Organizational Aspects of Child Health Services
The three papers in this issues ‘ssection of “Pediatrics for cisions. Emotions govern much of the decision making. It is in the Clinician ‘are addressed to three new and important as- the hope ofinforming all who carefor children about the cur-pects ofprotiding health care-methods to assure the quality rent state of affairs in these three important areas that these ofcare, principles offinancing care and a description ofa no- papers are published. In future issues we will address our-tional program to seek out and render care to poor children selves to other topics of organization and report mi c/ian ges hOt 110W receiring it. These three articles are not presented be- and progress in these three areas.
cause they are definitive orfinal statements about the
impor-tant problems, for they are not. Each area is in a state of great
f
erment. There is little data upon which to base orform de- ROBERT J. HAc;ERTY, M.D.PEDIATRICS FOR THE CLINICIAN
EPSDT
(Early
and Periodic
Screening,
Diagnosis
and
Treatment
Programs)
Morris S. Dixon, Jr., M.D.
In 1965 Congress passed Title XIX of the Social
Security Act (Medicaid) to increase the
availabil-ity of medical care to low-income groups by paying their medical expenses. It was designed as a state-administered program and consequently each state is unique in the extent of services
of-fered and the eligibility of recipients. The federal
government assists the states financially with matching funds ranging from 50-50 in New York to 81-19 in Mississippi. In return for the matching
funds, the Department of Health, Education, and
Welfare stipulates that the states must pay for medical services, including hospital and physician
care, at least to recipients in the four categorical
groups-Aid for Dependent Children, Aid for the Aged, Aid for the Blind, and Aid for the Disabled. Dental care, prescription drugs, eyeglasses, and hearing aids are optional services which may be offered in the state program, and each state has the option to include low income populations
which are not in the above categorical groups.
Medicaid in Fiscal Year 1974 is expected to pay 10 billion dollars for the medical care of 23 million children and adults. It is by far the largest single program for health care for children in the United States.
In 1967 President Lyndon Johnson presented
his Message on the Welfare of Children to the
Congress in which he included a declaration to
“expand our programs for early diagnosis and treatment of children with handicaps. “ As
Con-gress considered bills related to the Message, it
noted that state Medicaid programs were
primari-ly reaching sick people needing acute care, treat-ment for chronic conditions, and long-term care. It also noted the unevenness of health care re-ceived by children in low-income families in dif-ferent parts of the country, as illustrated by Crip-pled Children Services reaching as many as 17.7 children per 1,000 population under 21 years of age in one state and as few as 1.6 children per
1,000 in another state. It consequently assumed
that many children with potentially handicapping conditions were not being treated and that little
was being done in Medicaid programs to
encour-age families to obtain preventive health services. The 1967 Amendments to Title XIX intended to correct this deficiency by ordering the state Medi-caid programs to screen children under 21 years of
(Accepted for publication February 18, 1974.)
age for physical and mental defects and to provide
the necessary health care to correct the defects.2
The Early and Periodic Screening, Diagnosis,
and Treatment Program (EPSDT) conceived in 1967 was to begin July 1, 1969, but was delayed by
the formulation of the Regulations by HEW.
Fi-nally in December 1971, Regulations were issued stat:ing that states must initiate their EPSDT pro-grams by February 7, 1972, for children under 6 years of age, and for all eligible children under 21 years of age by July 1, 1973.
Congress reaffirmed its interest in EPSDT in 1972 when it added a penalty clause in H.R. 1,
“which reduces the Federal share of Aid for
Dc-pendent Children (AFDC) matching funds by 1% beginning in Fiscal Year 1975, if a State (a) fails to
inform the adults in AFDC families of the
avail-ability of child health screening services; (b) fails
to actually provide or arrange for such services; or
(c) fails
to arrange for or refer to appropriatecor-rective treatment those children disclosed by such
screening as suffering illness or impairment.”
THE EPSDT PROGRAM
Goals
Mr. Howard N. Newman, Commissioner, Mcdi-cal Services Administration, delineated the fol-lowing goals of the EPSDT program: (1) to im-prove childrens health now and to prevent
un-necessary and costly illnesses in the future; (2) to
promote preventive medicine, because the poor
arc not accustomed to preventive health
mea-suies; (3) to search out the eligible children and
in-form and encourage them to participate in the program; (4) to require the states to arrange for
screening, referral, and treatment services as a package.4
Federal Role
The federal government supplies matching
funds to the states for EPSDT in the same
propor-tion as for the general Medicaid program. The re-sponsibility for the administration of EPSDT lies in the Medical Services Administration, a Bureau of the Department of HEW, and includes the for-mulation of guidelines and the monitoring of the
program.
The Program Regulation Guide of June 28, 1972, is the current document governing the state programs. The following are important points in the guidelines
1. Coverage-All children under 21 years of age
who are determined eligible for medical assis-taiice under the state Medicaid plan must be
in-eluded in EPSDT.
2. Case Finding-State Medicaid agencies must
actively seek out children eligible for EPSDT.
Parents need to be informed about the Program
and its purpose. Families should be assisted in
finding EPSDT facilities and transportation must
be provided if needed. Consent of the parent or
guardian is a prerequisite before EPSDT services
are provided.
3. Early & Periodic-The guidelines are
some-what vague about these terms and request the
states to consult local health experts to help define periodicity. They do specify that children be
screened early in life or when they become
eligi-ble for medical assistance.
4. Screening-The purpose of screening is to
sort out children who may have a disease or
abnor-mality from those who are apparently well, by the
use of quick and simple procedures among large groups of children. Although the states are given a choice, the guidelines clearly say that screening is
intended to be carried out on large groups of
chil-dren by nurses, trained health aides, laboratory technicians, and trained volunteers, rather than on an individual basis by a physician. The latter approach may have to be used in rural areas.
The screening exam should contain the
follow-ing components as a minimum:
1. A medical history to include physical,
men-tal, and developmental assessment. This will
usually be a check-sheet obtained by a nurse or aide.
2. Physical growth assessment.
3. Developmental assessment to be obtained by history and perhaps by one of the developmental tests.
4. Unclothed physical inspection to note
ob-vious orthopedic, genital, skin, and other
observa-ble defects. A cardiac exam is desirable.
5. Ear, nose, throat, and mouth inspection for
obvious abnormal conditions. The guidelines note
that extensive dental screening should not be done
because so many children will require definitive dental treatment.
6. Vision testing appropriate for the child’s
age.
7. Hearing testing appropriate for the child’s
age.
8. Anemia testing such as a hemoglobin or
mi-crohematocrit determination.
9. Sickle cell testing on all Negro children.
10. Tuberculin test.
11. Urine screening for sugar, albumin, and bacteria.
12. Lead poisoning screening of all children 1
to 6 years of age, and older children when
mcdi-cally indicated.
13. Nutritional status.
14. Immmization status.
the need for further evaluation, the patient must be referred to a physician or health facility for
di-agnosis, regardless of the limits for treatment
under the state Medicaid plan. The Title XIX
agency must assist the patient to find diagnostic
facilities and provide for transportation if needed.
6. Treatment-If treatment is necessary, it must be provided within the limits of the state Mcdi-caid plan, and in addition, treatment of visual and
hearing defects (including eyeglasses and hearing
aids) and dental care must be provided regardless of state limitations.
7. Interagency Cooperation-The guidelines
stress that other health agencies should be utilized
in the screening program, and that where appro-priate those agencies should be compensated for the services provided.
Regional Role
The ten HEW Regional Offices are extensions of the federal government. Their EPSDT role at present is essentially reviewing the contents of the
state plans and monitoring their development.
The Regional Offices collect progress reports from the states each month which are then sent to
Washington with comments.
State Role
Each state is responsible for designing its own EPSDT program within the framework provided by the Program Regulation Guide. Consequently, EPSDT is really a collection of 55 individual state and territorial plans. (Arizona does not have a
Medicaid program as of this writing, but probably
will adopt one in 1974.) About half of the states are encouraging the establishment of separate screen-ing clinics for large groups of children, frequently under the supervision of state and local health
de-partments. The remainder are using existing
mcd-ical facilities, including private physicians, for the performance of individual health assessments. All states are relying on existing medical resources for diagnosis and treatment of children with possible abnormalities.
The implementation of EPSDT is a state
re-sponsibility. In most states the Department of
Public Welfare is the designated Medicaid agen-cy. Welfare administrators have generally had lit-tie experience in directing a medical care delivery
system like EPSDT which is much more
compli-cated than simply administering a third-party payment plan such as Medicaid. The mandatory outreach component of EPSDT has also added a new dimension to their Medicaid role. Many ad-ministrators have not welcomed these challenges and frequently do not have sufficient staff to han-die them.
State governments have been reluctant to pro-vide the necessary funding for their share of EPSDT expenses. They are under constant pres-sure to hold down welfare costs and have not wel-comed the new EPSDT program mandated by Congress.
PROGRESS
The Medical Services Administration publishes a quarterly Progress Report consolidating infor-mation received from the states via the ten Re-gional HEW Offices. The major portion of the Re-port is a brief statement of the problems of each
state, and plans for solutions. Because of the lack
of uniformity of the individual state plans and the difficulty in adopting standard definition of terms, the data collected are admittedly crude and will continue to be in the foreseeable future.
The most recent status report available (for the
quarter ending September 30, 1973)6 reveals that
all states except Pennsylvania and Arizona have implemented their EPSDT Programs and 34 are considered statewide in scope. (The previous quarterly report commented on the difficulty in defining “statewide.”) In July, New Hampshire eliminated all FY 1974 funds for EPSDT and thereby eliminated the EPSDT efforts in that state.
Most states with programs have informed
eligi-ble recipients about EPSDT, usually by a notice enclosed with the monthly payment check. It is
well known that a mailing is an ineffective method
of motivating families to seek EPSDT services, but few states have established satisfactory outreach arrangements because of lack of personnel. If the program is going to reach the children who are outside the medical delivery system, major out-reach efforts will be necessary because low-in-come populations in general do not consider pre-ventive medicine a high priority.
Most states rely on local caseworkers for
track-ing patients from screening to diagnosis and
treat-ment. This can only be a temporary method
be-cause caseworkers are already overburdened. As
an alternate means of following patients, a few of the larger states are planning to use computers in matching invoices received from the screening exam with those from diagnosis and treatment.
Many states are experiencing difficulty making arrangements with physicians for diagnostic and treatment services because the basic Medicaid
plan does not offer satisfactory remuneration and
involves too much paperwork. In rural areas
par-ticularly there are few physicians available to ac-cept new patients.
re-ferred for diagnosis and treatment. Many more of the 10,426,716 eligible children are receiving well-child care, but the reporting system is
made-quate to collect the data.
Evaluation of a program so large and un-structured is almost impossible. Each state has its own reporting form and comparable data will be
extremely difficult to collect. The Medical
Ser-vices Administration is formulating plans to evalu-ate sample areas rather than the entire EPSDT Program nationally. A large grant has been given to the University of Texas Health Science Center at San Antonio to assist in the evaluation and to develop guidelines for the states to use in their own evaluation.
Grants have been given to several organizations for the preparation of manuals for use in the EISDT Program. The American Academy of Pc-diatrics is currently producing a Manualfor
Physi-cal and Developmental Screening and a Manual
on Organization ofEPSDT Sercices. The American
Society of Dentistry for Children is preparing a
Gl4ide to Screeningfor Dental Defects. The Health
Facilities Foundation of Berkeley, California, has
a grant to produce a Model Program for Training Allied Health ProfessionaLs and Paraprofessionals to Perform Health Screening Services. The
Amen-can Medical Association’s Committee on Health
Care of the Poor is writing a Guidefor Professional
Health Provider Participation in EPSDT. These
manuals should be of great assistance to the
ad-ministrators of EPSDT Programs at the state and community levels.
Five pilot programs have been established with
grants from the Department of HEW to devise
and evaluate screening methods for children of
various ethnic backgrounds and geographical
locations.
Government programs historically have not be-en noted for their care in planning and speed in
implementation. In a program as immense,
com-plicated, and loosely administered as EPSDT, it is important not to expect too much too soon. There obviously wjll be a need for many changes in the years ahead.
ROLE OF THE
AAPThe American Academy of Pediatrics (AAP)
has been actively interested in EPSDT since 1970 when it provided testimony to congressional com-mittees in support of it. The Academy pointed out that the Medicaid program had a great potential to meet the health needs of the eligible children, but that important limiting factors were the fail-ui’e to give appropriate emphasis to preventive
services, lack of involvement of providers of care
in planning at the state level, and virtual absence of standards of child care.7
In October 1972, the Executive Board of the AAP adopted a statement8 which publicly sup-ported EPSDT and encouraged chapters and the membership to become involved in the planning and implementation of EPSDT at state and
com-munity levels. It expressed concern about the lack
of manpower to operate the program and the tre-mendous cost of providing comprehensive health care for the eligible children. It questioned the value of health screening that is not part of a mcdi-cal care program.
An Ad Hoc Committee on EPSDT was
appoint-ed in June 1972, which has established a strong li-aison with the Medical Services Administration. It
has provided technical and evaluation advice at
the national level, and has made
necommenda-tions to the Executive Board of the AAP on the
role of the Academy. The Ad Hoc Committee has
been requested to keep abreast of national devel-opments in EPSDT, to influence policies and guidelines so that the best interests of children will be represented, and to supply feedback to all
pan-ticipating and interested individuals and
agen-cies.9
Regional representatives have been appointed in the ten HEW Regions to provide technical
ad-vice to the SRS Regional Associate
Commission-ens, and to be a liaison between the Regional office and provider groups, such as state chapters of the AAP and state medical societies. To date, a mini-mum has been accomplished in this area because of lack of interest on the pant of the Regional Asso-ciate Commissioners and the lack of funds for reimbursement of the Fellows. Efforts are con-tinuing to increase the effectiveness of the region-al advisors.
The Executive Board and the Ad Hoc Commit-tee have stressed the need for state chapters to be-come involved at the state level because the states have a great deal of freedom in planning their EPSDT Program and have full responsibility for
its implementation. Most state chapters have been
in communication with state Medicaid adminis-trators with variable success. A few state chapters have played very important roles in planning their state programs. A survey of State Chapter Chair-men in the summer of 1973 revealed that of 37 replies, 23 chapters have EPSDT committees, 20 chapters have sent material about EPSDT to the Chapter membership, but only 4 chapters meet regularly with state administrators.
EPSDT cannot succeed if pediatricians and family physicians do not become involved at the community level. Screening can be performed by tnained nonmedical personnel. It will usually be better if there is pediatric expertise utilized in the planning and supervision of the screening pro-gram. Obviously physicians will be essential in providing diagnosis and treatment of children who are referred from the screening 12
Because of its interest in establishing standards of child care, the AAP has accepted a contract to produce a Manual on Screening which should be available in mid-1974. A companion Manual on
Organi:otion of EPSDT Services, which will
dis-cuss methods of organization of child cane, is in
the early stages of preparation and will be
pub-lished in late 1974.
COMMENTS
EPSDT has been criticized from all sides. State politicians complain that it is a costly, untried program that will overwhelm already strained health and welfare budgets. State Medicaid
ad-ministrators do not welcome their new role in
administering a complicated health program. Re-cipients who are not used to preventive care are disinterested and feel that it is just another pro-gram which will come and go without making much of an impact on their lives. Physicians look
on it as an extra burden in their already busy
prac-tice, and one which will require more paperwork without adequate compensation. Many of these criticisms are justifiable and are not readily an-swered satisfactorily.
Some have questioned whether Medicaid is the right vehicle for EPSDT. This is a theoretical question now because EPSDT is here as a part of Medicaid and will be a part of it in the foreseeable future. We need to give it an adequate trial. There is no question that the children on Medicaid need preventive health care, and the families need health education. In most states Medicaid covers only the children on federal categorical programs and many children in medically indigent families could benefit from similar services. Perhaps alter-natives such as increasing project funding for Neighborhood Health Centers, Children and Youth Programs, Public Health Clinics, and train-ing programs for paramedical personnel would be preferable in the long run, but these, too, have drawbacks. Many of these facilities will receive Medicaid payments for delivering EPSDT 5cr-vices. It is possible that EPSDT will demonstrate to Congress that additional medical facilities will be required to provide the continuing care which the majority of poor children are not receiving now.
Since a primary goal of EPSDT is to introduce eligible children to preventive health services, a logical question is whether screening in large groups is a desirable approach. Most pediatricians would argue that an individual health assessment by a concerned physician or a supervised pediat-nc nurse associate, who would then feel responsi-ble for continued primary care, is the ideal. Un-fortunately, there are not enough medical facili-ties in the inner cities and rural areas where most Medicaid families reside, and so screening by non-medical personnel is being used as an untried a!-ternative. Many of us are pessimistic that the screening exam, which is not associated with con-tinuing primary health care, will be an expensive failure, but if it is used as a portal of entry into a primary care facility it will have achieved its goal.
Will EPSDT further fragment health care for poor children? This is a concern to many pediatn-cians who have observed the increasingly episodic care received by large numbers of poor children who need continuing care even more than affluent families. In programs that are establishing screen-ing clinics unrelated to continuing care facilities, there undoubtedly will be some increased frag-mentation, but at least children with problems will be screened out and referred to ongoing medi-cal programs. It is possible that EPSDT could be-come a catalyst in bringing together the multiple medical services available in a community to share resources and minimize duplication. In states that are using the present health providers for screening there is a greater chance for families to find a medical home.
Frankenberg and North13 point out that a screening program assumes special obligations beyond that of traditional medicine. When a pa-tient seeks the advice of a physician because of a symptom, the physician is responsible only to do
his best to solve the problem. When a program
takes the initiative in discovering health problems in persons without complaints, it assumes a moral obligation that the discovery will do more good than harm. The health problems selected for screening should have affirmative answers to most of the following questions:
1. Is the disease important to the individual? 2. Is the disease important to the community? Contagious illnesses such as tuberculosis and envi-ronmental illnesses such as lead poisoning should have a high priority if there is a significant mci-dence.
3. Is the disease treatable? Many conditions,
such as mental retardation and sickle cell anemia,
are not curable but are treatable by counseling as
well as biomedical interference.
im-prove the effectiveness or reduce the cost of treat-ment?
5.
Is there a substantial “lead time” between the time that the problem can first be discovered through screening and the time that it willordi-narily be detected without screening?
6. Is there a safe, economic, and reliable
screening test available for the disease or
prob-1cm?
7.
Are sufficient skilled practitioners and facili-ties available to screen, diagnose, and treat the pa-tients adequately? Many pediatricians have cx-pressed concern that EPSDT will produce too many overreferrals from screening which will not only be expensive and wasteful, but will create un-necessary anxiety. Overdiagnosis of heart mur-murs may produce cardiac cripples. Overtreat-ment of enlarged tonsils by tonsillectomy is to be condemned.8.
Is the total cost of screening, diagnosis and treatment justified by the total benefits of earlier detection?9. Are there financial resources available for payment of all necessary diagnosis and treatment?
Will the children who are screened receive the necessary diagnosis and treatment? Screening without evaluation and treatment of abnormali-ties is a waste of valuable health resources and fre-quently is harmful because of the anxieties that
are created. It is imperative that diagnosis and
treatment arrangements are completed before a screening program is instituted in a community. Problems with referral are diminished if the screening is performed by a physician who can provide the diagnosis and treatment at that time, or in a clinic that has medical facilities too.
If
a re-ferral is made, some person, such as the screener or social worker, must assume the responsibility for the completion of the referral. The many oh-stacles to a successful referral such as lack of trans-pc)rtation, misunderstanding, baby-sitting prob-lems, and unpleasant attitude of the examiners, are frequently too much for a low-income person to accept the responsibility alone.EPSDT
must address itself to the psychosocialproblems and not just medical illnesses and dis-abilities. Each screener should ask himself at the end of the evaluation, “What are the child’s prob-lems and what can be done about them?” Many times solutions will be difficult, but nothing will be gained if not attempted. Treatment facilities are inadequate for the huge numbers of deprived children with emotional and developmental disor-ders, and there will never be enough money to pi-ovide adequate housing in nonviolent
neighbor-hoods. Perhaps EPSDT will serve as a stimulus for
increased funding of research about the causes of
the problems and improvement of techniques in
treating them. At the very least the screener can
be a concerned listener.
One of the great deficiencies of EPSDT at this time is the lack of commitment by state govern-ments and agencies in creating conditions to en-courage providers to participate in EPSDT. Re-sponsive people representing the state to provid-ens and adequate prompt payments for services with only necessary paperwork would go a long way to assure its success. If state Medicaid
agen-cies were required to publicly issue specific goals
for their EPSDT programs it would serve as an aid
for budgeting funds, a stimulus for action, and a
basis for evaluation of accomplishments.
Is EPSDT a precursor or model for a preventive care system under National Health Insurance? The answer to this question is unknown but it is likely that planners of a National Health Insur-ance system will study EPSDT carefully.
(Sena-tons Long and Ribicoff have specifically
recom-mended EPSDT in their proposal [S. 1416].) It is the largest government preventive care system in
the U.S.A. In time it will develop minimum
stan-dards for periodicity of the various screening tests
and further define how much can be done by
para-professionals. It will have a data collection system
and evaluation procedures. In short, it will have many features of a planned approach to medical care used by architects of a National Health Insur-ance program.
CONCLUSION
EPSDT is the means the federal government has selected to force the states to seek out poor children who are out of the mainstream of medical care and to offer them preventive services. The
use of periodic screening exams (as defined in the
Program Regulations Guide) is an untried method
of providing health care and may be unsuccessful,
but fortunately the states have been given much freedom in program design and future modifica-tion.
Major obstacles at present are the absence of specific goals at the state level, and a lack of com-mitment by state governments and administrators to provide adequate funds and direction for a
suc-cessful program. Inadequate health resources in
inner cities and rural areas, the lack of outreach
workers, and a low priority for health care on the part of the consumer all add to the problem.
goal-the attainment by all children of their full potential for physical, emotional, and social health.
REFERENCES
1. Legislative History of Early and Periodic Screening,
Di-agnosis and Treatment Program for Children
Under Medicaid. Medical Services
Adininistra-tion, January 1973.
2. Hoodwin, J.: Federal Policies, Expectations, and Hopes for Early and Periodic Screening, Diagnosis, and Treatment. Paper prepared for APWA Regional Conference, Denver, Colorado, May 2,5, 1972. 3. Program Regulations Guide (Interim). Dept. of HEW,
SRS, December 22, 1971. 4. Newman, H.N. : Personal communication.
5. Program Regulation Guide. Dept. of HEW, SRS, June 28, 1972.
6. Summary of States of Implementation of EPSDT for Quarter Ending September 30, 1973. Dept. of HEW, SRS, FY 74-42.
7. Degnon, C.K. : Background Memorandum Regarding Title XIX. American Academy of Pediatrics,
Ar-lington, Virginia, July 31, 1972.
8.
Early and periodic screening, diagnosis, and treatment(commentary). Pediatrics, 51:741, 1973.
9. Title XIX Early Periodic Screening: What is the Pedia-trician’s Role? American Academy of Pediatrics: Bulletin of Pediatric Practice, Vol. 6, No. 4, De-cember 1972.
10. Dixon, MS., Jr.: Title XIX EPSDT: The Implications for Pediatric Practitioners. American Academy of Pe-diatrics: Bulletin of Pediatric Practice, Vol. 6, No. 4, December 1972.
11. Dixon, M.S., Jr.: The Role of Academy Chapters in
EPSDT. American Academy of Pediatrics: News
and Comment, Vol. 24, No. 5, June 1973.
12. Campbell, W.D.: The Primary Care Physician and
EPSDT. American Academy of Pediatrics: News
and Comment, Vol. 24, No. 5, June 1973.
13. Frankenberg, W.K., and North, A.F., Jr.: Health Screen-ing of Children. American Academy of Pediatrics,
1974.
ACKNOWLEDGMENT
The author wishes to thank Viola Startzman, M.D., for her help in reviewing this manuscript.
Quality
Assurance
The
Road
to PSRO
and Beyond
Robert J. Haggerty,
M.D.
From the Department of Pediatrics, University of Rochester School of Medicine & Dentistry
Few recent legislative actions have called forth
so much debate, concern and anticipation among
physicians as that portion of PL 92-603 (popularly known by its bill number IIR1) entitled Pro-fessional Standards Review Organization’
The purpose of this article is to discuss the reasons for development of this form of publicly legislated quality assurance program, to demonstrate how it grew out of a long past and to discuss where it is likely to go in the future. I will concentrate on the state of the art and some of the problems of mea-suring the quality of health care today as we enter
a phase of greater public accountability in
mcdi-cine.
PSRO is only one stage in a long series of steps
by
which the profession and the public have sought to guarantee quality and control cost of medical cane. Improving and assuring the qualityof medical care is an issue central to all of medi-cine. Pediatricians have long been concerned and will be engaged in this program as is everyone else in medicine, even though the initial limitation of the law to Medicare, Medicaid and maternal and child health services under Title V means that pe-diatnicians will have a smaller involvement at present than many other specialties.
WHY PSRO NOW?
Recent public interest in quality assurance
stems from several forces:
(Accepted for publication February 18, 1974.)
ADDRESS FOR REPRINTS: Department of Pediatrics,
University of Rochester School of Medicine & Dentistry, 260
