On October 1, 1969, against substantial opposition from many of the faculty members at Harvard Medical School and others in the Boston medical community, Dr. Robert Ebert succeeded in launching the Harvard Community Health Plan. Forty years later, in 2009, several of my colleagues and I felt that four decades of innovation deserved some notice and review before the generation of founders faded from view. We planned a huge gala as the central focus of our celebration and produced a document in which we tried to note the historical high points of the remarkable organization to which we had dedicated much of our professional lives. (You should look at, or perhaps download, the PDF for the full story.) In the opening essay we wrote:

The year was 1969, the summer of Apollo 11’s launch and historic moon landing. In Boston, another historic mission was underway. Robert H. Ebert, M.D., Dean of Harvard Medical School, along with a group of dedicated pioneers, was putting the finishing touches on plans to launch the Harvard Community Health Plan (HCHP, or “the Plan”), which would revolutionize the way medical care would be financed and delivered in Boston. Joining Ebert in the planning were Jerome Pollack, Henry Meadow, and Sidney Lee, M.D., all associate deans at Harvard Medical School. For some time, H. Richard Nesson, M.D., then of Beth Israel Hospital, and Joseph Dorsey, M.D. of Peter Bent Brigham (now Brigham and Women’s) Hospital, had been working to recruit physicians from their respective hospitals to join the new Plan. They would become the Plan’s first medical directors. John Kenneth Galbraith was an early advisor to the group, and other enthusiastic collaborators included Francis Moore, M.D., Howard H. Hiatt, M.D., and Gordon Vineyard, M.D. of Brigham and Women’s Hospital. The latter was to become the Plan’s first surgeon and would later serve as interim CEO. Arthur Sutherland, professor of constitutional law at Harvard Law School, helped to negotiate the legalities, including the name of the Harvard Community Health Plan. 

The impetus for change was rooted in fundamental problems confronting American medicine during the 1960s: Medical costs were rising at an alarming rate, the neighborhood general practitioner was becoming extinct and there was increased demand for a dwindling supply of primary care physicians. Medical schools and their affiliated hospitals, along with payers and policymakers, were struggling to develop more efficient and accessible models for teaching and delivering primary health services. Solutions ranged from reorganizing outpatient clinics to developing neighborhood health centers in urban areas. 

Ebert and his team had a different idea: Their plan was to replace fee-for-service care with a prepaid group practice that would provide high quality ambulatory health care within the community, serving the sick while also providing preventive care to healthy members of the community. Comprehensive care services would be available under one roof, delivered by a group practice staffed by salaried physicians, working with clinician teams. Affiliation with Harvard Medical School would provide training for future physicians, and the program would provide care to patients from all sectors of society, including low-income, underserved populations. Most significantly, it would be the first medical school sponsored managed care organization in the nation. Despite the enthusiasm of the planners, the idea was met with skepticism and even scorn in the Boston medical community. Some called the idea “a medical moon shot” that smacked of “socialized medicine” and would never succeed. Ebert and his colleagues were persistent, having spent years in careful and conscientious planning. They secured the support of Harvard Medical School, received initial funding for the not-for-profit corporation, established relationships with the two Harvard teaching hospitals, and acquired space on the first two floors of an apartment building at 690 Beacon Street in Brookline. They developed the medical care programs and arranged for Blue Cross/ Blue Shield to market the Plan, and even to provide a guaranteed number of members. They staffed for a predicted 10,000 members, and then hastily modified that estimate to 1,000 just weeks before the opening.

As it turned out, the day that Harvard Community Health Plan opened its doors—October 1, 1969, there were only 88 members, most of whom were said to be employees of its affiliated hospitals. The first patient to visit was a man complaining of chest pains. The doctor who saw him could not find a stethoscope. During the first month, there were 13 patient visits. “What was on the horizon on the day we opened was a group of physicians with no patients,” said H. Richard Nesson, M.D., in 1980. “So the Harvard Plan quickly became one of the greatest donors of health care in the Greater Boston area. We made arrangements for the medical staff to work in neighborhood health centers and other places where people needed help—and for free, because we were paying them a salary. They just needed things to do.” One of these locations was the Mission Hill-Parker Hill Health Center. These decisions embodied the enduring HCHP/ Harvard Vanguard commitment to providing care to low-income residents of Boston.

You should examine the entire document if you are interested in the history after 1969, and the effort to become the pilot organization that tested Dr. Ebert’s concept that prepaid medical group practice with a focus on health maintenance and disease prevention might be the combination of “a conceptual framework and operating system” that would “provide optimally for the health needs of the population.”  For me, the full statement is the medical equivalent of we “we hold these truths to be self evident…” and should be inscribed on a monument with a statue of its author. Here it is once again:

The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.

He had articulated that concept in a letter written in 1965 to the President of the Commonwealth Fund. The letter was a request for funding of the research/teaching practice that he hoped would be a pilot that drew ideas from Kaiser and Group Health, but would go further in the exploration of “prepaid practice” connected to a medical school and staffed by a salaried professional staff. As he had expressed in a lecture that he delivered at Simons College in 1967, he saw a great need to move care, and medical teaching from the silos of the academic medical center back into the ambulatory environment. Kaiser and Group Health had established innovative ambulatory practices based on principles of health maintenance and preventative practice that we now call population management, but neither organization had a teaching mission as a primary reason for their existence. As Doctor Ebert said in the Simmons lecture, he was interested in training a generation of socially responsible physicians. 

My first awareness of HCHP occurred not long after it opened its doors. I had my “medicine” clerkship at the Peter Bent Brigham Hospital during the 1969-1970 academic year. Part of that experience was to spend time in the emergency room, but when it was obvious that a patient required admission, we would also be called to the EW to meet our new “admits” and do most of our evaluation and initial testing in the EW before the patient “hit the floor.” Once the patient got to the floor the nurses would need to go through their routine, so it was important to do a lot of work before they took over. It was also true that the Brigham was a “linear” hospital with the EW and Radiology at one end of the sprawl and the medical floors almost a quarter of a mile away down a very long hallway and tunnel called the “Pike” that connected all the buildings of the old Brigham. It made no sense to take a patient to the ward only to then take them all the way back down the “Pike” for a necessary exam.

The usual routine in the EW was for the medical student to see the patient first and then the intern or resident who would be admitting the patient would follow. The EW staff was populated by medical students, interns, and residents. The large majority of the patients that we saw were disadvantaged people who were uninsured and came from the nearby sections of Mission Hill, Jamaica Plain, and Roxbury. The Boston City Hospital also saw a similar disadvantaged population of patients from these same communities. If there was a complicated question, it was possible that a senior resident, or even the chief resident, might get involved, but we did not see an “attending physician” except for morning rounds. If a person who had a “private” attending showed up in the EW, usually it was a cardiology, oncology or renal patient, a ”fellow” associated with the service attending for the month from the academic department responsible for the patient might appear and provide direction and support. In very rare circumstances the fellow might be so concerned or bold that he/she would be brave enough to phone the “attending” or even more rarely, the private physician, in the middle of the night to ask for advice. No “attendings” or private physicians were ever seen in the EW, except for the EW attending of the month, and that person would appear only for teaching rounds with the students, interns, and residents early each morning. 

One night, long after midnight, I was surprised to see a professional looking woman in a business suit push back the curtain of the cubical where I was beginning to “work up” a young woman that I was admitting. My memory may fail me, it has been fifty years, but I think the patient had some kind of malignancy, perhaps a lymphoma, and had come to the EW with a fever. I can’t remember for sure whether she was in the middle of the course of one of the brutal programs of chemotherapy of that era or not, but let’s say that she was. What I do remember is that the moment my patient saw the woman who was her doctor enter through the curtain her face lit up and she extended her arms to hug the woman. The doctor introduced herself as Siggy Tischler, the patient’s oncologist from HCHP. Dr. Tischler let me finish my exam. When she stepped forward to talk with the patient I excused myself from the room and rushed to find the intern with whom I was working. I incredulously described to him what had just happened. His comment was something like, “Yeah, she is one of those doctors from that new group in Kenmore Square. They usually come in to see their patients.” It was not long until Dr. Tischler had finished her exam and then sought me out at the central desk where I was beginning to write my history and physical. We talked about the patient. She gave me a clear picture of her medical problems, and made sure that I understood both her medical and social concerns. 

That encounter got filed away in my memory under “unusual” experiences. Over the next eighteen months my ears became finely tuned to capturing any information in the air about HCHP. To my great delight on the first day of my internship in late June 1971, I discovered that my attending was Dr. Joe Dorsey, the “Brigham” medical director of HCHP. HCHP was initially composed of two faculty practices and initially had two CMOs. Joe Dorsey led the Brigham group, and Dick Nesson, who would later move to the Brigham to head their ambulatory care program, and after that to become the CEO of the Brigham and the founder of Partners Healthcare, was the medical director of the physicians from the Beth Israel Hospital. When Nesson left the BI, Dr. Dorsey became the CMO of the unified practices. Physicians from both hospitals practiced out of the same ambulatory offices on the first three floors of an apartment building, pictured in today’s header, in Kenmore Square, but we admitted primarily to our “home” hospital. We crossed covered each other in both hospitals which was easy since the hospitals are less than two blocks apart. Kenmore Square is less than a mile from either hospital and near Fenway Park. 

Fast forward to late 1974. By then I was a cardiology fellow at the Brigham. NIH funding for fellowships was thin, and I was supplementing my income by a heavy “moonlighting” practice in a local emergency room. I was not sure what was next for me. One of my mentors at the Brigham was Marshall Wolfe who was the cardiologist at HCHP. He knew that I was interested in practice and not in basic research. He informed me that he was leaving HCHP to become the house staff director at the Brigham. It was his idea that I take his practice at HCHP. It made sense to me. I never applied for the job. I just showed up on July 1,1975 and then spent more than 38 years in a great job. Once, about seven years into the experience, I thought about leaving for a job in a small town in a beautiful area of New Hampshire, but I quickly realized the problems that motivated me to think about moving were in my private life and not at work. The thought of leaving trusted colleagues and patients that I had known for several years was a barrier that I could not clear. It dawned on me that I was in such an innovative practice that I did not need to change jobs for a new challenge because my job was always changing around me. Where else would I be exposed on a daily basis to innovative thinkers like Don Berwick, Glenn Steele, Atul Gawande, and so many others with less fame, but no less a commitment to practice improvement?

As luck would have it, I have had two appointments this week back in my old practice. I am no longer a “provider” of care. [That is a joke. Ours was an egalitarian “left” leaning, progressive organization that referred to all of its employees with direct contact with patients as “providers,” some facetiously thought we should just call each other “comrade.”] I have moved to the other side of the sheet. Now I am a “frequent flyer” who looks like any other old 74 year geezer. I walk around virtually incognito filling prescriptions, having Mohs surgery, getting a half a dozen polyps removed at a colonoscopy, or getting my eyes checked since everything is getting fuzzy. I know that I can trust the care at Harvard Vanguard/Atrius because I know and resonate with the values upon which it was built.

There is a great book by Paul Elie about four mid twentieth century Catholic writers, Thomas Merton, Dorothy Day, Flannery O’Connor, and Walker Percy who was also a physician. The title of the book frequently comes to mind when I think about my experience at Harvard Community Health Plan and all the other names its practice has been called over the last fifty years, The Life You Save May Be Your Own. When I walked into the apartment building in Kenmore Square on that hot July day in 1975, I had no idea that I was going to be one of many dedicated professionals who would spend a professional life building a practice to improve lives. Nor did I realize that one day one of the lives that Dr. Ebert’s ideas and our collective efforts would improve would be my own. Happy BIrthday to Harvard Community Health Plan, Harvard Pilgrim Health Care, Harvard Vanguard Medical Associates, and Atrius Health, and thank you, thank you, to Dr. Ebert, Dr. Joe Dorsey, and all the founding “providers” who opened those doors on October 1, 1969 and welcomed in that first patient.