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.! Maybe, but the 'technocrats' largely shaping HEW policy fe l doctors can't be left ou , either The physician is losing control over the evolution of health care in this country. From his own community to lhe corridors of HEW, he is yielding up the reins of power to a new breed of professional who is moviDg the ha- ties more rapidly toward public-pri- vale systems thai can serve up compre- hensive health care on a prepaid basis. While physicians rein;fin the ex- perts in diagnosing and m;maging the problems of patients, lhesc "techno- crats"--systems analysts, economists, statisticians, social planners, and ad- mm~strators~arc gaming rccoguition as the experts in designing and m.anag- ing health-care systems. "l'hcsc ure highly cducated men who can bring finely' honed professional skills to [l~c solution of a complex and essentially lechmcal problem~the delivery, wid~ equalEy, of a high level of care to more than 200 million people. The writing is on the wall, big and bold: Doctors will continue to lead the team caring for paticnls, but will no longer dictate the shape o~ the systems under which they practice. "Right now. the physician is in somewhat the po~ition the military people were in 1961 when lechnocrats --the so-called Whiz Kids~took over the Defense Department," says Adam Yarmolinsky, }Iarvard luw professor and a member uf the National Acad- emy of Scicuccs bom'd ot~ medicine. "It was decided that war is too impt~r- lant to be left to "the generals. wise. physicians may be the experts in caring for palients, but they cannot be the ultimate decision-makers." "Physician" is un exact term; "tech- nocrat" obviously isn't. But there is a new kind of organizer al large in the la " ag " '" who can apply a "systems" approach to problems, "social engineers." They may indeed be engineers by profes- sion, or I,qx~3'ers, or business adminis- trators, or economists. What they have in common is art orienu~tion 'o prob- lems-to lhe "larger issues"--and a belief that scientific techniques plus modern organizational skills can pro- vide solutions. Such men are making their mark on American bu:dness and are being increasingly called upon to fill posts in government. They have al- ready put their sta~np on the health cure field: ~- HFW's much-publicized live-year plan for health (MW~, Sept. 5, '69) was the product of a lawyer--Lewis }3uric.-. Assistaut Secretary f,~r PIm~- ning and Evaluation. It listed depart- nlCtl| health priorities as manpower, family planning, improved health service delivery, facilities for anabula- tory care, environmental health, and prepakl medical care. F There were only five physicians in the 27-member HEW Task Force on panel that hammered out recommen- dations leading to the current freeze ot~ physician fees under Medicare and "1 don't like that term lechnocrat-I prefer generalist." So said Fred Malek in discussing the emergence of the new;model health administra- tor. However, "technocrat," which he epitomizes, is only one of several currently tashionable labels seem- ingly adopted with this intense, 33- year-old HEW deputy under secre- tary in mind. "Upwardly mobile" and "overachiever" are two others. But around the lifth floor of HEW" headquarters, where Frederic Vin- cent Malek has been officially oper- ating since April 1969, the phrase most often applied to him is "'brains incorporated - sometimes as a compliment, sometimes as an epi- thet, but always with a suggestion of awe. This is because Malek, in bring- ins to bear extraordinary skill in modern management techniques, may have started his sprawling de- partment on the road back from operational chaos. Should he succeed, he wifl have written another chapter in an emi- nently successful career history that may someday include a cabinet post. The son of a beer salesman in Ber- wyn, II1., young Malek opted for the U.S. Military Academy to get a first- rate education at next-to-no cost. By the time he graduated trom West Point in the top quarter of the 1959 class, however, he had decided against a military career. "If hard work and conscientiousness are the ingredients for a successful man,'" the 1959 edition of the USMA year- book read, "then Fred will undoubt- edly be one ol our most successfuL" With mililary duty facing hhn, Matek decided to "gel with the best" -meaning the Special Forces. By 1961, he was in Vietnam as a mem- ber of an advisory team training South Vietnamese in counter-insur- gency techniques. The following year he left the Army and married Martene McArthur, a pretty secretary from San Francisco. By then Malek had fh'mly decided that big business was where he was headed and that the prestigious Har- vard Graduate School of Business Administralion was the place to starL Two years later he graduated, again near the top of his class. "7 then went to work for McKinsey & Co., a management consultant firm, because l lelt I could learn top man- agement more quickly that way than by going into a large corporation 16 T!09681595

o | Medicaid. It also called for more fed- oral. leadership in the redesigning the nation's health care system, stressed group practice, and criticized the present laissez-faire character of Medicare and Medicaid. )" HEW's decision to offer a compre- hensive prepaid group practice bcnclit to Medicare p~ticnts thrm~gh beahh maintenance organizalions June 19) wus made primarily by attor- ney Butler ~nd Under Secretary John G. Vcneman--altho~gh it did stem from an idcn proposed by D:'. Paul M. Ellwood of the American Rchubifitu- lion Fotmdation. )- "1 he Administration's proposal to of- fer welfare families a package of health benefits styled along priva',e insurance lines in place of Medicaid was devised by HEW Deputy Under Sccrctt:ry Robert Patricclli, a lawyer who also dcsigacd the family assistance plan. "'We arc coming It) recognize th~Jt there has tf~ be a great deal ~3orc in-. depth planning for the distributio.~ of health care all0 manpower, aP, d that this doesn't necessarily require mad- ical knowledge," says HEW Deputy Under Secretary Frederic V. Malek (see story below). "If we are going to have a system rather thau a non-sy.,,- tern, it is goi,g to take a great amottnt of mamtgcmeut skill," adds this m- tense young man wi~o, as the archtyp- iczt technocrat, has already stream- lined lhe nmnagcment of some 50 gr;mt programs, mm]y affecting health. However, Malck and o{her dcpm't- mcut ollicials realize full ~ell bcalth planning witbtmt medical inpot could bc disaslrous. "You GII~ have all the planning iu the world but unless the principal providers of care arc in- valved, il u~ay not work," coum~.tl~ts Zamcs H. Cawmaugh, Deputy Assist- anl Secrcta~3' for Hc~dth ;rod Scientific Affai,'s. A Pb.l). lrai~?ed ~n.bcallh care administralion, Ca~ammgh points three only marginully successl:tlt health project~: for California m~grants, pr~ grtm'~s planned by IlI-3V oHicials Washington after very liElc constdta- li~m with laced pl~ysick:ns or the slam hca]lh department. Despite this readily admitted for prcffes:d,mal medicul advice, the tecbnocrats see little or no immediate hope of overcoming some of the tradi- tional barriers m doctor participatioa in m~tional poliey-making~the press of lira:', resistance to change, and cdv- cational gap~. "One of the first things that has to happe~L" says HEW's Malck, "is that doctors recognize that a change is oc- curring. There has to be greater com- munication between the medical pro- fc~sion and the federal government, Once (!~e physician ia Butte, Mont., understands what tl~e national prob- lems are and what some of the con- siderations urc, he wilt be in a better position 1o contribute to our thinking." "If you try to lalk to doctors about the broad isaues, they say: 'What n~ore do you wan( 0~c to do? l'm ah'cady working 60 Imurs a week,'" re,ponds Dr. Brym~ Williams, a Dallas internist and member of the NAS Institute of Medicine. HEW Secretary Elliot L. Richard- bun ~n i~t~rt b[m~3e~ lhe situatiou on the inhcrcl~t conservatism at AmcriGm and workh'~g my way up the I.:~dder." During the next if)roe years, Malek and some other young con- sultant.~ mapped out plc, ns for start- ing theiz own firm. "We were ready to go into the mobile-homes busi- ness," he recalls, "but a leader was dralted by Robert McNamara to help out at Defense."~Having regrouped, Malek and two colleagues in 1967 decided to move into the hand-tool industry, which one of them, his sal- ary paid by the others, had first care- tully scouted tar a year. They purchased a nearly defunct tool company in Orangeburg, S.C., and began to "do their thing." By 1969, they controlled the Triangle Carp., a publicly owned conglomer- ate of tour subsidiaries with $20 rail- lion in gross annual sales. Thus, when Robert Finch, "on the advice of a California insurance ex- ecutive, personally recruited Malek, the s/in;, quiet-spolren executive was v/orth in excess of $2.5 million. "That was then," says Malek with a grin. "I've dropped about a milfion and a half sh~ge because el the mart'~et. But surprisingly, it raally hash'! bothered me." Malek frankly enjoys his work at plications, he defends them as ba- sed on sound management. As for the future: "Well, i'd like to stay in this AdministraEon at feast } until 1972. Then back into business , somewhat.:,,. But this is a higher call'- ~ ing. I realize that now. So someday ,., I'd like to come back here as head HEW. He feels that ~,hc restructuring..of a domestic department." of health grants prc'..,3ram~ with more authority placed in regional direc- tors" hands, plus the defh}ition of precise objectives with firm target dates, has been a maior accomplish- ment in the heaPh field. And he is happy with FDA's revival under the guidance of Dr. Charles Edwards, and under the agency's new organi- zational structure, which Malel: de- signed. He is also aware lhat wilh some, he has gained a repulation as a cold-eyed, politica!ly motivated headhunter. But while he admits many of his plans have pofitical MEDICAL WORLD NEWS/Ju!,~" 31. 1070 17 T109681596

POLtCY-r4tAt'dNG ~.~;~ ~d medical organizations. Tbt: pl'of}~ssion, hc si'~ys, has been "slow to recognize and respond ~o the new sochfl demands being placed upon it. The re~,ult, pre- dictably, has been to weaken the volc~ of organized medicine in melters of public policy affecting its profession. Economist~ and social welfare plan- ners, acttmries, labor union spokes- men, and even lawyers have frequenl]y played a larger role than doctors them- selves in Ihe soaping of public pro- grams in the medical field." But resistance to change is not the only reamn, he contimms. "'1 cabinet help feeling lhal ~ major reason dec- tots have not had g,.realer inflnence on such matters is that they have usually not had enough educational back- ground in the economic and social as- pects of medical care to be abl~ to grapple with this kind of issue." "1 don't know the degree of formal training required, bul if the physician wants to be one of the molders of per icy, he is going to have to be equipped to do so," declares Rashi Fein of the Harvard Center for Community Health and Medical Care. "There are all kinds of tools :is well as models 18 is gtm~g to have to und,.rstand. Fein, a Ph.D., has helped set up a program in Harvard's John F. Ken- ncdy Scherzi of Government, a of study leading to a ms..tin s degree or doctorate in public polic) atxd which medical students can particl- pule. "'They spend a full yettr at the Kcmmdy school in a w~riely of courses lo qualify for the M.A.," he says. "'What we hope to turn mit is an MD with a degree in public policy and a good deal of knowledge about dccision-m;dzing, statistical theory, economics, and phi- arcs. In the initial class, last year. five of the 22 studenla enrolled were from the medical school. Aud two of them huvc gone on to take summer jobs with the Health " " ' Semccs Administration in New York Cily. But it will hz?. scvexal years before such physicians can take their place alongside managemen~ specialists in frmning heahh policies. In lhe mean- time. physicians arc linding their tradi- tional means of influencing national hcahh prognu~s.--organizcd medical an ma ~ eroups~mcreasi cllectual. Last year, for instance, the American Medical Asmcialkm and Amcric:m Hospital Association were irked to find that they had no say over the goverllmcnl's decision to freeze physician fees under Medicare and criminate Ihc 2% compcosatory pay- merit to hospitals. And, alfl,ough in- formed about the Health Maintenance Organization option just before it was revealed to the House Ways and Means Committee, the AMA was gk'- cn no opportunity to help shape the proposal. Again earlier this year, out- side health groups were not called in to consult with HEW on its Comprc- heasive Health Services amendments until the day the legislation was sent to Congress. Organized mcdlcine recognizes plight. The AMA, declares its execu- tive vice president, Ernest B. Howard, "hasn't been listened to sufficiently in lhe past few naonths, and has com- plained right up to the White House." But when AMA ot~cials met with Sec- retary Richardson before he wag con- firmed, he assured them that the. organization would be given a say on pending policy decisions. Rellecting his new boss" view, Malek ,;ays: "I think it's when people perched tip here in Washington get to- gether wilb those who understand the grass roots problems of physicians and hospilals that you come up with the best kind., of answers. I don't think the.technocrats can do it themsek'es. "But I don't think lhe doctors can do it alone either." Malck believes the post of Assisl- ant Secretary for Health and Scientific Affairs. now held by Dr. Roger O. Egeherg, should be upgraded to under- secretary status, but he feels that the man in lhat position need not be a phy- sician. "'If the guy is an administrator, a gencralist with some broad under- standing and the wiNingness and capa- biliw to learn in depth the problems and'realities of medicine, he could do the job. But if he happened to have a medical degree as well, he would be that much further ahead." Teamwork may be the ideal answer to the nation's health problems, but with the government committed to sys- tematiziug health care delivery, and xvilb.many MDs leery of this course, there is at growing ch;mcc that mcn who deliver Ihe care could play a Ics,;-than-signilieunt role in formulat- ing the systems. This state of affairs is consklered unacceptable by both phy- sicians and technocntls: bnt it is tl~e possible end result of present trends. As Malek points out. the federal gov- el'rment now purchases more than 25% of all health care, while state and local governments accotmt for another 12tL~. And with the advent of national hcahh btsurance, these percentiles will increase, becoming levers by which government pla,mers can force chailges ill. the health system. The physician is therefore being asked to recognize his new and dom- inant parmer in health affairs, and to heed this admonition from Under Sec- J'etary Venenian: "'The era of the pri- vate doctor.., cloistered in his privale office.., lobbying through traditional institutions out of step with the times, will be over. Doctors will have to be- come invok,ed to a greater extent in governmental decision-making. "'I[ you refuse," lie warns the doc- tor, "'your punishment will be to live under the judgment of less knowledge- able men than yourselves." • Ti09681597