New York Academy of Medicine formed a corporation, the Associated Medical Schools of Greater New York, Inc., which was awarded a two year - planning grant for the New York Metropolitan Regional Medical Program. Cornell Dean, John Deitrick, was chosen to be President for the first year of planning. The Deans, although not enthusiastic about the Program, were determined to control it through their new corporation. chairman for the advisory committee and changing its by laws -. Having emasculated the advisory committee, the Deans next turned to weaken the program's central staff, which, ac- cording to their own grant proposal, was supposed to be " responsible for coordinating the activities carried on by the staff located at the medical schools and for the proper alloca- tion and reallocation of resources within the project. " Instead, the Deans set up a decentralized structure, resting heavily on staff located in the various medical schools. They gave their appointed central director no say in the selection of the local staff. Each school (and the Academy too) simply took $ 45,000 each year to pay for whatever local RMP staff it wanted. One of the coordinators was not even seen by the Director during the year he was there. The Deans also decided that the coordinators were actually their representatives as well as staff of the project. So the coordinators often substi- tuted for the Deans at the meetings of the Trustees. The Director often found his " staff " acting as his boss. Regional Medical Specialization When the central staff did try to take initiative to broaden the interest of the program, their efforts were obstructed by the Deans. For instance, the Deans objected to the involvement of the central staff with the Model Cities Program. When the staff member who was the liaison between the programs left RMP, the involvement with Model Cities was quietly forgotten. The Deans also frowned upon the attempts of the Director (Continued Page 4) (3) A House Divided: View From The Top THE " HEALTH NEW DEAL " of the Johnson Administration schools for leadership. was more than just Medicare and Medicaid. The medical Strangely enough, the American Association of Medical liberals who helped shape the 89th Congress'health policy Colleges (AAMC) was not unanimously enthused about believed that it was not enough just to finance medical RMP. AAMC is divided into two main camps: the ivory care for the indigent - the best in medical care had to be made available to all. President Johnson's Commission on tower patricians, and the more expansionary, service- oriented liberals. The former view is summed up in a 1953 Heart Disease, Cancer and Stroke had stated, " a significant AAMC report authored co - by John Dietrick. Dietrick and number of Americans with heart disease, cancer, stroke Berson warned against " building up large empires which and related diseases die or are disabled because the bene- serve as welfare and semicharitable institutions, steadily fits of present knowledge in the medical sciences are not spreading their influence and control over many segments uniformly available throughout the country. " So the Re- of health care. " The expansionary view, summed up in gional Medical Program (RMP, Public Law 89-239, October the Coggeshall Report of 1965 declared that the medical 6, 1965) was enacted " to afford to the medical profes- schools " should be appraising the needs of society for sion and the medical institutions of the Nation the oppor- health care and health personnel " and " developing and tunity of making available to their patients the latest implementing plans to meet those needs. " Dietrick and advances in the diagnosis and treatment of heart disease, Berson were worried about the effects of " expansionist cancer, stroke and related diseases. " policies " upon the medical schools. The " [] already enorm- The Commission wanted to provide the best in medical ous and rapid growth of the service activities of the medical care by establishing a national medical system, at least schools is a drain on the time and energy of the faculties for the killer diseases. They envisoned establishing regional and on the finances of many schools. The extension of research centers, diagnostic and treatment stations in service activities beyond those needed to support a medical teaching hospitals, and a network to link the centers, sta- school's educational program already threatens the educa- tions and community hospitals. However, Congress re- tion of the medical student. " The Coggeshall Report was placed the Commission's blueprint with the vague concept worried about what would happen if the medical schools of " regional cooperative arrangements " among the existing DIDN'T expand their responsibility: " Failure to do so will health resources for research, training and demonstrations damage the standing of the profession and educational of patient care. institution and will invite - even make necessary less de- But who was to plan and implement the " regional co- sirable approaches, " such as the direct " intervention of operative arrangements "? Who was to have the reponsi- the government. " Dietrick and Berson wanted to preserve bility of making sure that the best in medical care was the traditional role of the medical school, the role of ex- made available to all? Although the law does not specify cellence in research and education. The Coggeshall Report this, it was clearly the intent of Congress that the medical was concerned with preserving the entire voluntary free schools should have this responsibility. Congress saw RMP enterprise medical system. " extending the influence of the medical teaching center Thus, on the national level, it was with much hesitation beyond the confines of the university. " With RMP, Con- and even passive resistance that the medical schools em- gress threw out a loose, open invitation to the medical barked on the Regional Medical venture. ANATOMY (From Page 3) to fund a Student Health Project in New York. Although the Student Health Project was finally funded by RMP, it was not by the metropolitan program, but by Washington directly. When the central staff suggested to the Deans that the medical schools become more involved in the continuing edu- cation of the unaffiliated physicians, they met vigorous resist- ance and even resentment. Deitrick, who was then president of the board of trustees, suggested that " the larger voluntary hospitals might undertake a program to upgrade medical education by providing better training for house and attending staffs and allied health personnel. " The medical schools were thought not to have a role and the unaffiliated doctors were to be ignored. Last October, the Diector was finally fired for being too independent of the Deans. Most of the central staff have since left the program. The New York Metropolitan RMP is now undergoing a re- organization which promises, if anything, to strengthen the control of the medical schools. The advisory committee is being made more representative. Its membership has been in- creased from 45 to 87 and will probably be increased to two hundred. A new Director was appointed in March and the central staff will have been fully restored by July. However, the medical schools are still in control. An advisory committee of over two hundred members will probably be little more than a rubber stamp for its steering committee, which will be just as dominated by the medical schools as was the old advisory committee and steering committee. Business As Usual Although the medical schools control RMP, they have neglected it. The Deans thwarted the attempts of leadership by the central staff, yet provided no leadership of their own. The Deans declared that they were responsible for the policy determination for RMP, that they would set the priorities, de- termine the program direction, and the philosophy of the local RMP. But, they haven't. They had doubts about RMP from the beginning and these doubts have not given way to enthu- siasm. One Dean is quoted as having said, " Sometimes when I go to bed at night, I hope that when I wake up in the morning, RMP will have disappeared. " As a result of the lack of leadership, priorities were never established and very little planning was done. The annual report of New York RMP suggests that the medical schools spent what little energy they could spare for RMP dividing up the turf. Downstate Medical Center got Brook- lyn; Einstein, the Bronx; Columbia took upper Manhattan; Mount Sinai and New York Medical College shared East Harlem and part of Queens; Cornell got Westchester and the rest of Queens. Actually, of course, the medical schools did (4) not develop borough - wide or regional responsibilities just be- cause of RMP. The medical school RMP coordinators, whose function was supposedly to stimulate grant applications in their entire region, rarely bothered to look outside their own institutions and affiliates. In New York City, then, RMP served to strengthen the existing medical empires. [See December, 1968 BULLETIN.] Rich Get Richer Unaffiliated hospitals, which fall between the city's empires, have been effectively shut out of RMP. When it comes to grant writing, it's hard enough for a small hospital to compete with a granted - padded major medical center. But it's virtually im- possible to compete with major medical centers which have special relations to RMP staff and leadership. RMP staff were not very sympathetic to the requests of small hospitals for more help in writing grants. In an editorial in the RMP news- letter, the RMP Director wondered disdainfully: " If the appli- cants have neither the time nor talent to describe clearly what will be done by the propect, will they have the ability to con- duct it? " Once a grant is written, it faces a volunteer review committee composed largely of experts from the major teach- ing hospitals, who have tended to fund their own institutions. One doctor was actually a member of the committee which reviewed his own grant application. A pulmonary center was awarded to Columbia rather than to a small hospital in Queens because of Columbia's " proven ability. " Thus the rich get richer. Considering the lack of leadership in the program, it is not surprising that only 51 applications were submitted in the two years of planning. Half of these were from Downstate where there was leadership by the local coordinator. This low number of applications reflects also the lack of interest of the medical school faculties in community projects. For example, NYU School of Medicine's Dean Thomas can not find anyone in his faculty to write a grant for an urban health institute, an institute that he has been pushing for the last year as his medical school's contribution to the solution of the urban medical care crisis. More disturbing than the paucity of grant applications is the quality of the applications. While most have scientific merit, very few are relevant to the intent of RMP to improve patient care. Most represent narrow institutional interest- cloaked in the new rhetoric of the Regional Medical Program. Of the 51 applications received in the last two years, only seven have been approved by the advisory committee (two have been funded so far), 16 have been rejected or withdrawn and the rest are either being reviewed, revised or developed, Counter Demonstration - Projects The two projects which have been funded after all this are little more than a mockery both of the planning process which is supposed to be part of RMP and of the purpose of the program. One of these, the application for the Pediatric Pul- monary Center at Babies Hospital at Columbia, was quickly THIS EDITION of the HEALTH - PAC BULLETIN combines the July and August issues. You will receive your next regular edition of the BULLETIN in September. Two of the major articles in this issue were written by HEALTH - PAC's medical student intern, Mills Matheson, who has returned to the West Coast to resume his second year at Stanford Medical School. solicited and pushed through the advisory committee. It ap- pears that Central RMP in Washington was given some money earmarked for pulmonary centers that had to be spent within a month. Washington asked the RMP in New York to quickly dig up a pulmonary center. The other funded project, the Mobile Coronary Care Unit at St. Vincent's Hospital, was plan- ned long before RMP was established in New York. When the Heart Association didn't fund it, it was submitted to RMP. In its application, Babies Hospital proposed a pediatric pul- monary center that appeared to be exactly the kind of inte- gration and extension of services the RMP was supposed to encourage. Babies proposed to extend the use of specialized procedures in the diagnosis and management of chronic res- piratory diseases by fusing a number of existing clinics and laboratories into a single pediatric pulmonary disease center and tightening its existing affiliation arrangements with six metropolitan hospitals. However, a federal audit has shown that Babies Hospital has done little to implement its proposal. It took the money, hired a few more researchers and con- tinued functioning as usual. The Mobile Coronary Care Unit, a specially equipped am- bulance, at St. Vincent's, will probably never benefit anyone but the community served by St. Vincent's. It provides on the spot emergency treatment to heart attack victims. This is an expensive and therefore hard to imitate demonstration project. It is basically a luxury. The money could have been better spent upgrading the training of ambulance attendants through- out the city or improving the existing inadequate arrange- ments among hospitals for the acceptance of ambulance patients. The one other project in New York that is funded by RMP is the Study of the Care of Cancer Patients at Memorial Hos- pital. This did not have to bother with advisory committee review and approval, however. Washington made funding the Memorial project, which was begun long before RMP started, part of the original RMP planning grant. Surveys, Not Service Of the five grants that have been approved and have just been sent to Washington for review, one is for a continuing education project at Downstate, the rest are surveys and reg- istries. A tumor registry has been proposed by Downstate; a hemiplegia registry, by Grasslands Hospital; (associated with New York Medical College); a survey of acute cerebrovascular disease, by Kings County (Brooklyn); and a study of facilities and services for respiratory diseases, by a TB association. The best that RMP can offer New York City after two years of planning and two million dollars seems to be just more surveys. The Regional Medical Program was conceived as a bold new departure in which, through planning, advances in medical science could be rapidly parlayed into improvements in pa- tient care. In New York, the program was destroyed by the very institutions it aimed to enlist. The medical schools failed to lead RMP and failed to use it for anything beyond their own narrow institutional interests. Much the same story appears to be true elsewhere in the nation. Congress and the Nixon Administration have acknowledged the failure of RMP by sharp cutbacks in funds. It is almost a truism now that the American medical system must be reorganized. Who is going to lead the task of coordinating and organizing a patient- centered American medical system? The failure of RMP shows that we cannot look to the medical schools for leadership. -Mills Matheson (5) Health & Hospital Planning Council THE DEATH OF A SALESMAN DURING THE LAST YEAR, the Health and Hospital Planning Council (HHPC) has lost some if its delusions of grandeur. For 20 years or more it was essentially the only regional health planning agency. A year ago it faced a rosy future as the best qualified group to be the local comprehensive health plan- ning agency under the Federal Comprehensive Health Planning Act of 1966. It saw itself, in the words of its annual report, " free from the pressures of political expediency yet sensitive to the needs and desires of local groups, " possessing " wisdom and courage in making the hard planning decisions, " taking " strong stands in recommending against narrowly conceived or inadequate proposals by hospitals. " But now the HHPC is fearful for its very existence. It seems probable that comprehensive health planning powers will be given to a new planning agency, with strong municipal and community representation. This will make HHPC ineligible for direct federal assistance (which currently amounts to half of HHPC's budget) unless it can contract with the new compre- hensive planning agency to do part of the health facilities planning. But if the community has any power in the new agency, few contracts are likely to come HHPC's way. Despite its self image - as an even handed - arbiter of the health needs of the city, HHPC has repeatedly been discredited as a tool of the voluntary hospitals and of Blue Cross. Health and Hospital Planning Council, like Blue Cross, was a child of the Depression. The Depression brought financial disaster to the voluntary hospitals as the poor crowded into the Municipal hospitals, leaving thousands of empty private beds in the voluntaries. In its search to ensure the economic wellbeing of the voluntaries, the United Hospital Fund, then as now the leading institution of the voluntary medical establish- ment, formed the Hospital Council (which has since become HHPC) and a local Blue Cross plan. Blue Cross was to ensure that there were enough paying patients. The Hospital Council was to ensure that there weren't too many beds. Despite the Depression there was a 6.6 percent increase in hospital beds in New York City between 1930 and 1935. This terrified most of the voluntaries; they had visions of losing their increasingly rare paying patients to the hospitals with newer facilities. They were also terrified that the Municipal hospitals with an occupancy rate of 97.2 percent (compared to 68.8 percent for the voluntaries) would expand and further draw patients away from the voluntary system. So the Hospital Council was formed in 1934 as an unincorporated voluntary association " to develop a coordinated hospital program for the City ". The Council took it upon itself to review all proposals for hospital construction with the criteria that no hospital project " be launched unless it can be shown to be necessary, timely, reasonably assured of support and wisely located. " In 1937, the Hospital Survey, a study initiated by the United Hospital Fund, recommended that a " permanent, representa- tive, and authoritative " central planning and coordinating body be established to save the community from the " extravagance and waste in hospital building and maintenance. " Its prestige enhanced by the recommendations of the Hospital Survey, the Hospital Council incorporated in 1938. Its only power to en- force its planning decisions was its ability to persuade bene- factors of hospitals to withhold financial support from unap- proved programs. In 1947 it got considerably more power when, as the regional agent for the Federal Burton Hill - Program hospital construction funds, it became itself a hospital bene- factor. Between 1948 and 1963 it determined how over $ 21 million of hospital construction funds were spent in the City. The financial distress of Blue Cross in the late fifties gave the planning movement in general and HHPC in particular a big boost. Increases in the cost of hospital care and in the utilization of hospitals threatened to bankrupt Blue Cross and its dependents, the voluntary hospitals. Up until the late 50's Blue Cross had been able to pass its cost increases on to its subscribers. Between 1945 and 1963 Blue Cross in New York State increased its group rates for family coverage by 453 to 708 percent. By the late 50's state insurance officials charged with regulating Blue Cross began to resist approving Blue Cross's never ending - applications for rate increases, in some cases actually refusing them. Caught in the bind between in- creasing costs and the increasing resistance of state offiicals and threatened by competitive private insurance companies who offered cash benefits rather than service benefits, Blue Cross turned to regional planning as a way to control its costs. But regional health planning meant little more to Blue Cross than stopping the construction of any new hospital beds or better still, reducing the number of beds. If there are fewer beds, fewer people can be filling them, and Blue Cross's max- imum liability is reduced. Restricting the number of beds also would lead to more optimal occupancy rates for the hospitals, so, by and large, their interests were met, too. In some states such as Michigan, Blue Cross moved to en- force its planning by refusing to reimburse hospitals that had been constructed without its approval. However, this has proven to be a too blatantly selfish use of power and has been challenged (unsuccessfully) in the courts. In New York, Blue Cross lobbied successfully for laws that gave authority to regional planning agencies to review all hospital construction and renovation. The Hospital Council, more fashionably re- named the Hospital Review and Planning Council (and still later, the Health and Hospital Planning Council), was given this authority in 1964 for the New York City area. Although final authority to approve or disapprove hospital construction rests in the State Department of Health, the State rarely re- verses the Council's decisions. To ensure that the Council had enough money to function " properly " under the new laws, Blue Cross (the Associated Hospital Service of New York) increased its annual support of the Council from $ 10,000 to $ 100,000. In 1968 the Council received over two thirds of its private (nongovernment) sup- port from Blue Cross, the United Hospital Fund and the Greater New York Fund (whose health donations are distributed by the United Hospital Fund). Support from religious and labor groups amounted to less than 10 percent of the amount given by Blue Cross and the United Hospital Fund. Altogether, the pri- vate support makes up only about a quarter of the total budget; the rest comes from the State and Federal government. Even within the HHPC, some have questioned the role of Blue Cross in health planning agencies. George Baehr, who is on the Board of Directors of the Health and Hospital Planning Council, has warned: " At the instigation of the Blue Cross plans, Hospital Review and Planning Councils in several states are now endeavoring to persuade state and local governmental (6) authorities to deny approval for the construction of any addi- tional hospital beds so that the number in their area may be kept to an irreducible minimum, and thereby'put the squeeze ' on the medical profession. The existence of an excessive num- ber of hospital beds in a community unquestionably encour- ages over utilization - . On the other hand, if controls are carried too far in an effort to keep down Blue Cross insurance rates through the device of bed scarcity, a serious public health hazard may be created. " In New York City, the Council's policy of limiting hospital construction has been quite successful: It has already pro- duced a public health hazard. The New York Times has re- cently reported that the voluntary hospitals are crowded to the crisis point. They are now operating at an occupancy rate of 92 percent, far in excess of the 80 to 85 percent occupancy rate that most administrators consider wise. A man in immi- nent danger of losing his life usually can get a bed somewhere but often it is a second- or third - rate hospital instead of the well equipped, well staffed one where he would have the best chance of survival. It is probably the proprietary (profit - mak- ing) hospitals which have benefited the most from the Coun- cil's bed limiting - policy. They are now operating at 86 percent of capacity whereas they were operating as recently as 1960 at 71 percent of capacity. The Council has also contributed to the critical shortage of ambulatory services and nursing home beds. Although the Council has given lip service to the need for these facilities, it often conveniently forgets about them when justifying its policies. In the last decade the number of nursing home beds in the City has fallen increasingly behind needs. There were fewer nursing home beds in 1966 than in 1960. Medicare and a State loan program for nursing home construction spurred a dramatic increase in nursing home construction but the need is still largely unmet. As of January 1968 there were 18,482 nursing home beds, just 1,450 more than in 1960 when the Council stated that there was a need of 13,000 more beds. The Council has done its best to keep down the number of nursing home beds. Using its 1962 pre Medicare - estimates of nursing home bed needs, the Council announced in February of 1967 that they had already approved enough applications for nursing home construction to eliminate all the need. They then stopped processing applications, letting a huge backlog pile up. The next year they reconsidered and decided that 3,000 more beds were actually needed. HHPC has stopped pretending to do objective health plan- ning and has openly become the voluntary hospitals'apologist. [See Box, this page.] According to some observers the Council has been so busy developing the art of apology that it has lost the technical expertise which has been its main advertisement. For instance, the Council recently failed to live up to a contract to deliver data. Late in 1967 the New York Metropolitan Re- gional Medical Program (RMP) made a sweetheart contract with the Council to supply RMP [see RMP story, Page 3.] with statistical data, mainly data on the city's unaffilated physicians. Compiling this data was essentially a mechanical job which, according to some RMP staff, could have been done in two weeks by two clearks. The Council got $ 25,000 and 20 weeks. But data promised for May 31, 1968, wasn't de- livered until May, 1969 - a year late, and then only after Federal auditors had urged RMP to get its money back. If HHPC dies, as expected, with the birth of a New York City Comprehensive Health Planning Agency, there will be few mourners. Community groups have long since recognized Ex Post Facto.. Somewhere along the line, the Health and Hospital Planning Council (HHPC) gave up all pretense of ob- jective planning and took on the role of apologist for voluntary hospital interests. The following two examples show HHPC acted counter to the " public interest. " St. Francis Hospital, in the heart of the South Bronx's health desert, was serving a population which was becom- ing increasingly poor and non white -. In 1965, the Arch- diocese of New York decided it wanted to close St. Francis. Having run $ 500,000 into the red in 1964, St. Francis was proving to be too much of a drain on the Archdiocese's resources. So they asked the Council to review the situation. The Council had previously see Report on Municipal Hospitals and Related Needs in the Bronx, 1961) thought favorably of St. Francis and stressed the need for it. In fact it called a modernization and expansion planned for St. Francis a " welcome development. " However, in response to the prodding of the Archdiocese, the Council in 1965 decided that it was " impracticable for St. Francis Hospital to continue operation as a voluntary general hospital care facility in the South Bronx " and recommended that the hospital " cease operations as soon as practicable. " In the uproar that followed, the Archdiocese changed its mind. The Council promptly reversed its recommendation too. In October 1966, the Council was to reverse itself once more. The Archdiocese withdrew its support for a new St. Francis, and in response the Council decided that the proposed new Lincoln Hospital left no place for the build- ing in the South Bronx of a new St. Francis. The Morrisania Hospital (also in the Bronx) caper is an illustraton of the Council's role as an ex post facto apologist for medical empire builders. Public and private healer- dealers had worked out a grand scheme for the Bronx. The voluntary health establishment would allow a new Fordham Hospital to be built provided that Morrisania Hospital would be relocated at Montefiore in hospital - rich northwest Bronx. The Council was then called in for its recommendations. In January 1968 the Council approved the Montefiore plan, even though this plan was in direct contradiction to the re- sults of the Council's most recent study of the Bronx (December 1966). In this study it concluded that it was " not possible at this time to determine an optimum site for a new Morrisania Hospital due to continuing shifts in population and hospitalization patterns in the Bronx, pat- terns which also will be influenced by the new Lincoln and Fordham hospitals. " Presumably to protect its credibility, the Council suppressed the Bronx report, which has never been released to the public. HHPC as the chief front - man for death dealing - hospital reduc- tion decisions. Other planning agencies, municipal health plan- ners as well as RMP, know better than to count on HHPC for routine data, much less longterm planning considerations. Even HHPC's voluntary hospital and philanthropic member agencies, who have long benefited from HHPC's permissive " planning ", would probably not go out of their way to defend the discredited Council. (The new Comprehensive Health Plan- ning Agency might well serve as a more plausible front any- way.) Understandably, HHPC refuses to recognize the depth of the dissatisfaction it has aroused. Instead, it feels done in by politicians, bureaucrats and irresponsible agitators. It refuses to acknowledge that there are hundreds of thousands of health service consumers, beating on the doors, demanding to be let in on the planning process. -Mills Matheson (7) Who Prints The Blueprints? A HIGH LEVEL - DECISION to build, or rebuild, a City hospital amples of mental health centers, they found they couldn't do is just the beginning of the process leading to actual con- the job without learning a great deal about psychiatry, mental struction. The two major steps on the road to a completed health, and treatment of mental " illness. " Since experience facility are functional architectural programming and, a recent and intuition provide the only clues to the relationship of addition, master planning. floor space - and staff specifications to functions, functional pro- The architectural programming for all New York City hos- grammers found themselves on shaky ground making - non- pitals is done by the Health Services Administration's (HSA's) programming and planning unit, Health SPACE - (Space, Plan- technical judgments in order to come up with usable programs. Thus some feel that good functional programming requires the ning, Architecture, Construction and Equipment). Created only kind of understanding of the local situation that only local two years ago, Health SPACE - was the City's major attempt to groups can provide. solve the tremendous bottlenecks in coordination and con- Consumer involvement in the translation of health needs struction of City health facilities. into health facilities, to the extent it exists at all, has been SPACE's first job was to coordinate construction and devel- rather remote from the functional programmers. For instance, opment of all facilities run by the Departments of Health and when there is a question or problem about a particular hos- Hospitals and the Community Mental Health Board and ex- pital, the Hospitals Commissioner or the administrator of that pedite purchasing of equipment. In its first months, SPACE hospital deals with the community. Lloyd Siegel, the head of was fully occupied assembling information on the various City SPACE, believes that since SPACE serves as the technical arm health facilities, the equipment needs, the administrative of the HSA, the proper relationship of SPACE to the com- procedures for purchasing, etc. Once that data had been col- munities is through the administrators of the local City hos- lected and mechanisms created for keeping it up to date, Health SPACE - took on the more ambitious role of functional pitals on the assumption that local administrators are in con- stant touch with their communities. programmer for City health and mental health facilities. While functional planning was conceptually a great leap Functional programming translates health programs into forward, it did not itself get facilities built. And while expe- staff and space requirements. From the space requirements, diting construction seems to be helping get facilities built, it the size of site and the costs of construction can be estimated; did not help to integrate health care and health facilities with a site can be chosen and a building designed. one another and with other community needs. Something which As SPACE functional programmers set to work, they quickly discovered a need to know more about health care itself. In could integrate functional programs into a total health care strategy seemed necessary. the case of community mental health centers (SPACE reviews The hospital " master planning " program was designed to plans submitted by hospitals which intend to run the mental fill this need. The master plan lays out a long term - strategy for health center programs), SPACE people needed a set of the development of a hospital center. It fills the inevitable standards. After reviewing reams of literature and many ex- time lag between the decision to build and the opening of a complete facility, stressing the need for flexibility, the ability to respond to changing community needs and health care Plans & Planners HOSPITALS MASTER PLANNERS AND CONTRACTING AGENCIES practices, and the relationships of health facilities and other community facilities such as housing. Master plans are prepared by architectural consultants. Be- cause the health facilities process is fragmented (construction Kings County Bellevue Perkins and Will: SPACE Health - Westermann and Miller SPACE: Health - divided betwen City and State and perhaps soon to be handled by new City Health and Hospitals Corporation), the contracts for hospital master plans are held by several different agencies. Coler and Goldwater Phillip Johnson: New York State Ur- (on Welfare Island) ban Development Corp. Elmhurst Skidmore, Owings, and Merrill: D- partment of Public Works (City) For example, Chapman and Garber's plan for Harlem Hospital Center was prepared for the Department of Public Works, while Russo and Sonder's plan for Metropolitan Hospital Center will be done for Health SPACE -. Health SPACE -, however, is supervis. ing all of the master planning, regardless of which agency Harlem Chapman and Garber: Department of Public Works actually contracts with the architects. [See Box, this page.] There is general agreement among the SPACE and consultant Seaview Metropolitan Glasser and Olhausen: Department of City Planning (City) Russo and Sonder: SPACE Health - architects that " master plan " is something of a misnomer, implying more integration with planning for other community needs than actually exists. Ideally, master planning would inte- grate information on excellent health care with structural plans Lincoln Max 0. Urbahn: Department of Public Works for delivering that care - a combination of functional program- ming with a strategy for building. It would integrate community Greenpoint Russo and Sonder; and Kallmann and McKinnell (a Boston firm): New York State Health and Mental Health Facilities Improvement Corp. judgment of needs and priorities with plans for providing health care both in the functional programming and in the strategy for getting things done. And it would integrate plans for health care facilities with plans for the total development of an area - its housing, its schools, its environmental quality. It is unlikely that the present hospital master planning (8) Turning The Other Deaf Ear COMMUNITY PARTICIPATION IN PLANNING, up until now, has Hospital and City planning personnel greeted this development almost always taken the form of stopping someone else's plans. with apprehension, but rapidly found that they preferred talk- Since most public and private health planning is well insulated from public view, particularly in the early stages, communities ing with another professional instead of community people. Thus it was discovered that the Department of Hospitals and the often learn of the existence of a plan only when their houses Department of City Planning had recommended different sites are slated for demolition or ground is broken. Little wonder for the hospital. Rather than express this disagreement before then that community action is directed at halting THE plans. the Community Advisory Board, each agency sought to per- There is no alternative. The following two case studies are suade the board's planning advisor of the merits of their site. examples of community groups that got in on the act of plan- Of course, the planning advisor did not takes sides, but re- ning earlier, but not early enough. Both communities valiantly ported the disagreement to the Community Advisory Board. struggled to define positive roles for themselves in the plan- This interagency disagreement provided the key for accom- ning process. But the establishment's response turned these plishing the board's second aim, opening the decision to the attempts into negative results, so that building was delayed public. Early in November, the advisory board sparked this in one instance, and programs were removed without replace- ment in the other. * * * process by inviting the Hospitals'commissioner to a public meeting at Fordham Hospital. Once the agency split became public knowledge, community groups began demanding in- FORDHAM CITY HOSPITAL, BRONX - The case of the Hospital volvement in the decision making process. This sent each Community Advisory Board vs. public planning officialdom: agency out wooing support for its site choice, particularly from In October 1968, Fordham Hospital's administrator an- residents of the other agency's site. These activities culminated nounced to the Community Advisory Board that the hospital in a stormy public meeting of Community Planning Board would be moved to a different location within the area served # 6 in mid February - . Although the experts aired their tech- by the hospital. Out of seven possible sites, one or two had nical differences, only the community stated clear planning been selected for presentation to the City's Site Selection priorities which would apply to either site: (1) resources and Board. The Community Advisory Board objected strenuously. official energy should go into improving the hospital's services Why hadn't it been consulted earlier in the planning process? before worrying about its location; (2) no housing should be How could it form an intelligent opinion without access to in- destroyed for the hospital until replacement housing had been formation on all the sites? built (several people pointed out that adding bus lines would The Community Advisory Board decided to take action. First, not destroy any housing); (3) planning done without solid com- it needed all the information necessary to make a reasoned munity involvement from the start is illegitimate. judgement about site location. Second, and more important, Unfortunately, public officials responded to this outpouring it wanted to establish the principle of community participa- of community interest with a rapid retreat. Instead of involv- tion in the planning process. To accomplish the first aim, the board obtained its own planning advisor, who was assigned to ing the community in choosing a site and then in accelerating the rest of the process preceding construction, the two collect information and report back to the advisory board. (Continued Page 10) (From Page 8) process in New York will achieve these goals. Since each hos- pital's master plan is prepared separately, the master plans cannot deal with citywide health needs or distribution of health facilities. " Areawide planning, " Mr. Siegel points out, " is something quite different. " Functional programmers and master planners are finding, after intensive research, that no one really knows what good health care really is. Those tech-. nicians who suspect that their work is irrelevant without sub- stantial input from the communities find no public, institution- alized process for involving communities in the decisions about their health care, with the result that a great deal de- pends on the attitudes and initiative of the private architects hired to do the job. Even at this early stage, it is clear that the lack of a formal, institutionalized, public process for community participation in planning for health facilities generates both technical diffi- culties and a series of frustrations. Interviews with architects indicate: (1) they are anxious to develop recommendations that really meet the needs of the areas they are planning, (2) they want to see plans implemented and good care provided, and (3) they regard community involvement as essential to de- veloping a good plan and to implementing the plan. They are therefore anxious to meet with community groups - for ideas and review of ideas and to enlist support for the resulting pro- posals. Architects do seek out community groups but must do so rather randomly. It seems likely that they will wind up working with those groups they feel comfortable with and who feel comfortable with them. And, whether or not that happens, no one can be sure they are getting any substantial representa- tion of community views. For the architects, the operational question vis vis - a - com- munity involvement is whom to talk to and how to set up an ongoing, productive dialogue. (Chapman and Garber have even written into their master plan for Harlem a proposal for a hospital board including community people - other than recom- mending it to the City, they have no way to help create a public process for community involvement.) For the communities, the question is basically whether or not talking to the architects is going to be worth the time, since hospital master plans are at best only a series of recom- mendations for City strategy with respect to City health ser- vices. The first completed master plan document is just now being submitted by Chapman and Garber. It remains to be seen whether master plans will have any effect or whether decisions will continue to be made the same old way with -- the volun- tary affiliates determining what happens on the basis of their own priorities. -Ruth Glick (9) Deaf Ear (From Page 9) agencies compromised privately. This delayed approval of a site for four more months. Though the community had tried to assert a positive role in planning, the result was delays without any meaningful involvement in the planning process. * * * THE LOWER EAST SIDE NEIGHBORHOOD HEALTH COUNCIL- SOUTH, GOUVERNEUR HOSPITAL - The case of the Lower East Side Neighborhood Health Council - South vs. Beth Israel Medical Center: Some critics of community participation in planning argue that, while it is relatively easy to arouse a community about a hospital site (which threatens their housing), it is very diffi- cult to mobilize people about program. The reason, they feel, is that community groups lack the expertise and overview necessary to understand the complexities of medical programs. The Lower East Side Neighborhood Health Council South's - (LESNHC - So) attempt to influence Gouverneur Hospital's health services disproves this cynical view of the community. The LESNHC - So has developed an increasingly sophisticated approach to program priorities. When Beth Israel (The affiliat. ing hospital for the Gouverneur Health Services) turned over its 175 page plus proposal for OEO funds to the Health Council, as mandated by OEO regulations, few thought the Health Council would be able to master the document. To Beth Israel's surprise and consternation, the Health Council's review of the proposal included a thorough analysis and some severe criticism of the hospital's program priorities with an explicit statement of the Council's own priorities and appro- priate justification. The health council acknowledged that the basic program of the Gouverneur Health Services should re- main the provision of comprehensive health care delivered through family health units (team practice) with emphasis on prevention and continuity. They vetoed a " cognitive testing " program to be carried out by the Department of Behavioral Sciences at Gouverneur, an obviously research rather than service criented endeavor. Also, they succeeded in replacing the ameliorative " patient guide " program suggested by Beth Israel with a " health advocate " program to be sponsored by the health council. This latter program had the potential for establishing a patients'grievance mechanism at Gouverneur. However, they argued, certain additional programs were essen- tial to meeting community health needs. These were: (1) a narcotics treatment and outreach program; (2) an employees training and career ladder program; (3) a Saturday clinic and improved transportation facilities for patients; (4) a lead poisoning detection program. The value of community priority - setting is in terms of the community's perception of need. Often, this perception is more sophisticated than the expert's understanding, and it always expresses a greater sense of urgency. For instance, Beth Israel is dubious that lead poisoning is a problem on the Lower East Side, since it has treated fewer than one case of acute intox- ication per year over the last half decade. Though aware that no massive screening has been done on the Lower East Side, Beth Israel staff members maintained in a meeting with the Health Council that a lead poisoning detection program is unnecessary. As evidence, they cited a small sample of 100 children tested for urinary coproporphyrins during January, 1969, in which no lead poisoning was found. Besides the fact that Beth Israel's technical arguments were weak (winter is a low incidence period for lead poisoning and coproporphyrins are notoriously unreliable screening procedures), Beth Israel did not take into account the community perspective on this problem. The Health Council was aware of scientists'statistics that projected over 25,000 cases of significantly elevated lead levels in the city, of whom only 600 cases per year were dis- covered and treated, according to Health Department records. Because it was their children who might potentially suffer brain damage from lead intoxication, the Health Council had a real sense of urgency about the problem. A recent survey at Bellevue Hospital (on the Lower East Side) seems to validate the community's concern. Bellevue's patients come from hous- ing similar to the housing of Gouverneur's patients. Since Bellevue has become more sensitive to the lead problem and adopted new screening tests, four cases of lead intoxication have been hospitalized in one month. The Health Council had taken its role seriously, but Beth Israel had not. All the effort at detailed review of the Beth Israel proposal brought only negative results. Beth Israel ignored the community's positive program suggestions, omit- ting the narcotics program, training program, and lead poison- ing detection program from the proposal they sent to OEO. OEO then slapped the Health Council in the face by cutting its meager budget from $ 32,000 per year to $ 1,500 per year. This eliminated the health advocacy program and left only enough money to pay transportation for health council mem- bers to council meetings, a minimum requirement to meet OEO guidelines vis vis - a - community participation. Thus the changes wrought by the Council's program planning efforts turned out to be largely exclusionary. Perhaps the real prob- lems were that the health council was polite and that it had only advisory powers. It may be true that new programs can be mandated only by communities that really control the planning process. -Ruth Glick Oliver Fein, M.D. | NEW S BR| IEF S Vanderbilt Challenged Students at Columbia College of Physicians and Surgeons (& P S) have begun a campaign to challenge the elitist, anti- community priorities of Columbia Presbyterian Medical Center. With a wide spectrum of community support, rang- ing from the Reform Democrats to the Black Panthers, the P & S students have focussed their attack on Vanderbilt Clinic, the public face of Columbia's Presbyterian Hospital. The Clinic, which serves about 60,000 West Harlemites, is resented for its impersonal, bureaucratic and fragmented service. Since the Clinic is largely supported by public funds, students and patients feel that the public ought to have something to say about how it runs. The are demand- ing (1) a community Board with priority - setting powers, (2) restructuring of the maternal and child care program to include community outreach and a midwifery program, (3) decentralization of the clinic to more convenient neigh- borhood settings. When white coated - students handed out leaflets supporting these demands to patients inside the Clinic, they were told to get out because the Clinic is " private " property. Now students and community residents are meeting regularly to plan a course of action for re- vamping Vanderbilt. (10) Behind Closed Doors The New York City Health and Hospitals Corporation act was no sooner signed into law than it went underground for weeks of secret, top level - planning. The job of setting up the Corporation's internal management structure goes (under a fat contract) to McKinsey & Co., a private consulting firm which is also being paid to install a Defense Department - style program planning / / budgeting sys- tem (PPBS) in all City agencies. Meanwhile, all the City's miscellaneous philanthropy and hospital special interest groups are scrambling for seats on the Corporation's Board of Directors. The City Council has five seats to hand out, and will be opening them up for bids any day now. The Mayor intends to use the five seats he has to dispense to ensure elite domination of the Board, and is shopping around for individuals with a " corporate, financial or legal background. " All the rhetoric about " community involve- ment " which preceded the Corporation bill's passage has been discretely forgotten. Blackened Blue Cross Blue Cross's fading " public service " image evaporated with its latest request for rate increases. The rate increase will hit hardest at the poor, that is, blacks, Puerto Ricans and the elderly. Meanwhile, Blue Cross's own claims to poverty are being sharply challenged by the New York State Assembly Insurance Committee. Dissection of the requested rate increases shows that Blue Cross aims for the same low risk -, low responsibility - role as its profit making - counterparts in the insurance in- dustry. While rates for certain categories of group sub- scribers are untouched, direct pay rates will rise as service is cut. People on direct pay rates include the self employed - (small shopkeepers as well as rich doctors), the retired, and workers in small, often marginal establishments, such as drug stores and groceries. Another provision of the Blue Cross proposal amounts to a set - up for future rate increases. Blue Cross wants to raise rates for " community " -rated groups, thereby forcing them to submit to " experience " -rating. Under community - rating, all groups of a given type, whether they use few or many services, pay the same rate This means that expenses are averaged out between low risk - groups (generally those con- taining young, middle income - people) and high risk groups (poorer and older people). Low - risk groups have tended to opt out of community - rating to experience - rating -- where their rates reflect the experience of their group alone, unblemished by the high - risk groups in the " community. " What's left over in the community - rated groups is increas- ingly the medical bad bets. Raising their rates, while hold- ing those of experience - rated groups steady is thus another attack on those most in need of service and least able to pay. Pressuring them to shift to experience - rating has the same effect, since it will result in eventual rate increases for these groups. Blue Cross blames the rate increases on steeply rising hospital costs. But Blue Cross itself is one of the forces behind the hospital cost explosion. Over the years, Blue Cross has made on attempt to force hospitals to operate efficiently and thriftily. It has paid the hospitals whatever they claimed as their " costs, " with few questions asked. A recent president of the American Hospital Association en- joined Blue Cross not to act as a " defender of its sub- scribers against the hospital rather than as an agency for the prepayment of hospital care as it is determined to be by the hospitals and the doctors... " Blue Cross served its masters well. Letters to Editor Community At Heart? Dear HEALTH - PAC: In Dr. Fill's [Comm., Community Mental Health Board] letter published in the June BULLETIN, he states that the CMHB is "... seeking genuine development of com- munity input... in giving communities the responsibility and the funding for the plan- ning and development of services. Where a community group becomes a legal incorpo- rated body, we have accepted it as the re- sponsible agent and sought funding. " If Dr. Fill's relationship with the West Harlem- Washington Heights - Inwood Community Meantal Health Council is any example, his remarks above appear quite disingenuous. First of all, it is extremely difficult to get incorporation papers that provide for com- munity consumer - control and development of any health services. The New York State Department of Social Services must approve all incorporation papers of organizations planning to relate to health services. If the community group plans to build and run a clinic, the State Department of Health must first inspect and license that clinic before the Department of Social Service will approve incorporation. However, for the community group to build the clinic, it must first receive funds and to receive funds it must first be incorporated. Thus, any community which plans to develop and control its own, new health services shouldn't hold its breath. To avoid delay in the community's devel- opment of a clinic, it is necessary for the community group to contract out to an al- ready existing health facility.... But before an institution like Columbia University will sign contracts with a community group [it] will insist that it control the administration of, and the setting of priorities for the pro- posed service, thereby negating the entire concept of community control. The CMHB has been pressuring the [local] Mental Health Council to turn to Columbia Univer- sity as the chief provider of services in order to accelerate the community's incorporation papers. At the same time, however, they are emasculating the powers of the community and negating the principles of meaningful community participation *.... The [local] Mental Health Council, in its attempt to become truly representative, has developed education and information com- mittees. However,... they need funds to handle the preparation and mailing of notifi- cation of and minutes from Council meet- ings. When asked for CMHB funds for post- age expenses, Dr. Fill said that if the Coun- cil wanted funds it should have cooperated with Columbia University in the first place, because it was up to Columbia to decide (Continued Page 12) (11) Letters to Editor (From Page 11) whether it wanted to share funds with the Council. When questioned whether some other institution in the catchment area might share CMHB funds with the Council, he stated he would have to take it up with the Board of Estimate. Such is Dr. Fill's inter- est in the community's development of their own services. - --R ichard Kunnes, M.D. Department of Psychiatry Columbia University From the Empire Dear HEALTH - PAC: There is much good analysis in [Einstein- Montefiore " Medical Empire " Issue,]. There are many constructive insights and much justified criticism. However, I wish to point out... these errors [among others]: There was indeed a threat of dismissal [of fee protesting - Jacobi Pediatrics house staff] by a minor assistant administrator which was immediately counteracted by the chief administrator of Jacobi Hospital. When I, as a representative of the " Einstein awlia- tion " was told to prevent the house officers passing out leaflets, etc. I told the adminis- trator in no uncertain terms that both I and the Einstein department involved supported the house officers. *b oth I and Dr. Ein- horn, the chief of the pediatric service at Lincoln Hospital brought the matter of am- bulance service forcibly to the attention of the Commisioner of Hospitals and his assist- ants and were told by these people that nothing could be done and that hopefully in the future these ambulance services would be run by the Fire Department. I do not see how this is the fault of the awliation group. We have as much to do with ambulance ser- vice as you do. We have been fighting this problem for the last fourteen years.... The pediatric services, both at Jacobi and Lincoln Hospitals, have no selective admis- sions practices, either for teaching or for re- search. Children are admitted if they need medical care and are ofte nadmitted for " social " reasons.... The patient load this year at the Bronx Municipal Hospital Cen- ter on Pediatrics has been running close to 100 percent. We have been told by the nurses who are not affiliated that if we admit beyond 100 percent of capacity they will quit.... The operation of the affilition program has much that merits criticism but it has not made things worse. In 1958, the Pediatric service at Lincoln Hospital was about to col- lapse. There was one part time - attending physician. There were no pediatric residents. There were a few pathetic rotating interns rotating through this service. There were many thousands of patients. The Pediatric service of the Albert Einstein College of Medicine took over this responsibility with no budget whatsoever... It was not until 1961 when Commissioner Trussell took over that we had any kind of a contract to run the Pediatric service.. If anyone thinks that the affiliation program with the Lincoln Department of Pediatrics is worse than it was before, he just doesn't know the situation. Small community projects could indeed hire a few saintly, primary physicians. I as- sure you they will not be able to hire radiol- ogists, anesthesiologists, surgeons, ophthal- mologists and all of the other groups which are so esential in running hopitals. If you are one who feels that medical care in the South Bronx should collapse totally in order that it become a complete disaster area, then perhaps the affiliation should be stopped im- mediately, but if any sort of medical care is to be given to the people of the South Bronx it will have to be under the auspices of med- ical colleges and well endowed - voluntary hospitals. You might not like this, nor might I, but it is a fact of life.... -Lewis M. Fraad, M.D. Professor of Pediatrics Bronx Municipal Hospital Center Albert Einstein College of Medicine On The Record Dear HEALTH - PAC: Your latest sweeping denunciation of the Affiliation record [HEALTH - PAC BULLE- TIN, April 1969] cannot go unchallenged, containing as it does misstatements and mis- interpretations of the facts. s There is no doubt at all that there has been qualitative improvement in medical care in those of the affiliated hospitals where it had steadily declined over a 20 year pe- riod. A careful study of medical records- which you have certainly not undertaken but which I have, clearly shows this to be true. I agree that the milieu in which this care is provided has not improved signif- icantly but remains deplorable.... [But] the Affiliation program should not be in- dicted for failures on the part of the City to match professional improvement with sim- ilar improvement in non professional - areas. It would be less than realistic to claim the Affiliations have provided ideal medical care at every level. Our out patient - and emer- gency care is far from what it should be but there is progress despite your disclaimers. The solution you purpose Community --- Control will not be a panacea. You fail to recognize that establishing community con- trol will not guarantee that good doctors will be attracted to work in such institutions. I am still naive enough to believe that good doctors are still a prerequisite for good medical care... - Paul W. Spear, M.D. Director of Medicine President of the Medical Board, Morrisania Montefiore - Affiliation (12)