The History of Regional Medical Programs: The Life and Death of a Small Initiative of the Great Society (review)

The Regional Medical Program (RMP), a policy of the Johnson administration that persisted until 1975, offered health professionals and provider organizations incentives to improve the integration of primary, secondary, and tertiary care for chronic disease under the leadership of medical schools and their principal teaching hospitals. In theory, research-based knowledge—especially about heart disease, cancer, and stroke—would move down regional hierarchies from academic health centers; patients would move up and down these hierarchies, as appropriate.

The RMP was the last attempt to make the hierarchical regional organization of health care more efficient. In retrospect, it is clear that this organizational model, the dominant method for arraying health services in every industrial country in the twentieth century, reached the limit of its influence in the United States in the 1960s. Since then, regional hierarchies have gradually been flattened in most parts of this country. They have eroded because medical specialists and the technology they used proliferated in an environment of cost-based reimbursement and subsidized capital: many of the complicated interventions that would in the past have been a monopoly of academic centers became available more cheaply and almost as safely in community hospitals, clinics, and even physicians' offices.

Stephen Strickland, the author of a useful book on the political history of the National Institutes of Health, ignores most of the secondary sources relevant to his subject. He cites only two accounts of regionalism in health care—one out of date, the other unpublished. Moreover, he misstates some of the facts he takes from these sources (for example, giving individuals jobs they never held and institutions primacy they did not earn). His neglect of the literature is the cause of his surprise that the American Medical Association (AMA) worried that creating or strengthening academic centers of excellence in the 1960s would threaten physicians' incomes and autonomy. The AMA had been complaining about academic health centers for most of the twentieth century.

Strickland also ignores pertinent sources for the history of the RMP. Many of his facts are wrong: he misnames or mislocates medical schools, and assigns more than a few people new first names, career paths, and credentials. He discusses "state pride," but ignores the literature on the political culture of the states. Further, he ignores an evaluation of the RMP commissioned by the federal government from a leading consulting firm, Arthur D. Little, Inc. This report described how the program had, in many states, drifted from its explicit mandate to disseminate new knowledge about killer chronic diseases to the goal of integrating the health-care system under academic leadership; but it had insufficient federal funds and support in the medical and public health communities to achieve this goal. In his conclusion, Strickland speculates about several causes of the demise of RMP but buries in midparagraph the finding of the Arthur D. Little team, incorporated in the statement by the secretary of what is now the Department of Health and Human Services, that it was the victim of its own "conflicting and changing emphases" which led to the alienation of interest groups essential to its success (p. 127).

Although Strickland conducted many interviews, he relies on a single source for most of his statements, thus falling below the multisourcing standard of both journalists and contemporary historians. He also credits a person he interviewed with exact memory of what someone else said thirty years earlier (and misspells the name of the person quoted). Further, the book is poorly edited. In addition to errors of fact there are numerous typographical errors, including three on a single page (p. 45). Strickland has, however, collected many engaging anecdotes about the implementation of RMP. The chapters on Alabama, California, Missouri...