[to a newspaper editor]

With reference to our recent telephone conversation, I thought you might be interested in the materials that Steven Schroeder of the Robert Wood Johnson Foundation sent to me.

Included was a copy of the Summer, 1992, issue of Health Affairs. Mr. Schroeder called my attention to articles by David Helms, Catherine McLaughlin, and William Schwartz. Of greater interest to me was an article he did not highlight. (Copies of individual issues can be obtained for $20 from Health Affairs, Project HOPE, Two Wisconsin Circle, Suite 500, Chevy Chase, MD 20815, (301)665-7401. The publication can be found in most medical libraries.)

Here are a few quotations from "GrantWatch" by Nancy Kane, Robert Blendon, and Susan Koch Madden, pp. 181-192:

"A foundation grant that represented only a small portion of an institution's budget could not overcome strong market forces or institutional self-interest to reshape a major health care institution. Cooperation occurred naturally only under specific market conditions-for example, when hospital occupancy levels were low or declining and managed care programs had a large market share, or when an institution's survival was at stake. Otherwise, strong incentives-financial or political-were needed to 'force' cooperation on what were otherwise competing and successful institutions."

"Perhaps most important to their success, both [successful projects] had AHC [academic health center] partners that were motivated to cooperate primarily by state political forces."

"The accomplishments of these consortia did not even approach their aspirations, which included consolidations and the development of a regionalized system of patient care and medical education....We concluded that the consortia maintained a balance of power among participants but did not achieve fundamental change. In addition, participants' motivations were generally short-term or nonvital, and no participant was willing to give up autonomy to the consortium, particularly the right to withdraw if it did not like the consortium's suggestions."

"True cooperative agreements are successful in only a limited set of circumstances. One or more of the following conditions must exist: there must be a balance of power between the two participants; cooperation must be in the interest of both parties; there must be governmental intervention and financial support; or the goals must be small and nonvital."

"The Commonwealth grant program was much more ambitious than the types of projects commonly funded by foundations....this program attempted to influence the basic missions, strategies, and internal organization of participating institutions and thus had the potential of affecting the viability and future of the institutions....

"Fundamental change might be most constructively viewed as first requiring a change in societal values that then requires institutions to adapt to those changed values."

"High managed care penetration and low hospital occupancy were essential ingredients to those few markets where price competition was feasible...Project choices should be guided by a well-informed sense of where fundamental change is most likely to occur, given local environmental circumstances."

Also in the GrantWatch section, p. 200, Steven Schroeder is quoted as stating: "'Getting the kind of broad-based political support needed to achieve universal access is going to be difficult,' Schroeder commented. America is very different from many other countries, he added; its citizens don't trust their government. 'How to try to reconcile the need for universal coverage with a reluctance to have government in control of it is a real challenge for us as citizens.'"�

"The earlier method RWJF used in trying to influence public policy, which was 'let's just put the data out there and assume that people will make the right choice, may not be effective as health becomes more of a political issue,' Schroeder noted."

In the Update section, commenting on the Washington Basic Health Program, Geoffrey Hoare, Marilyn Mayers, and Carolyn Madden of the Univ. of Washington, Seattle, comment:

"The struggle to enact legislation was lengthy and controversial. In retrospect, that was the easy part....

"While uncertainties [in a public/private partnership] can be managed and mitigated to a certain extent, they cannot be eliminated. Therefore, the most important element of management in program demonstrations involves not so much making rules as establishing processes for rule making."

Additional insights into how certain foundations see their role are in materials quoted in the AAPS brief, around p. 13.

As we see it, certain foundations seem to want to remake American medicine (if not American society) along the lines of their own model. The independence of institutions (and surely of individual physicians) is an impediment. So are present societal values. To overcome these impediments requires governmental intervention. What is the role of foundations in trying to bring about such intervention? And do they stand to profit from it?

A couple of facts: At least half the assets of RWJF are in the stock of Johnson and Johnson, the foremost supplier of contraceptives, along with many other medical supplies. RWJF grants have included one of about $400,000 to the Arkansas Dept of Health, under Dr. Joycelyn Elders (a member of Subgroup B of Working Group 22 of the Health Care Task Force Interdepartmental Working Group), for "five rural pregnancy prevention projects that will integrate teen pregnancy prevention into the state's effort to develop school-based health programs." A key feature of school-based health programs is providing information about contraceptives (and often the devices themselves). In the Clinton Plan, school-based clinics are "essential community providers," who have a priority claim on alliance funds (ahead of "nonessential providers" such as an extra surgeon).

Another feature of the Clinton Plan is to permit health alliances to designate single- source suppliers of medical equipment.

Are these not just two examples of serious conflicts of interest?

If a foundation has a vision about how society ought to be, why not present the arguments in a public forum, rather than working behind the scenes?

Please do not hesitate to call me at 800-635-1196 if I can be of any assistance.

Sincerely,

Jane M. Orient, M.D.