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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

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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 usedwhich 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

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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

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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

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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.