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Health Policy Advisory Center January 1971 # 127 HEALTH PAC BULLETIN BULLETIN Editorial: How to Fail at Harvard. Nonetheless the real story is much the same as with the Corporation. Al- though is was well planned - and well - fi- nanced, HCHP has failed its promoters even on their own terms. in Three Easy Lessons After three years of planning, $ 1 million of " seed " money, and application of the skills and wisdom of Harvard intellectuals, and shrewd insurance executives, after its first : Institutions attempting reform are often con- year of operation, HCHP is, by most criteria, fronted with two kinds of failure: the failure a failure. Enrollees lag far behind projected of reforms to serve the institution's own expectations. As a consequence the program needs; and the failure of reforms to serve the is in financial trouble. There are stirrings of needs of the public to which the institution is responsible. This issue of the BULLETIN reports on three instances which describe one or the other community discontent against HCHP to boot. If HCHP was intended, as it certainly was, to serve as national model for health care delivery, the nation has little to look forward or both varieties of failure. The institutions to. cited are the newly initiated - New York City Health and Hospitals Corporation, the Har- vard Community Health Plan (HCHP), and the New York City Bureau of Lead Poisoning Control. The program of the Lincoln Hospital Pediatrics Collective, a radical program, stands in contrast to the other three liberal It is probably too early to completely ac- cess how well or badly HCHP has served the needs of its subscribers. Some guesses, how- ever, can be offered. The program would ap- pear, on its face, to be strikingly unimagina- tive and uninnovative. It retains the worst aspects of professional elitism and hier- approaches. Six months ago New York City's Health and Hospitals Corporation was launched. Be- fore it got off the ground it was being her- alded as the " answer " to the indescribably abysmal service, condition, and financial state of the city hospitals. Realists within the Corporation itself were more modest in their expectations. They felt that, at the very least, the Corporation could be anticipated to bal- ance the budget of the city hospital system and straighten out the hospitals'chaotic fiscal practices. After six months of operation the program archical control. Instead of reaching out to the community to serve its medical needs, HCHP gropes inwardly to maintain the con- venience of doctors of working within the comforts of their traditional setting. The re- sponse of the community was predictable. Already enraged by the arrogance of Har- vard University's expansionist planning, the community is gearing itself for the long fight to control its share of the physical plant and practices of HCHP. The nation may still be lulled into a sense of false hopefulness when Harvard initiates a program, but no one in New York was dis- can only be described as a bomb. The Cor- illusioned to learn that New York City's Bu- poration has been a fiasco even in its own limited terms. It has not balanced the budget reau of Lead Poisoning Control had failed to meet its self proclaimed - promise. and the fiscal policies of the city hospitals The Bureau has failed primarily to serve are more chaotic than ever. Old bills have the needs of parents whose children are not been collected while new bills accumu- late. The Corporation itself faces the pros- pect of fiscal bankruptcy while its adminis- trators continue to receive fat paychecks in spite of their evident lack of competence. In serving the needs of the public, the Cor- poration has been an even crueler hoax. Pa- tient needs have yet to be addressed. Rather than improve patient services, the Corpora- tion, has elected instead to improve the bill- ing and collection facilities within the city hospitals and emergency rooms. The Harvard Community Health Plan has the dignified and aloof allure one has come to expect from years of elite medical practice afflicted with the dread but thoroughly - pre- ventable disease of lead poisoning. From the start the program was underfinanced, poor- ly conceived - and doomed to failure. The Bureau chose a high definition of what blood level of lead determines lead poisoning. In fact the Bureau's criteria was considerably higher than that of the U.S. Public Health Service. The result is the exclusion of thou- sands of children from preventive therapy. To make matters worse, the City recently cut the Bureau's already appallingly inadequate budget still further. As a result children will continue to suffer mental retardation and death. CONTENTS 2 Harvard Health Plan 6 Lincoln Pediatric Collective 8 Lead Poisoning 9 NYC Health Corporation The lessons to be learned from the failure of the Corporation, HCHP and New York City's Bureau of Lead Poisoning Control is that often the best - laid plans of the master controllers fail and invariably community people are the victims. Through all of this gloom, the Lincoln Hos- pital Pediatrics Collective beams forth as a ray of hope. With little help and much op- position from Lincoln's Chief of Pediatrics and the power wielders at Lincoln's affiliate institutions, Albert Einstein College of Medi- cine, a group of young doctors and nurses managed to recruit talented and dedicated doctors to fill Lincoln's intern and residency quotas for the first time in anyone's memory. They brought a boldly innovative and attrac- tive program to Lincoln. The collective sought and obtained community support and cooperation; initiated an efficient referral system from the emergency room to the clinic; and began to break down the sub- specialty fragmentation of care which is traditional at most teaching hospitals. As the program evolved, the goal of one patient - one doctor care was being realized. As success followed success the Chief of Pediatrics, Dr. Arnold Einhorn, and the trus- tees and administration at Albert Einstein College of Medicine escalated their attempts to sabotage the program. With complete ir- responsibility and unaccountability members of the Obstetrics and Gynecology Depart- ment quit, as did some members of the Pediatrics Department. This was followed by the resignation of Dr. Einhorn himself. To top matters off all the turmoil was blamed on the Pediatrics Collective. It is ironic that the Col- lective was the only group of individuals who gave up freely of their spare time to insure around - the - clock service to sick chil- dren at Lincoln Hospital. As prestigiously - supported liberal pro- grams flounder in their own inadequacies, the promoters'only response is to throw monkey wrenches into the machinery of radical change. Those with the vision and courage to implement real social change are stifled while the controllers retain their posi- tions of power. As can be seen with the continuing ferment surrounding Lincoln Hos- pital, the victims of this duplicity have yet to be silenced. Despite the obstacles, change will come. Harvard Health Plan Blushes Crimson With the prospect of National Health Insur- ance looming on the 1972 election horizon, the commercial insurance industry is tooling up to take a piece of the action. The most conspicuous evidence of this activity is the new willingness of the commercial insurance companies to subsidize medical school - re- lated prepaid group practices. Connecticut General Life Insurance Company has loaned $ 3.75 million to Johns Hopkins Medical School for developing a prepaid comprehen- sive health plan in the " new town " of Colum ' bia, Maryland. Not only is Connecticut Gen- eral offering this seed money, but it is also underwriting all deficits that the plan may incur during the first five years. Metropolitan ' Life is playing a similar role at Washington University in St. Louis. Ten commercial in- surance companies and Blue Cross are similarly involved at Harvard. What is the impetus for this new interest in health insurance? In the past, the com- mercials have complained that health insur- ance is at best a break - even business and more usually a loss item. Health Insurance is used only as a come - on for the profit - mak- ing life, accident and fire insurances. But with the advent of National Health Insur- ance and Nixon Administration propaganda about prepaid group practices, the com- mercials see a new ball game. First, National Health Insurance threatens to capture the entire health insurance mar- ket and turn it over to the Social Security Administration and / or Blue Cross. In either case, the commercials will be excluded. Thus the entire commercial insurance indus- try is working to shape National Health In- surance to its own purposes - that is, federal subsidy of existing health insurance policies. Failing that, the commercials would like to help administer any new program of Na- tional Health Insurance. Second, with the present groundswell of interest in prepaid group practice, the com- mericals are found wanting, with no experi- ence in this form of health care financing and delivery. The commercial insurance in- dustry has a desperate need to build its credibility as having expertise with these new concepts about delivery of care. The industry needs data to present before Con- gressional Committees and the public to Published by the Health Policy Advisory Center, Inc., 17 Murray Street, New York, N.Y. 10007. 212 () 267-8890. Staff: Constance Bloomfield, Robb Burlace, Vicki Cooper, Barbara Ehrenreich, John Ehrenreich, Oliver Fein, M.D., Marsha Handelman. Maxine Kenny, Ken Kimerling, Ronda Kotelchuck, Howard Levy, M.D., Susan Reverby and Michael Smukler. 1970. Yearly subscriptions: $ 5 students, $ 7 others. Application to mail at second class postage is pend- ing at New York, N.Y. 2 demonstrate its ability to cope with the com- plex medical financing problems it has de- liberately avoided in the past. In addition prepaid group practice holds the possibility of making money on health insurance, by providing mechanisms for reducing some of the costs of medical care. So, the commercial insurance industry has become more inter- ested in health insurance, and particularly in prepaid group practice. What better base is there for experimentation in new models. of delivery and financing than the medical school, where relationships are already established through board members from the insurance industry, and where there is suf- ficient concentration of liberal medical forces willing to explore prepaid group practice? For their part, the medical schools show little reluctance in developing strong ties with profit oriented - , capital - rich insurance company executives. Starved for funds due to the present research recession, medical schools leap at the opportunity for seed money from the commercial insurance indus- try which they can match with special gov- ernment and private foundation grants. In addition, medical schools envision increas- ing their faculties by employing faculty members in the medical school's prepaid group practice. This is not unlike supporting faculty members on research grants. The only difference is that faculty salaries will now come from patient care funds garnered from the prepaid group practice. Also, for some schools, there is the distant prospect of losing their teaching and research popula- tions, which becomes ever nearer with the enactment of National Health Insurance. Most medical schools still teach and do re- search on charity or public patients rather than private patients. Charity patients con- tinue to submit themselves to the indignities of research and teaching because they can- not afford any other care. With National Health Insurance poor patients may be en- abled to seek care in places other than the medical school hospital and clinics. Medical school related - prepaid group practices could provide " captive populations " that might be used for teaching and research purposes. So for many reasons, medical schools have been open to the advances of the commercial insurance companies, and in some cases have even stimulated them. This report is a case study of one such medical related school - prepaid group prac- tice the Harvard Community Health Plan (HCHP). Though it is unique in many re- spects, the Harvard Community Health Plan illustrates many of the problems of prepaid group practice in the medical school setting. As Medical Economics describes it, HCHP is the " prototype ". And, as Dr. Quigg Newton, president of the Commonwealth Fund, a pri- vate foundation which provided $ 435,000 of the $ 980,000 start - up funds for HCHP says: " It is a financially viable plan that can serve as a model for the rest of the country. " It is precisely this vision of HCHP as a national model that guided Jerome Pollack, Harvard's Associate Dean for Medical - Care Planning, in designing the plan. The Harvard Community Health Plan is the first operating medical school related - prepaid group practice program in the na- tion. In many ways, HCHP resembles other prepaid group practices, such as California's Kaiser Permanente - and New York's Health Insurance Plan (HIP). To join, subscribers must be members of groups, most often unions. For a fixed monthly premium (51.00 $ per month for a family of any size), HCHP subscribers get unlimited semi private - hos- pitalization pitalization including doctors'in hospital - visits, office visits, periodic check - ups, lab- oratory services, up to 100 days extended care in a convalescent or nursing home, and limited inpatient and outpatient psychiatric services. In essence, all medical care ex- penses are covered except dental care, drugs, orthopedic appliances and prolonged psychiatric care. This care is offered by a closed panel of doctors, six of whom are full- time primary practitioners, in internal medi- cine or pediatrics and 18 of whom are part- time specialists in obstetrics gynecology - , surgery, dermatology, ophthalmology, etc. Unlike Kaiser Permanente - , HCHP does not own or operate any hospitals. Rather it leases its own health center (the first three floors of a modern apartment building in downtown Boston) and has contracts for inpatient care with four Harvard affiliated hospitals - Peter Bent Brigham, Beth Israel, Children's and Women's Hospitals. As with most prepaid group practice plans, HCHP anticipates con- trolling its costs through the provision of preventive care and decreased length and number of hospitalizations. But HCHP differs in several respects from other prepaid group practice plans. @ HCHP is underwritten by ten com- mercial insurance carriers, such as Prudenti- al, Equitable, and Aetna, as well as Blue Cross. This differs from Kaiser Permanente - which was financed by Kaiser Industries and the Kaiser Family Foundation, and from Johns Hopkins'prepaid program in Columbia, Maryland, which was underwritten solely by Connecticut General. HCHP's diversified fi- nancing was no accident. First, it effectively divided the carriers so that no single carrier could control the program. This left control in the hands of Harvard. Second, theoretical- ly it provided a mechanism for replicating the plan in other parts of the nation by pro- viding experience in prepaid group practice for as many companies as possible. Pollack felt that only the commercial insurance com- panies possessed the wherewithal in terms of capital and nationwide organization to spread prepaid group practice across the country. He said to one Health - PAC inter- viewer, " If they (the commercials) could taste the success of the Harvard Plan, surely they would transmit it throughout the na- tion. " In point of fact, the final contracts did not spread the underwriting burden so even- ly. Blue Cross ended up with 70 percent of it, leaving the commercials with the rest. 3 @ HCHP differs from other plans in its versity Hospital, but this plan was defeated unique governing board structure which is by conservative forces within the medical comprised of one third - consumers, one third - providers and one third - independent " pub- lic interest " members. This structure was specifically designed to overcome the fears school and the county medical society. Rob- ert Ebert, now dean of Harvard Medical School, was chairman of the Department of Medicine at Western Reserve at that time, of both consumers and providers that one and worked actively to bring about the pre- group or the other would be in control. On paid group practice. Shortly after Ebert came many boards of voluntary hospitals, neigh- to Harvard in 1965, planning for HCHP be- borhood health centers and community men- tal health centers the conflict over control gan. At that time medical school related - pre- paid group practice was still considered a between providers and consumers remains unresolved. For many reasons, not the least real innovation. It was not just by chance that HCHP contained the name of Harvard. being conflict of interest, increasing numbers of consumers oppose a provider majority on these boards. Likewise, doctors are nervous What more prestigious association could there be than with Harvard Medical School? Again, it seemed that considerations of the about the implications of community / con- sumer control for the practice of medicine. Existing programs, such as Kaiser Perman- - plan as a national model had influenced de- cisions even down to the choice of a name. It is a reasonable assumption that a health ente have avoided this conflict by merely plan which was the product of three years of appointing representatives of Kaiser Indus- planning by Harvard University and $ 980, - tries, who are neither providers nor consum- ers [see November 1970 BULLETIN]. The HCHP solution consisting of a tripartite board 000 in private foundation and federal re- search grants would be a national model. It is also reasonable to assume that with such was projected as an answer not only for HCHP, but for the nation. extensive planning HCHP would have been an instant success. But this is not the case. OE Twenty percent of HCHP membership By most measurements, HCHP has been a will be drawn from a medically indigent population, including families on welfare, failure. After one year of operation, HCHP has only 6,000 subscribers out of the pro- whose fees will be paid by federal and state jected 13,000 it was supposed to have en- government. Until recently, all prepaid group rolled by this time. And this estimate of practices have been limited to middle in- 13,000 was a downward revision made early come groups - those employed in industries that offer health insurance options. Two in the program when enrollment was already lagging. Although financial records are not years ago, with considerable federal finan- cial inducement, the Kaiser Permanente - Plan shared publicly, such an enrollment failure indicates that financial losses during the first in Portland, Oregon, began to enroll indigent year must have been collosal. HCHP's priori- membership. However they stopped this en- ties and control were challenged vigorously rollment when poor people reached six per- within the first year by a grassroots communi- cent of the total membership. Likewise, over ty group and future problems with the com- the last three years New York's Health Insur- munity can be anticipated. In terms of in- ance Plan (HIP) took up to ten percent medi- novation in the delivery of health care, HCHP caid patients. But HCHP was the first prepaid has been remarkably unimaginative and group practice to agree to take such a large traditional in its approach. These failures led percentage (20 percent) of its membership to the resignation of the plan's architect, from poor populations. Lest it be thought that Jerome Pollack, from HCHP directorship in Harvard was behaving in an altruistic man- May, 1970. ner, it should be pointed out that the federal government had a substantial role in extract- ing such a commitment from Harvard. HEW's most recent policy is to make grants for pre- What accounts for HCHP's failure? Many factors are involved. Not the least of these was Harvard's desire to create a national model, which crippled HCHP's ability to op- paid group practice only to those institutions which agree that one fifth - of their member- erate effectively in the local community of Boston. ship will be drawn from indigent groups. In For instance, HCHP's tripartite board, con- addition, HCHP negotiated a handsome re- ceived as a national example of how to re- imbursement formula for taking medically solve provider and consumer conflicts in indigent families, in some cases totaling controlling health institutions, contributed to more than twice the annual premium for middle class families. HCHP's failure in enrollment and the growth of grassroots opposition to HCHP. Initially OE HCHP is the first prepaid group practice HCHP had great difficulty in attracting sub- program to be linked to a medical school, scribers, in part, because no subscriber although others are planned or are in early stages of operation. Traditionally, medical schools have steered clear of interfering with groups were included in the critical plan- ning phases of the program. A concentration on form rather than content and the tradi- the organization of the health care delivery tional elitism of Harvard, resulted in the ab- system. Even courses dealing with alterna- tive systems of care were excluded from the sence of labor union representation on the board. In addition, the one third - of the board curricula. In the early 1960's, Western Re- serve School of Medicine tried to establish comprised of consumers was not appointed until ten months after the plan went into a prepaid group practice within the Uni- operation. Harvard rationalized this delay 4 on the basis that the consumers should be users of the plan, which could only be de- termined after the plan was operating. Thus labor and the community were completely excluded from the planning process. Little wonder that labor unions didn't flock into the plan as they had done with other prepaid group practices, and that the community formed a grassroots organization to demand changes in HCHP. To the community, the tripartite board ap- peared to be little more than a clever manip- ulation by Harvard to prevent community control or any control other than Harvard's. By dividing the board in thirds, the com- munity could never achieve a majority of the votes. Harvard's implementation of the board confirmed this suspicion. All appointments to HCHP's board of directors are made by an eleven member - group, which sounds like a who's who of Harvard University: Nathan Pusey, president of Harvard University; Rob- ert Ebert, dean of the Harvard Medical School; Arthur Sutherland, professor of law at Harvard, etc. These notables selected the " providers " including Dean Ebert himself and even a medical student. They also picked the " independents " which consist of such ordinary citizens as John Kenneth Gal- braith and John Dunlop, both professors at Harvard University and Paul Garrity, pro- fessor of law at Boston University. Therefore it is not surprising that the Mis- sion - Hill Parker - Hill Community, a poor black and white community which was the target population for medical indigents for HCHP, challenged the priorities and control structure of the plan. HCHP had planned to establish an outreach center in that com- munity. However, the Harvard planners did not want to offer medical services from the outreach center because of the expense and inconvenience to the doctor involved. Be- sides, to offer medical service there would threaten the liberal Harvard rhetoric of " one door " service. Poor people would go to the outreach center, while middle income fami- lies would use the central facility. Therefore Harvard saw it only as a center for social services and transportation to the central facility. The community realized that Har- vard had the board of directors of the central facility sewed up and therefore if they wanted control over anything, it would have to be the outreach center. Therefore it organ- ized to demand medical services at the out- reach center and, of course Harvard resisted. With the threat of demonstrations (at a time when HCHP was appealing to middle - in- come Bostonians to enroll in the plan), Har- vard caved in rapidly. It agreed to set up the outreach center, staff it with medical serv- ices, and grant control to a community- dominated board. But there were other reasons for HCHP's failure in attracting subscribers, besides the exclusion of labor and the community from the planning process. Most Harvard planners attribute this failure to the higher cost of HCHP compared to other health insurance. While this may have been true in some cases, generally HCHP premiums were no higher than existing major medical insur- ance programs. In addition, the marketing of the plan was chaotic and ineffectual. Since HCHP relied on the ten commercial insurance companies and Blue Cross to sell the plan to subscrib- ers, many different insurance salesmen were involved. Most of these salesmen had never experienced a prepaid group practice and just did not know the advantages of the Harvard plan. What is more, they had no incentive to sell HCHP over a major medical plan. The result was that salesmen did not make a strong case for HCHP to potential subscriber groups. Harvard's success in sell- ing HCHP to a multiplicity of insurance com- panies guaranteed its failure to sell the plan to local subscribers. The requirements of a national model contradicted the needs of HCHP itself. It was not until HCHP developed its own marketing department, with sales- men familiar and enthusiatic about the plan and its advantages, that enrollment began to pick up, though never to anticipated levels. Symbolic of these causes of HCHP's failure is the use of the Harvard appellation in the plan's title Harvard Community Health Plan, rather than Boston Community Health Plan. Though this may accurately reflect the truth (HCHP is indeed Harvard's Community Health Plan), it appears that the planners adopted this name as much for its status and prestige as for the sake of truth. If the con- cern is a national model that others will copy, then the Harvard name is invaluable. But if the concern is enrollment of local Boston subscribers, the Harvard name is an albatross. To the ordinary Bostonian, Har- vard stands for the ruling class, dual systems of health care, teaching and training, land- grabbing, associations etc. - that put people off rather than attract them. These close links to Harvard also con- tributed to the almost total lack of innovation in the delivery of health services that HCHP represents. For example, it is not surprising that team practice (the collegial sharing of responsibility between doctor, nurse, social worker, etc.) has been difficult to implement at HCHP. Nurses at HCHP where recruited with the pitch that they would have new and diversified responsibilities as members of a health care team. Common is the complaint of one nurse: " The only new responsibilities I have are secretarial, since we don't have enough patients to justify hiring a secre- tary. " At Harvard, where medical hierarchy is steeped in traditional rigidity, innovations that take the doctor off of his pinnacle and make him part of the team are not made easily. The case case of the Harvard Community Health Plan is unique. Where else in the nation will there be a conflict of goals be- tween creating a national model and provid- ing local medical services? Are there any general lessons to be learned from the Harvard experience? 510 One message comes through clearly: Don't trust medical schools when it comes to the delivery of health services. Medical school priorities still favor teaching and re- search above patient care. Therefore medi- cal school interests may conflict with what are the best interests of the patient. For ex- ample, innovation in the delivery of health services may mean more and better services for the patient. But medical schools are peculiarly unfitting as innovators, they re- main the bastion of hierarchy with depart- mental baronies that mitigate against team and group practice. This conflict of interest between the needs of the patient and the needs of the medical school becomes more relevant when it con- cerns prepaid group practice. Prepaid group practice achieves efficiency by offering doc- tors a financial incentive to decrease utiliza- tion of health services, particularly hospital ization. Consumer interests are served by the use of preventive health care. But consumer utilization can also be decreased by delay- ing or not offering lengthy or expensive treatment, even though it may be vital [see November, 1970 BULLETIN for more details on prepaid group practices]. Thus prepaid group practices (or as Mr. Nixon is beginning to call them, Health Maintenance Organiza- tions) can be turned against consumers, particularly if they are run for profit. Con- sumer control is the only protection. As the Harvard experience demonstrates, medical school domination of prepaid group practice, does not necessarily result in the best plan for consumers. Medical schools must share their resources, particularly their manpower and technology, with prepaid group practices. But only the community served can and should control them. This is the lesson learned from Harvard's failure with HCHP David. - Mendelson (intern at Harlem Hospital) and Oliver Fein Lincoln: Saga of Assassinations Lincoln Hospital in the South Bronx continues to be center stage for the community / worker control struggle in New York City. But both community and workers (including the housestaff) had little control over the latest performance the firing and then rehiring of the Chief of the Pediatric Service. Charges of racism and radical politics splashed onto the headlines of all the New York newspapers when Dr. Arnold Einhorn was retired from his position as Chief of Pediatrics at Lincoln Hospital and Dr. Helen Rodriguez was hired to replace him. The an- nouncement of the firing followed a leaflet distributed by the housestaff of the Pediatrics Department - the Pediatric Collective - call- ing for Einhorn's removal. The press immedi- ately zoomed in on the Collective and blamed them for Dr. Einhorn's ouster as well as all the " trouble " at Lincoln over the past few months [see September and October, 1970 BULLETINS for an analysis of commu - ` nity struggle at Lincoln]. But the press completely ignored the ma- chinations within Albert Einstein College of Medicine that were really responsible for Dr. Einhorn's removal. The medical school, as affiliation manager of Lincoln Hospital, has the power to hire and fire all doctors em- ployed at Lincoln. The whole " Einhorn affair " was engineered, however poorly, from the top with no real input from the Collective or the community. Buu t lets begin from the beginning. The Pediatric Collective was the result of efforts by several pediatric interns and residents at Lincoln and Jacobi Hospitals (both Einstein affiliates) to develop a program in commu- nity pediatrics. (Jacobi housestaff in pediat- rics rotated through Lincoln every two months until this year.) In the fall, 1969, they approached Dr. Einhorn with the idea and he was delighted with the plans. Together with Dr. Einhorn, a community pediatrics program for the department was developed and housestaff was recruited. In the past, even though Lincoln was affiliated with Al- bert Einstein, only two American - trained housestaff were attracted to the program in pediatrics. It was regarded as a second - rate training program appropriate for foreign graduates only. Even intern applicants turned down by Jacobi were not encouraged to apply at Lincoln. But the attraction of a housestaff - initiated community pediatrics program was so great that Lincoln Pediatrics got 18 out of the first 19 interns they wanted. Moreover, almost all those who came shared a political and social commitment to community pediatrics. How- ever, everyone agreed that foreign house- staff who wanted to stay at Lincoln to complete their training should do so, even though they were less interested in commu- nity pediatrics. The newly recruited - housestaff numbering 32 interns and residents met several times before the new program began. The meetings served to familiarize the housestaff, which had been attracted from as far away as Denver and New Orleans, with the South Bronx and its monumental health problems. Community people, hospital workers, and even Dr. Einhorn spoke at these meetings. One outcome was the decision by the house- staff to call themselves a " collective, " a term which they felt embodied the process of de- cision making - they wanted to see at the hos- pital. Another outcome of the meetings was the establishment of goals for the Collective. First and foremost, the Collective wanted to 6 improve the delivery of health care to the people of the South Bronx. Second, they wanted to break down the traditional barriers of hierarchy that separate intern from resi- dent, nurse from doctor, nurses'aide from nurses, etc. and that makes the hospital and its training programs so oppressively in- sular. And third, they felt that improved serv- ices and new relationships among health workers could only be maintained through community / worker control of the hospital. When the full Collective arrived on July 1, 1970, the community was already in motion. The Think Lincoln - Committee composed of community residents and workers had al- ready set up a grievance table in the hos- pital. During July, Think Lincoln - and the Young Lords Party took over the administra- tion building (the old nurses residence) to dramatize the plight of the hospital which had been condemned over 25 years ago, and to implement community / worker control of ambulatory care. The Collective had only been at Lincoln for two weeks. Therefore, its response to the take over - was primarily sup- portive, in the form of a resolution upholding community control. It was also in July that the community forced the resignation of the chief of Obstet- rics and Gynecology at Lincoln. He was held responsible by the community for the un- necessary death of Carmen Rodriquez, a patient who died after an abortion. Follow- ing their chief, the entire housestaff in Ob- stetrics and Gynecology walked off the job, leaving their patients unattended. This episode jarred Dr. Einhorn to the roots. of his European medical training. Though obviously opposed to community / worker control, he refused to talk to anyone in the Collective about it. He began to curtail his teaching functions, refusing to appear at chief of service rounds, because " there was too much hostility. " He limited himself more and more to the premature nursery, where he re- fused to allow other attending physicians to make rounds. He resisted attempts to create family oriented - comprehensive care in the outpatient department by insisting on the maintenance of his own chief of service fol- low - up clinic. Meanwhile, the medical school began to worry about Dr. Einhorn's performance. He failed to recruit additional attending phy- sicians for adequate supervision of the de- partment. He appeared increasingly incapa- ble of administering his department. The final straw came when Dr. Einhorn was un- able to prevent the resignation of twelve residents and fellows in the department. This severely limited the ability of the Pediatrics Department to supply the needed services under adequate supervision, and thereby threatened the $ 8 million affiliation contract for Lincoln. What is more, there is evidence that Dr. Einhorn encouraged the foreign housestaff to leave, in order to pressure the Collective on its support of community con trol. In fact he sanctioned leaves of ab- sence for some foreign housestaff and found positions for others elsewhere in the City hospital system. Einstein was anxious to find a quiet way to sack Einhorn. When Einhorn suggested that he was ready for a sabbatical within the year, Einstein leapt at the opportunity to find a replacement. Recruiting efforts pro- duced a black doctor, Calvin Sinnette and a Puerto Rican doctor, Helen Rodriguez. The strategy was to get both Dr. Sinnette and Dr. Rodriguez to work at Lincoln as attend- ing pediatricians, with the promise of the departmental directorship when Einhorn left. Dr. Sinnette turned down the offer, but Dr. Rodriguez decided to apply. Einhorn then foiled the cleverly laid plans of Einstein, by sitting on Dr. Rodriguez's application for over two months. Pressure began to build. Dr. Rodriguez threatened to withdraw her application since she had received other offers. Einhorn re- fused to take his sabbatical. Einstein was forced to play its hand: Dr. Rodriguez was hired as an attending physician with a ver- bal promise of the directorship; arrange- ments were made to transfer Dr. Einhorn to Jacobi Hopsital. The Collective somewhat naively intervened with their now famous - leaflet calling for the removal of Dr. Einhorn. The battlelines were drawn. Einhorn felt the Collective had engineered the whole event. Bitterly, he refused to leave without a memorandum reaffirming his competence as a pediatrician and stating that his removal was based on " ethnic and political consid- erations. " Labe Scheinberg, dean of Albert Einstein College of Medicine signed and sent the memorandum. Shortly thereafter, Dr. Einhorn called a press conference in his New Rochelle home, announcing he had been forced out of Lin- coln on racist grounds. The liberal establish- ment was up in arms. The New York Times editorialized: " Does the efficacy of a penicil- lin injection depend upon the skin color of the physician who administers it? " But rather than blaming Einstein for the blunder, the Times went on to indict the Pediatric Collec- tive. The State Human Relations Commission was called in to investigate discriminatory practices. Even reactionary groups re- sponded. The Jewish Defense League, a mili- tant right wing - organization, sat - in in Dr. Scheinberg's office at the medical school. The result: Dr. Scheinberg ended up in the hospital with bleeding ulcers; Dr. Einhorn was reinstated for the rest of the academic year (although he reportedly is not func- tioning as director now and has effectively left the department); Dr. Rodriguez is the acting and actual director of the department; the Pediatric Collective has been threatened with extinction by a Lincoln medical board plan to rotate all services, including pediat- rics, with Jacobi. But the tangible changes are seldom re- counted. The Pediatric Collective are the only doctors who have not left their patients, even though the Pediatrics Department has 7 suffered severe losses in personnel amount- ing to more than 16 doctors. Yet there is not one peep from Albert Einstein about sharing this loss of personnel by transferring some of its interns and residents to Lincoln. In spite of these hardships, the Collective has tried to adhere to its original goals. They have improved delivery of health care to people in the South Bronx by: instituting continuity of care in the outpatient department - one doc- tor (the same each time) for one family; creating an appointment system in the out- patient clinics; decreasing the number of un- necessary subspecialty clinics and increas- ing the number of general pediatric clinics; developing a referral system for chronically ill children from the emergency room to the outpatient department; and establishing a problem - oriented record system to insure better quality of care. All of these improve- ments have been instituted by the Collective, in spite of Lincoln's affiliation contract with the medical school. There is no other muni- cipal hospital in the city, including Jacobi, that has instituted even these minimal re- forms. The Collective has broken down some of the barriers between interns and residents. Chief residents are expected to do " scut work " just like the interns. In fact, it is now the chief residents who take the most difficult shifts, such as the emergency room from midnight to 8 A.M. But hierarchy between doctors and nurses is a much higher hurdle to jump. Although some nurses attend Col- lective meetings, they are separated from the doctors during their daily duties because of the immense overload of work. There is much more ground to cover before new relation- ships are fully developed between the doc- tors, nurses and nurses'aides. But at least for the intern, many of the oppressive bar- riers of hierarchy have been alleviated. The goal of community / worker control is still far in the distance. But the struggle for its achievement at Lincoln has challenged Albert Einstein, and for that matter the entire medical establishment to its core, and has created the collective energy to make real changes for people in the South Bronx in the future -Ken. Kimerling NYC Launches Lead Balloon surface where the sample was found, even though the rest of the apartment may be 1 riddled with lead. Those inspectors who con- scientiously take samples all over the apart- ment and in the hallways are hassled be- cause they aren't producing enough " cases. " They are also instructed not to report Hous- ing Code violations to the Building Depart- ment for the same reason. The City had started undercutting the Bureau of Lead Poisoning Control, which just opened its door amid great publicity in July, 1970. Then it was called a " massive lead poisoning detection " program. Now its staff of 90 has been cut to 66. Strange goings - on for a high priority program. Actually, there have been questions about the Bureau's " massive effort " from the begin- ning. It does not approach the lead problem with a comprehensive process for detection and prevention. Apartments are inspected only after a child is found to be poisoned, even though it is common knowledge that thousands of children are walking around with undetected poisoning and that thou- sands of apartments are harboring lead. When lead is found in the apartment of a poisoned child, only that apartment can be fixed up. Inspectors may not test the other units in the building, nor is the landlord re- quired to remedy the other apartments, even though common sense indicates that if one apartment is leaded, they all are. The employees complain that they are forced to produce " cases " for their superiors. A " case " is an apartment with detected lead - in most instances, the inspectors need take only one sample to report a case. How- ever, the landlord is required to fix only that If a landlord does not start making repairs within a week, the Emergency Repair Pro- gram (which is part of the Housing Develop- ment Agency) is authorized to go in and make the repairs. However, they only repair those surfaces where leaded samples have been found, do not paint the wallboard they put up, and leave the place a shambles with- out cleaning up. The program does not even approach the lead problem on a sound medical basis. In New York City, a child with 0.06 milligrams percent lead in the bloodstream is consid- ered to be poisoned. Other cities have adopted the standard of 0.04 milligrams per- cent which has been suggested by the US Surgeon General as sufficient indication of lead poisoning. Authorities estimate that New York City's figure eliminates at least half of the lead poisoned - children in the City from treatment. Many of the remaining workers in the Bu- reau of Lead Poisoning Control are becoming justifiably indignant over the operation of the program. They claim that the lead detec- tion equipment they must use is farcical. It is heavy, inappropriate for field work, and unable to give on spot - the - analyses of the presence of lead; it cannot be tilted; it cannot 8 be used on ceilings (the source of many lead paint chips), and cannot be used on metal surfaces. Metal surfaces are generally primed with red lead paint. All Housing Authority units built prior to 1959 have leaded metal surfaces, including window sills, banisters, and door frames which have obvious appeal to children with pica (the tendency to chew on things). However, the Bureau's machine cannot measure these sur- faces and therefore the Housing Authority will not agree to resurfacing. The City ordered these machines (at ap- proximately $ 5,400 each) from a company which had no experience with this kind of equipment, despite the fact that better and cheaper machines already existed. The City has not paid for the machines yet, and the workers have petitioned the administration for better and cheaper equipment. They have received no response. The Bureau was created following pres- sure from the Young Lords Party and other community groups. The disenchanted work- ers feel that Lindsay does not care about the program, that he's only concerned with look- ing good in the press, and that it all amounts to a " big phony. " It appears that additional pressure will be necessary before the City makes determined and honest efforts to elimi- nates this disease Constance. - Bloomfield Corporation: Salvage Job Sinks in the Red In the middle of a recsession year, with its inevitable reports of Federal, State and City cutbacks in vital human services, the current crisis in New York City's Health and Hos- pitals Corporation has yet to make the head- lines. Two things about the crisis are clear: it is not simply the story of another govern- mental service starved for funding; and per- haps more interestingly, it is being kept extremely quiet. The Health and Hospitals Corporation, which began operation of the municipal hos- pital system July 1, was originally sold by its backers as a plan for bringing the " effi- ciency " of the private sector to the operation of the municipal hospitals [see Winter, June and September, 1959, BULLETINS]. The first year the City contracted to pay the Corpora- tion a flat sum approximately - $ 175 million -and additional revenues were to be raised through fees, reimbursements, and other means by the Corporation. The Corporation would have at least two major advantages over the City's old Department of Hospitals: it could implement modern management techniques and systems planning to replace the encumbered bureaucracy of the old City department; and it would place the hospital system on a sounder financial basis since it had the power to adopt a hard - line approach to collecting hospital bills, arrange additional Medicare and Medicaid reimbursements, float bonds and possibly even obtain grants from government or private sources. In this way the Corporation hoped to at least break- even if not make a profit. However, after its first six months of op- eration, the Corporation has not only failed to live up to these expectations but it finds itself in the throes of a financial crises. At press time, Health - PAC had learned the fol- lowing: OE The Corporation presently has a back- log of 90-100,000 uncollected bills or reim- bursement claims, known as " receivables. " These represent a total of roughly $ 100 mil- lion. The situation is so dire that the Corpora- tion may be forced to appeal to the City for funds beyond its original contract for this year. By law, the City is not obligated to " bail out " the supposedly autonomous - cor- poration, and for that matter it appears that city officials have not been fully informed about the extent of the shortage. So embar- rassed is the Corporation, that its budget submitted to the City in mid December - , re- portedly underestimated the full amount of the shortage by including only uncollected inpatient bills. These amount to less than half the shortage if the Corporation's uncol- lected out patient - bills are included. Evident- ly, most Corporation employees are also in the dark about the crisis and its possible threat to their paychecks. M@ A substantial number of the unpaid bills are in the form of reimbursement claims against " third party " insurers (Blue Cross, Medicare and Medicaid, and commercial in- surance companies). Many of these claims have not been, and may never be, paid by those third parties due to inadequate infor- mation provided by the individual municipal hospitals concerning patients treated and services rendered. The inadequate informa- tion reportedly stems from an improperly- designed reporting system " innovated " by the Corporation since July. OE Due to the alarming number of uncol- lected bills and claims, a " Receivables Task Force " was recently created within the Cor- poration to push collections more vigorously. One member of this Task Force confirmed that the Corporation was " 90 $ million be- hind " as of September. So far the Task Force has responded to the crisis with characteristic bureaucratic rationality: push bill collections even harder. Two suggestions are adding new bill collectors and investigators and forcing patients to provide billing informa- tion before they receive emergency room or outpatient services. Cash registers in munic- ipal emergency rooms may be the next step in the Corporation's drive to pay its bills 9 from the pockets of the City's poor. over $ 100 million to date through poor plan- OE The Corporation began operations in ning and sloppy business practices. Critics July with a backlog of " receivables " to which of the corporation idea argued from the be- it assigned top priority. At that time the Cor- ginning that fiscal integrity was an unreal- poration estimated it could not only collect istic goal. It was highly unlikely that in- the same percentage of bills as the old De- vestors or private foundations would pour partment of Hospitals, but that it could in- their money into a public system which has crease that percentage, thus generating new for many years been unable to generate revenues. Individual municipal hospitals sufficient revenues to meet its costs. In addi- were told to assign top priority to these back- " logged " receivables,'even if this meant tion, a clear trend in the reduction of monies available through Medicare Medicaid - reim- postponing current billing.The results have bursement had already emerged by the time been a lower percentage of collections than Corporation legislation was passed. The that of the old Department of Hospitals as claim that the Corporation could achieve well as a total breakdown in current billing solvency by collecting higher fees from its in many hospitals. The actual cost in lost reimbursements from this breakdown and users, the early critics pointed out, made sense only if municipal hospital services from the improperly - designed reporting sys- were to be denied to the non paying - poor. tem will probably never be completely as- sessed. Thus far, these criticisms have proved to be painfully true. The Corporation finds itself in a crisis which may eventually force it to It is ironic that the Corporation, created to drastically curtail hospital service or actual- bring the efficiency and solvency of the pri- ly shut down some municipal hospitals. No vate sector to a deteriorating, red tape - - en- wonder officials are maintaining silence cumbered municipal system, has squandered about the Corporation's current fiscal status! PREVENTING PREVENTIVE MEDICINE Lindsay's decision to institute a municipal austerity program and also lay - off 500 " non- essential " city employees may help his budgeting problems, but it is making short shrift of the health needs of New York's poverty population. Preventive medicine, which bare a " last to be hired first to be fired " relationship to the health system, is getting the axe. On November 16 doctors received the following note: " Due to budgeting restrictions, the Depart- ment of Health will no longer be able to furnish free of charge to private physicians, hospitals, or other institutions: gamma glob- ulin; vaccines other than rubella vaccine; Tine Tuberculin Tests; Isoniazid for chemo- prophylaxis against tuberculosis. " This restriction will have a fold two - effect: these vaccines and tests will not be offered routinely to patients; when offered, they will obviously result in increased costs to the patient - not the " doctor, hospital, and other institutions. " When patients cannot afford these increased costs, they will have to re- sort to the Department of Health Clinics, where service, especially in preventive medi- cine, is notoriously bad. This City cut back - falls hardest on the poor, not only because of the increased costs and cutbacks in serv- ice, but also because the demand for these particular treatments is highest among the poor. CORRECTION: In the November BULLETIN we reported that Morrisania Hospital was not doing abortions after ten weeks except with court referrals. The evidence was given by the Women's Abortion Project at the pub- lic hearings on the City's Abortion Guide, lines. The information was based on the data collected by the Project in September. On checking with the Hospital and the Project, it now appears that Morrisania is doing abor- tions after ten weeks. POWER, POLITICS AND PROFITS THE AMERICAN HEALTH EMPIRE: A REPORT FROM THE HEALTH POLICY ADVISORY CENTER Our first book, this is an angry and hard hitting - analysis of the American health system - who profits from it and who loses. It follows the growth of the health system from " cottage industry " to today's Medical Industrial Complex, exposing the ruthless priorities of the medical empires and corporations which dominate today's health scene. It documents - with vivid case studies - the bankruptcy of recent health " reform " programs, from Medicaid to National Health Insurance. It reports from the front lines of ongoing community and workers struggles for humane and democratic alternatives in health. A must for BULLETIN readers, and anyone else who cares about the quality, and quantity, of American life. The book is published by Random House and available at your bookstore for $ 7.95 10