I think also in that connection that third parties who pay for the costs of medical care have a responsibility for funding technology assessment. I think it's a crying shame that the Reagan Administration evidently intends to allow the National Center for Health Care Technology to die. It's falls economy. For an Administration which says that it's interested in reducing the cost of health care, that's a very foolish thing to do, because more effective assessment of health care technology is one of the best ways to save money.

Crimson: You have taken the position, as did your predecessor, that any article whose contents have appeared elsewhere will not be accepted by the Journal. Lawrence Grouse, one of the editors of the journal of the AMA has said that this policy has had "a chilling effect on the reporting of medical news in this country." Such a policy is said to make researchers reluctant to speak with reporters which slows the delivery of scientific breakthrough to the public. could you defend your policy?

Relman: I think those charges are really silly, and they are very far from the truth. We are a private journal and we have a policy which our authors are free to accept or not as they see fit. Authors who don't agree with our policy or philosophy can send their manuscripts elsewhere. We're not the only weekly journal in the English speaking world. There are many excellent journals with wide circulations that have different policies. So I don't understand why we not entitled to follow what we think are appropriate policies for us. A while ago I spoke about the pluralism in our society. I think it would be too bad if all journals had the same policy. We happen to believe that our policy is a sensible one. We happen to believe it's in the public interest. We also happen to believe that it actually is supported by the vast majority of people who do medical research in this country and by the vast majority of our readers.

Crimson: Is it in the public interest because...

Relman: Because it helps maintain the quality of information that gets to the public. The public interest is not served by rapid dissemination of premature, incomplete, inaccurate, sensational information. The public interest is better served by getting the facts straight, by getting reliable information at a time when the medical profession also has the information and can advise and can help explain what it means. When patients hear on TV or read in the headlines of newspapers some sensational story about some putative cure for a disease or some marvelous diagnostic technique that may or may not turn out to be true and they hear about it in the medical literature I don't think that's in the public interest.

Crimson: Has your policy affected reporting as far as you can tell?

Reiman: That's hard to say. I think that here are some science reporters and medical reporters who may be persuaded by our position although they may not say so.

Crimson: You mentioned in an editorial in July 1979 that there is an oversupply of doctors in this country and that "we are training more than enough students." Yet in some areas of the United States there is insufficient health care. This seems paradoxical. How do you explain it and more important how would you remedy the demographic problem?

Relman: You're right in pointing out that on that one hand the total number of doctors were producing seems to be, by all criteria, adequate or maybe excessive but that the distribution of doctors inappropriate...It's a very tough problem. I don't think you can solve it simply by throwing more doctors as it, by producing more doctors in medical schools. The new doctors that you produce are going to go to the same places that the old doctors went. The fact is...where solid citizens don't want to live, doctors don't want live and practice either. You are gonna have to figure out some way of getting health care to those devastated areas of the inner city and the rural slums where doctors don't want to practice.

Now the National Health Service Corp was one approach, giving scholarships to medical students in exchange for time spent working in underserved areas. That problem is going to be cut now along with many other health care programs.

Another approach of course is to improveiedical care facilities in those areas...to set up clinics and group health plants that will enable doctors to practice good medicine under good circumstances where they can earn a decent living without fear of their lives...

Another approach is simply to provide better transportation, to get people out of the South Bronx into other areas of the city for their health care...It's a social problem. It has to do with how you deal with the problem of slums in this country. It seems to me that the medical profession by itself can't solve that one. That's a total community problem.

Crimson:How would you change the reimbursment program to save money? Relman: The fee system should be changed so that there is not such a high payment for technical procedures as compared with personal services. As it is now, a few minutes spent peering through the end of some sort of instrument...is reimbursed at a rate that may be literally an order or two of magnitude greater than time spent, talking to the patient, examing the patient, counselling the patient or staying up with a sick patient at a hospital. These kinds of personal services that require a lot more time and no less skill are reimbursed at a fraction of the rate of the technical procedures...The insures, the government, and the bureaucrats are much more impressed by a procedure. If you bill a patient and say I'm charging you $50 because I spent an hour with you, talking to you and examing you the patient's not as much impressed as if you bill them $100 for carrying out some sort of technical procedure. It looks very impressive, maybe frightens the patient and seems to be worth much more.

Crimson:Massachesetts recently asked the Federal Government to let it impose a fixed budget on the state millions of dollars. Are you in favour of it?

Relman:In principle it sounds like a good idea...A big part of the reason that health care costs so much is that the insurance principle says "we will pay whatever the usual, customary charges are all we ask is that there be evidence that the procedure or test or treatment actually been carried out." If you have a bottomless well of money from the Federal Government and it's reimbursing costs of health care that way, even if there were no inflation...you would expect utilization to keep going up and up. And that's what happened. And what the state is saying, very sensibly, is no, we're not gonna do that anymore. What we are going to do is try to get Medicaid into the prepayment principle...We'll pay the provider a fixed amount of money with the provider a fixed amount of money with the understanding that the provider is obligated to provide all the necessary services no matter what. And if the provider can be efficient and economical and if his prices are fair and appropriate, he can make some money. He's got to take that risk.