(Many nonprofits are on this bandwagon, whether or not they arerelatedsomehowtotheRWJF.)Do all these well-paid warriors really care about whether everysinglechildreceivedallhismeaslesshotsontime?Theycouldbuyalotofvaccineforthepriceofthenewsletters.Dotheyreallythink that a national “mosaic” of computer registries will have fewer errorsthanrecordsthatmotherskeepabouttheirownchildren?Doyour constituents really prefer to spend money on this data bank in preference to helping individual children who have a bad diseasesuch as leukemia? Think about it. Consider the possibility that thecampaign is not really about vaccines but about establishing acomputer infrastructure for a relatively noncontroversial purposethatcanbeusedforotherpurposeslater.This campaign is described in a very expensive, glossy,colorful, boring book published by RWJF in August, 1996,availableonlineathttp://www.rwjf.org.Itsmoststrikingfeatureisthe cover; the photographs are slightly out of focus, anddeliberatelyso.Itstates:The focus on acute medical care has obscured thesimpler, but nevertheless urgent needs of the millions of people with disabling chronic conditions....[K]ey elementsof our current “system” of care its priorities, allocation of resources, training of professionals, and the incentivesinherentinitsfinancing appearoutofkilterandsometimessimplydysfunctional.Indeed,thegoalistochangethefocusofmedicine,andineffectto turn it upside down. As with the immunization initiative, thefocus is extremely broad. According to the book, the number of Americans with chronic disease will soon be 150,000,000, andalready is 100,000,000. That probably includes almost everybodywho has lived long enough. Everybody probably develops arthritiseventually, if nothing else. If young children are included in theimmunization program, older adults in the chronic care program,and adolescents in the “teenage pregnancy” programs, most of the population is covered. And if one is looking at people by thehundredsofmillions,theindividualfaceshavetobeoutoffocus.RWJF’s book acknowledges that “individuals suffer,” butclearly its accent is on the fact that[emphasis added]. Obviously, RWJF is not looking for ways tocure multiple sclerosis or arthritis or diabetes, but rather for thecheapestwaytoprovidebathtubrailings.The “challenges for the 21st century” are: “creating correctfinancial and other incentives to rebalance resources; creating the“right mix” of medical services; providing the “right mix of personal assistance and custodial care services”; “creating processes to coordinate, manage, and allocate resources so that therightservicesgettotherightpeople.”Doesthis,onthewhole,soundlikeabenignandboringagenda?Let’s translate it into more direct language: It is a call for governmentally controlled central planning with rationing. Itwould replace our current “non-system” (called freedom) withcompulsory institutions. Decisions would be made by anadministrative elite (called bureaucrats). These decisions wouldinclude how many specialists we may have, whom they may treat,and what methods they may use (“the right mix of services to the
“ChronicCareinAmerica”
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1
“society at large pays a toll inlost productivity and avoidable health care expenditures”
1
WhatDoesThisAgendaMean?
right people”). This new system will substitute for and oftenoverride the judgment of parents, family physicians, and otherswith direct knowledge of and responsibility for real individualliving and breathing unique human beings (many of whom maywellbe“thewrongpeople”).Thenewsystemwillenforceitsedictsthroughcontrolofallthemoneyandpossiblyalsothroughthecivil,criminal, and administrative legal system (which delivers law butnotnecessarilyjustice).This will be a top-down system, one that exerts its authorityoverpeople,notonethatderivesitsauthorityfromthepeople.Legi-slativeoversightandaccountabilityaredeliberatelydisconnected.Aretheseinferences,basedontwoexamples,unjustified?Let’slookatwhatRWJFhastosayforitself.WhenAAPS criticized the role of the RWJF in the Task Force,its President Stephen Schroeder telephoned me. He denied thatRWJF advocated any particular kind of system (such as managedcare). He stated that it funds a variety of different experimental projects. The latter is true, although in my assessment the non-managed-careprojectsaremeretokens,designedinsuchawaythatthey will probably fail. Most importantly, Mr. Schroeder sent me acopy of the summer 1992 issue of , as he apparently believed that it portrays the foundation’s program accurately. Themost interesting articles were not, as it turned out, the ones he haddrawntomyattention.Here are quotations from sections of interest [emphasis addedinallinstances]:InGrantWatch,Kaneetal.write:[C]ooperation was successful in only a few circum-stances. A foundation grant that represented only a small portionofaninstitution’sbudgetcouldnotovercomestrongmarketforcesorinstitutionalself-interesttoreshapeamajor health care institution. Cooperation occurred naturally onlyunder specific market conditions–for example, whenhospital occupancy levels were low or declining andmanaged care programs had a large market share, or whenan institution’s survival was at stake. Otherwise,..The consortium model [for obtaining cooperation] was adisappointment[inachievingtheFoundation’sgoals]:[C]onsortia maintained a balance of power among participants but . Inaddition, participants’ motivations were generally short-term or nonvital, and no.Amongtheconclusionsfromtheexperiencewithconsortiawasthe need for certain favorable circumstances, includinggovernmentintervention.The desired changes were fundamental: “[T]his programattempted to influence the basic missions, strategies, and internalorganization of participating institutions and thus had the potentialofaffectingtheviabilityandfutureoftheinstitution.”
Health Affairs strong incentives—financial or political—were needed to ‘force’ cooperation on what were otherwise competing and successfulinstitutions..did not achieve fundamental change participant was willing to give upautonomy to the consortium, particularly the right towithdrawifitdidnotliketheconsortium’ssuggestions
TheNeedtoForce“Cooperation”TheIntended“Change”
2,p1832,p1872,p1902,p190
Journal ofAmerican Physicians and Surgeons Volume 15 Number 1 Spring 201025
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