|
Items in cart [1] |
Questions? Call 888-624-8373 |
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 217
Elements of COPC in the
UMWA Health ant!
Retirement Funcis
Program
George S. Goldstein
The United Mine Workers of America (UMWA) funds program was clearly
not organized on the principles of COPC. Nevertheless, from the beginning,
the program was based on the kinds of community (that is, consumer or
member) oriented social service objectives that are essential for COPC.
In 1946-1950, when the program was first established, the UMWA lead-
ership decided not to buy care for its members via the traditional health
insurance mechanisms on the market as most other unions did at that time,
but instead they built their own program based on the social needs of the
defined population.
The genesis of the program is to be found in the exceedingly poor health
conditions extant in large areas of the industry, in the 1930s and 1940s,
that is in the Appalachian states. These conditions led in the 1946 and 1947
labor/management contracts to the establishment of a Welfare and Retire-
ment Fund (in 1974 renamed the Health and Retirement Funds) fed by a
5¢ (10¢ in 1947) royalty per ton of coal produced. This amount increased
considerably in later years. These contracts established a financing mech-
anism, but did not provide guidelines for the nature of the medical program.
Instead, the trustees (a union-management-neutral triumvirate responsible
for running the program) were left to determine its nature. Aiming at
meeting the needs of the beneficiaries, they adopted the broad goals of
comprehensive care, accessibility, quality assurance, and cost control.
The Funds leadership discovered early that to reach these goals it could
not depend on the established, market-based delivery mechanisms and,
with its own staff of experts, developed its own set of delivery mechanisms.
217
OCR for page 218
218
PART II: PRACTICAL APPLICATIONS
The basic member service orientation meant building the program on the
needs of the members, not the offerings of the traditional market-based
system. This was carried out by arranging for delivery of and payment for
services as much as possible on "retainer" (or fee-for-time and cost-reim-
bursement) concepts, rather than market mechanisms of purchased insur-
ance coverage and fee-for-service payment. The goal of comprehensive
coverage, as the program was implemented over time, came to include:
most ambulatory care services, hospitalization, drugs (for expensive, long-
term illness), and an emphasis on prevention, rehabilitation, and outreach
and ombudsman functions.
The goals of accessibility, quality assurance, and COSt control were de-
veloped by arranging for services under what amounted to two different
delivery mechanisms. Where the resources of the traditional, existing mar-
ket system were used—which applied to a majority of beneficiaries the
Funds established a structure of quality and CoSt controls, such as partici-
pating lists, prior authorization, restriction of payment to properly qualified
providers, and retainer payments. Where the concentration of beneficiaries
allowed and/or conditions of inadequate medical resources necessitated, the
Funds established an alternative delivery system of nonprofit hospitals and
clinics with full-time, salaried, group practice staffs. Most of these clinics
and hospitals were in Pennsylvania, West Virginia, Ohio, Virginia, Ken-
tucky, Tennessee, and Alabama. These group practice clinic organizations
varied widely in size, type of practice, type of policy control, and the extent
of social service orientation. In this way COPC-type programs in actual fact
developed.
This was, broadly, the nature of the UMWA funds delivery system through
the mid 1970s. The 1978 labor/management contract, however, turned the
provision of services for the bulk of the beneficiaries over to the traditional
fee-for-service market, in the form of health insurance industry contracts.
SPECIFIC ELEMENTS OF COPC IN THE UMWA PROGRAM
Although not organized specifically on COPC principles, some elements
of COPC did develop in the Funds program. These elements are seen more
clearly in the program if the "defined population" in the definition of COPC
is interpreted to include a single industry's workers and their families,
scattered over many communities, as opposed to one geographically con-
tiguous community. Two specific examples of major program activities of
the Funds appear to fit the definition of COPC well. The "Black Lung"
programs developed to deal with pneumoconiosis provide the clearest ex-
ample. These programs involved a combination of activities by the union,
the Funds health program, and governmental agencies on federal, state, and
OCR for page 219
UMWA Health and Retirement Funds Program
219
local levels. Included were: much epidemiologic study; diagnosis and treat-
ment of individual miners within programs involving family, community,
and educational activity; and social intervention via collective bargaining
and legislation, tO promote education, treatment, compensation, and pre-
ventive measures in the coal industry production methods. The second
major area was the strong rehabilitation efforts of the Funds, particularly
with reference to one of the most prevalent occupational hazards of the
coal industry, namely, orthopedic injuries resulting from rock falls.
Several other elements of the Funds' program activities, while they fit
the definition of COPC much less clearly because crucial elements of COPC
were lacking, nevertheless were illustrative of COPC concepts. These in-
cluded:
1. Quality assurance efforts and mechanisms.
2. Miscellaneous efforts in specific local communities in cooperation with
other community agencies, in such areas as high blood pressure detection
and treatment, family planning, mental health, and the health impact of
water and housing conditions.
3. Outreach programs designed to pursue optimum utilization of both
Funds and community services.
4. A drug program, using centralized mail-out sources of supply, patient
profiles, and a formulary for quality and cost-control purposes.
SOME LESSONS FOR COPC
Although the history of the UMWA program exhibits some significant
successes in developing COPC-type elements, this same history does not
encourage anticipation of major further COPC development in the United
States without some basic changes in national priorities. The Funds expe-
rience seems to be that the social service orientation necessary for COPC
cannot be sustained in one industry by itself, in a competitive market
economy.
Instead, in the coal industry, after 25 years the employers developed a
perception that the social service based Funds were neither in their interest
nor cost-effective. Whether the Funds program was, in fact, more or less
expensive than health insurance-type programs in other industries (and for
what reasons) remains a question for debate between the Funds and the
employers. They were no longer willing to provide the financial support.
The 1978 union/management contract ended the social service orientation
established in 1946-1950 and replaced an organized, industrywide, "com-
munity oriented" system of delivery of care with a fragmented system based
OCR for page 220
220
PART II: PRACTICAL APPLICATIONS
on the competitive cost goals of the market. There is little evidence that
this system, on its own, will pay much attention to COPC-type concepts.
Even within the earlier social service framework, economics and tradi-
tional attitudes prevented significant development of COPC. Given limited
resources, there was never agreement among the leadership on the propriety
of COPC-type activities that, while they may reduce costs in the long run,
clearly, in the short run, mostly increase costs. Attitudes in the Funds
program leadership illustrated generic obstacles to COPC. Business-minded
administrators concerned about costs looked unfavorably on COPC-type
programs; most medical administrators and physicians reflected the prej-
udices of the medical training system, whose lexicon excludes COPC con-
cepts. Further, in more recent years, union interest in social service issues
was lost in the pressures of internal, political, and external economic prob-
lems.
The outlook for COPC in the United States in the near term is poor.
In light of diminishing levels of federal support of organized primary health
care services, while it is technically true that the potential of COPC is not
limited to publicly sponsored health centers, all organizational forms of
practice- including hospitals, academic health science centers, private group
practices, etc.—could well concern themselves with a community focus;
nevertheless, the UMWA Funds history and the history of the U.S. delivery
system generally suggest the private sector will not provide the large nec-
essary funding.
The traditional system of health care delivery in the United States has
exhibited little predilection to establish the kinds of organized programs of
health promotion and prevention that are the necessary social framework
for COPC-type developments in the major necessary areas of work, namely
environmental, nutritional, and life-style. In fact, it is arguable that a system
based on the competitive cost constraints of the market will tend in the
. . .
Opposlte c .lrectlon.
Certain developments of recent decades, which seemed to offer hope of
reversing the traditional orientation, e.g., greater organization generally of
financing and delivery of health care; programs like the UMWA, a few
other unions, a few co-ops, and the OEO; greater federal involvement in
health care program development; a major movement toward some kind
of national health program; and the growth of nonprofit prepaid group
practice and HMO generally, all are now themselves facing reversal, with
market orientation once again in the ascendancy. Prepaid group practice,
and later HMO, seemed a particularly hopeful development for COPC,
but with the recent need for competing in the market, COPC may well get
lost there too.
Based on my experiences with the coal miners' medical care delivery
OCR for page 221
UMWA Health and Retirement Funds Program
221
program, I cannot be optimistic about the future of COPC in the United
States, short of a major shift in the basic premises of the U.S. health care
delivery system, away from the market and in the direction of the kind of
social service, social democratic orientation characteristic of those countries
where COPC has been most successful. Under these circumstances, never-
theless, it remains important to try to build COPC programs of whatever
scope possible with the limited resources that can be scrounged up, in order
to develop the concepts and to gather experience for better days. From a
practical point of view, what we need to do is to use the concepts of "pure
COPC" as a set of long-term goals or objectives, while trying, in a practical
world of real people and real communities, to go as far as a given program
can toward these goals. But, I believe we can expect no major impact on
health care in the United States until a national effort brings about a national
program based on different premises and priorities.
Representative terms from entire chapter:
funds program
