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tional and environmental health exposures. "^^

TABLE 6-2 Role of health associations in the U.S. health care system

Health Biomedical

Association Patient Care Promotion Research

Professional — x —

Voluntary x XXX x

XXX, considerable involvement; x, minimal involvement; — , little or no involvement.



As noted at the beginning of this chapter, professional and voluntary
associations were once heavily involved in research and patient care. In
the latter part of the twentieth century, however, three major functions of
the U.S. health care system are significantly advanced by health associa-
tions: promoting health and health awareness on the part of the general
public; educating and training health practitioners; and formulating policy
for, and regulating the practice of, the health professions. In general, the
professional associations are most concerned with the second and third of
these functions, education and policy formulation and regulation, while
health promotion looms larger on the agendas of the voluntary associa-
tions. A number of voluntary associations also carry out programs related
to the research function (typically by funding research programs or insti-
tutions); a few also carry out patient care activities. (See Table 6-2 for a
graphic representation of the role of health associations in the U.S. health
care system.)


The health promotion function includes activities aimed at promoting
health, such as fitness programs and informational campaigns. Though their
principal focus is elsewhere, professional associations are by no means
absent from this arena of activity. For example, the American Dental
Association's stated mission includes promoting the dental health of the
general public." To that end, the association provides most of the dental
health educational material used in the United States and sponsors the
National Children's Dental Health Month program.^"* Similarly, the Ameri-
can Optometric Association sponsors an allied organization, the American

Regulation/Policy Provision of Goods/

Education Formation Services


X — —


Foundation for Vision Awareness, which supports public information cam-
paigns focusing on the importance of comprehensive vision care.'^


The health promotion function is easily the most visible province of the
voluntary associations. Often this function is carried out through public
information campaigns. The National Safety Council, for example, produced
media campaigns during 1991 focusing on water safety and the hazards of
garage door openers.'^ The council also produces booklets and other publi-
cations for use in workplace safety training programs. ^^ Health promotion
may also be carried out in instructional programs for the public, such as the
American Red Cross courses in first aid, cardiopulmonary resuscitation, and
similar topics, which serve an annual total of 7 million people.'^

Groups devoted to specific diseases also tend to focus largely on health
promotion. The American Council on Alcoholism emphasizes public in-
formation activities to promote the prevention and early diagnosis of the
disease and rehabilitation for its victims,'^ and the National Mental Health
Association serves as the central national source for informational materi-
als on mental health and mental illness. *° The American Cancer Society's
Cansurmount program trains volunteers with histories of cancer to pro-
vide functional and emotional support to cancer patients.'*^

Organizations devoted to non-mainstream therapeutic techniques
and alternative schools of medical practice also tend to focus considerable
effort on health promotion. Examples include the American Center for
the Alexander Technique, which promotes a "technique that enables
individuals to use their bodies with ease, grace, flexibility, and freedom
from strain, "*2 and the National Center for Homeopathy, whose stated
purpose is to "promote health through the use of homeopathic medi-
cine. '"^^ In such cases, one may be inclined to question which is being
promoted — the health of the public or the use of a particular technique or
therapeutic approach. No doubt the organizations themselves would an-
swer "both," as the above quotation from the National Center for Home-
opathy suggests. However, even associations concerned with more main-
stream therapies sometimes engage in promotional activities. A number of
those concerned with transplantation, for example, have promotional
programs designed to overcome public reluctance to donate organs.


All the major types of professional association engage in educational
activities, including general medical associations, specialty societies, and


groups dedicated to specific treatments, allied professions, parallel profes-
sions, and alternative schools of medical practice. In general, the initial
education for the health professions is delivered through academic institu-
tions such as medical and nursing schools, with appropriate practical
training in patient care settings such as teaching hospitals. Professional
associations are not heavily involved in this aspect of the education
function except that they typically participate in the regulation of educa-
tional programs by accreditation or similar processes. This is discussed
later as an aspect of the policy formulation and regulation function.

Professional associations have also assumed a considerable role in
activities designed to keep health practitioners abreast of developments in
their fields. These activities include publications, meetings, and continu-
ing professional education programs. Typically, health practitioners must
participate regularly in formal continuing professional education as a
requirement for retaining licensure to practice.

The AMA, for example, publishes the well-known Journal of the
American Medical Association, and 10 specialty journals. The AMA also
offers an ongoing program of continuing education for physicians at its
Chicago headquarters, and offers practical advice to its members through
its Practice Management Department. The American College of Cardiol-
ogy considers that "continuing medical education is the College's princi-
pal priority" and operates a wide variety of continuing education pro-
grams. These include more than thirty programs on specialized topics
offered annually at the college's Bethesda, Maryland, headquarters; a
similar number of extramural programs offered at sites throughout the
United States; and the annual Scientific Session, featuring over 1,000
reports of original research, lectures, and similar presentations.'*'^ The
Association of Surgical Technologists places special emphasis on training
practitioners to pass the national certifying examination in surgical tech-


The education function is dominated by the professional associations,
since participants in this function are generally health professionals.
However, participation by voluntary organizations is not unknown. For
example, the Eye Bank Association of America, a voluntary association
focused on a particular therapy, operates a program to train technicians in
enucleating (removing) eyes for transplant.^^ The Epilepsy Foundation of
America supports professional as well as public education on epilepsy,
principally by funding fellowships in the medical and behavioral sci-
ences.'*'' Organizations devoted to alternative schools of medical practice


often are obliged to place great emphasis on education and training, since
they may well be the only avenues through which such training is
available. For example, the Himalayan International Institute of Yoga
Science and Philosophy of the U.S.A. "operates ... a graduate school,
which offers masters degrees in Eastern Studies and Comparative Psychol-


Most professional associations perform activities related to the policy
formulation and regulation function. Policy formulation involves coordi-
nating health care services within a specified region or jurisdiction on a
suprainstitutional level. In the nature of the case, activities aimed at
implementing this function fall primarily to government and quasi-gov-
ernmental agencies. However, associations do involve themselves indi-
rectly in this area, typically through legislative lobbying to influence
policy. The AMA, among its other activities, "represents the profession
before Congress and governmental agencies. '"^^ In the specific realm of
legislative lobbying, the AMA has in some years outspent all other organi-
zations. ^^ It has been joined in the lobbying trenches by other national
organizations such as the American Dental Association, American Nurses
Association, and American Hospital Association. ^^

Another type of policy activity in which professional associations
engage is the consideration and formal adoption of policy statements on
various issues by the membership, typically through resolutions of a
legislative body such as the AMA's House of Delegates. Although this
activity does not directly affect health care delivery policy as formulated
and enforced by governmental and quasi-governmental agencies, it
makes an association's views known and feeds them into the policy-
making process.

Professional associations also engage in nonlegislative regulation ac-
tivities, regulation being defined as the setting of standards for health
practitioners and institutions. The most important and noteworthy in-
stance of such activity is the participation of professional associations in
accrediting education programs. The AMA, for example, cooperates with
other entities to set standards for hospitals, residency programs, medical
schools, and continuing medical education courses^^; it also participates in
the accreditation process for nearly twenty allied health fields. The Ameri-
can Dental Association inspects and accredits dental schools as well as
schools for dental assistants, hygienists, and laboratory technicians.''^ The
American Nurses Association issues published standards for the profes-


sion,^'* and the National Association for the Advancement of Psychoanaly-
sis and the American Boards for Accreditation and Certification (one
organization, its title notwithstanding) sets certification standards for
individual psychoanalysts and psychoanalytic therapists. ^^

One conspicuous regulatory activity — the certification of individual
medical specialists — is largely absent from the agendas of the professional
associations, since it is generally performed by a separate system of
specialty boards that have no formal connections with the specialty
societies. Another such activity, discipline for infractions of professional
standards, is usually carried out at the local level, by a state or county
medical society rather than the AMA.


As discussed earlier, policy formulation and regulation for health profes-
sions are carried out preeminently by professional associations in con-
junction with other entities such as governmental agencies. Voluntary
associations are not appreciably involved in many aspects of this function,
such as certifying practitioners and regulating training programs. Other
activities supporting this function are, however, sometimes found on the
agendas of voluntary associations. For example, the American Council on
Alcoholism lists, among its activities, supplying expert witnesses in state
and federal proceedings involving alcohol issues. ^^ The Epilepsy Founda-
tion of America provides expert testimony in federal and state legislative
proceedings and enters amicus briefs in court cases affecting individuals
with epilepsy. ^-^

A number of large voluntary associations are considerably active on
the legislative lobbying front. For example, the cigarette-smoking ban on
domestic airline flights is largely the result of a cooperative lobbying effort
by the American Heart Association, the American Cancer Society, and the
American Lung Association. ^^ The National Safety Council has joined
with the National Highway Traffic Safety Administration and the National
Transportation Safety Board in an effort to encourage the adoption of
state laws mandating suspension or revocation of driver's licenses of
persons found driving under the influence of drugs or alcohol. ^^


As previously discussed, most of the functions of voluntary organizations
fall into the health promotion and education realms. However, a few such


associations are also involved in other health care system functions. These
include, to a small extent, patient care, and to a larger extent biomedical
research. A few voluntary associations do play a role in patient care by
funding goods and services for persons suffering from particular condi-
tions. One example is the mission of the Lions Clubs to aid visually
handicapped people, which involves providing eyeglasses, guide dogs,
and mobile glaucoma-screening clinics. Another example is found in New
York's Gay Men's Health Crisis and similar organizations devoted to
people with AIDS and HIV infection. The Gay Men's Health Crisis is
heavily involved in providing direct patient services, though these services
are for the most part complementary to medical treatment as such.
Services include meals-on-wheels programs, assistance with shopping
and household tasks, and legal and advocacy services. ^° A few other
voluntary associations also participate indirectly in providing patient care
by funding institutions, such as the Shriners' burn institutes. A more
direct role in patient care is taken by the Planned Parenthood Federation,
which has a network of over 900 health care delivery facilities.^ ^

Research grant programs are funded by a number of groups such as
the American Cancer Society and the American Heart Association. In
other cases — notably, again, the Lions and the Shriners — voluntary asso-
ciations sponsor research institutions focusing on their particular areas of
interest. One exceptional voluntary association, the American Red Cross,
operates its own biomedical research laboratory. The Jerome H. Holland
Laboratory for the Biomedical Sciences, in Montgomery County, Mary-
land, opened in 1987.^^

While many of the functions of professional organizations fall into the
education, regulation and policy formulation areas, brief mention should
be made of one additional distinctive function that is not a function of the
U.S. health care system per se: the provision of various membership services
to practitioners. Professional associations, including the American Dental
Association and the AMA, have become major providers of professional
liability and other types of insurance to their members. Many, if not most,
facilitate professional placement by publishing notices of available vacan-
cies and/or by operating formal placement services. Some also offer
nonprofessional group services, such as mutual funds and other invest-
ment opportunities. Finally, virtually every professional association mar-
kets patient information brochures and similar materials to its members.
This last activity may appear to straddle the functional boundaries be-
tween health promotion, patient care, and the provision of goods and
services, but it is too prominent to neglect.

The advocacy activities of special-constituency groups also deserve
brief notice in this category. To take an example, the National Black


Nurses Association espouses the role of advocate for improved health care
in the African-American community. ^^ Although such activities bear
some resemblance to both education and health promotion, they are
focused on the awareness of issues rather than directly on the preserva-
tion or restoration of health, and hence deserve to be considered as
distinct from either of those functions.

Finally, both professional and voluntary associations must devote a
portion of their attention and resources to the administrative function.
Again, this is not a distinctive function of the U.S. health care system, but
refers to those dealings with people, property, and money that any
organization must carry on to survive. In general, these functions in
health associations appear similar to their counterparts in other types of
association. The organizational chart of the American College of Cardiol-
ogy, for example, reveals a group of administrative committees with titles
like "Budget, Finance and Investment," "Buildings, Grounds and Acqui-
sitions," "Strategic Planning," and so forth. ^"^ Their counterparts in the
American Heart Association's Chicago chapter include "Budget, Finance
and Audit," "Management Services," and "Long Range Planning. "^^
Both professional and voluntary associations also share such administra-
tive activities as maintaining membership data bases, planning and exe-
cuting conventions, and interviewing and hiring personnel. Many volun-
tary health associations also devote considerable resources to fund raising.
For example, the American Heart Association describes "revenue genera-
tion" as one of its three principal enterprises.


The functions carried out by the umbrella associations naturally vary with
their mission and constituency. In the main, however, they tend to cluster
in the realms of education and policy formulation and regulation (which
are also the two main areas of concern to the larger class of professional
associations catering to individuals). Examples of the education function
include management education programs for medical school deans and
teaching hospital directors offered by the Association of American Medical
Colleges,^^ the American Hospital Association's in-service education pro-
grams for hospital personnel,^^ and a series of executive development
seminars for new and aspiring deans of nursing offered by the American
Association of Colleges of Nursing. ^^ Examples of the regulation and
policy formulation function include the efforts of the National Health
Council to secure uniform standards of financial reporting for voluntary
health associations^^; the National Association of Health Career Schools,
which cooperates with governments and other organizations to maintain


appropriate standards and policies in the realm of health career training''^;
and the National Association of Medical Equipment Suppliers, whose
lobbying influence is hinted at by its stated interest in "support [ing]
legislation and regulations that are beneficial to the home health care
industry and provide incentives for suppliers to continue to serve Medi-
care/Medicaid beneficiaries."^'

In some cases one function is overwhelmingly emphasized, owing to
the special nature of an organization's mission. Such is the case, for
example, with the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), a policy-formulating and regulating body by its
nature. JCAHO unites the American Dental Association, American Col-
lege of Physicians, American College of Surgeons, American Hospital
Association, AMA, and the public at large to establish standards and
conduct accreditation programs for hospitals, mental health centers, hos-
pice programs, and similar health care institutions and organizations.^-^
The Association of American Medical Colleges demonstrates a similar
overwhelming emphasis on the education function; alongside its many
general activities in support of medical education, this association also
administers the Medical College Admissions Test, a near-universal re-
quirement for admission to medical school. '^^



A typical medical professional society, the Illinois State Medical Society
(ISMS) celebrated its sesquicentennial in 1990. Thus, its 1840 founding
antedated by seven years the organization of the AMA. ISMS is now
among the half-dozen or so "unified" state medical societies — that is,
concurrent membership in the AMA is required of ISMS members. In
1990, ISMS had a membership of about 18,000, a staff of nearly 200, and
an annual budget of approximately $6.4 million. The society states as its
mission "to unite the [Illinois] medical profession behind: (I) promoting
the science and art of medicine; (2) protecting public health; (3) elevating
the standards of medical education; and (4) informing the public and the
profession of the advancements in medical science and the advantages of
proper medical care."^"* The education and health promotion functions
emerge graphically from this mission statement; regulation and policy
formulation are (as will shortly become apparent) implicit in the purpose
of "promoting the science and art of medicine." (It should be noted that
the ISMS mission statement uses "promoting" in the sense of "advanc-


ing" rather than the sense intended by the term "health promotion" as
used in this work).

Health Promotion Function Although it devotes most of its efforts to
policy formulation and education, the ISMS noted in its 1990 annual
report some health promotion activities, notably directed toward adoles-
cents and senior citizens. The society's AIDS and Adolescents program,
initiated in 1987, has sent more than 300 physicians into junior high and
high schools across the state to teach students about the transmission and
prevention of AIDS. The Partners for Health program, inaugurated in
1990, provides physician speakers to senior citizen facilities to make
presentations aimed at improving communication between physicians
and older patients.

Education Function Education activities loom larger than any other
single function in the reported 1990 programs of the ISMS. These activi-
ties included continuing professional education for practicing physi-
cians — for example, producing and distributing an instructional video
tape for physicians on HIV counseling and testing, and gathering and
distributing information to physicians on contractual relationships with
health maintenance organizations and preferred provider organizations.
The ISMS also assisted in funding medical education by raising and
contributing money to provide low-interest loans to medical students; and
it engaged in education-related research, conducting a study of the merits
of individualized continuing medical education programs.

Policy Formulation and Regulation Function The 1990 annual
report of the ISMS documented an active role for the organization in
influencing health care legislation in the state of Illinois. In 1990 the ISMS
was successful in securing passage of a bill providing immunity from civil
lawsuits to physicians who volunteer time in community-based free
medical clinics, and of another bill providing similar immunity to physi-
cians who notify spouses of a patient's positive HIV test. Also on the ISMS
legislative agenda were bills mandating Medicare assignment as a require-
ment for licensure of physicians, and providing for a "Canadian-style"
universal health care system, both of which the society opposed. Through
its Third Party Payment Processes Committee, the society worked with the
Illinois Department of Public Aid to improve access to prenatal care for
recipients of public aid; and its political action committee, IMPAC, for the
first time endorsed a candidate (the eventual winner) in Illinois's 1990
gubernatorial race. Society members were also involved in revising state
regulations affecting ambulatory surgical treatment centers and clinical



FIGURE 6-2 American Red Cross disaster relief services after the San Francisco

earthquake in 1989. Source: American Red Cross, National Headquarters

laboratories, and the society was authorized to accredit continuing medi-

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