While Hillary Rodham Clinton and Ira Magaziner were focusing the attention of their health task force on benefits packages and consumer alliances, short (or no) shrift was being given to one of the greatest concerns expressed by the actual users of our medical care system: the equitable distribution of high-quality medical services throughout the country. Whether they choose to enter their local hospital or a big city medical center, patients want to be assured that they will have access to diagnostic and treatment facilities that are of equal caliber.
The issue of local access to excellence has never been satisfactorily addressed by the vaunted Canadian system; it continues to be one of their program's glaring defects. To benefit from sophisticated medical technologies, Canadian patients often must be transferred to major medical centers in cities far from home, sometimes hundreds of miles away And yet, in one form or another, a solution to the access question has been proposed over and over again for more than a century--ever since a prototype first hit print in Hygeia, A City of Health, a utopian book written in 1876 by an Englishman named Benjamin Ward. For a variety of reasons, conditions never seemed ripe to carry it out. Without doubt, the time has finally come.
The solution is to be found in the fact that, with few exceptions, each of our nation's 126 medical schools is potentially capable of overseeing the needs of the region in which it is situated. Also, thanks largely to the Hill-Burton program of the Truman administration, the United States is endowed with a network of local hospitals that can satisfy the needs of their surrounding populations. The health care delivery scheme that would provide an organized structure for the Clinton plan is one divided among the 126 centers. From each of these centers expertise would radiate through a system of closely linked affiliations with every community, hospital in the region. Such a system lends itself to the principle of flexibility of choice that is basic to the Clinton proposals and to the protection of each state's or region's option to choose its own payment and organizational methods.
The most recent attempt at regionalization was made in 1964 as part of Lyndon Johnson's Great Society. Sadly, the president's efforts fell prey to bad press and poor organization. Called "Regional Medical Planning," a part of the Heart Disease, Cancer and Stroke Amendments of 1965, the Great Society's legislation aimed to promote regional centers of excellence at universities, from which the fruits of medical progress were to be disseminated to community hospitals. But the program's goals were unclear and its scope led to fears that government would intrude on the lives of average Americans. In time, each of the participating groups (hospitals, organized medicine and the public) began to mistrust each others' motives. Opposition grew when it was discovered that universities would be permitted to use federal dollars to pursue their own pet projects. Even worse, medical schools at the dine were inept at providing good basic primary and secondary care; they were also inefficient and very expensive. As William Kissick--now a professor of health care systems at the University of Pennsylvania, but then a legislative assistant to the RMP planning group--put it at a recent reunion of the program's participants, the regionalization of three decades ago "was the right concept, presented to the wrong culture.…Much has been changed in a quarter of a century. We need regionalization more than ever."
Not only the economy but the entire atmosphere of the American medical care system is vastly different than it was thirty years ago. In that biomedically simpler time, only 6 percent of America's gross national product went to health. Today, that figure is 14 percent, and it is expected to rise to 18 percent by 2000. We are trapped in what has been called the iron triangle of health care: cost containment, quality and access. Widening one angle only narrows the others. Regionalization offers a way out of this trap, for it addresses quality and access, and perhaps cost containment as well. What a refreshing relief from the current debate, which seems to direct all its energy on cost containment and addresses access primarily in terms of financial access; the definition of quality remains vague and its standards arbitrary.
There have been other changes, too. The medical schools are much more involved in the community than they were twenty-five years ago. During the past decade, they have been turning to community hospitals to learn how to deliver primary and secondary care efficiently. The major centers and the local hospitals need each other as never before.
A new approach to regionalization would incorporate provisions to avoid the pitfalls and suspicions that led to its earlier demise. Properly written affiliation contracts would protect the autonomy of the local hospitals, and the educational leadership of the medical schools; they would also provide for equal access to the appropriate facilities for all patients. Such contracts could guarantee that key physicians from local hospitals are also on the faculty of their regional medical schools and that they share responsibility for residency training, rotation of medical students and clinical research. These doctors also should have a voice in the decisions at the school that affect the network.
Moreover, every new medical staff appointment at any of the "affiliated hospitals should be approved by representatives of all the hospitals in the region. This would encourage uniformly high quality and continued interaction between the various hospitals. Another advantage of region-wide coordination of appointments is that it would enable hospitals to assess exactly what kind of staffing they need. By admitting to its staff only the number of physicians required to fulfill the needs of its own community, each local hospital would help solve the problem of overpopulation of specialists, and be certain that all of its specialists are fully employed in ways that make the best use of their skills.
Hospitals in each region should be encouraged to develop incentives that would attract physicians toward salaried employment as full-time members of the medical staff. This bonding of doctors and hospitals would go a long way toward mitigating or even eliminating the image of physicians as individual entrepreneurs, and of the American health care system as a "cottage industry:"
It's worth noting, too, that once all doctors are salaried, a more equitable distribution of physician income can be made within the area served by each local hospital and its region. Perhaps we'll finally be able to leave behind an insidious system in which talented young people are deterred from primary care or family practice because those careers pay much less than the high-tech specialties so highly valued by third-party payers, If the administration is really serious about seeking ways to increase the proportion of family doctors to 50 percent, equitable apportioning of income will help achieve that end. A corollary to the idea of hospital-based medicine is that all health functions in the community, including public health and health education, would grow up around the hospitals. Perhaps hospitals would become a source of community.
Any plan should see to it that each of the 126 networks would have access to cutting edge advances, continuing high caliber biomedical education and the backup clinical care that might be necessary for patients entering their local hospitals. When required, the transfer of patients from smaller to larger facilities must be expeditious and uncomplicated.
Consortium-wide decisions will be made with each of the 126 networks to determine which participating hospitals will provide which kinds of tertiary and other highly specialized care. This is an efficient way to prevent duplication of expensive services and equipment, and a judicious method of deciding when an unsteady hospital should be closed down. Less and less will it be necessary for patients to travel long distances from their communities to obtain high levels of modern care. Decentralization will increase as the system takes hold.
Finally, the sharing of educational opportunities and input is not to be restricted to the medical staff alone. By enlisting consultants from engineering, business administration, communications and health policy, the full resources of the university and the business community can be focused on the problems of file region's hospitals. Equally important is the fact that a regional organization carries with it a mechanism through which hospital CEOs may coordinate their efforts. Such joint undertakings will require the loosening of present antitrust regulations, a proposition that Hillary Rodham Clinton has already endorsed. Who knows, it may even be possible to integrate hospitals, physicians and health insurance into the same localized plan,
Comprehensive governance of such a decentralized system is crucial to the scheme's success. What will be required tinder the newly organized American health-care enterprise is leadership from nothing less than the authority of a subcabinet position, perhaps an Assistant Secretary of Health and Human Services whose office is designated for that purpose only. The president's proposed National Health Board seems too diffuse a concept for a system that will need direct overall management and a hierarchy of oversight and responsibility. No board will be able to control an industry as complicated as health care.
In our modern medical culture--one that is ready for regionalization--hospitals serve as centers of community caring, education and the two great American principles of volunteerism and pluralism. Each one is a social institution in the community it serves. Each one should be associated with an academic center in a manner that promotes excellence close to home. In this way. the benisons of the world's best biomedical science can be made available for every citizen.