pun EXCERPTS OF TESTIMONY AND MATERIALS Presented On MARCH 26 and 27, 1968 Re: Sections Of H.R. 15758* Relative To REGIONAL MEDICAL PROGRAMS Before The SUBCOMMITTEE ON PUBLIC HEALTH AND WELFARE Of The COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE HOUSE OF REPRESENTATIVES NINETIETH CONGRESS SECOND SESSION *A Bill to amend the Public Health Service Act so as to extend and improve the provisions relating to Regional Medical Programs... EXCERPTS OF TESTIMONY AND MATERIALS Presented On MARCH 26 and 27, 1968 Re: Sections Of H.R. 15758* Relative To REGIONAL MEDICAL PROGRAMS Before The SUBCOMMITTEE ON PUBLIC HEALTH AND WELFARE Of The COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE HOUSE OF REPRESENTATIVES NINETIETH CONGRESS SECOND SESSION *A Bill to amend the Public Health Service Act so as to extend and improve the provisions relating to Regional Medical Programs... CONTENTS Hearings held on— Page March 26, 1968..--------------------or rr 1 March 27, 1968. .------------------ 0 131 Text of H.R. 15758. --------------2-on 2 Report of — a Health, Education, and Welfare Department....---------------77- 2 Statement of — / Bratrude, Dr. Amos, Washington (State) Medical Association and Association of General Practitioucrs_---------2-----<5-7o5-- p77 197 Breslow, Dr. Lester, president-elcct, American Public Health Asso- ciation. ..--------- 22 ~ 168 Cannon, Dr. Bland W., member Council on Medical Ed i ‘American Medical Mc ee ee SN neat 47, 148 Chambers, Dr. J. W., representing the Medical Association of Georgia. .-.--------2--=-----7777-4-47-75 77" Wedioal Colleses. 208 Chapman, Dr. Carleton B., Association of American Medical Colleges- 123 De Bakey, Dr. Michael, chairman, Department of Surgery, Baylor University College of Medicine, Houston, Tex_-.---------------- 133 Elam, Dr. Lloyd, Association of American Medical Colleges.-...---- 123 Farber, Dr. Sidney, director of research, Children’s Cancer Research Foundation, Boston, Mass-----------------2--7 7 ae 139 Lee, Dr. Philip R., Assistant Secretary for Health and Scientific _Affairs, De artment of Health, Education, and Welfare--__----- 9 Likoff, Dr. jlliam, immediate past president, American College of Cardiology...------------ anne ence erence errr e errr r eer 161 Marston, Dr. Robert Q , Director, Division of Regional Medical Pro- grams, Department of Health, Education, and Welfare. ---.------ 9 Millikan, Dr. Clark, chairman, Council on Cerebrovascular Disease, American Heart Association .----~-------------7-e77 77a 163 Nelligan, William D., executive director, American College of Cardi- ology - - - = -- 22 - nnn 161 Ruhe, Dr. William, director, Division of Medical Education, American Medical Association --~------- nee ee neeee errr errr 147 Sibery, D. Eugene, executive director, Greater Detroit Area Hospital Council..------------- 2 een 218 Stark, Nathan J., chairman, Missouri regional medical program - -- -- 193 Additional information submitted for the record by— American Dental Association, letter from John B. Wilson, chairman, council on legislation. --------------"7-"" "enneth W worertre 303 American Hospital Association, letter from Kenneth Williamson, associate director. ----~------7----7- a teeeee wercctee a-o-7 299 American. Nurses’ ‘Association, Inc., statement of Judith G. Whitaker, neecutive director. ...-----------227s-7 7g 296 California Committee on Regional Medical Programs, statement of Dr. Lester Breslow - -----------"77 7 “Gguneil art eorgetraee 171 Greater Detroit (Mich.) Area Hospital Council, article from the Journal of the American Hospital Association, December 1967, entitled ‘Hospitals and Regional Medical Programs: A Plea for Coordinated Action”. .-------aa---pace0-77 7777 222 Hampton, Dr. H. Phillip, ‘Tampa, Fla., letter----------2-- yoo a 0G 304 Hawaii, University of, chool of Medicine, letter from Dr. Windsor C. Cutting, dean. .-------------7 000 t 303 Additional information submitted for the record by—Continued Health, Education, and Welfare, Department of: Criteria for the evaluation of regional medical programs, state- ment ON_------------ 2-30-29 eeanont Owen 86 Effectiveness of regional medical programs, statement on-------- 84 Estimated new obligation authority required under H.R. 15758 for fiscal years 1969-77 (table) _--------------- 7 119 Hospital administrators participating in regional medical pro- grams, statement On..----02--4--- ae ah Missouri 62 Involvement of the Kansas City General Hospital in the Missouri regional medical program, statement on. --.--------------777 85 Operational projects affecting rural areas, statement on_--------- - 76 Patient care costs supported with regional medical program grant funds. _-------------2---477 27 1 wroeeams, statement 65 Professional involvement in regional medical programs, statement ON... eee ewer een ine pesional medical 64 Public Health Service report on 12 operating regional medical programs. ------------2-75--7--"" “oy eontinuing 46 Television, radio, and telephone networks for continuing education. -----------------: "27-7" 7oy heart disease, 61 Regional medical programs, progress report, for heart disease, cancer, stroke, and related diseases. --------------3--y 7p 13 tegional medical program efforts directed against the health problems of the inner city, statement on_.-----------------~ 73 Status of regional medical programs, statement on-_------------ 66-72 Table 1.—Participation in regional medical programs by in- dividuals and organizations -------7-----s5- "=e pds 33 Table 11.—Regional medical programs, total obligation of funds, fiscal years 1966-69 onan wee cere errr : 34 Matsunaga, Hon. Spark M., a Representative in Congress from the State of Hawaii, letter._------------on ee 298 Missouri regional medical program, organization and goals. -.-------~ 195 National Tuberculosis and Respiratory Disease Association, letter _ from James E. Perkins, managing director..------------------7" 301 REGIONAL MEDICAL PROGRAMS; ALCOHOLICS AND NARCOTICS ADDICTS FACILITIES; HEALTH SERV- ICES FOR DOMESTIC AGRICULTURAL MIGRATORY WORKERS TUESDAY, MARCH 26, 1968 House or REPRESENTATIVES, Suscommitrer on Pusiic Hearty AND WELFARE, ComMITTEE ON INTERSTATE AND Foreign ComMERCE, Washington, D.C. The subcommittee met at 10 a.m., pursuant to notice, in room 2322, Rayburn House Office Building, Hon. Paul G. Rogers presiding (Hon. John Jarman, chairman). Mr. Kyros (presiding). The subcommittee will please be in order. The hearings today are on H.R. 15758, introduced by Chairman Staggers at the request of the administration. is bill would extend and expand the existing authorizations for regional medical programs, would extend the program of health serv- ices for domestic agricultural migratory workers, and would provide matching grants for construction and staffing of facilities for preven- tion of alcoholism addiction and for treatment of alcoholics and nar- cotic addicts. , REGIONAL MEDICAL PROGRAMS In 1965, the Congress considered legislation proposing the establish- -ment of regional medical programs designed to improve the health care of the American people in the fields of heart disease, cancer, stroke and related diseases. The Congress made substantial revisions in the proposed program, providing in general for a maximum of decen- tralization of the decisionmaking process and encouraging the maxi- mum feasible cooperation between public and private groups interested in the health of the American people. It is impossible to give a simple description of a regional medical program since every program established is different, with each pro- gram tailored specifically to the needs of the region served. Over 90 percent of the population of the United States is or will be covered by regional medical programs established on the local level either on an operational basis today or through programs currently in the planning stage. Eventually, 100 percent of our population will be covered by these programs. Many fears and reservations were expressed at the time the Con- gress was considering the initial legislation. It is my understanding, however, that many of the groups which had reservations about. the initial proposals have since modified their positions, in large measure (1) 2 because of the modifications that were made in the program by the Congress and the manner in which the program has been administer to date. ‘As I understand the bill presented to us, nO major changes are pro- posed. The principal purpose of the legislation is to extend the pro- gram beyond its scheduled expiration date of June 30 this year, with minor improvements that experience has shown to be necessary or de- sirable. Tn regard to the section on domestic agricultural migratory workers, the bill also proposes to extend for two additional years the existing . program of Federal grants for health services to domestic agricultural migratory workers. ; ; ; ’ The existing program 1S also scheduled to expire June 30 this year, so extension is essential at this time if these workers, who are among the neediest today, are to continue to receive the services they need. DEPARTMENT OF HEALTH, EpucaTIon, AND WELFARE, Washington, D.C., March 18, 1968. Hon. Hapiey O. STAGGERS, Chairman, Committec on Interstate and Forcign Commerce. House of Representatives, Washington, D.C. Dear Mr. CHAIRMAN > This letter is in response to your request of March 6. 1968, for a report on ER. 15758, 2 pill “To amend the Public Health Service Act so as to extend and improve the provisions relating to regional medical programs, to extend the authorization of grants for health of migratory agri- cultural workers, to provide for specialized facilities for alcoholics and narcotic addicts, and for other purposes.” This bill embodies the legislative proposal contained in a draft bill submitted by this Department to the Congress on March 4, 1968, to implement the recom- mendations on extension and improvement of regional medical programs con- tained in the president's March 4, 1968 Message on Health. The bill also includes the legislative proposal contained in that draft bill relating to temporary exten- sion of the program of grants for health services for migratory agricultural workers. In addition, FLR. 15758 embodies the legislative proposal contained in the draft bill submitted by this Department to the Congress on February 8, 1968, to implement the recommendations on prevention and treatment of alco- holism and narcotic addiction contained in the President’s February 7, 1968 Message on insuring the public safety and meeting the challenge of crime in our society. (This last mentioned proposal was also included in E.R. 15281, on which we reported to your Committee on February 26, 1968.) We urge early enactment of this proposed legislation. The Bureau of the Budget advises that enactment of this proposed legislation would be in accord with the program of the President. Sincerely, Wi.sur J. COHEN, Acting Secretary. [H.R. 415758, 90th Cong., second sess. } . A BILL To amend the Public Health Service Act so as to extend and improve the provisions relating to regional medical programs, to extend the authorization of grants for health of migratory agricultural workers, to provide for spectalized facilities for alcoholics and narcotle addicts, and for other purposes Be it enacted by the Scnate and House of Representatives of the United States of America in Congress assembicd, TITLE J—REGIONAL MEDICAL PROGRAMS EXTENSION OF REGIONAL MEDICAL PROGRAMS Sec. 101. Section 901(a) of the Public Health Service Act (42 U.S.C. 299a) is amended by striking out “and” before *$900,000,000" and by inserting after 3 “June 30, 1968,”-the following: “$65,000,000 for the fiscal year ending June 30, 1968, and such sums as may be necessary for the next four fiscal years,”. EVALUATION OF REGIONAL MEDICAL PROGRAMS Sec. 102. Section 901(a) of the Public Health Service Act is further amended by inserting at the end thereof the following new sentence: ‘For any fiscal year - ending after June 30, 1969, such portion of the appropriations pursuant to this section as the Secretary may determine, but not exceeding 1 per centum thereof, shall be available to the Secretary for evaluation (directly or by grants or contracts) of the program authorized by this title.” INCLUSION OF TERRITORIES Sec. 103. Section 902(a)(1) of the Public Health Service Act (42 U.S.C. 299b) is amended by inserting after “States” the following: “(which for pur- poses of this title includes the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Trust Ter- ritory of the Pacific Islands)”. COMBINATIONS OF REGIONAL MEDICAL PROGRAM AGENCIES Sec. 104. Section 903(a) and section 904(a) of the Public Health Service Act (42 U.S.C. 299c, 209d) are each amended by inserting after “other public or nonprofit private agencies and institutions” the following: “, and combina- tions thereof,”. ADVISORY COUNCIL MEMBERS Sec. 105. (a) Section 905(a) of the Public Health Service Act (42 U.S.C. 299e) is amended by striking out “twelve” and inserting in lieu thereof “sixteen”. (b) Section 905(b) of such Act is amended by striking out “and four at the end of the third year” and inserting in lieu thereof ‘four at the end of the third year, and four at the end of the fourth year”. MULTIPROGRAM SERVICES Sec. 106. Title IX of the Public Health Service Act is further amended by adding at the end thereof the following new section: “PROJECT GRANTS FOR MULTIPROGRAM SERVICES “Sec. 910. Funds appropriated under this title shall also be available for grants to any public or nonprofit private agency or institution for services needed by or which will be of substantial use to, any two or more regional medi- eal programs.” CLARIFYING OR TECHNICAL AMENDMENTS Sec, 107. (a) Section 901(c) of the Public Health Service Act is amended by inserting before the period at the end thereof “or, where appropriate, a prac- ticing dentist”. (b) Section 901 of such Act is further amended by adding at the end thereof the following new subsection: “(d) Grants under this title to any agency or institution for a regional medical program may be used by it to assist in meeting the cost of participa- tion in such program by any Federal hospital.” 9 Mr. Kyros. I understand our first svitness this morning will be Dr. Philip R. Lee, Assistant Secretary for Health and Scientific Affairs in the Department of Health, Education, and Welfare. Dr. Lee. STATEMENT OF DR. PHILIP R. LEE, ASSISTANT SECRETARY FOR HEALTH AND SCIENTIFIC AFFAIRS, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE; ACCOMPANIED BY RALPH K. HUITT, ASSISTANT SECRETARY FOR LEGISLATION; DR. RALPH Q. MAR- STON, DIRECTOR, DIVISION OF REGIONAL MEDICAL PROGRAMS; DR. STANLEY F. YOLLES, DIRECTOR, NATIONAL INSTITUTE OF MENTAL HEALTH; AND HELEN JOHNSTON, CHIEF, MIGRANT HEALTH BRANCH, BUREAU OF HEALTH SERVICES Dr. Lee. Thank you, Mr. Chairman. Mr. Rocers (presiding). I might say that the committee is pleased to have you with us, and particularly since your new duties have been stated by the Secretary to be coordinator for health, and “Mr. Health” for the Government. We are delighted to have you with us in this capacity today, and we are pleased to have your associates. We will be glad to hear your statement. Dr. Lee. Thank you, sir. Accompanying me are Miss Johnston, Dr. Marston, and Dr. Yolles. Mr. Ralph Huitt is with us this morning also. Mr. Rocers. We are glad to see Mr. Huitt here. Dr. Lez. Mr. Chairman and members of the Subcommittee on Health and Welfare, it gives me great pleasure to appear before you today in support of the Health Services Act of 1968, which contains an extension and improvements to the Heart, Cancer, and Stroke ‘Amendments of 1965, an extension of the Migrant Health Act of 1962, as amended in 1965, the transfer of authorities now in section 402 of the Narcotic Addict Rehabilitation Act of 1966 to the Community Mental Health Centers Act, and the establishment of a program to assist communities to improve treatment services to alcoholics, the latter two programs to be known as the Alcoholic and Narcotic Addict Rehabilitation Amendments of 1968. These programs are all designed to carry forward our commitment to make the best health services available to all Americans. In his special message to Congress on health in 1965, President Johnson stated : ; Our first concern must be to assure that the advance of medical knowledge leaves none behind. We can—and must—strive now to assure the availability and accessibility of the best health care for all Americans, regardless of age or geography or economic status. Although much has been accomplished in the last 3 years, much remains to be done. We must remove the barriers of discrimination that have so long barred the aleoholic and the narcotic addict from receiving truly comprehensive care—a discrimination based on diag- nosis, which is just as intolerable as discrimination based on race. The migrant worker suffers from not only the disadvantages of language, poverty, and geography, but often the even more difficult 10 problems of ignorance and inexperience in the use of modern medi- cal services. ‘ - The removal of a different kind of barrier—the time lag between discovery and effective application of new knowledge—is a goal of the regional medical program. In his health message this year, President Johnson stated: Its purpose is to translate research into action, so that all of the people of our nation can benefit as rapidly as possible from the achievement of modern medicine. Title I of H.R. 15758 extends the regional medical program through fiscal year 1973 and clarifies and improves certain aspects of the rogram. P ou will recall from your consideration of this legislation in the summer of 1965 that it was introduced as a result of the findings of the President’s Commission on Heart .Disease, Cancer, and Stroke. The Commission found that medical science has created the poten- tial to reduce the heavy tolls of these diseases but that this potential was not being realized for many of our citizens. The Interstate and Foreign Commerce Committee played a major role in clarifying both the nature of the program and the direc- tion in which it was to go. ° The basic objective of this program is to assure that the people of this Nation, wherever they may be, will benefit from the advances of medical science against the threats of heart disease, cancer, stroke, and related diseases. As an additional dividend, this program will have an impact extend- ing far beyond the control of specific diseases. The physicians and other health workers involved in the regional medical programs will be applying their new knowledge and new techniques to patients being treated under the medicaid, medicare, and other health programs. The lessons learned in the regional medical programs cannot help but enhance the quality and efficiency of these other activities. The progress already made has justified our expectation that this program would significantly improve the effectiveness and quality of medical care for those who suffer from the major killer diseases. The program is already bringing together diverse groups in the health field in an unprecedented fashion and in a manner that re- sults in a consideration of the unfilled health needs of the region, rather than those of the individual institutions. Despite the present shortage of manpower, the program has been successful in recruiting throughout the Nation talented persons willing to make firm career commitments to achieving the goals of the program. The programs have earned the support of the major health re- sources, professional and voluntary, at the national and regional levels. They have helped overcome hostilities and divisions which have existed in some cases for generations. Indeed, there has been a positive response to this committee’s man- date in the original legislation that this program would be community based—that the responsibility for planning and organizing the opera- tion of the program would belong to the region, not to the Federal Government. As evidence of this response almost 1,000 medical institutions are participating in the regional medical programs, including every med- 11 ical school and hundreds of hospitals. This involvement of medical schools and other teaching and research institutions helps develop close and continuous contact between medical advances and their ap- plication in the community. Almost 800 health organizations are participating, including every State medical society, State health department, State heart associa- tion, and State cancer society. Over 7,000 non-Federal-connected individuals are now actively engaged in the programs, including 1,800 employed either full- or part-time by the regional programs, over 1,900 members of the regional advisory groups required by the law who must advise on the development of the programs and approve all operational activities before they can be funded, and members of various subcommittees, task forces, and local action groups, who are contributing their time. This represents an involvement not only of the experts in the region but also the health personnel at the grassroots level, and this is illus- trated in table I (p. 33) which is submitted with the testimony. These people, institutions, and organizations are the forces which, with your support, will carry to fulfillment the high expectations for this program. The scope of the program is enabling the regional groups to assess thoroughly the needs and opportunities within their region and to implement the steps that can be realistically undertaken to improve the diagnosis and treatment of the major diseases. By coping with these problems on a regional scale, the groups are able to plan for the most efficient use of specialized resources for service or training from the largest. medical center to the isolated rural physician. The regions have found that many different types of activities can contribute to objectives such as demonstrations of advanced diagnos- tic and patient-care techniques, training and continuing education of health personnel, development of communication and patient data networks, application of computer and other modern technology to health care, and research into better means for organizing and deliver- ing improvements in health care. The first planning grant was awarded less than 2 years ago. Today there are 53 regions which have received planning grants and include the entire population, except Puerto Rico, and an application from that Commonwealth is now being reviewed. Eleven regions have received grants to support initial operational activities, and 13 other regions have submitted applications to begin the operational phase of their programs. To finance these activities there has been a rapid increase in the obligation of funds, and this is illustrated on table II, which is attached. The involvement in the regional medical programs by local insti- tutions and individuals has been enthusiastic. Within the next year all of the programs expect to enter the operational phase of their program. They are eager to continue the work they have begun. In addition to extending the basic authorities of the regional med- ical program, the bill before you contains amendments to those au- thorities that would help the regions accomplish their goals more effectively. It contains a provision that ‘vould. assure proper evalua- tion of the accomplishments of the program by providing that up to 12 1 percent of the appropriation for any fiscal year beginning with 1970 may be used by the Secretary for the evaluation. The bill makes clear that regional medical grants can be awarded to a combination of regional medical program agencies for carrying on a regional medical pro . ; . Also, a new authority is added which would permit the awarding of grants to any public or private nonprofit agency or institution for services which will be of substantial value and use to any two or more regional medical programs. Such services might, include producing education materials, developing evaluation techniques, creating uni- form data-gathering systems, and other types of activities which cannot always be developed most efficiently on the basis of the needs of a single region. The act is also amended to authorize the use of regional medical rogram grant funds to permit the full participation of Federal ‘ospitals in regional medical programs as the important community resources which they in fact are. Another amendment clarifies that a practicing dentist as well as a physician may refer a patient to a facility carrying out research, training, or demonstration activities which are supported by regional medical program funds. Dentists can play an important role in such areas as the early identification of oral cancer, and the amendment corrects an unforeseen limitation in the original act which does not permit such referrals, An increase in the Advisory Council membership, from 12 mem- | bers to 16, is provided in the bill, an expansion made necessary by the increasing workload of the Council in reviewing applications and the desirability of having members who reflect a broad diversity of interests, ” The bill also extends the provisions of the programs to Guam, American Samoa, and the Trust Territory of the Pacific Islands. The Hawaii regional medical program has indicated that it would be inter- ested in including these areas in its program. These provisions will strengthen regional medical programs and will provide the flexibility that will aid in making the most efficient use of all the health elements of the community in the program. The committee has received copies of the Surgeon General’s report on regional medical programs, which describes in detail the initial progress. I would like to submit for the record material which adds to that report and which will bring you up to date on the accomplish- ments of the regional medical programs. May I submit that for the record, Mr. Chairman? Mr. Rocers. Without objection, it will be received. (The document referred to follows :) 13 PROGRESS REPORT regional — medical | See ; For - : Heart Disease, Cancer, Stroke, And Related Diseases Division of Regional Medical Programs National Institutes of Health Bethesda, Maryland 20014 US. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service 14 Regional Medical Programs have been awarded planning grants*. . . © to develop operational proposals through ... @ surveys of needs and resources . @ feasibility studies © organization and staffing 1 —_- Regional Medical Program is currently under development * 15 Regional Medical Programs have received opera- tional grants*... @ to improve patient care through research, con- tinuing education, training, and demonstration projects ® io develop better methods for the exchange of information among medical schools, medical centers, community hospitals, practicing phy- sicians, and other health institutions, organi- zations, and personnel @ to continue to develop new and expanded plans for further improvement of patient care “As of February 29, 1968 16 REGIONS AND PROGRAM COORDINATORS OR DIRECTORS } ALABAMA B. B. Wells, M.D. U. of Ala. Med. Ctr. 1919 7th Ave. S. Birmingham, Ala. 35233 2 ALBANY, N.Y. F. M. Woolsey, Jr., M.D. Assoc. Dean Albany Med. Coll. 47 New Scotland Ave. Albany, N.Y. 12208 3 ARIZONA M. K. DuVal, M.D. Dean, Coll. of Med. U. of Arizona Tucson, Ariz. 85721 4 ARKANSAS W. K. Shorey, M.D. Dean, Sch. of Med. U. of Arkansas 4301 W. Markham St. Little Rock, Ark. 72201 5 BI-STATE . W. H. Danforth, M.D.. V. Chan. for Med. Affairs Washington U. ‘ 660 S. Euclid Ave. St. Louis, Mo. 63110 6 CALIFORNIA Paul D. Ward 655 Sutter St. #302 San Francisco, Calif. 94102 7 CENTRAL NEW YORK R. H. Lyons, M.D. State U. of N.Y. 750 E. Adams St. Syracuse, N.Y. 13210 8 COLORADO- WYOMING Pp. R. Hildebrand, M.D. U. of Col. Med. Ctr. 4200 E. 9th Ave. Denver, Col. 80220 9 CONNECTICUT H. T. Clark, Jr., M.D. 272 George St. New Haven, Conn. 06510 10 FLORIDA S. P. Martin, M.D. Provost, J. Hillis Miller Med. Ctr. U. of Florida Gainesville, Fla. 32601 11 GEORGIA J. G. Barrow, M.D. Med. Assoc. of Ga. 938 Peachtree St. N.E. Atlanta, Ga. 12 GREATER DELAWARE VALLEY W. C. Spring, Jr., M.D. Wynnewood House 300 E. Lancaster Ave. Wynnewood, Pa. 190% 13. HAWAIL W. C. Cutting, M.D. Dean, Sch. of Med. U. of Hawaii 2538 The Mall Honolulu, Ha. 96822 14 ILLINOIS Wright Adams, M.D. 112 S. Michigan Ave. Chicago, Ill. 60603 15 INDIANA G. T. Lukemeyer, M.D. Assoc. Dean Indiana U. Sch. of Med. 1100 W. Michigan St. Indianapolis, Ind. 46207 16 INTERMOUNTAIN C. H. Castle, M.D. Assoc. Dean U. of Utah Salt Lake City, Ut. 84112 17 IOWA W. A. Krehl, M.D., Ph.D. 308 Melrose Ave. U. of Iowa Towa City, la. 52240 18 KANSAS C. E. Lewis, M.D. Chairman Dept. of Preventive Med. U. of Kansas Kansas City, Kan. 66103 19 LOUISIANA J. A. Sabatier, M.D. Claiborne Towers Roof 119 S. Claiborne Ave. New Orleans, La. 70112 20 MAINE M. Chatterjee, M.D. 295 Water St. Augusta, Me. 04332 21 MARYLAND W. S. Spicer, Jr., M.D. 550 N. Broadway Baltimore, Md. 21205 22 MEMPHIS MEDICAL REGION J. W. Culbertson, M.D. Coll. of Med. U. of Tennessee 858 Madison Ave. Memphis, Tenn. 38103 23 METROPOLITAN WASHINGTON, D.C. Ty. W. Mattingly, M.D. D.C. Medical Society 2007 Eye St. N.W. Washington, D.C. 20006 24 MICHIGAN A. E. Heustis, M.D. 1111 Michigan Ave. East Lansing, Mich. 48823 25 MISSISSIPPI G. D. Campbell, M.D. U. of Miss. Med. Ctr. 2500 N. State Ct. Jackson, Miss. 39216 26 MISSOURI V. E. Wilson, M.D. Executive Director for Health Affairs U. of Missouri Columbia, Mo. 65201 27 MOUNTAIN STATES K. P. Bunnell, Ed.D. Assoc. Director Western Interstate Comm. for Higher Ed. Univ. E. Campus Boulder, Col. 80302 28 NEBRASKA- SOUTH DAKOTA H. Morgan, M.D. 1408 Sharp Bldg. Lincoln, Neb. 68508 29 NEW JERSEY A. A. Florin, M.D. N. J. State Dept. of Hith. 88 Ross St. : E. Orange, N.J. 07018 30 NEW MEXICO Reginald Fitz, M.D. Dean, Sch. of Med. U. of New Mexico Albuquerque, N.M. 87106 31 NEW YORK METR. AREA V. deP. Larkin, M.D. N.Y. Academy of Med. 2 E. 103d St. New York, N.Y. 10029 32 NORTH CAROLINA M, J. Musser, M.D. Teer House 4019 N. Roxboro Rd. Durham, N. C. 27704 33 NORTH DAKOTA T. H. Harwood, M.D. Dean, Sch. of Med. U. of North Dakota Grand Forks, N.D. 58202 34 NORTHEASTERN OHIO F. C. Robbins, M.D. Dean, Sch. of Med. Western Reserve U. 2107 Adelbert Rd. Cleveland, Ohio 44106 35 NORTHERN NEW ENGLAND Jj. E. Wennberg, M.D. U. of Vt. Coll. of Med. 25 Colchester Ave. Burlington, Vt. 05401 36 NORTHLANDS J. M. Stickney, M.D. Minn. State Med. Assoc. 200 Ist St. SW. - Rochester, Minn. 55901 309-653 O-68—-2 17 37 NORTHWESTERN OHIO C. R. Tittle, Jr., M.D. Medical College of Ohio at Toledo 38 OHIO STATE R. L, Meiling, M.D. Dean, Coll. of Med. Ohio State U. 410 W. 10th Ave. Columbus, Ohio 43210 39 OHIO VALLEY W.H. McBeath, M.D. 1718 Alexandria Dr. Lexington, Ky. 40504 40 OKLAHOMA K. M. West, M.D. U. of Ok. Med. Ctr. 800 N.E. 13th St. Oklahoma City, Ok. 73104 41 OREGON M. R. Grover, M.D. Director, Cont. Med. Ed. Sch. of Med. U, of Oregon 3181 S.W. Sam Jackson Portland, Ore. 97201 42 PUERTO RICO A. Nigaglioni, M.D. Chancellor, Sch. of Med. U. of Puerto Rico San Juan, P.R. 00905 43 ROCHESTER, N.Y. R. C. Parker, Jr., M.D. Sch. of Med. and Dent. U. of Rochester Rochester, N.Y. 14620 44 SOUTH CAROLINA C. P. Summerall, If, MD Dept. of Med. Med. Coll. Hospital 55 Doughty St. Charleston, S.C. 29403 45 SUSQUEHANNA VALLEY R. B. McKenzie 3608 Market St. P.O, Box 451 | Camp Hill, Pa. 17011 46 TENNESSEE MID-SOUTH S. W. Olson, M.D. 110 Baker Bldg. 110 2lst Ave. S. Nashville, Tenn. 37203 47 TEXAS *S. G. Thompson, M.D. Suite 724 Sealy-Smith Prof. Bldg. Galveston, Tex. 77550 48 TRI-STATE N. Stearns, M.D. 22 The Fenway Boston, Mass. 02115 49 VIRGINIA E. R. Perez, M.D. Richmond Acad. of Med. 1200 E. Clay St. Richmond, Va. 23219 50 WASHINGTON- ALASKA D. R. Sparkman, M.D. Sch. of Med. U. of Washington Seattle, Wash. 98105 51 WEST VIRGINIA C. L. Wilbar, Jr., M.D. W. Va. Univ. Med. Ctr. Morgantown, W. Va. 26506 52 WESTERN NEW YORK J. R. F. Ingall, M.D. Sch. of Med. State U. of N.Y. at Buffalo Buffalo, N.Y. 14214 53 WESTERN PENNSYLVANIA F. S, Cheever, M.D. Dean, Sch. of Med. U. of Pittsburgh 3530 Forbes Ave. Pittsburgh, Pa. 15213 54 WISCONSIN J. S. Hirschboeck, M.D. Wisconsin RMP, Inc. 110 E. Wisconsin Ave. Milwaukee, Wisc. 53202 * Associate Coordinator 18 NATIONAL ADVISORY COUNCIL E. L. CROSBY, M.D. J. R. HOGNESS, M.D. BE. D. PELLEGRINO, M.D. Director Dean, School of Med. Director of the Med. Ctr. American Hosp. Assoc. U. of Washington State U. of New York Chicago, Ill. Seattle, Wash. Stony Brook, N.Y. M. E. DEBAKEY, M.D. Jj. T. HOWELL, M.D. A. M. POPMA, M.D. Prof. and Chairman Executive Director Regional Director Dept. of Surgery Henry Ford Hosp. Mountain States Regional Baylor U. Detroit, Mich. Medical Program Houston, Tex. Boise, Idaho C. H. MILLIKAN, M.D. H. G. EDMONDS, Ph.D Consultant in Neurology M. I. SHANHOLTZ, M.D. Dean, Graduate Sch. Mayo Clinic State Hith. Comm. No. Carolina College Rochester, Minn. oer Dept. ¢ Hith. Durham, N.C. G. E. MOORE, MD. ichmond, Va. B. W. EVERIST, JR., M.D. Director, Roswell Park W. H. STEWART, M.D. Chief of Pediatrics Memorial Institute (Chairman) Green Clinic Buffalo, N.Y. Surgeon General Ruston, La. Public Health Service HISTORY AND PURPOSES OF REGIONAL MEDICAL PROGRAMS On October 6, 1965, the President signed Public Law 89-239. It authorizes the establishment and maintenance of Regional Medical Programs to assist the Nation’s health resources in making available the best possible patient care for heart disease, cancer, stroke and related diseases. This legislation, which will be referred to in this publication as The Act, was shaped by the interaction of at least four antecedents: the historical thrust toward regionalization of health resources; the development of a national biomedical research community of unprecedented size and productivity; the changing needs of society; and finally, the particular legislative process leading to The Act itself. The concept of regionalization as a means to meet health needs effectively and economically is not new. During the 1930's, Assistant Surgeon General Joseph W. Mountin was one of the earliest pioneers urging this approach for the delivery of health services. The na- tional Committee on the Costs of Medical Care also focused attention in 1932 on the potential benefits of regionalization. In that same year, the Bingham Associates Fund initiated the first comprehensive regional effort to improve patient care in the United States. This program linked the hospitals and programs for continuing education of physicians in the State of Maine with the university centers of Boston. Advocates of regionalization next gained national attention more than a decade later in the report of the Commission on Hospital Care and in the Hospital Survey and Construction (Hill-Burton) Act of 1946. Other proposals and attempts to introduce regionaliza- tion of health resources can be chronicled, but a strong national movement toward regionalization had to await the convergence of 19 other factors which occurred in 1964 and 1965. One of these factors was the creation of a national biomedical research effort unprecedented in history and unequalled anywhere else in the world. The effect of this activity was and continues to be intensified by the swiftness of its creation and expansion: at the _ beginning of World War IT the national expenditure for medical re- search totaled $45 million; by 1947 it was $87 million; and in 1967 the total was $2.257 billion—a 5,000 percent increase in 27 years. The most significant characteristic of this research effort is the tre- mendous rate at which it is producing new knowledge in the medical sciences, an outpouring which only recently began and which shows no signs of decline. As a result, changes in health care have been dramatic. Today, there are cures where none existed before, a number of diseases have all but disappeared with the application of new vaccines, and patient care generally is far more effective than even a decade ago. It has become apparent in the last few years, however, (despite substantial achievements), that new and better means must also be found to convey the ever-increasing volume of research results to the practicing physician and to meet growing complexities in medical and hospital care, including specialization, increasingly intricate and expensive types of diagnosis and treat- ment, and the distribution of scarce manpower, facilities, and other resources. The degree of urgency attached to the need to cope with these issues is heightened by an increasing public demand that the latest and best health care be made available to everyone. This public demand, in turn, is largely an expression of expectations aroused by awareness of the results and promise of biomedical research. In a sense, the national commitment to biomedical investigation is one manifestation of the third factor which contributed to the creation of Regional Medical Programs: the changing needs of society—in this case, health needs. The decisions by various private and public institutions to support biomedical research were responses to this societal need perceived and interpreted by these institutions. In addition to the support of research, the same interpretive process led the Federal Government to develop a broad range of other pro- grams to improve the quality and availability of health care in the Nation. The Hill-Burton Program which began with the passage of the previously mentioned Hospital Survey and Construction Act of 1946, together with the National Mental Health Act of 1946, was the first in a series of post-World War II legislative actions having major impact on health affairs. When the 89th Congress adjourned in 1966, 25 health-related bills had been enacted into law. Among these were Medicare and Medicaid to pay for hospital and physician services for the Nation’s aged and poor; the Comprehensive Health Planning Act to provide funds to each state for non-categorical health planning and to support services rendered through state and other health activities; and Public Law 89-239 authorizing Regional Medi- cal Programs. 20 The report of the President’s Commission on Heart Disease, Cancer, and Stroke, issued in December 1964, focused attention on societal needs and led directly to introduction of the legislation au- thorizing Regional Medical Programs. Many of the Commission’s recommendations were significantly altered by the Congress in the legislative process but The Act was clearly passed to meet needs and problems identified and given national recognition in the Com- mission’s report and in the Congressional hearings preceding pas- sage in The Act. Some of these needs and problems were expressed as follows: @ A program is needed to focus the Nation’s health resources for research, teaching and patient care on heart disease, cancer, stroke and related diseases, because together they cause 70 per- cent of the deaths in the United States. @ A significant number of Americans with these diseases die or are disabled because the benefits of present knowledge in the medical sciences are not uniformly available throughout the country. @ There is not enough trained manpower to meet the health needs of the American people within the present system for the delivery of health services. © Pressures threatening the Nation’s health resources’ are building because demands for health services are rapidly increasing at a time when increasing costs are posing obstacles for many who require these preventive, diagnostic, therapeutic and rehabilitative services. @ A creative partnership must be forged among the Nation’s medi- cal scientists, practicing physicians, and all of the Nation’s other health resources so that new knowledge can be translated more rapidly into better patient care. This partnership should make it possible for every community’s practicing physicians to share in the diagnostic, therapeutic and consultative resources of major medical institutions. They should similarly be provided the op- portunity to participate in the academic environment of research, teaching and patient care which stimulates and supports medical practice of the highest quality. @ Institutions with high quality research programs in heart disease, cancer, stroke, and related diseases are too few, given the magni- tude of the problems, and are not uniformly distributed through- out the country. © There is a need to educate the public regarding health affairs. Education in many cases will permit people to extend their own lives by changing personal habits to prevent heart disease, cancer, stroke and related diseases. Such education will enable indi- viduals to recognize the need for diagnostic, therapeutic or re- habilitative services, and to know where to ‘find these services, and it will motivate them to seek such services when needed. 21 During the Congressional hearings on this bill, representatives of major groups and institutions with an interest in the American health system were heard, particularly spokesmen for practicing physicians and community hospitals of the Nation. The Act which emerged turned away from the idea of a detailed Federal blueprint for action. Specifically, the network of “regional centers” recommended earlier by the President’s Commission was replaced by a concept of “regional cooperative arrangements” among existing health resources. The Act establishes a system of grants to enable representatives of health resources to exercise initiative to identify and meet local needs within the area of the categorical diseases through a broadly defined process. Recognition of geographical and societal diversities within the United States was the main reason for this approach, and spokes- men for the Nation’s health resources who testified during the hearings strengthened the case for local initiative. Thus the degree to which the various Regional Medical Programs meet the objectives of The Act will provide a measure of how well local health resources can take the initiative and work together to improve patient care for heart disease, cancer, stroke and related diseases at the local level. The Act is intended to provide the means for conveying to the medical institutions and professions of the Nation the latest advances in medical science for diagnosis, treatment, and rehabilitation of patients afflicted with heart disease, cancer, stroke, or related di- seases—and to prevent these diseases. The grants authorized by The Act are to encourage and assist in the establishment of regional cooperative arrangements among medical schools, research institu- tions, hospitals, and other medical institutions and agencies to achieve these ends by research, education, and demonstrations of patient care. Through these means, the programs authorized by The Act are also intended to improve generally the health manpower and facilities of the Nation. In the two years since the President signed The Act, broadly representative groups have organized themselves to conduct Regional Medical Programs in more than 50 Regions which they themselves have defined. These Regions encompass the Nation’s population. They have been formed by the organizing groups using functional as well as geographic criteria. These Regions include combinations of entire states (e.g. the Washington-Alaska Region), portions of sev- eral states (e.g. the Intermountain Region includes Utah and sec- tions of Colorado, Idaho, Montana, Nevada and Wyoming), single states (e.g. Georgia), and portions of states around a metropolitan center (e.g. the Rochester Region which includes the city and 11 surrounding counties). Within these Regional Programs, a wide variety of organization structures have been developed, including executive and planning committees, categorical disease task forces, and community and other types of sub-regional advisory committees. Regions first may receive planning grants from the Division of Regional Medical Programs, and then may be awarded operational grants to fund activities planned with initial and subsequent planning 22 grants. These operational programs are the direct means for Re- gional Medical Programs to accomplish their objectives. Planning moves a Region toward operational activity and is a continuing means for assuring the relevancy and appropriateness of operational activity. It is the effects of the operational activities, however, which will produce results by which Regional Medical Programs will be judged. On November 9, 1967, the President sent the Congress the Report on Regional Medical Programs prepared by the Surgeon General of the Public Health Service, and submitted to the President through the Secretary of Health, Education, and Welfare, in compliance with The Act. The Report details the progress of Regional Medical Programs and recommends continuation of the Programs beyond the June 30, 1968, limit set forth in The Act. The President’s letter transmitting the Report to the Congress was at once encouraging and exhortative when it said, in part: “Because the law and the idea behind it are new, and the problem is so vast, the program is just emerging from the planning state. But this report gives encouraging evidence of progress—and it promises great advances in speeding research knowledge to the patient’s bedside.” Thus in the final seven words of the President’s message, the objective of Regional Medical Pro- grams is clearly emphasized. THE NATURE AND POTENTIAL OF REGIONAL MEDICAL PROGRAMS GOAL—IMPROVED PATIENT CARE The Goal is described in the Surgeon General’s Report as «clear and unequivocal. The focus is on the patient. The object is to influence the present arrangements for health services in a manner that will permit the best in modern medical care for heart disease, cancer, stroke, and related diseases to be available to all.” MEANS—THE PROCESS OF REGIONALIZATION Note: Regionalization can connote more than a regional cooperative arrange- ment, but for the purpose of this publication, the two terms will be used * interchangeably. The Act uses “regional cooperative arrangement,” but “regionalization” has become a more convenient synonym. A regional cooperative arrangement among the full array of available health resources is a necessary step in bringing the benefits of scientific advances in medicine to people wherever they live in a Region they themselves have defined. It enables patients to benefit from the inevitable specialization and division of labor which ac- company the expansion of medical knowledge because it provides a system of working relationships among health personnel and the institutions and organizations in which they work, This requires 23 a commitment of individual and institutional spirit and resources which must be worked out by each Regional Medical Program. It is facilitated by voluntary agreements to serve, systematically, the needs of the public as regards the categorical diseases on a regional rather than some more narrow basis. Regionalization, or a regional cooperative arrangement, within the context of Regional Medical Programs has several other impor- tant facets: @- It is both functional and geographic in character. Functionally, regionalization is the mechanism for linking patient care with health research and education within the entire region to provide a mutually beneficial interaction. This interaction should occur within the operational activities as well as in the total program. The geographic boundaries of a region serve to define the popula- tion for which each Regional Program will be concerned and responsible. This concern and responsibility should be matched by responsiveness, which is effected by providing the population with a significant voice in the Regional Program’s decision- making process. @ It provides a means for sharing limited health manpower and facilities to maximize the quality and quantity of care and service available to the Region’s population, and to do this as eco- nomically as possible. In some instances, this may require inter- regional cooperation between two or among several Regional Programs. @® Finally, it also constitutes a mechanism for coordinating its categorical program with other health programs in the Region so that their combined effect may be increased and so that they contribute to the creation and maintenance of a system of comprehensive health care within the entire Region. Because the advance of knowledge changes the nature of medical care, regionalization can best be viewed as a continuous process rather than a plan which it totally developed and then implemented. This process of regionalization, or cooperative arrangements, con- sists of at least the following elements: involvement, identification of needs and opportunities, assessment of resources, definition of ob- jectives, setting of priorities, implementation, and evaluation. While these seven elements in the process will be described and discussed separately, in practice they are interrelated, continuous and often occur simultaneously. Involvement—The involvement and commitment of individuals, organizations and institutions which will engage in the activity of a Regional Medical Program, as well as those which will be affected by this activity, underlie a Regional Program. By involving in the steps of study and decision all those in a region who are essential to implementation and ultimate success, better solutions may be found, the opportunity for wider acceptance of decisions is improved, and implementation of decisions is achieved more rapidly. Other 24 attempts to organize health resources on a regional basis have ex- perienced difficulty or have been diverted from their objectives because there was not this voluntary involvement and commitment by the necessary individuals, institutions and organizations. The Act is quite specific to assure this necessary involvement in Regional Medical Programs: it defines, for example, the minimum composi- tion of Regional Advisory Groups. The Act states these Regional Advisory Groups must include “practicing physicians, medical center officials, hospital administra- tors, representatives from appropriate medical societies, voluntary health agencies, and representatives of other organizations, institu- tions and agencies concerned with activities of the kind to be carried on under the program and members of the public familiar with the need for the services provided under the program.” To ensure a maximum opportunity for success, the composition of the Regional Advisory Group also should be reflective of the total spectrum of health interests and resources of the entire Region. And it should be broadly representative of the geographic areas and all of the socioeconomic groups which will be served by the Regional Program. The Regional Advisory Group does not have direct administrative responsibility for the Regional Program, but the clear intent of the Congress was that the Advisory Group would ensure that the Regional Medical Program is planned and developed with the continuing advice and assistance of a group which is broadly representative of the health interests of the Region. The Advisory Group must approve all proposals for operational activities within the Regional Program, and it prepares an annual statement giving its evaluation of the effectiveness of the regional cooperative arrangements established under the Regional Medical Program. Identification of Needs and Opportunities—A Regional Medical Program identifies the needs as regards heart disease, cancer, stroke and related diseases within the entire Region. These needs are stated in terms which offer opportunities for solution. This process of identification of needs and opportunities for solu- tion requires a continuing analysis of the problems in delivering the best medical care for the target diseases on a regional basis, and it goes beyond a generalized statement to definitions which can be translated into operational activity. Particular opportunities may be defined by: ideas and approaches generated within the Region, ex- tension of activities already present within the Region, and ap- proaches and activities developed elsewhere which might be applied within the Region. Among various identified needs there also are often relationships which, when perceived, offer even greater opportunities for solutions. In examining the problem of coronary care units throughout its Region, for example, a Regional Program may recognize that the more effective approach would be to consider the total problem of the treatment of myocardial infarction patients within the Region. This broadened approach on a regional basis enables the Regional 25 Program to consider the total array of resources within its Region in relationship to a comprehensive program for the care of the myo- cardial infarction patient. Thus, what was a concern of individual hospitals about how to introduce coronary care units has been trans- formed into a project or group of related projects with much greater potential for effective and efficient utilization of the Region’s re- sources to improve patient care. Assessment of Resources—As part of the process of regionalization, a Region continuously updates its inventory of existing resources and capabilities in terms of function, size, number and quality. Every effort is made to identify and use existing inventories, filling in the gaps as needed, rather than setting out on a long, expensive process of creating an entirely new inventory. Information sources include state Hill-Burton agencies, hospital and medical associations, and voluntary agencies. The inventory provides a basis for informed judgments and priority setting on activities proposed for develop- ment under the Regional Program. It can also be used to identify missing resources—voids requiring new investment—and to develop new configurations of resources to meet needs. . Definition of Objectives—A Regional Program is continuously involved in the process of setting operational objectives to meet identified needs and opportunities. Objectives are interim steps toward the Goal defined at the beginning of this section, and achieve- ment of these objectives should have an effect in the Region felt far beyond the focal points of the individual activities. This can be one of the greatest contributions of Regional Medical Programs. The completion of a new project to train nurses to care for cancer patients undergoing new combinations of drug and radiation therapy, for example, should benefit cancer patients and should provide additional trained manpower for many hospitals in the Region. But the project also should have challenged the Region’s nursing and hospital communities to improve generally the continuing and in- service education opportunities for nurses within the Region. Setting of Priorities—Because of limited manpower, facilities, financing and other resources, a Region assigns some order of priority to its objectives and to the steps to achieve them. Besides the limitations on resources, factors include: 1) balance between what should be done first to meet the Region’s needs, in absolute terms, and what can be done using existing resources and compe- tence; 2) the potentials for rapid and/or substantial progress toward the Goal of Regional Medical Programs and progress toward re- gionalization of health resources and services; and 3) Program balance in terms of disease categories and in terms of emphasis on patient care, education and research. {mplementation—The purpose of the preceding steps is to provide a base and imperative for action. In the creation of an initial op- erational program, no Region can attempt to determine all of the program objectives possible, design appropriate projects to meet all the objectives and then assign priorities before seeking a grant to 26 implement an operational program which encompasses ail or even most of the projects. Implementation can occur with an initial operational program encompassing even a small number of well- designed projects which will move the Region toward the attainment of valid program objectives. Because regionalization is a continuous process, a Region is expected to continue to submit supplemental and additional operational proposals as they are developed. Evaluation—Each planning and operational activity of a Region, as well as the overall Regional Program, receives continuous, quan- titative and qualitative evaluation wherever possible. Evaluation is in terms of attainment of interim objectives, the process of regionali- zation, and the Goal of Regional Medical Programs. Objective evaluation is simply a reasonable basis upon which to determine whether an activity should be continued or altered, and, ultimately, whether it achieved its purposes. Also, the evaluation of one activity may suggest modifications of another activity which would increase its effectiveness. Any attempt at evaluation implies doing whatever is feasible within the state of the art and appropriate for the activity being evaluated. Thus, evaluation can range in complexity from simply counting num- bers of people at meetings to the most involved determination of behavioral changes in patient management. As a first step, however, evaluation entails a realistic attempt to design activities so that, as they are implemented and finally con- cluded, some data will result which will be useful in determining the degree of success attained by the activity. REVIEW COMMITTEE K. P. BUNNELL, Ed.D. G. E. MILLER, M.D. D. E. ROGERS, M.D. Assoc. Director Director, Off. of Research Prof. and Chairman Western Interstate Comm. in Med. Educ. Dept. of Med. for Higher Ed. Coll. of Med., U. of TIL School of Med. Boulder, Colo. Chicago, Tl. Nt i G. JAMES, M.D. P. M. MORSE, Ph.D. asamille, Tene: (Chairman) Director, Operations C. H. W. RUHE, M.D. Dean, Mount Sinai Research Ctr. Assistant Secretary School of Med. Mass. Inst. of Tech. Council on Med. Ed. New York, N.Y. Cambridge, Mass. on Med. Assoc. H. W. KENNEY, M.D. A. PASCASIO, Ph.D. icago, Tl Medical Director Assoc. Research Prof. R. J. SLATER, M.D. John A. Andrew Memorial Nursing School, Uz of Executive Director Hosp. Pittsburgh The Assoc. for the Aid of Tuskegee ieuidie Pittsburgh, Pa. N Crippled Children uskegee, Ala. 5. H. PROGER, M.D. ew York, N.Y. E. J. KOWALEWSKI, M.D. Prof. and Chairman J. D. THOMPSON Chairman, Dept. of Med. and Prof. of Public Hlth. Committee of Environ. Med. Physician-in-Chief School of Public Hlth. Acad. of Gen. Practice Tufts N.E. Med. Ctr. Yale U. Akron, Pa. Pres, Bingham Assoc. Fund New Haven, Conn. Boston, Mags. CHRONOLOGY DECEMBER §f Report of the President's Commission on Heart Disease, Cancer, and Stroke FEBRUARY TO Congressional hearings JULY OCTOBER § Enactment of P.L. 89-239 DECEMBER §f National Advisory Council meeting §§ Initial policies and pre- liminary Guidelines reviewed Establishment of Division Publication of preliminary Guidelines National Advisory Council meeting FEBRUARY Policy for review proc- eas and Division activities set APRIL Review Committee meeting National Advisory Council] meeting § 7 planning grants awarded JUNE Review Committee meeting National Advisory Council meeting @ 3 planning grants awarded JULY Publication of Guidelines Review Committee meeting AUGUST National Advisory Council meeting ff 8 planning grants awarded Report material SEPTEMBER § First of 5 meetings of Ad Hoc discussed Committee for Report to the President and Congress OCTOBER § Review Committee meeting NOVEMBER § National Advisory Council meeting § 16 planning grants awarded Review Committee meeting National Conference 1967 JANUARY National views on Programs & information for Report provided 10 planning and 4 opera- FEBRUARY § National Advisory Council meeting tional grants awarded APRIL Review Committee meeting MAY National Advisory Council meeting § 5 planning and 1 opera- tional grant awarded JUNE Report to the President & Congress JULY Review Committee meeting / AUGUST National Advisory Council meeting § 2 planning grants awarded OCTOBER § Review Committee meeting NOVEMBER [f National Advisory Council meeting 2 planning and 3 opera- tional grants awarded Regional activities and ideas presented 1968 JANUARY I coneence Workshop 28 PUBLIC LAW 89-239 Through grants, to afford to the medical profession and the medical institu- tions of the Nation the opportunity of planning and implementing programs to make available to the American people the latest advances in the diagnosis and treatment of heart disease, cancer, stroke, and related diseases by estab- lishing voluntary regional cooperative arrangements among - - - @ Voluntary Health Agencies @ Federal, State, and Local Health Agencies @ Physicians @ Hospitals © Medical Schools © Research Institutions @ Civic Organizations REGIONAL ADVISORY COUNCILS The activities of Regional Medical Programs are directed by fulltime Co- ordinators working together with Regional Advisory Groups which are broadly representative of the medical and health resources of the Regions. Membership on these groups nationally is: Hospital Administrators Practicing Public Health Physicians Officials Other Health Workers Voluntary Medical Center Health Agencies AN. School Official: Members of the Public Dr. Lee. I would like to insert in the record two tables, showing participation in the regional medical program, and total obligation of funds. (The documents referred to follow :) TaBLe I.—Participation in regional medical programs by individuals and organizations Individuals -.-....--._--- pee n eee eee 7, 200 Staffs of 54 programs__..._._____........---_-_-_--ee eee 1, 800 Members of regional advisory groups_._____.._.-...--__-___-----_ 1, 900 Subcommittee members___.....____---.-.--- eek 2, 500 Local action group members____.....--.-. 1, 000 Institutions ~----.-----.1.--- een 934 Hospitals ___..--------- eee 800 Medical schools___-...-.--------...2..-.----e_ een 7103 Dental schools___--_-....-.----2- 2. ee 18 Schools of public health._..-__.._-..-.-- eee 13 Organizations __-.-..-_--.____-_____ ee 179 State medical societies..__....._------ ee 152 County medical cocieties.___.._-_-- eee State health departments........-.....-____-----__- 152 State cancer societies__.......-._..__.--___-.-_---__u---- 151 State heart association___..__.....---_-____u_- 152 State hospital association._..._._...-_.__.-.-__-_-___-----__--. 40 Areawide health facility planning agencies_._...____.___._____ 30 State dental association...._.._.___.----_____------- 29 Other professional societies, local voluntary agencies, ete____..___ 383 1100 percent participation. 34 TABLE II.—Regional medical programs, total obligation of funds Fiscal year: 1966 _.__---_---------------~------------------------------ $2, 500, 000 1967 _._____-----.----------+--------~------+----+---------- 28, 900, 000 1968 ..--.----.------------------------- 2+ one nnnno +53, 800, 000 1969 __.-_.---..--.------------------- ---- en nen 799, 800, 000 1 Projected. 2 president's budget. Dr. Ler. Thank you, Mr. Chairman, for this opportunity to explain to this subcommittee our views on H.R. 15758. Mr. Huitt, Dr. Marston, Dr. Yolles, and Miss Johnston will be happy to answer any questions you may have. Mr. Rocers. Thank you very much, Dr. Lee, for your statement covering the proposed legislation. I think we will start our questions by Mr. Kyros. Mr. Kyros. Thank you, Mr. Chairman. I want to commend you, Dr. Lee, on a very excellent statement and to welcome you here. I would like to start with the last thing you said on page 18 of your statement. How will community mental health center completions, where you will have facilities for treatment of alcoholism and narcotic addic- tion, make a vital contribution toward preservation of such problems? Dr. Lee. I would like to ask Dr. Yolles to comment on that, and then T will comment also. Dr. Youuxs. The prevention referred to in terms of these programs, which are primarily pointed to treatment of alcoholics and addicts, re- fers to secondary prevention. The secondary prevention approach is, in effect, early intervention to prevent further pathology from occur- ring. We would hope that the preventive aspects—education, consulta- tion with other agencies, would be handled under other legislation, Public Law 89-749, the Partnership for Health Act, which also will deal with these problems. Mr. Kyros. Will these centers be similar to some of the mental health centers in Massachusetts? Will they treat people as outpatients? Dr. Youtes. Depending on the type of case, you may have a varila- tion in types of treatment. If someone came in in an acute state, he would be hospitalized, generally in a general hospital, and then go on to perhaps transitional day care or night care and then outpatient care, and followup thereafter. Mr. Kyros. Let me ask a question generally about the regional medi- cal program. . a understand it, it has been in operation nearly 2 years, is that right? r. Les. That is correct. ” Mr. Kyros. Have you been able to make qualitative analysis on whether this program has made knowledge of medical science avail- able to practitioners in rural areas? Dr. Ler. Yes; I think we can cite examples. I would like to emphasize that the efforts until now, of course, have been primarily bringing the various groups together, building the foundation on which the opera- tional programs will be moving forward rapidly. 35 Dr. Marston ? Dr. Marston. This is not an easy question to answer at this early stage in the program. We do have operational grants awarded which include more than 100 projects that are underway in the regions. Perhaps the best way I could answer this might be to take the ex- ample of one region and how it has moved in the area of heart disease, cancer and stroke. I would like to use, from time to time, some of the words of the ap- plicant, because this is a program that is occurring in the region. The North Carolina regional medical program decided in the late summer of 1967, about a year after it received its planning grant, that it had attained readiness for operational status. Conceptual strategy to achieve the goals of the regional medical program had been de- veloped. A unified, representative leadership of the region, the prin- cipal health interests in the region, had been organized for the stimu- lation of productive, cooperative effort for guidance and coordination of program development, and an organization structured for effective decisionmaking based on needs in the region had been developed and adequately tested. During 1966 and 1967, North Carolina had had a small project in the area of heart disease. This development was described in the re- gion’s progress report as follows: Since cooperative arrangements in- volving such a wide assortment of people and institutions in one proj- ect was a novel departure for us, the experience has been invaluable. We quickly learned that the original project contained seriously inade- quate provisions for manpower. Thus, in our operational grant appli- cation submitted in October 1967, an expansion of the project was proposed, and as time passes, further modification is anticipated. Con- ferences with staffs of small community hospitals and observations of patients with acute myocardial infarcts being treated therein convinced us that an effort had to be made to determine the feasibility of an ap- propriately designed coronary care unit for these small hospitals. The region’s report goes on later to describe the availability of cor- onary care units, and particularly the ability in these units to do some- thing as far as the rhythm or the electrical disturbances in the heart is concerned, which is not possible without the specialized equipment and trained people in these units. - The growing interest and availability of coronary care units in this region also has generated the need to provide a cardiopulmonary and resuscitation training program to expand on an earlier, limited pro- gram of the North Carolina Heart Association. Additional projects in the heart area, which are in various stages of implementation or planning, include the diagnosis and treatment of hypertension, the use of specially equipped ambulances, pediatric cardiological screening, and so forth. _ Inthe cancer area, the North Carolina program worked with exist- ing groups who have worked in the cancer field before, and they state an increasing number of community hospitals and their staffs are at- tempting to meet the standard of the American College of Surgeons for the approval of their cancer programs. In this region there are only seven hospital programs that currently are approved, and they would hope to increase this through the regional medical programs. 36 The North Carolina regional medical program now enjoys, accord ing to a report of progress, an unusually active cooperative arrange ment with all of the major groups concerned with planning an implementing cancer activities. The cancer subcommittee of the regional advisory group provide a mechanism whereby efforts can be better coordinated and tasks mor: rapidly and effectively accomplished. They are about to initiate ; central cancer registry and a central cancer information service. Thei goal is to establish a well-coordinated, comprehensive cancer progran with full participation of State agencies, academic agencies, com munity hospitals, and professional and voluntary organizations. Thi roup of cooperating groups also includes a special cancer commissio established by the Governor some years ago, before the advent of th regional medical program. The North Carolina program reports that much less has been ac complished in the area of stroke than in the other disease categorie: but there is an emphasis in this statement that there is an intent ft bring the program into balance. Knowledge sufficient to launch and maintain a meaningful strok program in both urban and rural North Carolina communities is avai able, and they have an application before us for development of community stroke program. I would like to just mention one other thing, not in a categoric: area, about a particular problem that this region has identifie through its associate director for hospitals. In the western part of tl State there are seven hospitals in as many communities that are facir manpower problems—that are facing the problem of keeping up. Dr. Amos Johnson, who is a past. president of the American Aca emy of General Practice, told the 1968 Washington conference wor] shop on regional medical programs that these seven hospitals w: be brought together in a coordinated program by the people in tl region. These hospitals are prepared to go so far as to apply as a grou for a single accreditation under the Joint Commission on Accredit tion of Hospitals. Thus, North Carolina is in the midst of testing the concept of unique regional hospital organization where no one hospital is ab to provide the full range of necessary capabilities. Mr. Kyros. Thank you. Dr. Les There has been in the last 3 years—and we want to make clear we do not take credit for this with respect to the regional medic programs—a significant decline in deaths from high blood pressw It is about a 20-percent decline over the past 3 years. I think there no question that as the regional health programs develop activity a) the knowledge of early detection of hypertension, and early treatme becomes more available, we will see an acceleration of this very signi - cant decline, which, of course, will affect particularly the stroke pre lem and, to a lesser extent, the deaths from coronary disease. Mr. Kyros. Dr Lee, pursuing the question of the effectiveness of t program, let’s think for a moment about costs. As understand it from your table IT, “Regional Medical Program a total obligation of funds for the fiscal years 1966 through 1968, y show approximately $85 million, either in planning or operatio! grant obligations. 37 Now, as measured against that $85 million, have you made any kind of an analysis or evaluation which shows that, for that kind of money, we have achieved some significant advance through the regional medical program ? Dr. Lex. The program to date primarily has been one of planning and developing the mechanisms which then can be evaluated. For example, we a developing the data base which in many areas is seriously lacking. After we develop such a data base in the regions, we will carry forward the evaluations for which we are asking specific earmarked funds. I think it is really too early to be able to state with any degree of certainty a cost-to-benefit effect. T think that we should also recognize what I think is going to be one of the most significant contributions of the program. That is the spin off of benefits, well beyond the program itself, not only in terms of people whose care is paid for through medicare or medicaid. For example, as improvement takes place in community hospitals the way Dr. Marston described it, as physicians are able to participate in these programs in community hospitals, the program is bound to have a significant impact on improving quality. ; I think the best buy in medical care is good care, high-quality, and this, to me, is going to be one of the most important long-term con- tributions of the program. And I think this is one of the reasons that we see the kind of enthusiastic support among practicing physicians in many parts of the country who were at first really very suspicious of the program. As they have seen it develop, as they have participated, they ‘have become increasingly enthusiastic. We will be developing for this spin- off some techniques for measurement so that we can determine the additional conditions of the program. Mr. Kyros. Dr. Lee, in this bill as it is proposed, I understand that $65 million is sought for the fiscal year ending June 30, 1969. Dr. Ler. That is correct. Mr. Kyros. What carryover of funds will we have for this program? Dr. Lee. The carryover is $30 million. Mr. Kyros. So of the approximately $95 million we are talking about, you have $30 million unobligated as yet. B a Ler. Yes, That is held in reserve, actually, by the Bureau of the udget. . Mr. Kyros. My next question is a general one about your program. | Has the American Medical Association now endorsed this program as it is being carried out? Dr. Marston. I think the best answer to that is a paper that Dr. Dwight Wilbur gave at a conference workshop—which has been pub- lished in the current issue of JAMA. It is very supportive of the program, Mr. Kyros. What does this program do for a general practitioner, say, ina rural area like in my own State of Maine? Dr. Ler. I might add one thing. If the AMA has endorsed it, these are actions that would have to be taken by the house of delegates. They would have to vote on a resolution saying they endorse it, and I am not sure that action has been taken. 309-653 O-68-—-3 38 Mr. Kyros. But the President has put ina statement that he supports it. , Can you tell us specifically how a general practitioner in a rural area gets involved in a program? Say there is a regional program in the area in which he practices, but he is in a small town that doesn't have a hospital. Dr, Marsrox. A number of examples come to mind. There was a problem—again in North C arolina, to take up where I left off— of a community that was about to be without a physician, and the peo- ple in the community turned to the regional medical program for assistance. The regional program was able to examine what the problems were in attracting physicians to that community and growing out of that, there has developed a rather major study for that region in the prob- lems of the rural area. The principal example, I think, is an easy one: The tradition of the Birmingham Associates which, as you will recall from testimony lead- ing to passage of this legislation, was held up as a model of how various health institutions and resources can have a relationship through an organization such as the associates. The activities of the Birmingham Associates are being expanded and carried further by the regional medical programs. There are a variety of other things being done to assist the physician in rural areas where no hospital exists. There are opportunities for physicians from one part of Washington State to come into and actually spend time in larger hospitals. This includes an exchange so that someone arranges to take over their practice for a period of time. There are the usual continuing education programs, but I think with a different emphasis—with the emphasis on doing those things that meet the needs of the physician rather than offering a course that is pre- selected for him. The difference has been that the physician is involved in decisions and in planning in terms of his needs rather than coming in at a later stage. There are also other facilities or services in a number of the regions that are planned and will be implemented for the physician. Dr. Lee. I would just add another comment on that, and this relates toa personal experience I had visiting Vinel Haven Island, where there is one physician in general practice. He has been able to attract occa- sionally third- and fourth-year medical students to come and spend part of the summer with him, and this has been a tremendous stimulus to him. It has provided him the best possible opportunity to keep up. It has also been a unique educational experience for the students, be- . cause people have lived there for many, many generations, and certain disease patterns there are somewhat unique. He has developed relation- ships with, for example, diabetic experts at Harvard, who have been interested in diabetes in this particular population group. He has been able to keep up far more effectively than the average practitioner, and one of the things that is being explored in the pro- gram is the participation of third- and fourth-year medical students in these community hospital teaching programs. The development of teaching programs in community hospitals, the extension of teaching programs, will attract young physicians to areas 39 that would otherwise not have been attractive to them. They have been used to active teaching programs in the university centers, and they have tended not to want to go too far from these. But I think the opportunity to keep up professionally, to interact with other people and with students on a continuing basis, will be an added benefit. Maine is a very good example of the needs of the country to attract physicians to areas other than these urban areas where most of them have settled, or the suburban areas. I think that the regional medical programs are making and can con- tinue to make a significant contribution to this. Mr. Kyros. I have one last question, Mr. Chairman. That is this: You have seen the program in operation for a couple of years now. What can you say about the fact that this is Federal money, that there is a possibility, always, when using Federal funds, that the Fed- eral Government gets some kind of control over the medicine and medi- cal practice. You know, we hear this all the time, and we are concerned about it, and I wouldn't want to see Federal control over medicine. How can you say, sir, as administrator of this program, that Federal control is not an encroachment on medical practice through this program? . Dr. Marston. I think this committee took a very important step when it gave essentially veto power to the regional advisory groups. This means that we cannot establish on the national level any regional operational activity that has not had prior approval of the appropriate Regional Advisory Group. And this is perhaps the strongest point. The other point is that, again, the Surgeon General is limited by the fact that every application must be recommended for approval by the non-Federal, National Advisory Council on regional medical pro- grams. I think basically these are the two sharpest assurances that the contro] will remain at the regional level. A third assurance is that the programs are working with the control remaining at the regional level. This is recognized, I think, at the Federal level as well as throughout the country. Mr. Kyros. You have had no feedback of any problems concerning complaints of Federal control like we have had in programs, such as OEO and others? Dr. Ler. I think there was a great deal of speculation that this would bo the case. The fact that it has not been the case, the fact. that there has been increasing participation by practicing physicians in the planning of the programs and as the operational programs develop, the extent of participation, the fact that there are 800 hospitals with their staffs participating are indications that this, in the planning and early operation stage, really has grassroots support. I would add one other thing to what Dr. Marston said. I think the actions of this committee and the periodic oversight of the program by the Congress is another assurance to physicians, with the law as it is written, that there will not be Federal control. Certainly, the way in which the program has been administered has been just in the opposite direction, to stimulate to the maximum extent possible, local initiative. Those who participate have to solve their local differences, which have been considerable in some of the regions. 40 Some people have felt that the program was moving too slowly, but takes time to work out differences which have long existed. But as we view it, the way we are proceeding gives the best: possible foundation for the program, because it is stimulating local initiative all over the country. Mr. Kyros. I am delighted to hear you say that, Dr. Lee. I know from my experience from talking with doctors in the State of Maine, that they think the program is an outstanding one, that it doesn't encroach on them, and I think this is a credit to your administration. You are the people who have to do a hard job, and I want to com- mend you highly on administering a program like this, which is com- plicated—and particularly because of the important relationship be- tween doctors and patients. You have done an outstanding job, and Lam proud of you. Mr. Rocers. Mr. Carter? Mr. Carter. I notice that the new bill will include an authorization for funds for treatment of alcoholics, and it will also include funds for treatment of addicts, too. Dr. Les. Yes, sir. Mr. Carrer. How much will that be this year and next year, your additional authorization ? Dr. Lee. The amount that we have requested is, for the alcoholics, $7 million, and for the narcotic addict rehabilitation, $8 million, and in fiscal 1970, $15 million for the alcoholics and $10 million for the addicts. Most of that money will be for the development of services rather than construction. It is about 30 percent for construction or renova- tion of facilities. Mr. Carter. Will these treatment centers for alcoholics and narcotic addicts be an integral part of the mental health centers, or will they be separate? Dr. Ler. I would like to ask Dr. Yolles to further elaborate on that Dr. Yours. These treatment facilities, Dr. Carter, would be built into the community health center and would be an integral part of it We would even relate the special facilities for homeless alcoholics t« this continuum of services. This is the key point in the legislation t: relate these services for treatment of alcoholics and narcotic addicts t the total panoply of services in the community health center. They may be physically separated, but there would be adequat transfer of patients and records between the services, just as in th basic program. Mr. Carrer. I think that it is good that it is so. Tt will be less div ficult, as I see it. . T notice that in your regional health development, 11 regions has been funded. Is that right? Dr. Lee. Yes, 11 operational grants have been funded, and 53 pla’ ning grants. Mr. Carrer. This is in its infancy at the present time? Dr. Lee. That is correct, sir. Mr. Carrer. Of course, there has been a decrease in the number strokes in the past 3 years, but you really wouldn’t attribute all th decrease to the establishment of these 11 regions? Dr. Lee. No, not at all, Dr. Carter. 4] I think we would not want to imply that either these programs or some of the other programs that have been initiated in the last 3 years that have been making good progress would in any way have done so. They may have contributed, but certainly, as far as the national figure is concerned, it would be a slight contribution to date. Mr. Carver. Actually, there are improved methods of treatment, really, different medicines used in treatment of strokes that have been mainly responsible for this. Dr. Ler. Yes, sir. I think the improved drugs and the earlier diagnosis.of the hypertensive association that they get under treatment at an earlier stage of the disease have contributed to this. Mr. Carter. I would like to know how the specific organization of a region is. Could you give us a plan, who is head of it, and how it branches down? Dr. Marston. I think what one needs, Dr. Carter, is the organization of more than one region toachieve what you want. The one thing that has to be established in each region is a broadly representative regional advisory group. It is a requirement of the law that this be established. In every region, so far as I can remember, there are task forces in the areas of heart disease, cancer, and stroke, which include people with special knowledge in these areas. In each region there is also a core administrative unit, a staff that varies in size. But on the average in the regions funded for planning only, it is about 20 to 26 people, and in the operational regions, the staff that is actually paid on an average number about 90. Operation of the program is set up differently in different regions. In Connecticut there are 10 subregions. In Kansas there are 10 sub- regions. In Georgia, there is really a subregion for each county, with representatives from every hospital in the State, and with representa- tives from every county medical society. These local-level groups are active in determining their local needs. In some instances these units are called local advisory groups. Now, to come to a specific region, in Kansas these local action groups ’ may either respond to information that has come from studies carried out by the regional staff or, indeed, other groups in the State. Or the local action groups may propose projects that they themselves identify as being particularly needed in that area. In designing these projects, the local action groups can work with the staff of the regional medical program, calling on experts from outside of the region, if necessary. Kansas has a substantive review committee, that is, a committee that reviews, on the basis of scientific and professional merit, the proposals. Finally, with the results of this review available, the application, which may have been stimulated either at the local level or may~have been stimulated as the result of data that has been gathered elsewhere, comes before the regional advisory group, which must approve all operational project proposals. A recent example of this process in Kansas resulted in about half of the proposals that came to the regional advisory group being returned to the originators for one reason or another for additional work before final approval at the regional level. After regional ad- 42 visory group approval is gained, a grant proposal for funding pro- gram activities comes to the Division of Regional Medical Programs. "At this point, we have the opportunity to have special site visits as ire did in the case of the Washington—Alaska Region’s operational application. In this case we actually yisited the locations where pro]- ects were proposed, and made a report to our review committee and, finally, to our National Advisory Council. Does this help? Mr. Carter. Yes, sir; that is helpful. What procedures do you have for continuing education to get to the general practitioner and communities your advances in research ? Dr. Marston. Again, this has varied. There have been some in- stances in which a community took the lead. Great Bend, Kans., for example, has established an sducational subcenter, if you want, for the area immediately surrounding Great Bend. The purpose here is to try to focus education and to focus care as close to the patient’s home as possible. ‘And in the instance of Kansas, yow find this focus has been moved out away from the university to : spbcenters. y In other areas, preexisting programs and facilities have been utl- Med—Albany, N.Y., for example, has a two-way radio system which provides in-hospital education throughout much of the New England area. This has been augmented by the Albany regional medical program. T would say continuing education related to the physician and the yatient’s needs, as opposed to continuing education that somehow has drifted away from the care of patients, is a very major focus of the program. Mr. Carter. Do you have regional seminars on newer concepts in medicine attended _by practitioners from the subregions? Dr. Marston. There was & major one in Oregon that a member of my staff attended not long ago. Mr. Carrer. The purpose of this bill is to diminish deaths from heart disease, cancer, and stroke. Do you have available to the practitioners in the subregions close liaison with specialists in the regional areas so that they can get in- formation quickly, or advice, or help in treatment? Dr. Marston. There is an example in Wisconsin of a 24-hour-a-day telephone service to physicians in the area. There is a specialty team in Towa that has been activated to actually go out to the scene and provide consultation to the local physician and his stroke patients. Mr. Carter. That is part of your regional system at the present time ¢ i- Dr. Marston. Yes. ’ Ma. Carter. I want to congratulate you on that. I think that is very ood. I certainly feel that these ideas, or these questions which I have asked you should be further implemented, if possible. Thank you, Mr. Chairman. Mr. Rocrrs. Mr. Skubitz? Mr. Sxverrz. Thank you, Mr. Chairman. Doctor, J am a new member on this committee, and I am from the great State of Kansas that you have been praising so highly. Doctor, Lam interested in a number of things. 43 First, I want to say I appreciate the fact that you are interested in Kansas. I hope we can get some money to keep this show on the road. How much money was authorized, Doctor, for these regional medical programs in 1966? Dr. Marston. The authorization was $50 million. Mr. Sxusrrz. How much was appropriated ? Dr. Marston. $25 million, including $24 million for grants—$25 million total. Mr. Sxusirz. In 1967, how much was authorized ? Dr. Marston. The authorization was $90 million. The appropria- tion was $43 million for grants and $2 million for direct operations. Mr. Sxvsrrz. You havea total of how much? Dr. Marston. $45 million was appropriated for 1967, $25 million appropriated for 1966, so that would be a total of $70 million. Mr. Sxusrrz. In 1968, how much was authorized ? Dr. Marston. $200 million. We have received $53.9 million in ap- propriations for grants and $4,900,000 for direct operations, for a total of $58.8 million. Mr. Sxusiz, Out of this total amount of appropriations, how much do you have available to you now? , Dr. Marston. $53.8 million—including $4.9 million for direct opera- tions. This total is comprised of $27.9 million of our 1968 appropria- tion—$30.9 million was put in reserve—plus $25.9 million in carry- over funds. Mr. Sxvnirz. The thing that bothers me, Doctor, is that you come here with an excellent program. It looks fine on paper. But, unless this Congress gives you money we accomplish nothing. So far as Tam concerned, I want to be as helpful as I can to assist you in this impor- tant work. Thank you, Mr. Chairman. Dr. Lez. I would like to make an additional comment: on that, Mr. Chairman, As the program has developed, of course, with the evolution of the planning, the authorizations were well above those required, and as we move into the operational phase, we feel that, of course, sig- nificantly more funds will be required with the operating programs. Planning is one thing, but operating programs is quite another. Mr. Carter. Mr. Chairman, would the gentleman yield? Just how has this money been spent, Doctor, most of it? Dr. Ler. The money, primarily, goes, of course, for the hiring of staff and for the activities of the staff, in some cases for the purchase of equipment, the development of coronary care unit, or for long- distance transmission of cardiograms, which is being tested on an experimental basis. ‘ This kind of thing, staff and equipment, which would be related to the educational efforts— Mr. Carter. Do you have a central place in each region, to which place cardiograms may be transmitted by phone? Dr. Ler. Not in each region. I think that the experimental pro- gram is going on in Missouri. 44 Dr. Marston. That is a major one, which has been supported by the National Center for Chronic Disease Control over the last 5 years. It is being field tested in Missouri at the present. Mr. Carrer. In one region you have such— Dr. Marsron. Yes. Vr. Carter. Do you envision in the future the use of such cen- tralized diagnostic aids? ; Dr. Lre. If we find the experiment in Missouri is successful, and it is demonstrated that you can improve patient care, and that it 1s feasible from a cost standpoint, that other regions will then want to develop similar programs. It may be that. a computer would serve perhaps more than one region. These are expensive, depending on the kinds of programs that are developed, such as automated multi- phasic screening. Mr. Sxusirz. For example, to detect some of the diseases early, cancer and cardiovascular diseases particularly, the development of the automated long-distance cardiograms—as other advances take place, say, in the area of radiology, it may be that those would also be applied on a regional basis. I think it is wise to test them out first in a single area, as is now being done in Missouri, to find out how feasible it is at the level of the community hospital, and in the communities where the patients are and the physicians are in practice, to see if it is practical. Mr. Carrer. Many of our community hospitals have lines to these places to interpret their cardiograms in that way. Dr. Marston. Dr. Carter, this goes a bit beyond that. The reason they wanted to try this advanced system is that, in addition to the usual telephone lines for the transmission of EKG, this new system doesn't take the place of interpretation by the physician, but does save time in supplying the attending physician with an analysis of the clectrocardiogram done by a centrally situated computer. What this project is facing is the fact that we are not going to have enough trained manpower over time to do EKG analyses, and we have to develop some system to augment the highly skilled manpower required in this area. So this system is more than a telephone line. Mr. Sxusrrz. Mr. Chairman, may I ask one more question ? Mr. Rocers. Yes. Mr. Sxuprrz. Did you say $200 million was authorized in 1968? Dr. Marston. Yes, sir. Mir. Skunrrz. How much did Congress appropriate ? Dr. Marston. $53,900,000 for grants, and $4,914,000 for direct operations. Mr. Sxusirz. Thank you. . Mfr. Rocers. What do you think of combining the comprehensive health planning program and the regional program? What would you think of combining these two programs? Dr. Ler. The two programs have a different purpose. As we move down the path and as these programs develop, the will be obviously closely coordinated and integrated. But I don’t believe they should be combined into a single program. Mfr. Rocers. You don’t feel that a comprehensive health plan for a State should include what we are doing in this regional program? 45 Dr. Lee. Yes, I think as we develop our capabilities at the State level for planning and a capability in the areawide planning, it will encompass concerns with migrants, with other kinds of disadvantaged groups, and it will also include considerations of regional medical programs. Mr. Rocers. In the comprehensive plan, don’t we give money for treatment of heart disease toa city ? Dr. Lee. In the partnership for health, a formula grant goes to the State, and project grants for the development of comprehensive health services, and these may include services for people who have heart disease or other diseases. The focus of the regional medical programs, and I think this is fundamental to an understanding of the program, is that they have developed a foundation for cooperative arrangements that simply didn’t exist before. We did not have this—in some areas, there were programs of continuation of education, such as in Kansas, or we had the Bingham Associates in New England, but we had not seen the kind of grassroots participation focusing on improving patient care. The comprehensive health plan has to encompass manpower, en- vironmental health problems—the full spectrum—and the project grants can relate to a variety of these things. Mr. Rocers. I realize we are getting this program started now, and it is in a beginning stage, but I would think your planners should be giving thought to combining these programs where there will not be an overlap, because I would think that there would be some areas where there would be rather considerable overlap within a State plan, partic- ularly for heart, cancer, and stroke. Dr. Ler. We are concerned not only about the relationship of the regional programs with the partnership for health, but also the better and more efficient use of all of the programs, such as OEO programs, and we have seen in the Watts area an excellent example of close cooperation between a regional medical program, the develop- ment of a community hospital, and the neighborhood health center program funded by OKO. We are concerned at the national level with stimulating at the State and local level the close integration of these programs so that we can make most efficient use of manpower, which is our scarcest resource, but also the funds available. Mr. Rocers. Yes. I hope to see some of these OKO programs under your department. I feel strongly on this. I realize this was an innova- tive approach, but I think it should be tied in more closely. Let me ask a few questions that you may want to give answers for the record, that you may not have with you. How many regions are actually operating as of January 1968? Dr. Marston. There are now 12 with funded operational programs. Mr. Rocers. I know funds. I am talking about operating. Are they really operating now? Dr. Marston. Yes, sir; they are beginning. This will vary from one T signed yesterday, which is obviously not doing much, to ones that have been operating a year. Mr. Rocers. Would you just give us for the record a rundown of each of these 12, the personnel, how they are involved, how much money they are getting, and I would like to know where that money is being 46 spent, how much on television tie-ins, and how many hospitals are tied in, what improvements are made in hospitals. In other words, when we passed this bill, the idea of the thrust of this program was to make sure the new methods of treatment were going to get to the people. , Now, I realize it 1s very early and too soon for us to make a critical judgment, probably, but I get the feeling that this may be stopping in the dean's office at the medical colleges. Well, I just want to find this out. [{Laughter. | Dr. Ler. It had better not be. (The following information was received by the committee :) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE (PUBLIC Heartu SERVICE) Report ON 12 OPERATING RecionaL MEDICAL PROGRAMS ALBANY REGIONAL MEDICAL PROGRAM The Albany Regional Medical Program was one of the first regions to receive an operational award on April 1, 1967. Currently funded with $755,605, the region has approximately 43 operational staff members, including approximatel) 14 physicians, 17 nurses, 5 other allied health personnel, and 6 general suppor personnel. Over two-thirds of the staff are from the community hospitals, anc they are working closely with the local medical center and RMP staff to increas the capabilities for quality care at the local hospitals. Approximately 60 hospitals from the Albany Region are participating in th: program. Approximately 30 of these hospitals are directly participating in th: operational projects outlined below. Two hospitals are represented on the Ad visory Committee, and the remaining are involved in on-going planning activitie: Operational Projects 1. Two-way radio communication system, direct cost—$144,100 This project will expand an existing two-way radio network to include 6 hospitals and 24 high schools. It will provide continuing education for physiciar and allied medical personnel. It will also provide information and education pr grams for administrators, members of boards of trustees, voluntary health age! cies, adult education classes, and selected civic groups. 2. Community information coordinators, direct cost —$73,800 Former pharmaceutical representatives will be used to contact local phys cians to tell them about Regional Medical Programs and to evaluate their att tudes towards RMP. 3, Postgraduate Instruction Development Panel, direct cost—$102,600 This program proposes to have experimental and control groups of doctors determine their educational needs. These doctors will then participate in i structional programs. Afterwards they will be tested to determine the effectis ness of the instruction. 4. Community hospital learning centers, direct cost-—_$75,800 This project will establish learning centers at community hospitals using “‘S: Instruction Units” and audio-visual equipment for rapid dissemination of nt medical knowledge. Eyentually, the directors of this project hope to evalua physician progress. Initially, 8 hospitals will be involved. 5. Albany Medical Center coronary care training and demonstration progra) direct cost—$125,200 , 4 coronary care unit will be established at Albany Medical College to sel as a model and training unit for training physicians and nurses who will th be able to establish similar units at community hospitals. This project will at ment the existing Coronary Intensive Care Unit at the Albany Medical Cent 47 6A and 6B. Community hospital coronary care training and demonstration pro- gram, direct cost—355,400 This will complement project #5 by establishing coronary care units of three beds each at three community hospitals: Pittsfield General, St. Lukes, and Vassar Brothers, These will serve as demonstration and educational projects for other hospitals in the region. A continuing educational program will serve the perma- nent Unit Staff and staffs from smaller hospitals. 7. Training and demonstration project, intensive cardiac care unit Herkimer Memorial Hospital, direct cost—$3,500 The initial phase of this project is to train 6 or 8 nurses from small community hospitals in-cardiac anatomy and physiology, coronary disease, the principals and staffing of a cardiac intensive care unit, and in handling the complex equipment. These nurses will also be sent to Albany Medical Center for active training with specialized equipment. . INTERMOUNTAIN REGIONAL MEDICAL PROGRAM The Intermountain Regional Medical Program received its first operational grant award on April 1, 1967 and its current operational award totals $1,832,800. Approximately 80 staff members are serving in the operational projects, about one-third of whom are from community hospitals working together with the Re- gional Medical Program staff from the medical center, they are bringing to local health practitioners and hospitals throughout the region modern techniques for treating patients with the categorical diseases. Approximately thirty hospitals are currently participating in the Program. Three hospitals are represented on the Regional Advisory Group, and almost every major hospital in the region has established a local planning group to study local needs and to serve as liaison with the Central IRMP staff. Seventeen hospitals are participating in the operational projects outlined below, and as the program continues to grow, it is anticipated that additional hospitals will become involved. Operational Projects 1. Regional faculty and core-staff seminar, direct cost—$12,600 The University of Utah Medical School will hold a series of quarterly seminars on comprehensive health care, continuing education, contemporary learning the- ory, behavioral science principles, and measurement technology. The faculty, ex- perts from across the country, will address an audience of health professionals in- volved in IRMP. 2, Network for continuing education in heart disease, cancer, stroke, and related diseases, direct cost-—-$243,000 The objectives of this program are to develop a communications network be- tween patient-care and research institutions to encourage liaison between health care personnel in the area. The currently existing 2-way radio system, including 11 hospitals in 7 communities in or near Salt Lake City, will be extended to re- mote hospitals to serve as one link. Closed circuit TV and use of KVED (Uni- versity of Utah education TV) is also planned. This may establish the community hospital as the locus of continuing education. 3. Information and communications exchange service, direct cost—$40,000 The CIES is a region-wide clearing house for information about IRMP. Staff will be put in local communities to act as public relations representatives and alxo to distribute information to medical personnel and the public. The community staff will also gather information on community needs and resources and re- sources and serve as a station for collecting economic, social, and medical data. 4. Cardiopulmonary resuscitation training program, dircct cost—s63,400 The University of Utah will give a 3-day course in resuscitative techniques to selected physicians from small communities. Each physician will then be responsi- ble for teaching the techniques to health personnel in his community. This “resuscitation consultant” will also collect data about the number of times resuscitation is employed and the results. 48 5. A training program in intensive cardiac carc. direct cosi—$118,600 A core faculty of experts in using Cardiac Care Units and diagnosing and treat- ing heart dixease will teach short courses in their subjects. The students will be interested physicians and nurses from community hospitals pbuilding coronary care units. 6. Training for nurses in cardiae care and cardiopulmonary resuscitation, direct cost—$34,000 This ix an integral part of both the cardiac care and cardiopulmonary resus- citation programs for physicians (#4. #5). Nurses trained in Salt Lake City will return to their communities to serve as a core faculty for reaching the techniques at the local level. The nurses will work closely with the similarly trained physicians. y. Clinical trainee program in cardiology, direct cost—365,700 This program has two emphases— (1) To provide general practitioners, internists and cardiologists with training programs in heart disease techniques tailor made to their individ- ual situations. (2) To increase the number of formally trained clinical cardiologists through a training period (3 months to one year) at the existing cardiology school at the university of Utah. 8. Visiting consultants and teacher program for small community hospitals, direct cost—$14,800 Small communities will be given the option of requesting one or two-day clinics. A minimum number of four cardiac patients will be required. These clinics will upgrade the level of care to victims of heart disease living in remote areas. Visiting physicians will assist the local physician in a precise diagnosis in a precise diagnosis of his patients. 9. A regional computer-based system for monitoring physiologic data on-line from remote hospitals in the regional medical program, direct cost—$637, 100 This project’s purpose is to test the feasibility of using a central computer to process a variety of physiological signals generated by patients in remote hos- pitals, feeding the results of calculations from these signals back to stations within the hospitals, and using the information for diagnosis. 10. Cancer teaching project, direct cost —$94,300 This project attempts to upgrade the level of care available to local communi- ties. The coordinator will direct a program of physician education to create trained cancer specialists who in turn, will become centers of cancer information in their local communities. The physicians will receive a small stipend for teaching and obtaining information. A region-wide tuinor registry will be started, as will a training program in new techniques for pathologists. 11, Stroke and related neurological diseases, direct cost—-398,700 This project will establish clinics to bring expert consultation service in stroke and related neurological diseases to local communities ; will provide continuing education to local physicians and Nurses; will collect data about stroke patients seen and the problems they present to the practitioner. A 24-hour telephone con- sultation service and information library service will be maintained at the Utah Medical Center to provide community physicians with immediate advice. In addi- tion, practicing physicians will be trained aft the medical center in the latest diagnostic and treatment techniques. The courses will last from 4 weeks to one year. . 12. Educational program in respiratory therapy for physicians and nurscs, direct cost—$25,300 | To train physicians and nurses to utilize the special techniques and equip ment in respiratory therapy. Five day seminars and follow-up 2 day refresher courses will train participants to administer therapy and to teach others. 13. Regional endocrine metabolic laboratory, dircet cost—$237,900 To provide service facilities where practicing physicians can obtain laboratory data essential to the diagnosis and treatment; to create awareness among physi- cians of the possible presence of metabolic and endocrine abnorinalities; te 49 derive statistical information. Three laboratories will be established : an immuno- assay laboratory, a chemical laboratory to measure steroid hormones, and a developmental laboratory to refine techniques. Seminars will be held both inside and outside of the laboratories, Abnormal findings will be reported to the refer- ring physician by telephone by a physician who is competent to offer consultation. i KANSAS REGIONAL MEDICAL PROGRAM a The operational activities of the Kansas Regional Medical Program began on June 1, 1967, and are currently funded at the level of $699,852. Approximately 80 individuals with varied backgrounds, comprise the current staff, of which about one-sixth are physicians, one-fifth are nurses, and an additional one-fifth are other types of allied health personnel. The remaining staff includes related health personnel, such as communications specialists and social scientists, and general support personnel. About half the staff are from the medical center and: the other half are from community hospitals. Together they are working on programs to improve community capabilities for treating the categorical diseases. Approximately 20 community hospitals are currently involved in the Kansas ’ Program, and it is anticipated that additional hospitals will become involved as expansion takes place during the next few years. Ten of these hospitals are directly involved in operational projects, two are represented on the Advisory Committee, and eight are involved in on-going planning activities. Operational Projects 1. Educational programs—Great Bend, Kans.—$261,000 (direct cost) To develop a model educational program in this small community a full-time faculty, which will be affiliated with the Kansas Medical Center, will be in residence, Included in this comprehensive program are plans for continuing phy- sician and nurse education and clinical traineeships for heath-related personnel. Studies will be made of community needs, resources, etc. 2, Health Sciences Communication and Information Center—$77,900 (direct cost) This project is engaged in conducting studies to determine the feasibility of establishing communication linkages vital to education, service, and research . -programs. Specific studies to be undertaken are a physician communication sys- . tem, TV teaching, electronic linkages, and Medlars search capacity. 3. Study of the quality and availability of medical care—$149,000 (direct cost) To determine unmet needs of patients, locations, professional education, and -working arrangements of physicians and those in the health related disciplines. 4. Hospital information system and data facilities—$67,500 (direct cost) To conduct studies within the region concerning various aspects of community resources and needs, epidemiologic data and participation of health care per- sonnel in continuing educational programs. A computer system will be used. 35. Cardiovascular nurse training—$98,500 (direct cost) To develop an in-service training program to prepare nurses, who are the main- stay of coronary care units in community hospitals, with basic physiological knowledge of coronary care, ability to use instruments and equipment in coronary care units, experience in home care, and familiarity with social agencies that can aid in the rehabilitation of patients. 6. Cancer detection program—Providence Hospital—$25,000 (direct cost) To evaluate the strengths and weaknesses of the Cancer Detection Center now operating as an area referral center in Providence Hospital in Kansas City, Kansas, The records of patients will be studied to show effectiveness and yield of test results, type of personnel who have used the clinic and their source of referral, and effectiveness of follow-up. 7. Cardiovascular work evaluation—$21,100 (direct cost) This project will demonstrate the Cardiac Work Evaluation Unit and show its usefulness for the evaluation and rehabilitation of the patient. It is developing an effective technique for showing physicians and the community at large the ability of patients to return to work after receiving the appropriate rehabilita- tion. 50 METROPOLITAN DISTRICT OF COLUMBIA REGIONAL MEDICAL PROGRAM operational activities on March 1, 1968, with an award of $418.318. 4 staff of 47, including about 11 physicians, two nurses, seven other allied health personnel, and 27 other types of supportive personnel such as computer programmers, coding clerks and secretaries will work together to improve local medical capablities and resources. About half of the staff is from the medical center and the other half is from community hospitals and other jJocal health agencies. This combination of medical center-community personne) helps assure a quality, community oriented program. Seven hospitals are currently participating, and this number will increase as the program expands over the next few years to reach out to the entire region. Three of these hospitals are directly participating in the projects outlined below, two additional hospitals are on the Regional Advisory Group, and two are serving on planning subcommittees. However, several additional hospitals will benefit from these programs as they send their personnel to be trained in the programs outlined below. This region began its Operational Projects Stroke Station for the Diagnosis, Treatment, and In- vestigation of Cerebral Vascular Disease, direct cost——$181,889 This project is a comprehensive approach to stroke, from diagnosis and treat: ment to home care and rehabilitation in an urban Negro area. Based in the Freedman’s Hospital, a community hospital in the region, the stroke statior will serve as 2 teaching component for physicians and medical students. Relatec epidemiological and socio-economic studies will be undertaken. 9, The Washington, D.C. Regional Cerebrovascular Disease Followup and Sur veillance System, direct cost —$94,200 Under the sponsorship of Georgetown University, this project is attemptin: to establish a uniform system for measuring and evaluating medical care give: to stroke patients in the area, in order to facilitate nursing and follow-u services. It will provide information helpful in determining community medica facilities requirements, and in carrying out epidemiological or demographi studies. Patients entering the system through the various community hospital in the region will receive follow-up attention and therefore greater continuity ¢ care. 3, A training program. for cardiovascular technicians, direct cost—$74,707 Qualified students are peing trained at the Washington Hospital Center i Washington, D.C. in specific areas of medical observation and procedures to col plement nurses’ activities. In addition to training personnel for work in ho pitals throughout the region, this project hopes to produce a manual for trainiz: these technicians in the other regional hospitals. 1. Freedman’ Hospital MISSOURI REGION AL MEDICAL PROGRAM Operational activities began in Missouri on April 1, 1967, and current oper tional funds amount to $2,619,000. An estimated 160 operational staff peop! with diverse packgrounds, are serving on the Program, including approximate 15 physicians, four nurses, 416 allied health personnel, three social scientisi and approximately 60 computer specialists and their supporting personnel. T remaining staff provide overall support, such as research and staff assistan and administrative and clerical personnel. * The developmental approach being employed by this region and outlined tions below suggests that hospital involvement will inerea project descrip rapidiy over the next two years. Currently, nine hospitals are involved in t program, including two hospitals which are represented on the Regional 4 visory Committee. Operational Projects 4. Smithville community health service program—dircct cost $200,947 The purpose of this project is to establish a model community health serv program including continuing education and training programs and hea education for the public; emergency intensive and restorative care facilitit home care programs; public health, preventive medicine, and school health; ordinated with voluntary health agencies. Program centered around Smithy 51 and to include about 50,000 persons in county (Clay). Activities are centered around Smithville Community Hospital and the group practice clinic as a nucleus. 9, Multiphasic testing of an ambulant population—direct cost $421,471 This project is designed to establish centers for performing series of diagnostic laboratory tests to identify the most useful tests feasible for screening large rural population groups; determine the different patterns for ill and healthy populations as an aid in detection of heart disease, cancer and stroke in pre- clinical stages. Model test centers will be established at the University Medical Center, Columbia, Missouri, and the State Mental Hospital in Missouri. A third ig planned for the Smithville complex. 3. Computer fact bank—direct cost $279,365 This project is designed to develop and apply techniques for delivering latest information on diagnosis and care of patients with stroke and allied diseases to the local physicians. Electronic data information storage and retrieval system will be developed at the University Medical Center (Columbia, Missouri) and later extend to include Smithville and other communities in the region. 4}. Mass screening-radiology—direct cost $54,814 ; This project will help improve the aceuracy of radiologic diagnosis of heart disease, cancer and stroke through electronic communications media. Three small rural hospitals will be hooked into the University of Missouri computer and Department of Radiology to evaluate diagnostic efficiency and determine applic- ability of ultra-sound and thermography in diagnosis and therapy. 5. Comprehensive cardiovascular care units-—Springfield, Mo:, direct cost $69,347 A comprehensive care unit for grouping patients with heart disease or other circulatory system illness or who have been admitted for other purposes but require close cardiac observation is being developed. The project is to be under: taken at hospitals without a house staff, where it is hoped that grouping of patients will relieve the workload for nurses on general medical and surgical wards, St. John’s Hospital medical staff and Greene County Medical Society are coordinating activities with 3 local hospitals in Springfield. 6. Communication research unit—direct cost $61,743 Supporting research unit for program to identify public attitudes and knowl- edge about heart disease, cancer, and stroke; to understand motivations for seek- ing health care and to determine and develop effective methods for communicat- ing with public and lead them to seek medical care. 7. Data evaluation, computer simulation and systems design—direct cost $329,712 This program will help to determine data needed from the public and physicians for early detection of heart disease, cancer and stroke through studies on the form of data, mechanisms for classifying, storing and retrieving data most effectively. 8. Bioengineering project—$229,129 The aim of this activity is wider distribution in rural areas of sensor trans- ducers, for early detection of heart disease, cancer and stroke and to generate more information on physiological patterns of these diseases. 9. Program evaluation center—direct cost $103,899 Through a multidisciplinary research approach accumulate data in two sep- arate communities about health care, needs and attitudes as a base for developing instruments for measuring quality of care and levels of health in terms of an individual’s function in his community. 10. Automated patient history—direct cost $77,561 This project is testing the feasibility of an automated system for obtaining patient history and analyze complaints prior to examination by physicians, as an aid in early disease detection. U1. Automated electrocardiography in a rural area—direct cost $369,000 To provide hospitals and physicians in rural areas with automated facilities for transmitting electrocardiograms and an automated system for analyses of ECG’s; to demonstrate the feasibility of such systems where this service is limited or non-existent, and to develop, test and implement the use of bioengi- neering signals as aid in diagnosis, ” 52 12. Operations research and systems design—direct cost $39,058 This activity will help develop systems concerned with testing “early detec- tion” hypothesis-develop operational methods of early detection tests for a large rural population. 13. Population study group survey—direct cust $65,200 Using National Health Survey questionnaire study factors contributing to use of health services in small towns, with emphasis on the influence of availability of care. 1h. Automated hospital record system—direct cost $52,100 This activity is testing the automation of hospital record data through use of computer systems to organize a ready reference service and easy access to hos- pital data as a pase for measuring effectiveness of changes. 15. Computer Assembled On-Going Manual of Medical and Paramedical Sere- ices-—direct cost $26,842 16. Central core administration, planning and coordination—direct cost $238,805 (University of Missouri Medical Center, Columbia, Missouri ) Missouri Re- gional Medical Program. MOUNTAIN-STATES REGION AL MEDICAL PROGRAM This four-state region (Idaho, Montana, Wyoming and Nevada) began its operational activities on March 1, 1968 with an operational award of $206,913 to include one activity in coronary care. An operational staff of approximately eleven will serve in the project, and includes five physicians and six nurses. The hospitals involved will include the community hospital in which the activity is taking place as well as those hospitals who will send their staff to the unit for training. The Regional Advisory Group also includes two hospital representatives. Operational Projects 4. Intensive coronary care in small hospitals in the region—direct cost $206,913 Hospitals in the Region will send Registered Nurses into St. Patrick’s Hospital, Missoula, Montana for coronary care training. This 3 week course will be offered three times a year for 21 nurses, and there will be follow-ups at the home hospi- tals four times a year. In addition, a 4-day training program especially designed for small town physicians will be held at the University of Montana four times a year. NORTH CAROLINA REGIONAL MEDICAL PROGRAM On March 1, 1968, the North Carolina Regional Medical Program received a combined planning and operational award totalling $1,485,341. The operational component of this award totalled $753,759 in direct costs only. The operational staff includes approximately forty individuals, including twenty-eight physicians. one nurse, six other allied health personnel, and five general support personnel. North Carolina has already involved twenty-seven of its hospitals in the Pro- gram. The Advisory Group includes four hospital representatives and planning subcommittees include an additional ten hospitals. Approximately twenty-one hospitals are participating in the operational projects outlined helow : Operational Projects j. Education and research in community medical care, dircet cost—$209,200 To develop resources for training more medical and allied medical students to provide new types of educational experiences which will make family practic more attractive; to have a post-graduate education program at the medica school; to strengthen ties between the medical school faculty and practicing phy sicians; and to have the medical school become involved in community plannin: for improving the quality and availability of medical care. Affected by this proj ect are the following groups: the University Community; the Caswell Count: Rural Health Services Project; the Regional Health Council of Eastern App? lachia, Inc,; the State of Franklin Health Council, Inc. ; the Charlotte Memori2 Hospital; the Moses Cone Memorial Hospital, Greensboro ; and the Dorothea Di Neuromedical Service. 53 2. Coronary care training and development, direct cost-—$56,938 To use the project as a medium for developing cooperative arrangements among the various elements in the health care community. Initial and continuing education will be provided to nurses and physicians in community hospitals, con- sultation will be available to hospitals in establishing CCU’s, and a computer- based system of medical record keeping will be developed. This project has led to new working arrangements: (1) between the university medical centers; (2) be- tween medical and nurse educators; (3) between doctors and nurses in commu- nity hospitals; (4) between university medical centers and community hospitals. 3. Diabetic consultation and cducational services, direct cost—$132,981 To establish three medical teams to deliver services throughout the state; to ussist in expansion of diabetic consultations and teaching clinics; to provide seminars for physicians and teaching sessions for nurses and patients to assist in organization of a State Diabetes Association and local chapters; to test techniques of data collection. Many people of different disciplines in many com- munities are involved in this project. 4. Development of a central cancer registry, direct cost-—$66,615 To devise a uniform region-wide cancer reporting system, integrated with the PAS, the computer-stored data from which can be retrieved to serve a broad range of educational, research, statistical, and other purposes. The following hospitals are participating in the first year of the project : Duke University Med- ical Center, North Carolina Memorial Hospital, North Carolina Baptist Hospital, Charlotte Memorial Hospital, Veterans Administration Hospital, Watts Hospital, Hanover Memorial Hospital, Southeastern General Hospital, Craven County Hospital. In subsequent years the registry will be expanded to include all hos- pitals and physicians in the region. 5. Medical library cxtension service, direct cost—$25,839 To bring medical library facilities of the three medical schools into the daily work of those engaged in medical practice. Local hospital personnel will be trained to assist medical staff; libraries will be organized into a functional unit for responding to requests for services. Bibliographic request service will be established. 6. Cancer Information Center, direct cost—$41,716 To provide practicing physicians with immediate consultation by telephone and follow-up literature. Each of the three medical schools will be responsible for providing service in its geographic locale. The aims of this project are two-fold: (1) to assist physicians in providing optimum care of patients with cancer; and (2) to continue the education of the physicians by giving new information in a patient-centered experience. 7. Continuing education in internal medicine, direct cost—$33,313 To bring practicing internists from all over the state to the Medical Center for a month of up-to-date training in their subspecialities. They will share responsi- bilities with attending physicians and make ward rounds with students, staff, and together. This experience should enhance the appreciation in the University, both at faculty and student levels, for the expanding role of the medical center for the quality of care in the community. 8. Continuing education in dentistry, direct cost—$67,500 To provide physicians and dentists with the knowledge of murual concern which will enable them to be more effective members of the health team. Courses will be given at the University of North Carolina and in communities. Studies will be made of facilities needed to provide dental care in hospitals. The purpose of this project is to insure that as many patients as possible who suffer from heart disease, cancer, stroke, or a related disease receive appropriate dental care asa part of their comprehensive treatment. 9. Continuation cducation for physical therapists, direct cost—$27.838 To develop and establish regional continuing education programs for physical therapists in order to strengthen physical therapy services for patients in all parts of the state. Subregions will be delineated where needs and interests will be identified and committees will be organized to arrange local activities. 309-653 O-68-—4 54 10. The establishment of a network of coronary care units in small community hospitals in Appalachia, North Carolina . This is a proposal to develop coronary care units in seven hospitals in this rural, mountainous area. RMP will supply the monitoring equipment (the hospital pro- vides suitable space) when adequately trained physicians and nurses are avail- able. An intensive training course for physicians will be conducted in the geo- graphic region, and continuing education programs will be conducted when necessary. ROCHESTER REGIONAL MEDICAL PROGRAM On March 1, 1968 the Rochester Program began its operational activities with a modest operational grant award of $255,487. Approximately 15 people are cur- rently serving on the staff which will expand with additional recruitment. The current staff includes 13 physicians, and two allied health personnel. A majority of the staff are from community hospitals, and are working closely with medical center and RMP staff to improve the quality of local patient care. Approximately eleven hospitals from the region are now participating in the program, and this will expand as the program moves forward over the next few years. Four hospitals are initially participating in the operational projects. Three of these four are represented on the Regional Advisory Committee. Seven addi- tional hospitals are serving on the Advisory Committee and planning subcom- mittees. ‘ Operational Projects 1. Renovation and equipping of facilitics for a learning center for projected training programs related to heart disease, cancer, and stroke, direct cost— $26,490 The awarded funds are for the purpose of altering and renovating space in Helen Wood Hall, which houses the Departments of Nursing at the University of Rochester. It is planned to convert five rooms into two rooms for self-instructional learning. These facilities initially will be used for four 4-week coronary care training courses for nurses and physicians in the region. New techniques that are disseminated by means of these courses will then be caried to the various com- munity hospitals and rural areas in the region by the training course participants. 2, Postgraduate training program for the physicians in the Rochester 10-county region, direct cost—$83,900 The objectives of this project are centered around the further development of a postgraduate program in cardiology. Learning opportunities will be made avail- able for general-practitioners and internists. as well as cardiologists practicing in the region. Several different programs are planned and vary in length from one-half day to two weeks. It is anticipated that a number of the participating physicians will represent community hospitals in rural areas, 3. Registry of patients with acute myocardial infarction in the Rochester re- gional hospitals, direct cost—321,200 One objective of this registry is to provide a uniform data collection system from which both periodic information as well as longitudinal analyses may be extracted. Appropriate information as to prognosis and treatment will be dissemi- nated to participating hospitals and cooperating physicians in the region. Strong Memorial Hospital in Elmira, New York is already participating in this project, and it is anticipated that several other community hospitals, especially those in rural areas, will soon also be participating. 4. Proposal for establishment and support of a regional laboratory for the educa- cation and training in the care of patients with thrombotic and hemor- rhagic disorders, dircct cost—$69,400 At the present time no single, central facility concerned with the diagnosis and therapy of patients with thrombotic or hemorrhagic disease exists in the Ro- chester region, Laboratory technicians from the regional hospitals will be invited to spend three or four days in the new facility. In addition, the physicians direct- ing this project will visit the participating communities so that a continuing edu- cational program for practicing physicians in the care of patients with thrombotic diseases will be maintained. TENNESSEE MID-SOUTH REGIONAL MEDICAL PROGRAM On February 1, 1968, the Tennessee Mid-South Regional Medical Program _ began its operational activities with a diverse array of programs designed to 55 provide local health practitioners and hospitals with advanced techniques and facilities necessary for quality health care. Over fifty people are currently serv- ing on the staff of the operational program, including approximately thirty-five physicians, five nurses, five other allied health personnel, and nine general support personnel. About one-fourth of the staff are from conimunity hospitals and the remaining are medical center staff who are working on the community oriented projects discussed below. Seventeen hospitals are currently participating in the operational projects, representing broad geographic spread throughout the region. Ten of these hos- pitals are also represented on the Regional Advisory Group. Operational Projects 1, Continuing medical education—Meharry, direct cost—$44,800 Meharry Medical College is informing Negro physicians in the region about more effective techniques for treating heart disease, cancer, and stroke. Teams of physicians will teach two-week courses in the three areas at the Medical Cen- ter, using various audio-visual aids and, where feasible, programmed instruction. One of this plan’s interesting provisions is sending a senior resident from Meharry to care for the physician’s practice while he is attending the course. 2. Continuing education—Vanderbilt, direct cost—$141,600 Vanderbilt proposes to establish continuing education centers at community hospitals linked to a proposed Department of Continuing Education at Vander- bilt. Libraries and information centers at the local hospitals will bring Vander- bilt’s information resources to the local physician. The program, though planned and coordinated by Vanderbilt, will function through the local centers and em- phasize bringing information to the physician at the times he needs it. 3. and 4. Hopkinsville Education Center and Chattanooga Education Center, direct cost—$73,700 These are the first of the local continuing education centers specified in the Vanderbilt plan. At each hospital, a full-time Director with an appointment at Vanderbilt and an assistant director will supervise resident and physician edu- cation in their area. Their services will be available to physicians at smaller community hospitals in each area, as will the enlarged hospital library facilities. The Chattanooga and Hopkinsville locations provide the basis for looking at problems in continuing edvication in urban and rural settings. 5. Special training for practicing radiologists—Vanderbilt, direct cost—$50,400 This plan focuses on developing practicing radiologists’ skills in vascular radiology, but might later be broadened to include all aspects of diagnosis and therapeutic radiclogy. Two post-graduate educational methods will be used. One to three month courses for technologists will be offered. In addition, emi- nent radiologists will preside at two-hour monthly seminars to which all radiologists in the region will be invited. 6. Cardiac nurse training program—Mid-State Baptist Hospital-Nashville, direct cost—$49,600 The key factor in reducing mortality from cardiac arrest is the immediate availability of a knowledgeable person to initiate resuscitation. Mid-South Baptist proposes to instruct cardiac nurses in new resuscitation techniques by holding three four-week courses. These nurses will then be available to hospitals throughout the region. 7, School of X-ray and technology—Meharry, direct cost-—$19,500 Meharry plans to establish a two-year program for training at least ten X-ray technologists per year. The faculty will be Meharry’s Radiology staff. Feasibility studies for establishing nuclear medicine and radiotherapy programs will be conducted. . 8. Radiology technologist training program—Vanderbilt, direct costs—$30,300 Vanderbilt proposes to increase the number of X-ray technologists, improve the quality of their training, and increase their opportunities for continuing educa- tion, Three small hospital training programs in the area will be discontinued as separate entities and subsumed by a new schoo] of X-ray technology at Vanderbilt. Practical clinical experience will be both at Vanderbilt and the smaller hospitals. 56 9. Nuclear medicine training program—Vanderbilt, direct cost—$25,300 A new series of courses taught by paramedical and medical personnel will be made available to physicians and technologists to increase their skill in nuclear medical techniques. When possible the physician and his technologist will spend some training time together to work out procedures suited to their situation. Trainees will be accepted from smaller community hospitals planning to establish or improve nuclear medicine services. 10. Expansion of Schoot of Medical Technology—Baroness Erlanger Hospital— Chattanooga, direct cost—$35,400 To augment medical technology capabilities in the area, this plan makes two proposals: (1) Expand the Baroness Erlanger program for medical technologists ; and (2) establish a school for certified lab assistants who could free technologists from more routine work for more complex procedures. 11. Vanderbilt Coronary Care Unit, direct cost—$51,600 This project’s purpose is to establish a network of coronary care units with adequate equipment, staffed by well trained personnel. Vanderbilt will be the training and information center for the region; a demonstration unit there will provide a focal point for continuing education. In addition, communication systems will be set up to facilitate the flow of information from Vanderbilt to the community hospitals. Studies are being made to see if the small hospitals connected with Vanderbilt can become, in turn, centers for local networks of coronary care facilities in still smaller hospitals. 12. Franklin Coronary Care Unit—Williamson County Hospital—Franklin, direct cost—$31,400 , This is one of the subsidiary units mentioned in the Vanderbilt proposal. This is primarily a pilot project to study the feasibility and usefulness of establishing a center in a small community hospital. : 13. Hopkinsville Coronary Care Unit—Jennie Stuart Memorial Hospital—Hop- kinsville, Ky., direct cost—$49,500 This plan is similar to the Franklin plan, except that it mentions establishing links to smaller community hospitals by helping set up smaller care units in them, thus providing for the grouping of rural community hospitals for more efficient use of existing resources. 14. Clarksville Coronary Care Unit—Clarksville M emorial Hospital, direct cost— $19,000 As the Franklin program, this project is a subsidiary of the Vanderbilt pro- posal. Since this hospital has been operating a unit, the plan calls for its expan- sion, continuing education anda phone hook-up to Vanderbilt. 15. Nashville General Coronary Care Unit—Nashville Metropolitan General Hos- pital, direct cost—$42,100 Again, this is like the Franklin plan. Nurses here will be included in the in- service training progranis initiated throughout the participating hospitals. 16. Afeharry Medical College Coronary Care Unit, direct cost—$35,800 Meharry intends to establish a demonstration unit of coronary care facilities which will serve as a continuing education center for smaller hospitals in its region. 17. Murray Coronary Care Unit—Murray—Calloway (Ky.) County Hospital, direct cost—$38,800 . Murray-Calloway County Hospital, the training center for Murray State Uni- yersity School of Nursing. will serve aS a demonstration center for the sub- region, Direct phone communication will be established with Vanderbilt, which will send consultants from its school of continuing education. This project has the dual objective of relating the Murray State Nursing program to an established medical center and providing regional training resource to a remote area. 18. Chattanooga Coronary Care Unit—Baroness Erlanger Hospital, direct cost— $14,400 Baroness Erlanger plans to establish a coronary care unit in a program of Cco- operation with Vanderbilt. Both telephone communications and electronic main- tenance systems connected with Vanderbilt will be installed. This unit will serve as a center for the smaller hospitals in Chattanooga. 57 19. Baptist Hospital Coronary Care Unit—Mid-State Baptist Hospital, Nash- ville, direct cost—$51,000 This plan is similar to the others included in the Vanderbilt plan. Baptist Hospital will expand its present facilities and aid establishment of smaller cen- ters at Tullahoma and Crossville, Tennessee. Direct telephone lines will be estab- lished for consultations. The unit director will have a Clinical faculty appoint- ment at Vanderbilt. He will devote approximately 25% of his time to the unit. 26. Crossville Coronary Care Unit—Uplands Cumberland Medical Center, Cross- ville, direct cost-—$28,300 This project has two purposes: (1) to establish a two-bed coronary care unit in the hospital; and (2) to determine the feasibility of operating acute coronary care units in rural areas. The hospital will cooperate with Mid-State Baptist Hospital ahd Vanderbilt. 21. Tullahoma Coronary Care Unit—Harton Memorial Hospital, Tullahoma, Tenn., direct cost—$28,800 See Baptist Hospital Program. 22. Meharry supervoltage therapy program, direct cost—$58,300 This project is aimed specifically at improving cancer therapy for a large in- digent population. Meharry will use its funds to obtain a cobalt 60 High Energy Source for therapy and a computer hook-up with Vanderbilt. These facilities will also be used to improve undergraduate and graduate radiology training programs at Meharry. 23. Project to improve patient care in a remote mountain community by recruit- ing and training health aides for a new extended care facility—Scott County Hospital—Oneida, Tenn., direct cost—310,300 . Manpower shortage in this isolated mountain hospital is critical. Personnel to man an extended care facility now under construction will be obtained by two methods: (1) In-service training for hospital personnel; (2) an educational director (an RN) to serve as a liaison to the high schools to encourage young people to enter the medical field and come back home to practice. In addition a training program leading to the LPN would be initiated. Clinical training will be supervised by the Educational Director while local high schools provide basic training. - 24, Health evaluation studies on a defined population group—multiphasic screen- ing—feharry Medical College, direct cost—$ 436,000 Meharry will determine the effectiveness of a comprehensive health program and multiphasie screening examinations in early diagnosis of heart disease, can- cer, stroke and their precursors. To run this experiment, a neighborhood medical center supported by OEO will serve a selected population of 18,000. The test population and a control population will be evaluated with reference to morbid- ity, changes in health attitudes and utilization patterns, effectiveness of the sereening procedure and the cost per patient diagnosed or treated. 25. Experiment to test and implement a model of patient care—Vanderbilt Uni- versity Hospital, direct cost-—$110,400 This is an attempt to define a new structure for patient care. New personnel called stewardesses will be trained to take over the nurses’ non-clinical duties. Nurses would then be free to spend more time with the patient and to keep up their specialized skills, After the model is refined at Vanderbilt, it will be tested in community hospitals—specifically Baptist and St. Thomas. 26. A medical surgical nurse specialist graduate program to improve nursing care of paticnts with heart disease, cancer, and stroke—Vanderbilt University School of Medicine, direct cost—$23,600 Vanderbilt is developing a program to train medical surgical nurse specialists to improve nursing care of heart, cancer, and stroke patients. It will be a master’s degree program staffed by physicians and clinical nurses (1 calendar year) plus one year of clinical experience half at Vanderbilt and half at the community hospital. Stipends will be provided during the first year only. WASHINGTON-ALASKA REGIONAL MEDICAL PROGRAM With an operational grant award of $1,032,003 on February 1, 1968, this two- state region began its efforts to bring quality care to the dispersed populations 58 of this area. About forty operational staff members are currently serving on the program, including about seventeen physicians, three nurses, six other allied health personnel, and fourteen related health and general support personnel. About one-third of the staff is from the medical center, another third is from com- munity hospitals and the last third is from other health and medical organiza- tions. The entire staff is working in concert to bring up-to-date medical tech- niques to communities throughout the region. . Strong hospital involvement in the Washington-Alaska program is evident in the project descriptions below. Approximately 36 hospitals are currently partici- pating in the program, almost 20 of which are directly involved in operational activities. Six of these hospitals are represented on the Regional Advisory Groups, and an additional four of these are on planning subcommittees. The re- maining participating hospitals are involved in current planning activities. It is likely that these, and the many other hospitals in the region, will become in- creasingly involved in operational activities. Operational Projects 1. Central Washington—Communication system for continuing education for physicians—$18,181 (direct cost) This project is designed to bring the medical resources of the University of Washington to physicians and community hospitals in Yakima, who in turn will act as consultants to surrounding smaller communities through seminars and conferences, educational TV, other audio-visual instruction; and exchange of teachers and practitioners. Jt will also connect internists in Central Washing- ton to Yakima cardiologists via EKG telephone hot-line, to permit quick analysis (starting with 5 community hospitals). Three general hospitals in Yakima in- volved are: St. Elizabeth’s, Yakima Valley Memorial, and New Valley Osteo- pathic. Nine other community hospitals to be reached initially are located in Ellensburgh, Moses Lake, Othello, Toppenish, Prosser and Cynnyside. 2. Southeastern Alaska—Postgraduate education—$27,062 (direct cost) This program will help improve communication between Seattle Medical Com- munity and University to alleviate problems of the isolated physicians in south- east Alaska cities and communities: Juneau, Sitka, Ketchikan (8 largest). As in Central Washington several methods will be used such as telelectures, consul- tant services, seminars and the EKG hot line to hospitals in Juneau, Sitka, and PHS Native Hospital at Mt. Edgecumbe and Ketchikan community hospital. 3. Postgraduate preceptorship for physicians—Coronary care—$17,610 (direct cost) A pilot project to provide opportunity for practitioners from isolated com- munities to spend a week or more under a preceptor at major medical centers to study advances in care of coronary heart disease. The 4 major medical centers in Seattle are Providence Hospital, Swedish Hospital, Virginia Mason Hospitals and Medical Center, and University Hospital and Medical Center ; two in Spokane are Deaconess Hospital and Sacred Heart Hospital. 4. Coronary care unit coordination—$70,255 (direct cost) This activity will serve as coordinating unit for CCU related projects—their development, improvement of operations, and training activities: A mock-up coronary care unit will be used in the educational programs for nurses and physi- cians ; audio-visual self-instruction materials will be produced and evaluated. .5. Cardiac pulmonary technician training—$41,554 (direct cost) This program will help develop a formal program for training cardio-pulmo- nary technicians to perform non-critical functions in coronary care units and free physicians for other duties. Four larger general hospitals in Spokane will parti- cipate with Spokane Community College. The 4 hospitals are Deaconess, Holy Family, Sacred Heart and St. Luke’s Hospital. . 6. Information and education resource support unit—$522,304 (direct cost) This program will help provide medical communities with the skilled assist- ance which will help identify their educational needs and serve as a support unit in developing programs to meet them; to establish a central production unit, to coordinate audio-visual projects and the distribution of materials, to penetrate the entire region. SECO TS Aa 59 7. Two-way radio conference and slide presentation—$8,445 (direct cost) Six pilot programs on heart, cancer and stroke topics to be transmitted via two-way radio-telephone slide conferences, to physicians and hospital staffs on topics selected by a panel of physicians, starting with 20 hospitals in Washington are underway. It will explore potential for continuing network series with local and remote regions, 8. Continuing education and on-the-job training of laboratory personnel—$53,446 (direct cost) Primary purpose of this activity is to train technical personnel in newer clinical laboratory procedures, and shorten gap between availability of advance in techniques and actual use. First phase is to be directed at 5 local designated training centers in Washington (cities of Seattle, Tacoma, Spokane, Yakima and Vancouver) and Anchorage, Alaska. University of Washington will select from a list of available lab procedures, arrange training courses for technicians in specific ones at designated facilities and establish quality control criteria; they will follow through with education of physicians in newer and practical tests for better diagnosis and treatment. 9, Alaska medical library facilities —$21,754 (direct cost) This activity will help develop a community medical library located at the PHS Alaska Native Medical Center, Anchorage, for Alaska physicians and health related staffs and agencies. It will have close ties with community col- leges, Arctic Health Research, University at Fairbanks and to supplement con- tinuing education projects for Southeast Alaska and the Anchorage cancer project. . 10. Anchorage cancer program—t51,450 (direct cost) This project will aid in providing a supervoltage therapy unit for cancer patients to be located in an addition to Providence Hospital in Anchorage. It involves training of radiologist and technical staffs, consultant clinical confer- ences and accumulation and analysis of dianogstie data. Presbyterian Com- munity Hospital in Anchorage will be participating. : 11. Care of children with cancer (study) —$28,080 (direct cost) This is an epidemiological study to determine the impact of different methods of care for children with cancer, focusing on differences among children treated in local communities and at major centers; to be conducted by the staff of Children’s Orthopedic Hospital and Medical Center, Seattle. 12. Radiation physicist consultation program for radiologists in Washington and Alaska—$56,393 (direct cost) This project will provide consultation services of a radiologist-physicist for smaller hospitals, in dosimetry and other problems of radiotherapy. To enhance postgraduate education for radiology residents and paramedical trainees outside of the University system. 13. Computer-aided instruction in heart disease, cancer, and stroke and related diseases-—353,390 (direct cost) To develop and evaluate the effectiveness of computer-aided instruction for teaching medical techniques. Participants will be instructed in the use of com- puter terminals. WESTERN NEW YORK REGIONAL MEDICAL PROGRAM With an award of $357,761, the Western New York Regional Medical Pro- gram began its operational program on March 1, 1968. The current operational staff of seven physicians, one nurse, and two secretaries will be expanded to over 20 during the next several months. Over forty hospitals are currently in- volved in this program, almost all of which are slated to be part of the devel- oping regional two-way TV network for continuing education, Eleven hospitals are represented on the Regional Advisory Group, and an additional two hos- pitals are serving on planning subcommittees. Operational Projects 1. Two-way communications network, direct cost—$170,519 A two-way communication network will link hospitals of Western New York and Erie County, Pennsylvania to the Continuing Education Departments 60 of the State University of New York at Buffalo and the Roswell Park Memorial Institute. The network will serve several purposes, such as continuing educa- tion for physicians and the health-related professions, public education, ad- ministrative communication, consultation with experts, and contacts among plood banks. It will assist both the physician and community hospital in either the rural or urban environment in having at their fingertips the jJatest advances in the diagnosis and treatment of heart disease, stroke, and cancer. Particular emphasis will be placed upon involving rural hospitals in this program there- by improving both their didactic and restorative function. 9, Coronary care information coordinators, direct cost-—$.127,544 This project will test a training technique for providing qualified nurses who will be required to staff developing coronary care units in the Region. Approxi- mately $0 nurses will be selected from all parts of the Region for a combined academic and clinical course. It is planned that the nurses receiving this train- ing will return to poth rural and urban hospitals for the purpose of provid- ing a diagnostic and didactic function. While the program will be housed at the medical center, the community hospitals of this region will be the bene- factors of the project. Since there are few nurses trained to work in coronary care units, particularly in the rural environment, special attention will be paid to attracting nurses who will return to the community hospital. WISCONSIN REGIONAL MEDICAL PROGRAM The Wisconsin Program began its operational activities on September 1, 1967 when it became the first Regional Medical Program to be awarded a combined planning and operational grant. Currently funded with $630,147, about one third of which is for operational activities, the operational staff num- pers 20. About one-third of the staff are physicians, another third are allied health personnel, and the last one third are supportive and other type of per- sonnel. Approximately 20 hospitals are involved in the current phase of the Pro- gram. Eleven of these hospitals are directly involved in the operational projects. Five are represented in the Regional Advisory Group and the remaining are represented in planning subcommittees. AS the program develops additional activities during the next few years, it js anticipated that many additional hospitals will be involved. 1, Study program for uterine cancer therapy and evaluation, direct cost—$49,100 This pilot project js designed to review and evaluate current radiotherapy for patients with uterine cancer. In its first phase it will involve information ex- change and dosimetry standardization. Hospitals at Marquette and the Uni- versity of Wisconsin will be connected to a central, computerized data pank jn Milwaukee which will compute radiation classes. When the necessary computer rechniques are developed, it is projected that the central facility will be linked to other hospitals outside the Milwaukee and Madison areas with similar treatment programs, and the long-term result will be to improve local medical capabilities for the treatment of ali uterine cancer patients in the Region. 2. A pilot demonstration program for pulmonary thromboembolism, direct cost— $84,600 In this project a center is being established at Marshfield Hospital in Marsh- field, Wisconsin, for demonstrating diagnostic techniques and the available therapy for pulmonary thromboembolism. The project has a continuing educa- tion component which will reach physicians from many hospitals in the Region. This will involve a 24-hour consultation service, the preparation of a movie on the topic, and special training sessions for groups of physicians. The project will demonstrate 4 comprehensive program which will encompass diagnostic, preventive, therapeutic, and rehabilitation procedures for patients, postgraduate education, a rapid transportation system for patients from Northern sections of the state, and cooperation between the clinic and other hospitals and medical schools in the State. 8, Telephone dial access tape recording library in the areas of heart disease, can- cer, stroke, and related diseases, direct cost —$18,959 This feasibility study will be carried out by the University of Wisconsin which will record and store short, 4-G minute, tapes on various aspects of treating patients with the three diseases. Any physician anywhere in the 61 ! Region can dial the library at any time and request a tape relevant to a problem in which he is interested. 4. Nursing telephone dial access tape recording library in the arcas of heart disease, cancer, stroke, and related. diseases, direct cost—$18,800 This feasibility study, similar to the one above, will establish a central tape library with information recorded on nursing care in emergencies, new pro- cedures and equipment, and recent developments in nursing. Nurses from any hospital in the region will be able to call at any time to have a tape played to them. 5. Development of medical and health related single concept film program, in community hospitals, direct cost—$33,259 This education feasibility project involves ten community hospitals in its first phase. Fifteen films on procedures and techniques used in treating heart, cancer, and stroke, will be developed, Projectors and the films will be installed in the hospitals for use by physicians and other health personnel at their ‘con- venience as a continuing education device. After four to six months the ma- terials will be relocated in ten additional hospitals. TELEVISION, Raplo AND TELEPIIONE Networks For CONTINUING EDUCATION OPERATIONAL PROJECTS i. Albany Regional Medical Program Pwo-way radio communication system— Direct cost, $144,100 This project will expand an existing two-way radio network to include 57 hospitals and 24 high schools. It will provide continuing education for physicians and allied medical personnel. It will also provide information and edueation programs for administrators, members of bourds of trustees, voluntary health agencies, adult education classes, and selected civic groups. II. Intermountain Regional Medical Program Network for continuing education in heart disease, cancer, stroke, and re- lated diseases—Direct cost, $243,000 The objectives of this program are to develop a communications network between patient-care and research institutions to encourage liaison between health care personnel in the area. The currently existing two-way radio system, including 11 hospitals in 7 communities in or near Salt Lake City has been expanded to 10 additional remote hospitals to serve as one link. This system will be expanded to additional hospitals in response to physician requests. Closed circuit TV and use of KVED (University of Utah education TV) is also planned. This may establish the community hospital as the focus of continuing education, III. Kansas Regional Medical Program Health sciences communication and information center—Direct cost, $77,900 This project is engaged in conducting studies to determine the feasibility of establishing communication linkages vital to education, service and research Programs. Specific studies to be undertaken are a physician communication sys- tem, TV teaching, electronic linkages, and Medlars search capacity. Linkages will be established at hospitals in Great Bend, Pittsburg and Kansas City. IV. Washington-Alaska Regional Medical Program Central Washington—Communication system for continuing education for physi- cians—Direct cost, $18,181 This project is designed to bring the medical resources of the University of Washington to physicians and community hospitals in Yakima, who in turn will act as consultants to surrounding smajler communities through seminars and conferences, educational TV, other audio-visual instruction: and exchange of teachers and practitioners. It will also connect internists in Central Washington to Yakima cardiologists. via EXG telephone hot-line, to permit quick analysis (starting with 5 community hospitals). Three general hospitals in Yakima in- volved are: St. Elizabeth's, Yakima “clley Memorial, and New Valley Osteo- 62 pathic, Nine other community hospitals to be reached initially are located in Ellensburgh, Moses Lake, Othello, Toppenish, Prosser and Sunnyside. Southeastern Alaska—Postgraduate education—Direct cost, $27,062 This program will help improve communication between Seattle Medical Coim- munity and University to alleviate problems of the isolated physicians in south- east Alaska cities and communities: Juneau, Sitka, Ketchikan (3 largest). AS jn Central Washington several methods will be used such as telelectures, con- sultant services, Seminars and the EKG hot line to hospitals in Juneau, Sitka, and PHS Native Hospital at Me. Edgecumbe and Ketchikan community hospital. Two-way radio conference and slide presentation—Direct cost, $8,445 Six pilot programs on heart, cancer and stroke topics to be transmitted via two-way radio-telephone slide conferences, to physicians and hospital staffs on topics selected by a panel of physicians, starting with 20 hospitals in Washing- ton are underway. It will explore potential for continuing network series with local and remote regions. Y¥. Western New York Regional Medical Program Two-way communications network—Direct cost, $170,519 A two-way telephone communication network will Hnk over 40 hospitals of Western New York and Erie County, Pennsylvania to the Continuing Education Departments of the State University of New York at Buffalo and the Roswell Park Memorial Institute. The network will serve several purposes, such as con- tinuing education for physicians and the health-related professions, public ed- ucation, administrative communication, consultation with experts, and contacts among blood banks. . Mr. Rocers. I notice you said in the North Carolina program there were some coronary care units. How many coronary care units? I ¢ want to know what is happening to the hospitals. Now, how many hospital administrators or people involved in the actual administration of hospitals where services are delivered? How many are on your national council? Dr. Marston. One, Dr. J. T. Howell, of the Henry Ford Hospital. The executive director of the American Hospital Association, Dr. Edwin Crosby, is also a member, so this is 2 out of 12 directly repre- senting the viewpoint of hospital administration. (The following information was received by the committee :) DEPARTMENT OF Heatta, Epucation, AND Wetrare STATEMENT ON FlosPpiTaL ADMINISTRATORS PARTICIPATING IN REGIONAL MEDIOAL PROGRAMS Number of hospital Percent of tota! administrators membership Total. on---cve cece veneer 338 10 Regional advisory groupS..-------2-----ereer 222 12 Subcommittees..-----------e---ne eee - 83 7 Boards of directors 1...-.-.---------22---nc neers tere 33 19 1 Boards of directors of the 14 new organizations formed as the coordinating agencies for their programs. HOSPITAL ADMINISTRATORS ON REGIONAL MEDICAL PROGRAM STAFFS Approximately 40% of the regions have established a Division of Hospital and Facilities Planning. These are, as a rule under the direction of a hospital administrator. EXAMPLES OF HOSPITAL ADMINISTBATOR PARTICIPATION IN RMP Georgia In Georgia, each hospital in the region was encouraged by the Georgia RMP to appoint a local advisory group to work with the Program to advise on local needs 63 and problems and to serve as the Maison group between the Georgia Central Regional Medical Program office and the local community. To date, 121 hospitals have appointed local advisory groups out of the total 178 hospitals in the region. These represent 90% of the general and limited services hospital beds in the region. These groups consist of a physician, a hospital administrator, a nurse, and at least one interested member of the public. Connecticut In Connecticut, four Advisory Conferences have been established to aid the Advisory Board in its work. These four conferences consist of: (a) the Presidents of the Boards of Trustees of the hospitals of Connecticut; (b) the Chiefs of Staff of these hospitals; (c) the Administrators of these hospitals; and (dad) rep- resentatives of over 50 “health” agencies of Connecticut. Directors of Medical Education from Connecticut hospitals have also been invited to meetings of the Advisory Conferences. Albany Part of the Albany operational program is concerned with the equipping of hospitals with two-way radio equipment. The Regional Medical Program person- nel have visited the non-participating hospitals and discussed with the adminis- trators and members of the staffs the advantages of joining the radio network. The number of hospitals involved in this network increased by 50% in the first year, bringing to 36 the number of participating hospitals. Maryland In Maryland, the RMP staff has devoted considerable effort to developing con- tacts with the community hospitals. At least 21 of the 38 hospitals in the region have been visited by the Regional Medical Program staff. In November 1967 a three-day planning workshop was held by the Maryland RMP. Invitations were extended to all the hospitals in the region and over half of the short-term, non-federal hospitals sent one or more representatives. Those who attended expressed a genuine desire to cooperate in the planning process. OTHER DEVELOPMENTS Community planning committees have been organized in several other regions including South Carolina, Intermountain, and Greater Delaware Valley. These local planning committees all include hospital administrators in their mem- bership. HOSPITAL ADMINISTRATORS ON THE NATIONAL ADVISORY COUNCIL AND ON THE REVIEW COMMITTEE Council: (1) Edwin L. Crosby, M.D., Director, American Hospital Association, Chicago, Il. (2) James T. Howell, M.D., Executive Director, Henry Ford Hospital, Detroit, Mich. Committee: (1) Mr. John D. Thompson, Director, Prograin in Hospital Adimin- istration, School of Public Health, Yale University, New Haven, Conn, Formers Members: (1) Mark Berke, Director, Mount Zion Hospital and Medical Center, San Francisco, Calif. (2) Howard W. Kenney, M.D., Medical Director, John A, Andrew Memo- rial Hospital, Tuskegee, Ala. Mr. Rogers. It seems to me the thrust of this program has got to get down to that. How about in your regional medical councils, the local ones? Dr. Marston. Ten percent of those represent hospitals. Mr. Rocers. Should there be more? Dr. Marston. I don’t know the answer to that, Mr. Chairman. Mr. Rocers. Give us your thinking on that. I am concerned that we are not getting enough of the people involved who are meeting the patient. and getting care to him. 64 Dr, Marston. The American Hospital Association is having @ con- ference at our request in June to focus on just the problem you are bringing up. Mr. Rocers. I would be interested in following the results of that conference and your actions on it. Now, what other professions are involved in these regional medical programs, and in the field? Could you give me a rundown on that? Tf you will let us have this it would be helpful. Are you really tying them in—nurses, dentists, and so forth—as well as educators? (The following information was received by the committee :) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON PROFESSIONAL JNVOLVEMENT IN REGIONAL MeEpIcaL PROGRAMS The scope of professional involvement in Regional Medical Programs is both broad and balanced, and is evident in all facets of the programs across the country. Broad professional involvement is seen in the composition of Regional Advisory Groups, planning committees, program staffs and operational activities. Such involvement reflects the essential cooperative nature of Regional Medical Programs as they work toward harnessing the multiple health and medical resources in local areas in order to help provide high quality care in heart, cancer, stroke and related diseases. The membership of the Regional Advisory Groups, which eurrently totals ap- proximately 4900 individuals, includes 21.9% practicing phyicians ; 15.6% medi- cal center officials; 13.1% hospital administrators; 11.7% voluntary health agencies; 7% public health officials; 8.1% allied health workers; 15.3% mem- per of the public and 7% others. Planning committees, which currently include about 2500 individuals, also demonstrate broad involvement. The membership includes : 18% practicing physicians ; 41% medical center officials ; 18% hospital administrators; 6% voluntary health agencies; 6.5% public health officials ; 10% allied health workers; 5% members of the public, and 5% others. In terms of participating organizations, it is estimated that over 1700 orga- nizations are DOW involved in Regional Medical Programs. These include all of the medical schools, state medical societies, state heart and cancer societies, and state health departments. Almost 60% of the state nursing and dental associations are involved; about 80% of the schools of public health and state hospital associations are involved ; and about 35% of the schools of denistry. In addition, many schools of nursing and other allied health professions are involved as well as a broad array of other professional organizations and institutions. CORE PLANNING AND ADMINISTRATIVE STAFF Reports from the Regions indicate that approximately 47% of the professional and technical planning staff are physicians. Allied health professionals including nurses, hospitals administrators, dentists, and others account for approximately 12% of the core staff. Related health professionals, including health economists, medical sociologists, statisticians, and others account for approximately 19%; general supportive staff accounts for about 16% ; and “other” groups account for 6%. OPERATIONAL STAFF The operational staff personnel are concerned with the implementation of specific operational projects. The manpower involved in these projects comes from a broad range of specialities, including physicians (25%) ; nurses (8%) 3 other allied health (10%) ; education and communications (5%) ; computer and other electronics specialists and their supporting personnel (16%) ; other techni- cians (14%) ; administrative and clerical (20%) ; and other 2%. Dr. Marston. I spoke to 80 nurses in Wisconsin last night, via a telephone lecture system—— Mr. Carrer. Will you yield on that ? Mr. Rocers. Yes. 65 Mr. Carrer. I notice this bill provides that dentists may refer patients to some of the regional centers, and I want to say that I think that is very good. I am happy that dentists and oral surgeons are included. Mr. Rocers. Thank you. Do you provide for patient care in hospitals under this program ? Dr. Marston. Patient care costs must be limited to those which are incidental to research, training, education, or demonstration activities funded by the regional programs. We consulted various hospital groups to get advice of how we would administer this, and their advice was that we should be very cautious about the actual payment of patient cost, so we have not spent much. Mr. Rocrrs. Let me have a breakdown on what you have done and where it has gone. ; (The following information was received by the committee:) ‘The Department of Health, Education, and Welfare has determined that the following patient care costs, hospitalization costs, have been supported with regional medical program grant funds: (1) Missouri Regional Medical Program—$90,050. Mr. Rocers. Do you use consultants, and where are these used mainly as far as the regional medical program is concerned ? Dr. Marston. We have used consultants at the national program from just about every area of health—hospital planning groups in- cluded. We receive a grant request and we use consultants with ex- pertise inthe area covered by the request, on the site visit. Mr. Rocers. Who determines what the region shall be? Do you de- termine it? Dr. Marsron. Essentially, the Surgeon General must determine this. Mr. Rocers. Are they too large now? Dr. Marston. Some are quite large, but I think it will change. Mr. Rocers. Are there any plans for changing these? Dr. Marsron: There is discussion during the planning period in every region regarding the extent to which the regional approximation has worked, and this is commented on in the grant applications that come in to us. I think there will be changes over time, but I think many areas are finding they want the advantages of the larger regions and yet the opportunity of breaking down into subregional groups, and we have not discouraged this. Mr. Rocers. What has happened in Florida? I don’t think they have gotten off the ground there; have they ? Dr. Marston. They have a planning grant that was made this year, Mr. Rocers. So you would anticipate a year-—— Dr. Marston. Yes. I take that back, partially. We have had an ap- plication from Florida since that planning grant asking for funds for a feasibility study, which the National Advisory Council allows under a planning grant. This application arrived on my desk yesterday. Mr. Rocers. I would like the status, if you could give it to us, of all the regions, the 53, what States they are in, when we can expect to see something get down to the local hospitals and into the medical pro- fession there. 66 (The following information was received by the committee :) DEPARTMENT OF JIEALTH, EpUCATION, AND WELFARE STATEMENT ON THE Stratus OF . REGIONAL MepiIcaL PROGRAMS As indicated in the table below, all Regions except Puerto Rico have embarked upon planning ; and 41 of the 54 Regional Medical Programs have been engaged in planning activities for a year or longer. These planning activities have in- volved a large number of diverse health and nealth related professionals (€.2-5 physicians, medical sociologists, hospital administrators, epidemiologists, allied health personnel) representative of a wide spectrum of health institutions and organizations, including community hospitals, local and state medical societies, official and voluntary health agencies, and state hospital associations. These indi- viduals are serving on planning task forces and local advisory committees 4S well as Regional Advisory Groups. In addition, & number of such individuals are also serving on the central core staffs of many Regional Programs. Experience to date clearly demonstrates that the involvement of community hospitals and other local health resources, private practitioners, and other health professionals becomes more extensive and intensive aS Regional Programs enter the operational phase. At that stage, for exainple, community hospitals become the sites for coronary care unit demonstration and training programs ; local physicians and hospitals undertake the training of cardiopulmonary technicians needed in the community ; private practitioners and their patients in rural areas penefit from automated EKG readings utilizing telephone lines ; and programs to recruit and train sub-professional health aides required to staff extended care facilities, are initiated. Initial operational grants have peen awarded to 12 Regional Programs to date. Another 12 Regions have submitted initial operational grant requests which are now under review. Based upon the best information currently available, it is a0- ticipated that the other 30 Regions will enter the operational phase pefore the end of fiscal year 1969. Thus, involvement and participation by community hospitals and private practitioners in Regional Medical Programs should become more widespread and increasingly evident over the next 42-15 months. STATUS OF REGIONAL MEDICAL PROGRAMS (AS OF MAR. 30, 1968 Beginning date Funding : Regional medical program Currently available Cumulative awards Operational status Planning Operational ~ Planning Operational Planning Operational Alabama—State of Alabama. ...-..----------------- Jan. 1,196? -..--.-------- $393,788 -.------..---- $661,756 .--.---...---- Initial operational grant request anticipated in fiscal year . Albany—Northeastern New York, portions of southern July 1,1966 Apr. 1, 1967 384, 244 $921, 510 707, 033 $921, 510 Vermont and western Massachusetts. Arizona—State of Arizona. ....---------++--------0- 119,045 _...-.-..----- 119,045 . Do. Arkansas—State of Arkansas_....------------ 360,174 ... 360, 174 Do. Bi-State—Eastern Missouri, centered around St. Louis 603,965 ....---n-ewne 603,965 ....---.----++ Do. and southern Milinois. . California—State of California........-.------------- Nov. 1,1966 ...--.-------- 3,226,225 ...---------- 4,079,593 ....-..------- Initial operational grant request under review. Central New York—Syracuse, New York and 15 sur- Jan. 1, 1967 .-....-..----- 268,634 .--..--.------ 434,156 ....--.------- Do. rounding counties. , . - . Colorado-Wyoming—States of Colorado and Wyoming....--. d0_....----e nee eee ee eee 339,605 ....--.---.--- 488, 359 Initial Spergnonal grant request anticipated in fiscal ear . Connecticut—State of Connecticut. .....---.--------- July 11,1966 ......-------- 338,513 ...-.-.------- 419,932 . Initial operational grant request under review. Florida—State of Florida......--.-.---------------- Nov. 1, 1967 ..---..------- 240,000 ....--.------- 240,000 - Initial operational grant request anticipated in fiscal ear . . Georgia—State of Georgia. ...-.------.-------55--<- Jan. 1,1967 .-.-..-..--.-- 341,824 ..------------ 694,427 ......-------- Initial operational grant request under review. Greater Delaware Valley—Philadelphia-Camden (N.J.) Apr. 1, 1967 ..---.-------- 1,534,494 -..-...--.---- 1, 534, 494 -......-----+- Initial operational grant request anticipated in fiscal metropolitan area and adjacent areas of eastern year 1969. Pennsylvania, southern New Jersey, and State of Delaware. Hawaii--State of Hawali__.......----------------+-- July 1, 1966 194,771 212,781 .-----2------- Do. Miinois—State of IIlinois.....---.-------------- =e eee eee do......--- 336, 366 336, 366 . Do. Indiana—State of Indiana_.-..----.-.----------7--- June 1, 1967 496, 013 706, 889 .. Do. Intermountain--Utah and portions of Colorado, Idaho, July 1,1966 Apr. 1,1967 363, 524 2,038, 123 608, 615 2, 038, 123 Montana, Nevada, and Wyoming. - . . lowa—State of lowa.-------.--------------- 2-2 ee Dec. 1,1966 ...-.-..-..--- 290,591 ...---.------- 552,939 ..-.---------- Initial operational grant request under review. Kansas—State of Kansas---- July 1,1966 June 1, 1967 281,627 699, 852 371, 240 . .. . Lovisiana—State of Louisiana.......-.-------------- Jan. 1,1967 ....---------- 454,445 .neen-neneeen 0,290 ......-------+ Initial operational grant request anticipated in fiscal . year . . Maine-—State of Maine....-.......---------------=- May 1,1967 ........------ 193,909 ....-----0---+ 193,909 ... _.. Initial operational grant request under review. Maryland—State of Maryland. ....-.---------------- Jan. 1, 1967 -..-2.--0----+ 770, 230 2. ---------- 967,459 ..------------ tnitial o acne grant request anticipated in fiscal year . See footnotes at end of table. L9 STATUS OF REGIONAL MEDICAL PROGRAMS (AS OF MAR. 30, 1968)}—Continued Beginning date Funding Regional medical program . Currently available Cumulative awards Operational status Planning Operational - Planning Operational Planning Operational Memphis—Western Tennessee, northern Mississippi Apr. 1,1967 ..-.-.-------- $173, 119 -------------- $173, 119 -..---.------- Initial operational grant request under review. and portions of Arkansas, Kentucky, and Missouri. Metropolitan Washington, 0.C.—District of Columbia Jan. 1,1967 Apr. 1,1968 527, 089 $418, 318 651, 171 $418, 318 and ‘surrounding suburban counties in Maryland and irginia, ’ Michigan—State of Michigan June 1,1967 1,294,449 ..------------ 1, 294, 449 Do. Mississippi—State of Mississippi-. -- 1, 1967 322,845 _..-..-------- 322, 845 Do. ae of Missouri excludin Apr. 1,1967 324, 254 2, 887, 903 §35, 967 t. Louis. . beater States--States of Idaho, Montana, Nevada, Nov. 1,1966 Mar. 1, 1968 1, 082, 107 206, 913 1, 747,370 206, 913 and Wyoming. Nebraska-South Dakota—States of Nebraska and Jan. 1, 1967 .------------- 349,367 ..--.---+----- 597,609 .....--------- Do. South Dakota. New Jersey—State of New Jersey_-----------------" 1, 1967 .------------- 297,466 -..------+---- 297,466 _....--------- Do. New Mexico—State of New Mexico 1, 1966 453,270 _-- : a ~ Initial operational grant request under review. New York metropolitan area—New: York City, Nassau, June 1, 1967 .- 967, 010 967,010 .....--------- (nitial opertional grant request anticipated in fiscal Suffolk, and Westchester Counties. year 1969. North Carolina—State of North Carolina.....-.------- July 11,1966 Mar. 1, 1968 773, 674 1,652, 164 1,000, 374 North Dakota—State of North Dakota.-...---.----7;- July 1,1967 ...----------- 188,010 ....---------- 188,010 ...-.--------- 0. on Ghio—Cleveland and surrounding 12 Jan. 1,1968 .-...--------- 285, 783 ...---------+- 385,783 ...----------+ Do. counties. Northern New England—State of Vermont and 3 July 1,1986 -..----------- 723,920 ...--------+-- 883,695 -_..-.-------- Do. counties in northeastern New York. Northlands—State of Minnesota...------------------ Jan. 11,1967 ...---------- . 629, 887 .---.------+-- 1,000,791 -------------+ Do. 89 $--89-O £S9-60E Northwestern Ohio—20 counties in northwestern Ohio, centered around Toledo. Ohio State—Central and southern 34 of Ohio (61 counties) centered around Columbus, excluding Cincinnati metropolitan area. Ohio Valley—Greater Gayton-Cincinnati, Ohio, areas Jan. 1,1967 -------------- and contiguous counties and part of Kentucky. Oklahoma—State of Oklahoma...-.---------------7- Sept. 1, 1966 Oregon—State of Oregon...---------~= . Apr. 1, 1967 Puerto Rico—Commonwealth of Puerto Rico...--.---- 1 Rochester—Rochester, NY., and il surrounding Oct. 1, 1966 Mar. 1, 1968 counties. South Carolina—State of South Carolina... ..-------<- Jan. 1, 1967 Susquehanna Valley—24 counties, centered around June 1, 1967 .. Harrisburg-Hershey in central Pennsylvania. Tennessee-Mid-South—Eastern and central Tennessee ‘and contiguous counties of southern Kentucky and northern Alabama. ...-.---------------- 2-2-0970" July 1,1966 Feb. 1, 1968 Texas-—State of Texas. ---..-------2----g2-- ocean do_..----------+------+ Tri-State—States of Massachusetts, New Hampshire, and Rhode Island_....-.---------------eeer renee Dec. 1,1967 ..-.---------- Virginia—State of Virginia. ---—---~------cne- 392-72" Jan. 1,1967 -.------------ Washington-Alaska—States of Washington and Alaska_ Sept. 1,1966 Feb. 1, 1968 West Virginia—State of West Virginia. -.-~.----=—--- Jan. 1,1967 ....---------- Western New York—Buffalo and 7 surrounding New Dec. 1, 1966 Mar. 1, 1968 York counties and Erie, Pa. Western. Pennsylvania—Pittsburgh, Pa., and 28 sur- Jan 1,1967 .-.---------=- rounding counties. |. . Wisconsin-—State of Wisconsin. .-.------------+2-7-- Sept. 1,1966 Sept. 1, 1967 309, 180 136, 771 346, 797 282, 100 231,125 ---- 318, 286 379, 246 263, 530 523, 738 1,260, 181 439, 037 2.630, 149 309, 180 Do. 136,771 ---------++--+ Do. 472,096 ...----------- Do. 330, 318 - Do . . 353, 760 ~ Award of initial operational grant pending. Initial operational grant request anticipated in fiscal year 1969. 500, 425 502, 773 Initial operational grant request under. review. nee ecuenarseeneeees Initial operational grant request anticipated in fiscal year 1969. 673, 421 1, 630, 304 | 1,667,194 .- Initial operational grant request under review. 439,037 . Initial operational grant request anticipated in fiscal year 1969. 545, Pe - Do. 282, 663 .:.-- Do. 313, 033 340,556 .-.------+---- Do. 344, 418 630, 149 1 §nitial plancing grant application has been received and is un der review. 2 Combined planning and operational grant; includes some $340,000 for planning. oS o 70 ILLUSTRATIVE EXAMPLES OF CURRENT STATUS In addition to this listing of grant awards and the projected initiation of operational activities by the 54 regions, some specific examples of activities can serve to illustrate the status of activities in the Regional Medical Program and how these activities relate to achieving some of the major objectives of the program. P.L. 89-239 makes clear that activities under it are to be considered part of, and contributors to the evolution of a system which establishes and strengthens, on a regional basis, functional relationships among the elements of the health system, The law assumes that only through such regional arrangements can the health status of the patient penefit fully from the accomplishments of medical science. The following examples show how these mechanisms have been effective or give promise of being effective in influencing the quality of health care under the following headings: 1) Cooperative Arrangements; 2) The Relationship of Science to Service; 3) Education and Training ; 4) Demonstrations of Patient Care; and 5) Experimental Projects. 1. Cooperative Arrangements Regional Medical Programs are based upon voluntary cooperative arrange- ments among all the health resources in each Region. These cooperative ar- rangements characterize the type of regionalization with which this program is concerned, The word “regionalization” in the context of Regional Medical Pro- grams does not refer to the development of a rigid plan which has been imposed from above. Rather, it stresses the process whereby local resources are joined together to jdentify needs and opportunities, to assess resources, to define objec- tives, to set priorities, and then finally to implement a program and to establish methods of self-evaluation. Here are some specific examples of how such arrange: ments can be expected to affect patient services directly. Four hospitals in Lafayette, Louisiana, are pooling resources in cooperation with the State Heart ‘Association and one of the medical schools, to improve the care of patients with myocardial infarction in that area of the Region through the establishment of a coronary care demonstration and training unit. The local decision was made to concentrate on developing a high quality coronary care unit in a single hospital. These varied institutions joined with the public to raise private funds, recruit and train staff, and equip the unit. Although the invest- ment of Regional Medical Program funds was limited, the cooperation engendered by the program not only accomplished much, but also has served as a model of cooperative action to the Region. The community of Anchorage, Alaska, in response to the needs identified by the Washington-Alaska Regional Medical Program for a high energy radiation source closer than Seattle, Washington, is now conducting a fund raising cam- paign. Solicited private funds will be used to construct housing for the equip- ment, which will be purchased by the Regional Medical Program. The treatment center will be operated as @ regional resource by the Providence Hospital, as planned and approved by local and regional advisory groups. The decision to support this activity involves cooperative arrangements at another level also, for the National Cancer Institute conducted the on-site visit which gave assur- ance of the sound scientific and professional basis of this project. The Anchorage Building and Construction Trades Council, comprising some 14 unions have taken on the construction of the building as a project, thus contributing more than one half the total cost from this one source. One of the most meaningful associations sponsored by Regional Medical Pro- grams is between Vanderbilt University Medical School and Meharry Medical College on the one hand, and the Neighborhood Health Center supported by the Office of Economic Opportunity, located near Mebarry on the other. Consultants from Vanderbilt are working with the faculty of Meharry and the staff of the Health Center to provide comprehensive health care for impoverished commu- nities formerly without adequate care. In many other Regions similar collabo- rations between institutions of varying maturity and strength have resulted in achievements heretofore difficult, if not impossible. 2. The Relationship of Science to Service / The complex problem of relating the more sophisticated and advanced ac- tivities available in only 2 few institutions within a Region to the broader needs of people of the Region is a significant mandate for the programs. This task is being carried out ina variety of ways. 71 The computer expertise and facilities of the University of Missouri and the previous work of the Public Health Services’ National Center for Chronic Dis- ease Control, are being used by local physicians to test the effect of the avail- ability of computer-assisted and semiautomated interpretation of electrocardio- grams on the care of patients. The Intermountain Region has an outstanding multidisciplinary research group investigating computer application to clinical problems. Automated phy- siological monitoring has been extended from the Latter-day Saints Hospital in Salt Lake City to four other hospitals in the Region, through the use of remote computer consoles, allowing a more sophisticated level of treatment in these hospitals. In this case, as in many others, the developmental work was sup- ported by the National Heart Institute, which now is jointly funding with Re- gional Medical Programs the application of the technologie advances. The latest and best in medical science exists also in institutions other than universities and research institutes. Wisconsin has a death rate from pulmonary embolism higher than the nation’s average, and in Wisconsin, the Marshfield Clinic has a group especially knowledgeable about thromboembolic disease. The Wisconsin Regional Medical Program is supporting a unit at the Marshfield Clinic for the demonstration of the best techniques for diagnosis and non-surgical management of patients with pulmonary embolism. The Marchfield Clinic has established referral routes from five hospitals in the Region for emergency care of patients suspected of having pulmonary embolism. The effect of this unit has already been made apparent by the increased demand from physicians through- out the Region for educational services there. The unit already has treated more than 30 patients, with results better than the national average—a distinct improvement in patient care. : Research institutions are anxious that medical practice benefit from research efforts. For several years, the Memorial Sloan-Kettering Cancer Center has ex- tened its consultation and teaching programs out to the practicing community in six hospitals. Now, through the New York Metropolitan Regional Medical Program it is able to expand its coverage to surrounding areas, and is planning to include 28 additional hospitals so that the knowledge and talent of the Memo- rial Sloan-Ketering Cancer Center can be made available to practitioners through- out the area. In many similar projects, Regional Medical Programs serves as a vehicle for transmission of the latest scientific advances to the bedside. 8. Education and Training Education and Training have been traditional methods of improving quality in all fields. The emphasis in Regional Medical Programs has been to sepport education and training, not as separate isolated activities, but rather in terms of recognized needs for the improvement of patient care services and as an in- tegral part of other activities. An example of the development of this type of training and edueational pro- gram arose in the Rochester Region, where 29 hospitals were faced with the problem of establishing coronary care units. Through their Regional Medical Program, they have been able to focus instead on the problems of giving the best diagnosis and treatment to all patients with myocardial infarction in the Region. A recently awarded operational grant will support training and con- tinuing educational programs for physicians and nurres to staff the units. the development of evaluation techniques, and the establishment of a coagulation resource in & community hospital. The California Region plans to anticipate the needs for education and training in a new community hospital to be completed within the next three years in the Watts area of Los Angeles. A Post-Graduate faculty will be recruited now and sponsored jointly by the Charles Drew Medical Society. the University of Cali- fornia in Los Angeles, and the University of Southern California. Once built, the hospital itself will support the faculty, but Regional Medical Program funds are being sought for interim assistance. ~ , Numerous programs are seeking to provide expert consultation on request. These include making consultation available by telephone or two-way radio on a 24-hour basis, a dial access. telephone-audio tape system in Wisconsin, and a Pao jukebox in Albany which will show a variety of single concept films on emand.. 4. Demonstrations of Patient Care Demonstrations of patient care are proving to be effective in serving the goals of the program, and have been 4 major expression of cooperative arrangements for the betterment of a particular situation. Resources in Mississippi-for the management of stroke patients are limited. Four intensive care beds for the demonstration of latest advances and modern potential of stroke care have been established under Regional Medical Programs, The usual hospital costs are being supported from other sources but with thig newly funded demonstration unit, physicians, nurses, and all allied health pro- fessionals have access to excellent training. The result of such training and “on line” experience is already leading to improved care for stroke patients. In Iowa, a different demonstration pattern is being used. Through the Iowa Regional Medical Program, 4 stroke team with physicians and allied health competence is available for on-site consultation. This unit, taken to the patient, provides specific consultation and comprehensive education for those responsible for continuing care. In Smithville, Missouri, an entire community has enthusiastically become a “demonstration project.” With the funding of a much needed rehabilitation unit in that town of 2,500, which serves 4 population of 50,000, the imagination of the community was captured. Impressed by the potential of Regional Medical Programs, the town leaders sought and became 4 “demonstration sub-region” for the Missouri program. Thus, over a dozen regional projects are now being tested in Smithville. There are many examples of units demonstrating care of patients with acute myocardial infarction. The units are varied. Some are in smali and some in large hospitals. Some represent joint efforts between “Medical Centers” and outlying hospitals. Some are administered by physicians while others are administered by nurses, These models recognize the realities of manpower shortages, and of the significant differences in the locales where patients are treated. 5. Experimental Projects Regional Medical Programs are offering an excellent opportunity for the use of information coming out of research into better methods for making available the advances of medical science. North Carolina is paying considerable attention to the special problems of an area in the western part of the state known as the “State of Franklin.” For example, seven hospitals in as many different communities are testing the fea- sibility of a common Board of Trustees and a coordinated program to the extent that they will request accreditation ag one hospital by the Joint Commission on Accreditation of Hospitals, Separately these hospitals, plagued with manpower and facility shortages, face not only an uncertain future, but the knowledge that they will have increasing difficulty in maintaining quality patient care, AS a result of the Regional Medical Program, these hospitals are now testing the concept of a unique regional hospital organization which will make possible the implementation of improved care in heart disease, cancer, and stroke. The University of Michigan School of Engineering is cooperating with the Intermountain Regional Medical Program in a systems and operations study of coronary care. Here we see recognition of the need for the health system to in- crease the effectiveness and efficiency of care modalities. In this era when na- tional attention is dircted to rising medical care costs, many resources and types of expertise will be needed to minimize needless expense. Vermont igs in- volved in a modified cost benefit analysis of several health activities being ini- tiated. The data collected should provide not only the Vermont Regional Medical Program, but the health industry in general with information upon which deci- sions can be made on substantive rather than intuitive bases. : Mr. Rogzrs. Is there any particular emphasis given in the regional programs to the core city problem! _ Dr. Marston. Yes, sir. The program has tended to go more slowly in the very large, complex urban areas, I think, probably for the same reason some other programs there have gone more slowly. But there are some key examples of our activities in urban areas. In the California region, the Watts group is working on a program ey the local chapter of the National Medical Association, an ; 73 The Tennessee-Midsouth region, in Nashville, is supporting a pro- gram in combination with OKO—I could give you a list of these. Mr. Rocers. Let us have a list of these, and what hospitals in these areas are involved and the personnel involved. (The following information was received by the committee:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON REGIONAL MepicaL ProcRaM Errorts DIREcTED AGAINST THE HEALTH PROBLEMS OF THE INNER CITY In August 1967, the National Advisory Council on Regional Medical Programs issued a statement which gave consideration to the health problems of metro- politan areas and their {nner cities. While recognizing the complexities of the urban environment, the Council stressed the responsibility of Regional Medical Programs to contribute to the solution of health problems there. In addition, it recommended, that an appropriate group of national leaders be named and ealled together to consider how the attention of Regional Medical Programs could best be focused on the issue. In response to the statement and to the Surgeon General’s memorandum of October 9, 1967 “Improving the Health Status of the Urban Poor,” a meeting was held on November 16, 1967 to consider the problem. Among those persons invited to attend were hospital representatives, RMP coordinators from urban areas, health planners, representatives from OEO, medical school officials and physicians with responsibility for the provision of care to the urban poor. The discussion concerned the need for immediate action to reduce the health status differential which now exists, the need for experimentation in the methods of delivering health care, and the need for coordinating the activities of diverse groups which provide health care services in the inner city as well as specific approaches and projects which might be undertaken. At the local level, Regional Medical Programs which include major metro- politan areas have developed yaried approaches to solving these problems. These efforts include cooperative arrangements between hospitals, health departments, medical schools, voluntary agencies and practicing physicians to meet the health needs of the poor. Examples of. these approaches now under development or in operation can be summarized as follows: California Regional Medical Program has established a subregion covering the Watts-Willowbrook area of Los Angeles which will facilitate the develop- ment of activities aimed at meeting the specific needs of the people there. Through the Regional Medical Program, the University of Southern California School of Medicine and the UCLA School of Medicine are cooperating with the local Charles R. Drew Medical Society (an affiliate of the National Medical Associa- tion) in establishing a post-graduate medical school at the Southeast General Hospital now under construction in Watts. This school will provide back-up services to the OEO neighborhood health center in the area, develop training programs for allied health personnel, provide stimulus for additional physicians to enter the practice within the community and will develop training programs for physicians already there. California Regional Medical Program has requested funds for partial support of the school in the early stages of development. In addition, work is now underway at the University of Southern California School of Medicine on the application of cancer case finding methodology to poverty groups. New Jersey Regional Medical Program has organized an urban health unit within their office and has established a Task Force on Urban Health Services under the chairmanship of Mrs. Anne Somers, a member of their Regional Advisory Group. Membership on the Task Force includes representatives of the New Jersey Hospital Association, the New Jersey State Department of Com- munity Affairs, county medical societies, local OLO CAP programs and other groups. The function of the group will be to stimulate and review projects for improving the availability of health services to persons living in urban areas of the state, particularly low income groups. The group currently is working on the development of hospital based group practices at Middlesex General Hospital in New Brunswick and at West Jersey Hospital in Camden, as demonstrations of improved systems for patient care for heart disease, cancer and stroke. The New Jersey Regional Medical Program will assign a coordinator/planner to the Model Cities offices in Trenton, Newark, and Hoboken. The function of Rl 74 these persons will be to gather data on services and the facilities available for people suffering from heart disease, cancer and stroke; to provide liaison be- tween Regional Medical Programs and the Model Cities programs; and to assist the Model Cities offices in developing a program of health services for the com- munity which will be consistent with the overall goals and objectives of the Regional Medical Program. : : Tennessee-midsouth Regional Medical Program has developed a number of projects which affect the health care of the poor in Nashville. Coronary care units will be established at Nashville Metropolitan General Hospital and Hub- bard Hospital, which serve patients largely drawn from an indigent population. Meharry Medical College will conduct continuing education programs for Negro physicians and will establish a supervoltage radiation unit to improve cancer therapy in the community and improve graduate and under-graduate radiology training. In addition, there is a project to test the effectiveness of multiphasic screening examinations in the early diagnosis of heart disease, cancer and stroke. Meharry will establish a screening center which will operate in support of 4 comprehensive neighborhood health center funded by OHO and will serve a pop- ulation of 18,000 people. The test population and a control group will be evaluated and compared with reference to changes in morbidity, patterns of utilization of health services, health attitudes and cost per patient diagnosed. Tri-State Regional Medical Program received a planning grant in late 1967 and is only now becoming completely organized. Since that time Dr. Norman Stearnes, Program Coordinator, has been involved in a number of meetings where he has made known Regional Medical Program’s interest in working to improve the availability of health services to the urban poor. He also is serving on an ad hoc committee formed in Boston by Blue Shield to discuss the planning of home services and will sit on the Health Services Advisory Committee to the Boston City Department of Health and Hospitals. At this time, there are two projects for earmarked funds under development in the Boston area, a stroke project at the New England Medical Center which will have a tie-in with the Columbia Point Neighborhood Health Center and a hypertension project being developed by Dr. Edward Kass of the Channing Laboratory, Boston Department of Health and Hospitals. Tilinois Regional Medical Program has established a number of formal and informal contacts with persons in the Chicago area responsible for providing health services to the inner city including Dr. David Greeley, Associate Direc- tor, Chicago Board of Health and Dr. Mark Lepper, Vice President, Presbyterian- St. Luke’s Hospital which operates an OEO financed neighborhood health cen- ter. Now in the planning stage at Presbyterian-St. Luke’s Hospital is a com- munity hypertension detection program which will be focused on the Mile Square area of Chicago. Included would be evaluation of case finding methodology, ef- fectiveness of treatment, nurse interviews with patients and an analysis of the interaction of the program to the community. Michigan Regional Medical Program: At its recent February meeting the Re- gional Advisory Group of this program formally adopted a statement for prior- ities for Regional Medical Program action which reads in part “the first priority for Regional Medical Program support will be given to those projects which are concerned with the improvement of the delivery system of health care including such aspects as (a) improvement of the delivery system of health care to low income groups; and (b) innovations and improvements in the utilization of manpower...” Underway is a planning project supported jointly by Regional Medical Programs and the State Health Department (Project ECHO) for gather- ing data on the health needs in depressed areas of Wayne County, Michigan. Wayne County General Hospital has submitted a project to study the use of subprofessional workers to assist the physician in patient care and will design and establish training for such persons recruited from the local community. Wayne County General Hospital serves the indigent population of Wayne County and is located adjacent to a large indigent group in western and southern Wayne County, Michigan. : In addition, Regional Medical Program staff at Wayne State University School of Medicine is working to establish liaison with urban health programs in Detroit including OEO and Model Cities. The Executive Director of the Detroit Urban League has been named to the Wayne State Advisory Group. Indiana Regional Medical Program is working with Flanner House, a volun- tary community agency in Indianapolis to develop a multiphasic health screening program for low income population groups. With State and local support the 75 Regional Medical Program is conducting planning and feasibility studies to determine the types of screening procedures which will most effectively reach target population groups and which can in part be administered by previously untrained persons from the community who have received on-the-job training. New York Metropolitan Regional Medical Program has made specific assign- ments to members of their core staff for maintaining liaison with community mental health programs, OEO and Model Cities. Particular effort has been made to develop a working relationship with the Provident Clinical Society, the mov- ing force behind an OEO health center in Brooklyn and as a result the president of this organization has recently been appointed to the Regional Advisory Group. In upper Manhattan, the Regional Medical Program is practicing with representatives of the National Medical Association, Columbia University Col- lege of Physicians and Surgeons, Mount Sinai School of Medicine and St. Luke's Hospital in the development of continuing education programs for unaffiliated physicians. The Regional Medical Program is also taking leadership in co-spon- soring a conference on health careers for the underprivileged to bring together all interested forces in the area to develop a coordinated program. Also in the developmental stage, are several projects for earmarked funds including a pediatric pulmonary disease center at Babies Hospital, a feasibility study for the development of screening and treatment of stroke patients at Harlem Hospital, and a mobile coronary care unit to operate out of St. Vincent’s Hospital in Greenwich Village. Metropolitan Washington, D.C., Regional Medical Program will establish a stroke station at Freedman’s Hospital, the teaching hospital of Howard Uni- versity Medical School. The project will improve the care of patients from a predominantly Negro population group by setting up an intensive care stroke unit in the hospital and by developing extensive follow-up services for stroke patients. The unit will be used for training medical students, area physicians, nurses and paramedical personnel in the latest techniques of stroke management. There will be research studies undertaken on diagnostic methods, epidemiology and the cultural, behavioral and socio-economic consequences of stroke. Also submitted for review are stroke projects to be operated at George Washington University Hospital, D.C. General Hospital and Glenn Dale Hospital which would combine university and D.C. Department of Public Health efforts. Missouri Regional Medical Program will establish at Kansas City General Hospital a special diagnostic and treatment unit for patients with cerebrovas- cular disease. Approximately 500 patients a year will be referred from the emergency room, outpatieit department, clinical services of the hospital and from physicians in the surrounding communities. Kansas City General Hospital serves the majority of indigent patients in the Kansas City, Missouri area and will provide the back-up to an OEO neighborhood health center now under develop- ment in the community. Missouri Regional Medical Program and Kansas Re- gional Medical Program hare also established a greater Kansas City liaison com- nittee to review and coordinate the activities of both programs in the metropoli- tan area. Georgia Regional Medical Program has submitted for review a project for the development of a community hypertensive control program, to determine the most effective methods to identify symptomatic hypertension in an urban racially mixed community in Atlanta. The project which would be conducted by the Georgia State Health Department would assess the most effective methods to achieve good blood pressure control in these hypertensives, train lay blood pres- sure aids, and determine whether a community program in hypertension control is economically feasible using public health methods. Mr. Rocers. What about the rural areas? Dr. Marston. I think things have tended to move more rapidly in the rural areas. Mr. Rocrrs. Let us have a breakdown there, too, please. (The following information was received by the committee :) 76 DEPARTMENT OF HEALTH, Epucation, AND WELFARE STATEMENT ON OPERATIONAL Prosects AFFECTING Rural AREAS ALBANY REGIONAL MEDICAL PROGRAM Many of the Albany operational activities will serve to enhance the capabili- ties of health professionals in the rural areas. By bringing professionals from small communities into the medical center for continuing education and by im- proving communications between the medical center and the communities they hope to raise the Jevel of patient care in those communities. The following pro}- ects involve rural areas: . Operational Projects 1. Two-way Radio Communication System: Direct Cost, $144,100 This project will expand an existing two-way radio network to include 57 hospitals and 24 high schools. It will provide continuing education for physicians and allied medical personnel. Jt will also provide information and education pro- grams for administrators, members of poards of trustees, yoluntary health agen- cies, adult education classes, and selected civic groups. 2, Community Information Coordinators: Direct Cost, $73,800 Former pharmaceutical representatives will be used to contact local physicians to tell them about Regional Medical Programs and to evaluate their attitudes towards RMP. 8. Community Hospital Learning Centers: Direct Cost, $75,800 This project will establish learning centers at community hospitals using “self Instruction Units” and audio-visual equipment for rapid dissemination of new medical knowledge. Eventually, the directors of this project hope to evaluate physician progress. Jnitially, 8 hospitals will be involved. 4. Community Hospital Coronary Care Training and Demonstration Program: Direct Cost, $55,400 This project will establish coronary care units of three peds each at three community hospitals: Pittsfield General, St, Lukes, and Vassar Brothers. These will serve a8 demonstration and educational projects for other hospitals in the region. A continuing educational program will serve the permanent Unit Staff and staffs from smaller hospitals. 5. Training and Demonstration Project, Intensive Cardiac Care Unit Herkimer Memorial Hospital: Direct Cost, $3,500 The initial phase of this project is to train 6 or 8 nurses from small community nospitals in cardiac anatomy and physiology, coronary disease, the principals and staffing of a cardiac intensive care unit, and in handling the complex equipment. These nurses will also be sent to Albany Medical Center for active training with specialized equipment. INTERMOUNTALN REGIONAL MEDICAL PROGRAM The Intermountain Regional Medical Program has essentially three types of projects for remote communities. Several projects are educational involving the training of health professionals who are brought into the medical center. Other projects send specialists from the medical center to the small communities to aid local physicians with specific areas of patient care. A third type involves the use of electronic monitoring equipment which transmits physiological signals from patients in remote areas to the medical center for interpretation. A listing of these projects follows. Operational Projects J. Network for Continuing Education in Heart Disease, Cancer, Stroke and Re- lated Diseases: Direct Cost, $243,000 . The objectives of this program are to develop 4 communications network be- tween patient-care and research institutions to encourage liaison between health care personnel in the area. The currently existing 2-way radio systems, including 11 hospitals in 7 communities in or near Salt ‘Lake City, will be extended to remote hospitals to serve as one link. Closed circuit TV and use of KVED (Uni- versity of Uteh education TV) is also planned. This may establish the community hospital as the locus of continuing education. 77 2. Information and Communications Exchange Service: Direct Cost, $40,300 The CIES is a region-wide clearing house for information about IRMP. Staff will be put in local communities to act as public relations representatives and also to distribute information to medical personnel and the public. The community staff will also gather information on community needs and resources and serve as a station for collecting economic, social, and medical data. 8. Cardiopulmonary Resuscitation Training Program: Direct Cost, 363,400 The University of Utah will give a 3-day course in resuscitative techniques to selected physicians from small communities, Each physician will then be responsi- ble for teaching the techniques to health personnel in his community. This re- suscitation consultant will also collect data about the number of times resuscita- tion is employed and the results. 4. A Training Program in Intensive Cardiac Care: Direct Cost, $118,600 A core faculty of experts in using Cardiac Care Units and diagnosing and treat- ing heart disease will teach short courses in their subjects. The students will be interested physicians and nurses from community hospitals building coronary care units. 5. Training for Nurses in Cardiac Care and Cardiopulmonary Resuscitation :Direct Cost, $84,000 This is an integral part of both the cardiac care and cardiopulmonary resuscita- tion programs for physicians (#38, #4). Nurses trained in Salt Lake City will re- turn to their communities to serve as a core faculty for teaching the techniques at the local level. The nurses will work closely with the similarly trained physicians. . 6. Visiting Consultants and Teacher Program for Small Community Hospitals: Direct Cost, $14,800 Small communities will be given the option of requesting one or two-day clinics. A minimum number of four cardiac patients will be required. These clinics will upgrade the level of care of victims of heart disease living in a remote area. Visit- ing physicians will assist the local physician in a precise diagnosis of his patients. 7. A Regional Computer-Based System for Monitoring Physiologie Data on-line from Remote Hospitals in the Regional Medical Program: Direct Cost, $637,100 This project’s purpose is to test the feasibility of using a central computer to process a variety of physiological signals generated by patients in remote hos- pitals, feeding the results of calculations from these signals back to stations with- in the hospitals, and using the information for diagnosis. 8. Cancer Teaching Project: Direct Cost, $94,300 This project attempts to upgrade the level of care available to local communi- ties. The co-ordinator will direct a program of physician education to create trained cancer specialists who, in turn, will become centers of cancer informa- tion in their local communities. The physicians will receive a smail stipend for teaching and obtaining information, A region-wide tumor registry will be started as will a training program in new techniques for pathologists. 9. Stroke and Related Neurological Diseases: Direct Cost, $98,700 This project will establish clinics to bring expert consultation service in stroke and related neurological diseases to local communities; will provide continuing education to local physicians and nurses; will collect data about stroke patients seen and the problems they present to the practitioner. A 24-hour telephone consultation service and information library service will be maintained at the Utah Medical Center to provide community physicians with immediate advice. In addition, practicing physicians will be trained at the medical center in the latest diagnostic and treatment techniques. The courses will last from 4 weeks to one year. KANSAS REGIONAL MEDICAL PROGRAM The Kansas Region is emphasizing cardiovascular care in its rural programs. In addition it is setting up a comprehensive model training program in a small community. The project descriptions follow : . oie 78 Operational Projects 1, Education Programs—Great Bend, Kansas: Direct Cost, $261,090 To develop a model educational program in this gmall community a full-tim: faculty, which will be affiliated with the Kansas Medical Center, will be i residence. Included in_ this comprehensive program Are plans for continuin: physician and nurse education and clinical traineeships for pealth-related pel sonnel. Studies will be made of community needs, resources, ete. 9, Cardovascular Nurse Training: Direct Cost, $98,500 To develop an in-service training program to prepare nurses, who are th mainstay of coronary care units in community hospitals, with pasic physiologica knowledge of coronary care, ability to use instruments and equipment in core nary care units, experience in home care, and familiarity with social agencie that can aid in the rehabilitation of patients. 8. Cardiovascular Work Evaluation: Direct Cost, $21,100 This project will demonstrate the Cardiac Work Evaluation Unit and show it usefulness for the evaluation and rehabilitation of the patient. It is developin: an effective technique for showing physicians and the community at large th ability of patients to return to work after receiving the appropriate rehabilitation MISSOURI REGIONAL MEDICAL PROGRAM The Missouri Regional Medical Program operational activities involve project directed toward improved screening techniques, early disease detection an rapid diagnosis, and more effective delivery of services. These are coordinate with automated systems for transmission of information and health data to ai physicians and community hospitais in the treatment of patients with hea: disease, cancer, stroke and related diseases. Six projects focus on the healt needs, the care of patients, and training of staff for rural communities. Operational Projects 1, Smithville Community Health Service Program: Direct Cost, $200,957 To establish a model community health service program including continuir: education and training programs and health education for the public; emergenc intensive and restorative care facilities; home care progranis ; public healt’ preventive medicine, and school health ; coordinated with voluntary health age: cies. Program centered around Smithville (population of 3,500) and to incluc about. 50,000 persons jn Clay County. Activities are centered around Smithvil Community Hospital (75 beds), and the group practice clinic as a nucleus. 9, Multiphesic Testing of an Ambulant Population: Direct Cost, $421,471 To establish centers for performing series of diagnostic laboratory tests 1 identify the most useful tests feasible for screening large rural populatic groups; determine the different patterns for jll and healthy populations as ? aid in detection of heart disease, cancer, and. stroke in preclinical stages. Mod blished at the University Medical Center, Columbia, t! test centers will be esta! State Mental Hospital and a third is planned for the Smithville complex. 3. Afass Screening—Radiology: Direct Cost, $54,814 To improve the accuracy of radiologic diagnosis of heart disease, cancer al stroke through electronic communications media, Three small rural hospitals w be hooked into the University of Missouri computer and Department of Ra ology; to evaluate diagnostic efficiency and determine applicability of ultr sound and thermography in diagnosis and therapy. . 4. Comprehensive Cardiovascular Care Units—Springfeld, Missouri: Dire Cost, $69,347 To develop 2 comprebensive care unit for grouping patients with heart d ease or other circulatory system illness or who have been admitted for oth purposes but require close cardiac observation. The project is to be undertak: at hospitals without @ house staff, where it is hoped that grouping of patien will relieve the workload for nurses on general medical and surgical wart Springfield (a community of over 100,000) has 4 general community hospita 79 ranging in size from 34 to 511 (a total of about 1,200 beds). St. John’s Hospital medical staff and Greene County Medical Society are coordinating activities with 8 local hospitals in Springfield. 5. Automated Electrocardiography in a Rural Area: Direct Cost, $369,000 To provide hospitals and physicians in rural areas with automated facilities for transmitting electrocardiograms and an automated system for analyses of ECG’s; to demonstrate the feasibility of such systems where this service is limited or non-existent, and to develop, test and implement the use of bioengi- neering signals az an aid in diagnosis. 6. Operations Research and Systems Design: Direct Cost, $39,055 To develop systems concerned with testing “early detection” hypothesis- develop operational methods of early detection tests for a large rural population. MOUNTAIN STATES REGIONAL MEDICAL PROGRAM Operational activity in the Mountain States Region is specifically designed to benefit small hospitals in rural areas and to train health professionals from rural areas. Operational Projects 1. Intensive Coronary Care in Small Hospitals in the Region: Direct Cost, $206,913 Hospitals in the region will send registered nurses into St, Patrick’s Hospital, Missoula, Montana, for coronary care training. This three-week course will be offered three times a year for 21 nurses, and there will be follow-ups at the home hospitals four times a year. In addition, a 4-day training program especially designed for small town physicians will be held at the University of Montana four times a year. NORTH CAROLINA REGIONAL MEDICAL PROGRAM In North Carolina there are 10 funded operational projects all of which have a direct effect upon hospitals, health professionals, and patients in rural areas. Some are concerned with education and training of physicians and allied health personnel, and others with patient care. All of them are designed to bring the latest scientific advances down to the community level. The projects are listed as follows: Operational Projects 1. Education and research in community medical care—direct cost, $209,200 To develop resources for training more medical and allied medical students; to provide new types of educational experiences which will make family practice more attractive; to have a postgraduate education program at the medical school; to strengthen ties between the medical school faculty and practicing physicians; and to have the medical school become involved in community plan- ning for improving the quality and availability of medical care. Affected by this project are the following groups: the University Community ; the Caswell County Rural Health Services Project; the Regional Health Council of Eastern Appa- lachia, Ine.; the State of Franklin Health Council, Inc.; the Charlotte Memoria] Hospital; the Moses Cone Memorial Hospital, Greensboro ; and the Dorothea Dix Neuromedical Service. ° 2. Coronary care training and development—direct cost, $55,938 To use the project as a medium for developing cooperative arrangements among the rarious elements in the health care community. Initial and continuing educa- tion will be provided to nurses and physicians in community hospitals, consulta- tion will be available to hospitals in establishing CCU’s, and a computer-based system of medical record keeping will be developed. This project has led to new working arrangements: (1) between the university medical centers; (2) be- tween medical and nurse educators; (3) between doctors and nurses in commu- nity hospitals; (4) between university medical centers and community hospitals. 3. Diabetic consultation and educational services-—direct cost, $132,081 To establish three medical teams to deliver services throughout the state; to assist in expansion of diabetic consultations and teaching clinics; to provide 80 seminars for physicians and teaching sessions for nurses and patients; to assist ocal chapters; to test tech- in organization of a State Diabetes ‘Association and | p niques of data collection. Many people of different disciplines many communt ties are involved in this project. 4. Development of @ central cancer registry—direct cost, $66,615 To devise a uniform region-wide cancer reporting system, integrated with the PAS, the computer-stored data from which can be retrieved to serve a broad range of educational, research, statistical, and other purposes. The following hospitals are participating in the first year of the project : Duke University Medi- cal Center, North Garolina Memorial Hospital, North Carolina Baptist Hospital, Charlotte ‘Memorial Hospital, Veterans’ Administration Hospital, i tal, Hanover Memorial Hospital, Southeastern General Hospital, C Hospital. In subsequent years the registry will be expanded to include all hos pitals and physicians in the region. §. Medical library extension service—direct cost, $25,839 To bring medical library facilities of the three medical schools into the daily work of those engaged in medical practice. Local hospital personnel will be trained to assist medical staff ; libraries will be organized into a functional unit for responding to requests for services. Bibliographic request service will be established. 6. Cancer information center—direct cost, $41,716 To provide practicing physicians with immediate consultation by telephone and follow-up literature. Each of the three medical schools will be responsible for providing service in its geographic locale. The aims of this project are two- fold: (1) to assist physicians jn providing optimum care of patients with cancer; and (2) to continue the education of the physicians py giving new information jin a patient-centered experience. . : 7. Continuing education in internal medicine—direct cost, $33,313 To bring practicing internists from all over the state to the Medical Center for a month of up-to-date training in their subspecialties. They will share respon- sibilities with attending physicians and make ward rounds with students, staff, and together. This experience should enhance the appreciation in the University, poth at faculty and student levels, for the expanding role of the medical center for the quality of care in the community. 8. Continuing education in dentistry—direct cost, $67,508 To provide physicians and dentists with the knowledge of mutual concern which will enable them to be more effective members of the health team. Courses will be given at the University of North Carolina and in communities. Studies will be made of facilities needed to provide dental care in hospitals. The purpose 0! this project is to insure that as many patients as possible who suffer from heart disease, cancer, stroke, or 2 related disease receive appropriate dental care as 3 part of their comprehensive treatment. 9, Continuing education for physical therapists—direct cost, $27,838 To develop and establish regional continuing education programs for physical therapists in order to strengthen physical therapy services for patients in a parts of the state. Subregions will be delineated where needs and i jdentified and committees will pe organized to arrange local activities. 10. The establishment of a network of coronary care units in small communitt hospitals in Appalachia, North Carolina—direct cost, $93,019. This is a proposal to develop coronary care units in seven hospitals in thi rural, mountainous area. RMP will supply the monitoring equipment (the hospi tal provides suitable space) when adequately trained physicians and nurses ar available. An intensive training course for physicians will be conducted in th geographic region, and continuing education programs will be conducted whe necessary. TENNESSEE MID-SOUTH REGIONAL. MEDICAL PROGRAM. Due to the geographical diversity of the region, the Tennessee Mid-Sout Regional Medical Program has been concerned with both the health problen of the urban poor as well as the health problems of remote rural areas. Tennessee program has sought solutions to these and other regional progran 81 through a system of linkages between the medical centers and the rural areas. In addition to providing programs to allow medical personnel and practicing physi- cians from rural community hospitals to come to the medical center for training courses, the Tennessee program has endeavored, through the use of modern com: munication techniques, to create medical education resources in the rural areas. The Hopkinsville Education Center and the deployment of coronary care units are two examples of such projects. Operational Projects 1 and 2. Hopkinsville Education Center and Chattanooga Education Center— direct cost, $73,700 _ ‘hese are the first of the local continuing education centers specified in the Vanderbilt plan. At each hospital, a full-time Director with an appointment at Vanderbilt and an assistant director will supervise resident and physician educa- tion in their area. Their services will be available to physicians at smaller com- munity hospitals in each area, as will the enlarged hospital library facilities. The Chattanooga and Hopkinsville locations provide the basis for looking at problems in continuing education in urban and rural settings. 3. Franklin Coronary Care Unit—Williamson County Hospital—Franklin— direct cost, $31,400 This-is one of the subsidiary units mentioned in the Vanderbilt proposal. This is primarily a pilot project to study. the feasibility and usefulness of establishing a center in a small community hospital. 4. Clarksville Coronary Care Unit—Clarksville Memorial Hospitai—direct cost, $19,000 As the Franklin program, this project is a subsidiary of the Vanderbilt pro- posal. Since this hospital has been operating a unit, the plan calls for its expan- sion, continuing education and a phone hook-up to Vanderbilt. 5. Murray Coronary. Care Unit—Murray-Calloway (Ky.) County H ospital: Direct Cost, $38,800 Murray-Calloway County Hospital, the training center for Murray State Uni- versity school of nursing, will serve as a demonstration center for the sub-region. Direct phone communication will be established with Vanderbilt, which will send consultants from its school of continuing education. This project has the dual objective of relating the Murray State Nursing program to an established medi- cal center and providing regional training resources to a remote area. 6. Crossville Coronary Care Unit—Uplands Cumberland Medical Center Cross- ville: Direct Cost, $28,300 : This project has two purposes: (1) to establish a two-bed coronary care unit in the hospital; and (2) to determine the feasibility of operating acute coronary care units in rural areas. The hospital will cooperate with Mid-State Baptist Hospital and Vanderbilt. %. Tyllahoma Coronary Care Unit—Harton Memorial Hospital, Tullahoma, Tenn.: Direct Cost, $28,800 See Baptist Hospital Program. &. Project to Improve Paticnt Care ina Remote Mountain Community by Recruit- ing and Training Health Aides for @ New Extended Care Facility—Scott County Hospital—Oneida, Tenn.: Direct Cost, $10,300 Manpower shortage in this isolated mountain hospital is critical. Personnel to man an extended care facility now under construction will be obtained by two methods: (1) In-service training for hospital personnel; (2) an educational di- rector (an RN) to serve as a liaison to the high schools to encourage young peo- ple to enter the medical field and come back home to practice. In addition a training program leading to the LPN would be initiated. Clinical training will be supervised by the Educational Director while local high schools provide basic training. 9. Hopkinscille Coronary Care Unit—Jennie Stuart Memorial Hospital—Hop- kinsville, Ky,: Dircet Cost, $49,500 This plan is similar to the ¥ranklin plan, except that it mentions establishing links to smaller community hospitals by helping set up smaller care units in them, 82 thus providing for the grouping of rural community hospitals for more efficient use of existing resources. WASHINGTON-ALASKA REGIONAL MEDICAL PROGRAS The Washington-Alaska Regional Medical Program operational projects con- cern themselves largely with continuing education and training activities to en- hance the medical and paramedical capability. They focus on communications techniques and instruction materials and methodologies which are adaptable to the far flung and remote communities in the vast State of Alaska and the many seattered rural communities in Washington State. Several projects are being con- ducted to improve the health manpower resources in communities with limited or no specialty health services, which are distant from a major medical center. Operational Projects 1. Central Washington—Communication System for Continuing Education for Physicians: Direct Cost, $18,181 To bring the medical resources of the University of Washington to physicians and community hospitals in Yakima, who in turn will act as consultants to sur- rounding smaller communities through seminars and conferences, educational TV, other audio-visual instruction; and exchange of teachers and practitioners. To connect internists in Central Washington to Yakima cardiologists via EKG tele- phone hot-line, to permit quick analysis (starting with 5 community hospitals). Yakima is a community of about 45,000. The total population in 6 Central Wash- ington counties exceeds 300,000. In addition to three general hospitals in Yak- ima—St. Elizabeth, Yakima Valley Memorial, and New Valiey Osteopathic—nine other community hospitals to be yeached initially are located in small rural com: munities of Ellensburg, Moses Lake, Othello, Toppenish, Prosser and Sunnyside, (population ranges from 500 in Moses City to some 8,600 in Ellensburg. ) 2. Southeast Alaska—Postgraduate Education: Direct Cost, $27,062 To improve communication between Seattle Medical Community and the uni- versity to alleviate problems of the isolated physicians in southeast Alaska cities and communities: Juneau, Sitka, Ketchikan (3 largest). As in Central Washing- ton several methods will be used such as telelectures, consultant services, semi- nars and the EKG hot line to hospitals in Juneau, Sitka and Ketchikan. The popu- lation in these 8 cities totals about 17,000. 3. i ll Preceptorship for Physicians—Ooronary Care: Direct Cost, 7,610 A pilot project to provide opportunity for practitioners from remote and iso- lated communities to spend a week or more under a preceptor at major medical centers to study advances in care of coronary heart disease and carry out these practices in their communities. The 4 major medical centers in Seattle are Provi- dence Hospital, Swedish Hospital, Virginia Mason Hospital and Medical Center, and University Hospital and Medical Center and two in Spokane are Deaconess Hospital and Sacred Heart Hospital. 4. Cardiac Pulmonary Technician Training: Direct Cost, $41,554 Develop a formal program for training cardio-pulmonary technicians to per- form non-critical function in coronary care units and free physicians for other duties. Four larger general hospitals in Spokane—Deaconess, Holy Family, Sacred Heart, and St. Luke’s—will participate in this training program with Spokane Community College. . 5. Tico-way Radio Conference and Slide Presentation: Direct Cost, $8,445 Six pilot programs on heart, cancer and stroke topics to be transmitted via two-way radio-telephone slide conferences, to physicians and hospital staffs on topics selected by panel of physicians, starting with 20 hospitals in Washington. To explore potential for continuing network series with local and remote regions. 6. Alaska af edical Library Facilities: Direct Cost, $21 754 . To develop a community medical library for Alaska at the PHS Alaska’ Native Medical Center, Anchorage for Alaska physicians and health related staffs and agencies; to have close ties with community agencies, Arctic Health Research, University at Fairbanks and to supplement continuing education project for Southeast Alaska and the Anchorage cancer project. 83 WESTERN NEW YORK REGIONAL MEDICAL PROGRAM Both of the programs in the Western New York region have a direct effect upon hospitals, health professionals, and patients in the rural areas. Particular empha- gis will be placed upon involving community hospitals and on training nurses from community hospitals in rural areas. The projects are listed as follows: Operational Projects 1. Tw3-Way Communications Network: Direct Cost, $170,519 A two-way communication network will link hospitals of Western New York and Erie County, Pennsylvania to the Continuing Education Departments of the State University of New York at Buffalo and the Roswell Park Memorial Insti- tute. The network will serve several purposes, such as continuing education for physicians and the health-related professions, public education, administrative communication, consultation with experts, and contacts among banks. It will assist both the physician and community hospital in either the rural or urban environment in having at their fingertips the latest advances in the diagnosis and treatment of heart disease, stroke, and cancer. Particular emphasis will be placed upon involving rural hospitals in this program thereby improving both their didactic and restorative function. 2. Coronary Care Program: Direct Cost, $127,544 This project will test a training technique for providing qualified nurses who will be required to staff developing coronary care units in the Region. Approxi- mately 80 nurses will be selected from all parts of the Region for a combined academic and clinical course. It is planned that the nurses receiving this train- ing will return to poth rural and urban hospitals for the purpose of providing a diagnostic and didactic function. While the program will be housed at the medi- cal center, the community hospitals of this region will be the penefactors of the project. Since there are few nurses trained to work in coronary care units, par- ticularly in the rural environment, special attention will be paid to attracting nurses who will return to the community hospital. WISCONSIN REGIONAL MEDICAL PROGRAM Four of the Wisconsin projects have relevance to the improvement of health care in a rural setting, through the provision of education and infor- mation. Physicians and allied health personnel in community hospitals will benefit from the following projects: Operational Projects 1. A pilot demonstration program for pulmonary thromboembolism: direct cost, $84,600 In this project a center is being established at Marshfield Hospital in Marsh- field, Wisconsin, for demonstration diagnostic techniques and the available . therapy for pulmonary thromboembolism. The project has a continuing edu- cation component which will reach physicians from many hospitals in the Re- gion, This will involve a 24-hour consultation service, the preparation of a movie on the topic, and special training sessions for groups of physicians. The project will demonstrate a comprehensive program which will enconi- pass diagnostic, preventive, therapeutic, and rehabilitation procedures for pa- tients, postgraduation education, a rapid transportation system for patients from Northern sections of the state, and cooperation between the clinic and other hospitals and medical schools in the State. 2. Telephone dial access tape recording library in the areas of heart disease, cancer, stroke, and related diseases: direct cost, $18,950 This feasibility study will be carried out by the University of Wisconsin which will record and store short, 4-6 minute, tapes on various aspects of treating patients with the three diseases. Any physician anywhere in the Region can dial the library at any time and request a tape relevant to a problem in which he is interested. . $8, Nursing telephone dial access tape recording library in the areas of heart dizease, cancer, stroke and related diseases: direct cost, $18,800 This feasibility study, similar to the one above, will establish a central tape library with information recorded on nursing care in emergencies, new pro- 84 cedures and equipment, and recent developments in nursing. Nurses from any hospital in the region will be able to call at any time to have a tape played o them. 4. Development of medical and. health related single concept film program in community hospitals: direct cost, $33,250 This education feasibility project involves ten community hospitals in its first phase. Fifteen films on procedures and techniques used in treating heart, cancer, and stroke, will be developed. Projectors and the films will be installed in the hospitals for use by physicians and other health personnel at their con- venience as a continuing education device. After four to six months the ma- terials will be relocated in ten additional hospitals. Mr. Rogers, When do you expect to have your first evaluation of a regional medical program ? Dr. Marston, We have evaluations each time a region applies for a supplement, and we require an annual progress report. In one of the regions, as the funding was beginning to get up to a sizable level, we decided that in addition to these normal reviews that we should mount a special site visit and evaluate the region’s status from the standpoint of the program. We now are doing this all of the time, picking out times of program movement, particularly the shift from planning to an operational grant and upon receipt of a supplemental request for an enlarged activity. We go back and re- view the entire history of the grant. Mr. Rocers. What is the oldest region! Dr. Marston. The first four operational programs were funded at approximately the same time, Intermountain, Kansas, Missouri, and Albany, N.Y. . . Mr. Rocrrs. Could you let us have your evaluation of how effective these have been, for the record. . ; (The following information was received by the committee :) DEPARTMENT OF HeaLtH, EpucaTion, AND WELFARE STATEMENT ON EFFECTIVENESS or REGIONAL MEDICAL PROGRAMS The effectiveness of Regional Medical Programs is determined in the following ways: Evaluation of the effectiveness of each Regional Medical Program is a con- tinuous process which involves review by the Federal Government, its non- Federal advisors, and the grantee itself, These review activities are specifically intended to determine the extent to which the region has implemented the proc- ess of regionalization which includes seven essential elements: involvement, jdentification of needs and opportunities, assessment of resources, definition of objectives,, setting of priorities, implementation of program activities, and self- evaluation. This process of regionalization is the means by which the region moves toward its ultimate objective—the assurance of easily accessible improved patient care for heart disease, cancer, stroke, and related diseases. A systematic and comprehensive review of the scientific and administrative aspects of each Regional Medical Program has been designed in order to deter- mine the extent to which each Regional Medical Program implements this proe- ess of regionalization for the purpose of achieving its goal of improved patient care. This review process includes surveillance at the regional and Federal level, and is conducted by both non-Federal and Federal experts. By law each opera- tional activity must be approved by the Regional Advisory Group prior to its submission to the Federal Government for review and approval. Frequently the regions themselves have elaborated on this requirement by establishing local, in addition to regional, advisory bodies and/or scientific review bodies which also carefully examine proposed activities. 85 A site visit by members of the Review Committee and the National Advisory Council on Regional Medical Programs to the region is included as an integral i operational program for a region. As the operational pro- elops and is expanded additional site yisits are made. Finally each Regional Medical Program is required to submit an annual progress report which describes in detail the region’s program. oo. Any proposed modification in program direction by the grantee must be justified in writing and subjected to these review procedures. ; Within the context of this comprehensive review process it is possible to deter- mine whether or not 4 regional program is in fact evolving a regional system intended to improve patient care. The Missouri, Kansas, Albany, New York, and Intermountain Regional Medical Programs were the first to enter the operational phase of development. The determination of their readiness to begin operations was 2 result of the review process described above, ineluding a site visit by members of the National Ad- visory Council and members of he staff of the Division of Regional Medical Programs. The progress of these regions has been further evaluated during the review of supplemental grant requests which have been received from all four regional programs. Further site visits by Council and/or staff to review the first year’s progress have either just been carried out or are scheduled for the immediate future. The results of these reviews carried out to date indicate that these Regional Medical Programs are making substantial progress toward the goals set forth a year ago as the basis for the operational grant award. The major problems encountered have been difficulties in recruiting personnel and slowness in the delivery of important equipment. These factors have caused some delays in implementing particular projects. . Tn addition to this evaluation at the national level, the regional programs are developing their own capabilities for self-evaluation. Special staff has been added to the central staff of the regional programs with specific competence in evaluation techniques. These techniques are being further developed and ap- plied to the operational activities. Mr. Rocers. In Kansas, is Kansas City General Hospital involved in that? Dr. Marsron. In Kansas City, there is a joint committee from Kansas and Missouri to work together in the Kansas City area, and the Kansas City General Hospital has been involved ; yes. Mr. Rogers. Could you let us know to what extent? Dr. Marston. Yes, sir. (The following ‘nformation was received by the committee :) DEPARTMENT OF HEALTH, EpUcATION, AND WELFARE STATEMENT ON THE INVOLVE- MENT OF THE KANSAS Crry GENERAL HospiTaL IN THE Missouri REGIONAL MEDICAL PROGRAM The Kansas City General Hospital is directly involved in the planning for and development of the Missouri Regional Medical Program. The Missouri Regional Medical Program has allocated $82,926 for planning in Kansas City with head- quarters located at the Kansas City Generali Hospital. Several staff share respon- sibilities for Kansas City General Hospital operations and Missouri Regional Medical Program planning, including the Executive Director of the Kansas City General Hospital. Several proposals related to the Kansas City General Hospital have been submitted by the Missouri Regional Medical Program to the Federal Government for review. A project to develop programmed comprehensive cardio- vascular care at Kansas City General Hospital is pending final review by the Review Committee and the National Advisory Council on Regional Medical Programs. Planning studies are underway on manpower training and post- graduate medical education in heart disease, cancer, and stroke. Mr. Rocrrs. How do you evaluate your regional medical program! Could you let us know the criteria used for evaluation? I think the committee would be interested in that. Dr. Marston. Yes, sir. (The following information was received by the committee :) 309 -653 O-68—-6 86 DEPARTMENT OF HeaLTH, EDUCATION, AND WELFARE STATEMENT ON THE CRITERIA . FOR THE EVALUATION OF REGIONAL MEDICAL PROGRAMS Each planning and operational activity of a Region, as well as the overall Regional Program, receives continuous, quantitative and qualitative evalution wherever possible. Evaluation is in terms of attainment of interim objectives, the process of regionalization, and the Goal of Regional Medical Programs, easily accessible improved patient care for heart disease, cancer, stroke, and related diseases. The criterion for judging the success of a region in implementing the process of regionalization is the degree to which it can be demonstrated that the Regional Program has implemented the seven essential elements of that process: involvement, identification of needs and opportunities, assessment of resources, definition of objectives, setting of priorities, implementation, and evaluation. Ultimately, the success of any Regional Medical Program must be judged by the extent to which it can be demonstrated that the Regional Program has assisted the providers of health services in developing a system which makes available to everyone in the Region improved care for heart disease, cancer, stroke, and related diseases. It is also important to note that each Regional Medical Program is encouraged to build self-evaluation methodologies into its ongoing program. These evalua- tion methodologies then form an integral part of the total evaluation of the Region’s program. A fuller description of the process of regionalization is contained in the Progress Report on Regional Afedical Programs (see p. 18) which was submitted for the Record during the hearings on H.R. 15758 and ig the process upon which interim evaluations of each program are based. Myr. Roczrs. I know on page 2, section 103, it is simply a correction to allow the District of Columbia, Commonwealth of Puerto Rico, and so forth, in. This amends the public health law itself. Doesn’t this go to the entire act 2 Dr. Lizz. Yes. Mr. Rocprs. So that this would affect every program of the Public Health Service, would it? Well, perhaps you can give us the information. Mr. Kart Yorpy (Deputy Director, Regional Medical Programs, HEW). Actually, there is a general definition in the Public Health ‘Act which does not include these additions. These additions have been made to certain other programs in the act. This is bringing the regional medical programs into line on that. Mr. Rocers. Thank you. I am delighted to see the Department sup- port this program for migrant health, which I have been interested in and helped to write the original law. And I took a very active part since then in following this program. I have been very pleased with it, Miss Johnston. I think you have done a good job, and I think it is very essential that we recognize this is a program that should be continued rather than letting it get into the partnership as yet, because T don’t think this has been well planned for in many of the States. Dr. Les. We would agree with that, Mr. Rogers, and also at the time the partnership for health comes u for review again, this would come up for review at the same time. And we would be able to then recommend, and you would be able to decide whether it should con- tinue as a separate special program or whether it could, in fact, be incorporated within the fabric of the partnership-for-health program. Mr. Rocers. When you look over a partnership plan from a State, will the Department see that this plan has in it the necessary guide- lines to carry out this type of health program 4 87 Dr. Ler. As we develop, and as the States develop the capability for planning, the purpose, of course, of the partnership for health will continue to be to create a mechanism in the States and permit the States to set their own priorities. We then review that in relation to the priorities that have been set within the States; and certainly in terms of national needs and national priorities, those are also looked at as they relate to these State plans. But we want ta have the States make these determinations. And this, of course, presents unique problems with the migrants, because they do move from State to State, and it is difficult to encompass that within any single State plan. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ESTIMATED NEW OBLIGATION AUTHORITY REQUIRED UNDER H.R. 5758 FOR FISCAL YEARS 1969-77 New obligation authority Fiscal year Fiscal year fiscal year Fiscal year Fiscal year Fiscal year fiscal year Fiscal year Fiscal year 1969 1970 i 1 1973 1974 1975 1976 197 i 1. Regional medical programs. << aenoaareerg 7 TTT it, Special grants for health of migratory workers. - Lf. Alecholic and narcotic addict ee A, Construction grants and staffing, operation, maintenance grants..--.2---re tT 5, 000, 000 25, 000, eS ee }. Alcoholic rehabilitation - --------~ . @ 000, 000) as, 000, 000) - - 2. Narcotic addict rehabilitation - .--------4- (8, 000, 000) (10, Bay oT g. Continuation costs for staffing, operation, and , maintenance tS neneseereeoeeo TT inoeseeenee 15, 309, 000 13, 276, 000 11, 242, 000 $10, 176, 000 $10, 176, 000 $10,176, 000 © $5,330, 000 1, Alcoholic ants aijot sgecnee eT «io, 424, 000) (3, 050, 000) (7,675, 000) 6, 877, 000) (6, 877, 000) ¢$ $77, 000) (3, 988, 000) 2) Narcotic addict ltlion ogi socleeeeeneee (4, 885, 000) (4,226, 000) (3, 567, 000) (3, 299, 000) (3, 299, 000) 3, 299, 000) (1, 342, 000) 29, 000, 000 180, 000, 000 215, 309, 000 288, 276, 000 361, 242, 000 10, 176, 000 10, 176, 000 10, 176, 000 5, 330, 000 Total NOA required see ————— ent Note: The projections contained in this table represent departmental predictions and do not represent the administration position on the future program or budget requirements. Personnel requirements will be dependent on program developments and budget factors which at this time cannot be fully predicted. 6IT 122 Mr. Rocers. Our next witness is Dr. Carleton ‘Chapman, dean of the Dartmouth Medical School, who will be appearing for the Associa- tion of American Medical Colleges, and he will be accompanied by Dr. Lloyd Elam, of the Meharry Medical College. Nashville, Tenn. oth of you here. ‘We appreciate your Doctor, it is a pleasure to have rom your testl- giving your time so that the committee may benefit f mony. 123 STATEMENT OF DR. CARLETON B. CHAPMAN, REPRESENTING THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES; ACCOM- PANIED BY DR. LLOYD ELAM Dr, Cuarman. Thank you, Mr. Chairman. I am Carleton B. Chap- man, dean of Dartmouth Medical School, and on my right is Dr. Lloyd Elam, who is president of Meharry Medical College. We are on this occasion spokesmen for the Association of American Medical Colleges. Our association represents the 88 medical schools in the United States as institutions, a large proportion of the Nation’s medical educators as individuals, and 330 major teaching hospitals. Mr. Chairman, I would like to point out that we would like to speak to the regional medical programs, because medical schools are inti- mately involved in these programs, and while we favor in general the other provisions of the bill, we can claim special expertise in these areas. We spoke before this group in favor of the adoption of the heart disease, cancer, and stroke amendments in February 1965, but em- . phasized that the Nation did not then possess enough trained personnel to carry out the provisions of the proposal. At the time, our spokesman noted that our medical schools, originally set up solely to train physi- cians, were already developing into medical service centers with con- stantly expanding responsibilities in the health field. He went on to say: This experience makes it clear that the professional and institutional relations are complex and delicate. It also makes it clear that it is painfully difficult to procure and maintain an adequate supply of trained manpower. A functioning regional complex .. - would make the efforts of the practicing physician more effective, but the development and operation... will require a marked in- crease in trained manpower. He also noted that the success of a regional complex is heavily dependent on the continued and growing effectiveness of the medical school and the medical center. At this time, 3 years later, we consider these observations still highly pertinent. But, in general, we believe the discernible effects of Public Law 89-239 to date have been salutary. It has created a mechanism by means of which the Nation's medical schools have begun to relate to community and consumer health needs, and to work with man lay and professional groups in designing new methods of coping wit. these needs. It has initiated the organization of the Nation into re- gions, for the purpose of delivery of health services, very effectively. ‘And although this organizational process has not yet proceeded to completion, the results to date more than justify the passage of the law. We are well aware that efforts to implement the legislation have been associated with many problems. Regional organizational struc- tures and, for that matter, the definitions of regional boundaries, are in some instances unduly complex and clumsy. Some health profes- sionals complain that they do not understand the intent of the law and some are suspicious of it. Lay and professional groups which, in some regions, are attempting to reach joint decisions for the first 124 time, are having some difficulties. And occasionally one hears the view that the medical schools are attempting to use the law asa meals of gaining control of the Nation’s health care system. But in our view, these difficulties were to an extent predictable and inevitable. The important point is that the law, by mobilizing local initiative, is effecting a cooperative attack on health problems which, although highly necessary, had not been operative before. In our view the general consensus lay and professional is highly favorable to the law. oo, ; The medical schools themselves have had difficulties in discharging their obligations under the law. Many of them, when the Jaw was assed, had no administrative personnel that was capable of dealing with these new responsibilities. In some instances programs develop- ing under the law involved commitment of professional personnel that is already fully committed. Far from attempting to take over control of the program many, and perhaps most, medical schools have been slow to become involved largely owing to shortage of ersonnel. This has been especially acute as the schools move to begin to meet the growing shortage of physicians. Yet there is no doubt in our minds that our medical schools wish to be involved as effectively as possible, not to gain control but, in keeping with the intent of the law, to make their talents and facilities more readily available to all who need them. But this vital matter, and the equally vital matter of improving and expanding our educational function, together constitute an obli- ation that cannot be met optimally in a few months, or even perhaps in 2 or 3 years. The medical schools seek no special privilege under the regional medical program law but wish, on the contrary, to as- sist materially in its successful implementation. We believe that the original law has operated exceedingly smoothly, considering the nature of the planning processes it has initiated. We also believe, however, that enough experience has been or soon will be gathered to justify a few minor procedural alterations. When the law first began to be implemented, there were no generally applicable prototypes for regional organizations of the general types specified. ‘A number of different patterns have now emerged, some more effective than others. It may, in our view, soon be appropriate for more defini- tive organizationa guidelines to be provided by the Division or Re- gional Medical Programs. Tt will also be appropriate in the future to reconsider critically the geographic structure of the various regions. he responsibility and authority of advisory groups, many of which are too large to function effectively, require clearer definition. And the main thrust of the legislation requires, in our view, to be restated and clarified. Tt has been frequently noted that its central focus of the law is the patient and his needs. This is unquestionably true. But a more rele- vant way of saying the same thing is to indicate that the law proposes to “* * * afford to the medical profession and the medical institutions of the Nation, through cooperative arrangements. the opportunity of making available to their patients the latest advances in the diagnosis and treatment of the diseases named in the law.” In other words, the law provides us with the means and authority to find ways of assisting physicians and other health workers to pro- 125 vide American citizens, wherever they may be, with better health care and to provide that care more efficiently. ; iy Cooperation between lay and professional groups in designing such methods has, in general, been most impressive, but the balance has not invariably been ideal. Good faith and understanding between such groups cannot be created overnight, but one of the most striking accomplishments of the original law 1s that it has set the stage for the development of effective cooperation between these groups. The original law is accomplishing ;what it seb out to do but the ace at which such developments can proceed must be viewed real- istically. We are not in agreement with those who say that the pace is unsatisfactory; on the contrary, the rate at which planning has proceeded has, to date, been very impressive, owing In No sina measure to the understanding and wisdom which have characterized the administration of the law. The next 3 years will be critical ones in that what has been done will have to be critically evaluated; that which is successful must then be encouraged; that which is inefiective discarded, At this stage, as in the planning phase, the medical schools can and no doubt will render signal service. We believe, Mr. Chairman, the law should contiriue to operate for the present without substantive change but that the results it is producing must soon begin to be critically evaluated and scrutinized. The Nation’s medical schools are now involved, for the most part, to the extent of their capabilities, not in an effort to gain control, but rather to help to rovide the Nation a critical service. And as we go about meeting our obligations under the law, we seek the understanding of our critics ; those who feel that we are reaching for dominance, no less than those who feel that we are not moving fast or vigorously enough on the other. Weare, Mr. Chairman, placed squarely in the middle but we recognize that the essence of the regional medical program activity is vital to the welfare of the Nation. It is one of several major obligations which we must discharge. Mr. Rocers. Thank you, Dr. Chapman, for an excellent statement. I might say, too, that I recall that many of your suggestions were accepted by this committee in the writing of the original law. You were most helpful to the committee. . ine questioning, if we could have a statement from Dr. Lloyd am. Dr. Evam. Mr. Chairman, my name is Lloyd Elam. Iam president of Meharry Medical College in Nashville, Tenn. Before assuming that position, I was chairman of the Department of Psychiatry at Meharry and for a brief time, dean of the School of Medicine. I speak today as an official representative of the Association of American Medical Colleges and wish to comment specifically on rela- tionships between regional medical programs and medical schools. L come before you today as one who has had direct experience with a regional medical program, & program which is already entering the operational phase after having made remarkable progress in bringing together various health resources in the Midsouth area during its plan- ning phase. I have a deep concern about the availability and quality of health care among the poor, especially in our cities; I am particularly 126 interested in what regional medical programs can do in this critical area. The regrettable fact that my institution, Meharry Medical College, has limited personnel and resources allows me to emphasize the point that the responsibilities we assume under regional medical programs must not become a drain on our finances or our manpower. Thus, as we enter into cooperative arrangements with other health resources of our region, to improve diagnosis and treatment of heart disease, cancer, and stroke, we must do so without jeopardizing our primary educa- tional obligation. Within these constraints, Meharry and the other medical schools of the Nation wish to express a strong sense of responsibility for the health problems of the communities that surround us. Regional medi- cal programs offer an opportunity for such involvement. Indeed, we see in them the possibility for strengthening our colleges to carry out their unique obligation n community health, especially in the derel- opment of better ways to apply new and advanced procedures and im- proved ways of educating health personnel for this task. Let me describe Driefly how the Tennessee Midsouth regional medical rogram came «nto being and what we expect to accomplish in the next ew years. The program was initially established through the co- operative endeavors of & wide variety of interested groups in Ten- nessee and southern Kentucky. The discussions involved Meharry Medical College, Vanderbilt Uni- versity School of Medicine, Hospital and Health Planning Council of Metropolitan Nashville, private hospitals, medical societies, public health agencies, and voluntary health organizations. A regional adv1- sory group was established and planning funds were received in August 1966. a In our area, as in many regions across the country, the bringing together of these interests for planning purposes has resulted in an en- tirely new perception of health problems of the region and of new ways to solve them. 1 can indicate the extent of our progress by telling you that in June 1967, a little more than 10 months later, a request was made for operational funds for 34 projects to be carried out in the region. The projects varied widely in content and in scope, but each yas concerned with solving & articular health care problem in heart disease, cancer, Or stroke which had been identified during the plan- ning process. . a One project which typifies the region’s activities, and allows me to speak toa particular pro lem that we at Meharry are addressing, is the regional medical any project concerned with long-term evaluation of the health status o 30,000 underprivileged persons In an urban pov- erty area known as north Nashville. ° Our department of family and community health, in conjunction with the Office of Economic Opportunity, is establishing a neighbor- hood health center for this group of needy people. This is, aS you can imagine, a large undertaking and one ewhich requires & great deal of medical skill and effort. One of the major problems is to determine ex- actly what type of health care is actually required by these persons. Another, of course, is to measure the quality of care and to find out if it is actually achieving what it sets out to do. The regional medical 127 program is supp sng the means by which Meharry, with the coopera- tion of Vanderbilt University, can, establish 2 multiphasic screening Jaboratory as an adjunct to the neighborhood health center. The co- operation with Vanderbilt involves consultation and computer serv- ‘ces needed for the automated laboratory procedures and recordkeep- ing. Regional medical program support will help us uncover heart: disease, cancer, and stroke in this population in the earliest stages, provide documentation of the incidence and type of these disorders, aS- sist in the initiation of necessary treatment, and aid in evaluating the treatment these patients receive at the neighborhood health center. The potential of a cooperative arrangement between a multiphasic screening laboratory for the identification of need for medical care through early diagnosis and of a neighborhood health center for meet- ing that need is very great. This activity would have been difficult, if not impossible, to undertake without the help of regional medical pro- grams. Many of the essential and important elements of regional medical programs are present in this one project: The bringing to- gether of previously disparate elements of the medical care system— providing of manpower and funds to get things done—and the coming to grips with the really significant health issues of our region. Fhe involvement in regional medical programs of Meharry and Vanderbilt medical schools and of many other medical schools in this country, is far from superficial. Indeed, in many areas the medical school was instrumental in the establishment of the regional medical program and these institutions have lent their expert assistance in launching this major new program. They are accepting responsibilities beyond the traditional ones of teaching medical students and conduct- ing research. They have begun new programs to translate more promptly the fruits of medical research into improved care for the people within the regions that they serve. I shall like to close simply by giving my earnest and enthusiastic support to the legislation extending this program. I sincerely hope that you will agree with my estimation o its great importance. Thank you for the privilege of speaking before you today. Mr, Rocers. Thank you, Dr. Elam. ‘Are there any questions ? Mr, Kyros. I have only a few questions. Dr. Chapman and Dr. Elam, I want to welcome you here and thank you for your statements. Dr. Chapman, on page 2 of your statement you include in your re- marks that occasionally one hears the view that the medical schools are attempting to use the regional medical program for the purpose of gaining control of the Nation’s health care system. Would you kindly expand on that a little bit? What is the problem there? I didn’t know such a problem existed. Dr. Crapman. This is something that has largely begun to dis- appear, I think. We heard this a good deal when the law was first passed. In addition, we have heard fears expressed that the medical schools might simply take funds that were available under this law and use them for standard, ongoing medical school purchases. Of course, this is not possible under the law, and I think I can state with assurance that no medical school is doing that, Most of us have 128 attained small amounts, relatively small amounts of funds in order to find the personnel, provided the personnel that we needed to enable us to be involved effectively in this program, but I don’t think, Mr. Kyros, that these criticisms are at the moment very serious. Mr. Kyros. In the State of Maine, I have been told by doctors that one of the valuable benefits of this program is that in a State where you don’t have a medical school, as in Maine—and I imagine there are “ther States in the United States that don’t have a me ical school— you serve an educational function by disseminating vital and cur- rent information to doctors who normally would not have that kind of information. Dr. CHAPMAN. Yes, sir; and many of us who are deans regard many of the most important aspects of this activity to be the continuation education feature for physicians, and in our own northern tier of States, Mr. Kyros—of course, we represent three regions there, Maine and Vermont are separate regions, and Maine is tied in with New Hampshire. We are meeting regularly with the Maine and the Vermont regional medical program officials, and one of the main things is this: the con- tinuation of medical education. Mr. Kyros. On page 4, you talk about the desire, perhaps, in the act to obtain a more definitive organizational guideline and to reconsider critically the geographic structure of the various regions. What spe- cifically are you suggesting ? Dr. Cuapman. New England is a good case in point. As you well know, sir, New England for a lon time was been working itself as a region with the northern tier of States focusing for many purposes on Boston, and to some extent on Montreal and Albany as well. Our present regional structure will undoubtedly have to undergo modification. In fact, I would say it already is in a functional sense. The northern tier of States is a similar region in terms of population, climate, geography, and medical health problems. Mr. Kryros. On page 4 again, you Say cooperation between lay and professional groups in designing such methods—that is, of getting the latest advances in diagnosis and treatment translated into action for the patient have been most impressive, but the balance has not been invariably ideal. What does that mean? Dr. Cuaruan. I think it is a matter of groups that have never real- ly worked together before are now having to do so, and as I said earlier, T think, in the State, some such difficulty was inevitable and indeed predictable. In our own area, the balance is coming around very nicely, as I see the operating in the advisory group, which has brought together people who ad certainly never approached any serious proposals together jointly. Mr. Kyros. Do I understand your testimony this morning to be en- tirely in favor of the program that 4s set forth in the act before us today ¢ Dr. Cuapacan. Yes, sir. We would consider it very distressing in- deed if it were not continued. It 1s at the point now. where we wil begin to obtain the critical information we need in order to bring forth a program that will really do the job, and will really carry out the intent of the original act. 129 Mr. Kyros. Are you satisfied with the $65 million provided for fiscal 1969? . . Dr. Cuarman. I am really in no position to speak to that. T believe under the circumstances +t Will take us the next step. ; ; Mr. Kyros. Dr. Elam, I understand your multiphasic screening turned up uterine cancer in patients that would not otherwise have been found. Will that be continued ? Dr, Evam. Yes, sir; and the results of the screening will be sent to a doctor in the anticipation of turning up such things. Mr. Kyros. Thank you. _ Mr. Rocgrs. Dr. Carter? Dr. Carrer. No questions. Mr. Rogers. It has been helpful to have your testimony, and we appreciate your sharing your knowledge wit the committee. I hope that you will let us have your suggestion for any improvement that you think the program Should undertake. Particularly I am con- cerned about bringing in, more hospital people. I think maybe this balance that you are talking about the people in the program, along with the medical people—I think it has got to involve more people, and I would like to get more details if you could submit that to us, on your examination program. T think this could be most helpful to the committee. . Dr. Cuarpman. Thank you, Mr. Chairman. Mr. Rogers. Thank you. The committee stands adjourned. (Whereupon, at 12 :30 p.m., the committee adjourned, to reconvene at 10 am., Wednesday, March 27, 1968.) REGIONAL MEDICAL PROGRAMS, ALCOHOLICS AND NARCOTICS ADDICTS FACILITIES; HEALTH SERV- ICES FOR DOMESTIC AGRICULTURAL MIGRATORY WORKERS WEDNESDAY, MARCH 27, 1968 Housn or REPRESENTATIVES, SUBCOMMITTEE ON PUBLIC FisaLTH AND WELFARE, CommMiTTer on INTERSTATE AND Foreren CoMMERCE, Washington, D.C. The subcommittee met at 10 a.m., pursuant to notice, in room 2322, Rayburn House Office Building, Hon. Paul G. Rogers presiding (Hon. John Jarman, chairman). 131 133 Mr. RocERs. Our next witness 18 40 old friend of this committee, Dr. Michael De Bakey, chairman. of the Department of Surgery, Baylor Univer- sity College of Medicine, Houston, Tex. { might say that Dr. De Bakey was on the President’s Commission for Heart, Cancer, and Stroke, which was really the guiding force for the formation of the regional medical program. It is a pleasure to have you with us, and we are pleased to receive your testimony at this time. STATEMENT OF DR. MICHAEL De BAKEY, CHAIRMAN, DEPARTMENT OF SURGERY, BAYLOR UNIVERSITY COLLEGE OF MEDICINE, HOUSTON, TEX. Dr. De Bagey. Thank you. I am grateful for the opportunity to again appear before this committee, as I did on July 7, 1965, in sup- port of the regional medical programs and to report on their progress. T would like to tender my thanks for what this subcommittee and the entire Committee on Interstate and Foreign Commerce have done to develop this program, a program which is already setting © pattern for enhanced medical care within the Nation. T come before you in strong support of title 1 of H.R. 15758, intro- duced by the chairman of your full committee, Mr. Staggers. T have been a member of the National Advisory Council] on Re- - gional Medical Programs since its creation, and I, therefore, have had the opportunity to see this program in its planning phases, and see it develop throughout the country as we hoped it would. There have been times when I have been guilty of impatience, but the fact is that this program has developed, I think, at a normal pace and in a very sound way. Now we are at a point where I think we will begin to see the first fruits of this program in terms of its original objective, which was to provide the best possible care for the patient at all levels of our society, and to extend this kind of care to every citizen. T his was a need we have recognized but were not able fully to achieve in the past. I believe this program will achieve its main objectives ; certainly in the fields of heart disease, cancer, and stroke, and hopefully in all the related areas. ‘At this time there are certain aspects of the legislation I would like to discuss in more specific terms. You will recall, Mr. Chairman, in the original testimony, and in the original bill, there was much discussion of construction authority. J think the committee was wise in pointing out that without this type of authorization for new construction—there was authorization 134 for renovation—that the program would not be jeopardized in the planning phase. Now, however, we are in the area of actual operation, and already there are 11 programs functioning. I would say by the next several months, perhaps 40 or 50 percent of the programs will be in some phase of operation. So we are moving, you see, quite rapidly. . As we move into this area, construction needs will become increas- ingly more apparent, and already we have evidence of this need. This construction is fairly specific in nature and fairly limited in scope. It is not on the same scale as already existing construction needs within the medical centers—construction for which the centers already have the authorization if not the money. Now, the construction authority we need for the regional medical programs applies primarily to the community hospitals and to the more peripheral units, where the past construction has not anticipated this type of program. In the Surgeon General’s report there is documentation and outlin- ing of the various types of construction needed. What I should like to do, Mr. Chairman, rather than take your time now, is to submit a formal statement for the record within the next few days. I had hoped to have this ready for you today, but I got involved in a series of emergencies over the weekend. Mr. Rocers. We understand, and without objection, your formal statement will be made a part of the record, following your testimony. Dr. DeBaxey. This is the limited but well- lefined need for new construction. I leave to the committee’s judgment as to how this best should be met. ‘Allow me to point out that it ‘s essential for the future of the pro- gram to find means of meeting these needs of the community hospitals. These needs include construction space for classrooms; particular types of diagnostic facilities, laboratory space of special types; and treatment units relating to heart disease, cancer, and stroke. The out- lying hospitals simply do not have this type of space available, and frequently have no means of finding the funds to provide this kind of construction. Finally, Mr. Chairman, I would emphasize that we have reached the stage in this program where we must look to the funding levels over the next 3 to 5 years. As we move More and more into operation, 1 think the cost of these programs will reach the figures we visualized in our original concepts and the original proposals in the President’s Com- mission’s report. You will recall that we expect this to reach authorization levels of wel} over $450 million by the end of 5 years. Now we are beyoud that point in our thinking, and we now have better evidence of what the needs are going to be. T would say they will approximate $5 or $10 million in each region within the next 5 years. Therefore, I would hope the committee will contemplate authorization levels of some $500 mil- lion within the 5-year period. This level will not be reached soon, of course. However, T would think by 1971 we would be close to the $300 million level. { would hope by that time the opportunities to provide funding at this level would be more readily available than at this moment. 135 Mu. Chairman, I will be glad to answer any questions you have. Mr. Rocers. Thank you very much, Dr. DeBakey, for giving us your viewpoints on this program and its importance. Could you give us an example of one region that you may be aware of, or maybe you would want to do this in your statement. ‘Dr. DE Baxey. Well, rather than take your time about it, let my statement provide this information. I would like to discuss an area where they have not only accepted the total concept of the prograin but are utilizing the program in 2 most efficient way to provide the particular three elements that I think are essential: research, educa- tion, and patient care. These three elements must be combined at the level at which the physician meets the patient. Mr. Rocers. This has been my concer! with the program, and I realize it is still very young. But T am beginning to get feedbacks that the program is not reaching the practicing physician yet. It is not a to the hospital. It has stopped at a little higher level, at the dean’s office. Dr. De Baxey. This is understandable at the planning stage. Only at the operating stage will they begin to feel the program. The most important thing to me 1s the fact that the program is be- coming better understood by the practicing physician, and there is developing an enthusiasm for the program at the grassroots level that really is in striking contrast to some of the earlier experiences. Mr. Rocers. That is right. I remember very vividly. I think it might be helpful to point out some of these areas where you feel the program is being effective in getting to the community hospital, and where the people in the community are really beginning to receive the benefits. This would be helpful to the committee, and also to spread it wpon the record so that other areas can see what is being done m the most successful programs. Dr. Dz Baxey. I will be very pleased to do this and include it in the statement I will file with you. Mr. Rocers. Thank you. Mr. Kyros? Mr. Kyros. We are happy to have you here, sir. These programs of construction that you are talking about would still have to be initiated at the local level and passed on by the Ad- visory Council. Dr. Dr Baxry. Yes; and they would also have to show justification as being within certain guidelines, as being essential to the efficacy of this program. There are all kinds of construction needs, but we have various types of construction authorities, and I would think the important thing is that we limit the construction to the needs of this program: that 1s, where it can be demonstrated unequivocally that without the construc- tion space the program couldnt be effective, couldn’t be implemented. Mr, Kyros. I don’t know how familiar you are, sir, with the money requirements of the program; but the figures yesterday were that it srould be about $30 million carryover from the last fiscal year, and the bill this vear carries $65 million. Do you think $95 million will be enough for this kind of planning this coming year! 136 Dr. Ds Baxzy. Well, if I read the situation within the next year correctly, I would say we would come close to that, certainly; and don’t think it is going to jeo ardizethe program. , What I am concerned about is when we get into the operational phase within the next—well, say by 1971. I would say within this 2- to 3-year period we are going to see a real escalation in activity and, there- fore, in funding needs. Mr. Kyros. I understand, thank you very much. Mr. Rocers. Mr. Nelsen? Mr. Nevsen. I have no questions. Mr. Rocers. Dr, Carter? Mr. Carrer. It is an honor, Dr. De Bakey, to have you here. You are 50 well known to many of us as being absolutely dedicated to the serv- ice of humanity. Weare honored to have you here. T would like to ask about how the funds that you want—are they to be for something similar to intensive care units in different hospitals? Dr. Dr Banzy. Yes. Well, some of them would be used in that way. For example, let us take the community hospital that is in a program. They need and can use, and in a sense can support, an intensive care unit; but the hospital is built in such a way that they can’t even reno- vate space. You are familiar from your own experience, I am sure, in your own area of Kentucky, where hospitals, even those built with Hill-Burton funds, are now So jammed that it would be denying the use of the space for some very essential purpose. So they need additional space. To build this, they have to have money. It may be a relatively small sum. It may amount to a hundred thousand dollars, but it is still money that is hard to find for this purpose. ‘An intensive care unit would be one wing. Another would be—I hope my colleague will point this out in his testimony to you—in terms of acute stroke units. There will be diagnostic facilities of certain specific character. ; We point out in the Surgeon General’s report, which the Council had the opportunity to review, the types of space needed. They will need classroom facilities. This 33 the kind of space that is essential to carry- ing out the program. r. Carrer. Certainly we have seen that many of our hospitals in the smaller areas, and I am sure it is true in cities, that in the past few years building has taken place, but still it is inadequate. Dr. De Baxsy. Completely inadequate, and also 1b doesn’t take into consideration these kinds of needs, They didn’t even visualize these needs in the early plans. heir concern was with immediate needs that they had to meet. . Mr. Carrer. I see the need of these things. Dr. Ds Baxer. May I say to you, Dr. Carter, that it was part of your understanding that helped produce this program, and I want to thank you again for your insight into this whole program. Mr. Carter. Thank you, sir. Dr. De Bazey. It was tremendous help to us. Mr. Rocers. Mr. Skubitz? Mr. Sxusitz. Thank you, Mr. Chairman. 137 _ Thave no questions, Dr. De Bakey, but I want to join my colleagues in weleoming you here today. I am looking forward to receiving your recommendations. Dr. De Baker. I want to express my appreciation to the commit- tee for the wisdom and kindness and generosity they have shown, and it is good to know there are public servants like yourselves. Mr. Rocers. Thank you. (Dr. De Bakey’s prepared statement follows:) STATEMENT OF MICHAEL BE, De Baxey, M.D., PROFESSOR AND CHAIRMAN, DEPART- MENT OF SURGERY, BAYLOR UNIVERSITY COLLEGE OF MEDICINE, IioustTon, TEx. Mr, Chairman and members of the subcommittee, I am Michael E. De Bakey, Professor and Chairman of the Department of Surgery, Baylor University Col- lege of Medicine, in Houston, Texas. I had the honor of being named by President Johnson as the Chairman of the Commission on Heart Disease, Cancer, and Stroke, whose report led to the initial recommendation of the Regional Medical Programs legislation which this committee developed and passed in 1965, Since its creation, I have been a member of the National Advisory Council on Regional Medical Programs and am also a member of the Regional Advisory Group of the ‘Texas Regional Medical Program. I testify today in strong support of Title I of H.R. 15758 introduced by the distinguished Chairman of your fuil committee, Mr. Staggers. If enacted, Title I would extend the authorizing legislation for Regional Medical Programs for an additional five years as well as clarify certain technical aspects of P.L. 89-239. I would like briefly to reiterate the basic concept of the Regional Medical Programs, the future of which this subcommittee is presently considering. The Regional Medical Programs comprise a group of units added—wherever possible—to already existing medical centers in regions throughout the country. ‘The units are part of the overall research, teaching, and medical care going on ‘within the medical centers in regard to heart disease, cancer, and stroke. These units together make up a national network for research, for teaching new developments to doctors and nurses, and for care of patients under investi- gation. Thus each physician served by this network has, readily accessible to him for his patients, the full range of up-to-date knowledge and skills developed through nation-wide research. At the same time the doctor epntributes to re- search, for his observations add to the total knowledge. Each of these units we are discussing has its own facilities and staff, though they function as part of the existing medical work force, to pull together and strengthen the medical resources now in existence. The Regional Medical Programs as initially authorized, placed principal em- phasis on regional voluntarism, as the means by which their goal might be achieved. Today I can report that your confidence in this approach has been -well placed. Within the last three years 54 Regional Medical Programs have been brought into being. By this summer approximately one-half of these will have entered the operational phase. The remaining regional programs will shortly thereafter begin operation. With its emphasis on voluntary cooperation the Regional Medical Program mechanism has managed to harness the creative energies of practicing physicians, hospitals, medical schools, voluntary, state and local health agencies. All too frequently in the past these creative energies have been isolated from one another or, even worse, in competition. Regional Medical Programs make it possible for all providers of health services to combine their strengths to improve the care of patients with heart disease, cancer, or stroke. Thus our aspirations of 1965 today are working entities. One of the most important developments is the large and increasing involve- ment of the medical profession. In a recent speech the President-elect of the American Medical Association said, “As a whole, the medical profession at the beginning of the year 1968 is probably more deeply involved in the planning process to determine the nature of the Regional Medical Programs than it has ‘been in the planning of any previous Federal program.” Now in considering the future of these Programs, Mr. Chairman, I would like to discuss the legislation before your committee. I was disappointed to 138 find that Title I of the bill does not propose to broaden the construction authority for Regional Medical Programs. During the initial hearings before the Inter- state and Foreign Commerce Committee on Regional Medical Programs in 1965, there was much testimony that construction authority would be necessary if the requirements of the legislation were fully to be met. The committee 1n modifying the bill deleted the authority for new construction. In its report on the bill the committee reasoned that the program would not be jeopardized by the lack of such authority in its jnitial planning phases. Furthermore, the committee felt in those instances in which new construction might be require for Regional Medical Programs, other Federal sources of funding should be sought. Finally the committee in its report indicated its intention to review this question at the time of the legislation’s extension. Mr. Chairman, I would like to commend the committee’s wisdom on this matter. In fact, the Regional Medical Programs have not been jeopardized during these past three years, during which they haye organized themselves, planned their programs and begun to enter the operational phase. However, this situation is rapidly changing. Already 12 of the 54 Regional Programs are operational and within the next year or so all of them will have begun operations. Accordingly, their needs for additional facilities will rapidly increase. The Surgeon General’s Report to the President and The Congress 02 Regional Medical Programs documents the case for limited Regional Medical Program construction authority. It is extremely important to understand that these facilities would principally be located in community hospitals, not our medical schools, Examples of needed community hospital construction described in the report juclude class and conference rooms for regional continuing education programs, space for special demonstrations of community patient care, and expanded diagnostic laboratory facilities. These needs are not now being met under existing Federal construction pro- grams. There are two interrelated reasons for this: (1) The competition for Federal funds for the construction of health facilities has grown enormously as 4 result of an overwhelming demand for such facilities. (2) By definition, the nature of Regional Medical Program construction needs goes beyond the needs of a single institution to the needs of the region. Accordingly, it is unreasonable to assume that any single jnstitution would be willing to divert its scarce funds for matching purposes when the benefits of the facility are intended for many institutions. Since it is essential that there be no substantial distortion of the concept of Regional Medical Programs, I concur that rather strict limitations should be placed on this vitally needed construction authority. The kinds of limitations one finds in the Surgeon General’s report, having to do with the amount of funds available for construction purposes, seem entirely reasonable to me. Having considered the limitations, what kind of Regional Program projects are we working to generate? How does such a project work? An example of the effective implementation of the program involving community hospitals is pro- vided by the Rochester (New York) Regional Medical Program whieh has jnaugurated an initial five-part operational program in the area of cardiovascwar disease. Each part is specifically designed to meet observed or expressed needs in the delivery of specialized medical care to the heart patient. One project will provide postgraduate training in cardiology for general practitioners and inter- nists who practice medicine in the ten counties which make up this region. Sev- eral different training programs will be offered so as to best meet the individual needs of the physicians who will participate. This program is being persented in direct response to the requests of physicians for this type of assistance, One phase of this program includes visitations to peripheral hospitals by the eardi- ologists who will provide this instruction. Certain audio-visual equipment will be placed in these peripheral hospitals for continued use by the local physician. A parallel program will present intensive month long courses to prepare pro- fessional nurses in the management of coronary care units. The growth in the number of coronary care units which provide essential medical care during the acute phases of cardiac illness, has created an urgent need for an increased num- ber of well trained nurses; the latest advances in nursing techniques and modern life-saving equipment demands specialized instruction in the nursing skills re- 139 quired. Hospitals in the region have already expressed their intent to have nurses participate in this program as soon as it is activated. The objectives of this program go beyond that of supplying specially trained nurses for coronary care units in general hospitals; every effort will be made to train coronary care unit nurses from the smaller community hospitals as well, even though they may not as yet have such a unit. Three additional activities will also be pursued under this initial operational program, A regional laboratory will be established for education and training of medical personnel in the care of patients wnth thrombotic and hemorrhagic disorders. This is the first such facility in the region and will be based in one of the general hospitals participating in the Rochester Regional Medical Pro- gram, A region-wide registry of patients with myocardial infarction will be implemented which will gather uniform information from the coronary care units of participating hospitals and provide immediate as well as longitudinal data for analysis. A relatively small amount of funds has been made available to the region to develop the first learning center in the region where some of the educational programs in heart disease, cancer, and stroke may be preseuted to physicians and nurses. The first year award for this multifaceted program in cardiology is $343,729. Having described an example of what we are building, Mr. Chairman, I should like finally to say a word or two about the level of funding I believe essential if Regional Medical Programs are to have a fair chance to achieve their goal. We all realize that the maintenance of health is assuming an increasing!y important role in our socio-economic area of concern and activities. The health industry today accounts for an expenditure of $50 billion but it is scheduled soon to increase to an expenditure of $75 billion. If the Regional Medical Program is to fulfill its function as the interface be- tween the moving parts of this health care mechanism, it must continue to be able to influence that increasingly expensive device. We would be short-sighted engineers, indeed, to derive authorization ceilings for the next five years of this program by looking backward at the cost of these programs at the time they were being planned. The cautious development of those programs has unleased a chain reaction of operational activity which will necessitate substantially increased funding levels. It is already clear that on the average these programs will be operating at a level of between $5 milion and $10 million each within the next five years. It is, therefore, necessary that an authorization level of roughly $500 million be used as the yardstick with ’ which one measures the funding levels of the program contemplated by this extension. Mr. Chairman, I am indeed privileged to again have the opportunity to present my views to the committee which has done so much to shape health legisla- tion in general and the Regional Medical Programs in particular. Mr. Rocers. Our next witness is Sidney Farber, director of research, Children’s Cancer Research Foundation, Boston, Mass. Dr. Farber is also an old friend of the committee, and he was helpful in the formulation of the original legislation, having served as chair- man of the Cancer Panel of the President’s Commission. Welcome back, Dr. Farber. STATEMENT OF DR. SIDNEY FARBER, DIRECTOR OF RESEARCH, CHILDREN’S CANCER RESEARCH FOUNDATION, BOSTON, MASS. Dr. Farser. Thank you. It is a great honor to be once more before this committee, where my memories are as heart warming as any mem- ories I have in my entire professional career. I join Dr. DeBakev and all our colleagues in expressing gratitude to this committee and Congress for starting what I regard as the most important program in the field of medicine in the history of our country that is applied directly to the care of the patient. I speak strongly in favor of H.R. 15758, the purpose of which is. among other things, to amend the Public Health ervice Act so as 140 to extend and approve the provisions relating to regional medical health programs. I join my colleague, Dr. DeBakey, in stron, recommendation for construction funds, and I will give one example of this later, which will illustrate the great need for construction funds in this program. What we are asking today is authorization for the next 5 years for these funds, with the hope that funds will be available, released from other sources, which will make the support of this program and so many other worthy programs before the Congress possible. I would like to say just a few words about these programs. There has been a magnificent beginning already. I want to give evidence that the administration is excellent under Dr. Marston in the division of regional medical programs, and that the Council and advisory boards are composed of wise and courageous men. who are not afraid to say no, nor are they not afraid to say yes, in the approval of programs that deserve approval. ; ; ; T have the privilege as a member of the National Advisory Council to represent that council to the Regional Medical Programs Council; this is my second year of watching and listening wit great appre- ciation and helping, when I am asked for help, in the deliberations of these advisory boards. The regional medical program represents the first time in the history of American medicine where all segments of society concerned with the health of our people have come together to achieve a common goal of better health, reservation of lives, and the prolongation of good life for people who suffer from these dread diseases. This is a great triumph in itself, and would be worthy of the entire cost of this program if this were the only spin-off of what has been done. The regional medical programs, quite simply, are concerned with bringing to every man, woman and child suffering from these dread diseases, and eventually, I hope, from all diseases, all that is known today that might save lives or prolong good life. This is accomplished in the simplest terms in two ways. We begin with the community hospital and the doctor in practice. We give added strength first in manpower in trained personnel in those community hospitals, and, second, technical facilities for what is lacking. And we link these community hospitals with so-called “centers.” These centers are not buildings in one place. They are not in one building, but they represent a portion of a given region where there is a concentration of expertise in medical schools, teaching hospitals and research institutions, where there are facilities and manpower and expertise that cannot be duplicated endlessly. The country just can’t afford that. If we can bring these two segments of the medical community to- gether, the community hospitals and these medical complexes, and with good means of communication in the modern idiom for rendering diagnostic assistance and therapeutic advice, we will achieve some- thing that in the field of cancer, and other fields, will bring great rewards. I want to mention figures that I had the privilege of mentioning once before before this committee. a a a 141 In cancer, if we could bring to every man, woman and child every- thing that is known in diagnosis and therapy today, there would be a saving of 100,000 to 300,000 who are destined to die of cancer this year. In the field of heart disease and the field of stroke, this can be multiplied as evidences of what this program can accomplish. For the remaining 200,000 of the 300,000 for whom we have nothing available today and who will die of cancer, we require research. The great research programs of the National Cancer Institute and the American Cancer Society and the many private institutions of the country will provide the research in the course of time which will bring answers to the problems which cannot be answered today. But if we can focus our. attention on those who can be saved with knowledge presently available, this goal is worthy enough. I want to point out one example in regard to construction. You are familiar with the great returns from the privtae sector to the Hill- Burton Act and to the Health Facilities Construction Act, and so on. In those there has been an outpouring of private money. That will hap- pen here, too, in those parts of the country where the private sector ean aid. In those where the private sector is unable, this program should shoulder the entire burden, because human life is precious wherever it is, There is one example that I learned about just before coming here. The community of Anchorage, Alaska, in response to the needs identified by the Washington-Alaska regional medical program, for high-energy radiation facilities closer than Seattle, Wash., is now conducting a campaign to build the facility. Solicited private funds will be used to construct the housing for the equipment, which is very expensive, . . The equipment will be purchased by the regional medical program. The treatment center will be operated as a regional resource by the Providence hospital, as planned and approved by the local and and regional advisory groups. : The decision to support the activity involves cooperative arrange- ments at another level also, and of this I am very proud. The National Cancer Institute conducted the site visit, which gave assurance of the sound scientific and professional basis of this project. Here is a beau- tiful example of two segments of the National Institutes of Health cooperating. . I have just heard that the Anchorage Construction Trades Council, comprising 14 unions, have taken on the construction of the building, contributing more than one-half of the total cost from this one source alone. This is heart-warming, indeed, to see a community as a whole joining with a Federal program in aidin people suffering from can- cer by providing a form of treatment that had been lacking in that part of the country. The time has come now to recommend greater support for this pro- gram on the basis of the fine progress which has been made. You have already heard from Dr. DeBakey in response to questions for the amount which is recommended for this year. May I mention two other figures? By 1971 this program should be supported by an amount no less than $300 million, not counting construction. And we should reach TEES 142 the figure of $500 million within 5 years’ time if we are to utilize to the full the strength of what has been mobilized in the various regions of the country in behalf of the health of our own people. I close these remarks, Mr. Chairman and gentlemen, confident in the belief that the leadership to the Congress offered by your com- mittee will permit these regional medical programs to make a truly great contribution to the health of all of us. Thank you. (Dr. Farber’s prepared statement follows:) STATEMENT OF Dr. SipNEY FARBER, DrrEcTor oF RESEARCH, CHILDREN’S CANCER RESEARCH FouNDATION, BosToN, Mass. Mr, Chairman and members of the Subcommittee on Public Health and Welfare. it is with gratitude that I acknowledge this opportunity to appear before you in strong support of H.R. 15758, the purpose of which is, among other things. “te amend the public health service act so as to extend and approve the provisions relating to Regional Medical Programs.” My name is Sidney Farber. I am founder and Director of the Children’s Cancer Research Foundation in Boston, and Chairman of the Staff of the affiliated Chil- dren’s Hospital Medical Center. For almost 44 years I have been associated with Harvard Medical School as a student and member of the Faculty, where I am now the 8. Burt Wolbach Professor of Pathology. My medical, research, and teach- ing activities have been devoted to children and to the field of cancer. At the present time I am President-elect of the American Cancer Society which derives its great strength in its struggle to control cancer. from more than 2 million volunteers in all parts of the country. Presently I am a member of the National Advisory Cancer Council of the National Institutes of Health, and represent that Council to the National Advisory Council on Regional Medical Programs. It was my privilege to serve as a Member of the President’s Commission on Heart Dis- ease, Cancer and Stroke, as Chairman of the Panel on Cancer. It was this Com- mission which produced the renowned DeBakey Report which culminated in the enactment of P.L. 89-239, the Heart Disease, Cancer and Stroke Amendment of 1985. It was my privilege, too, to testify before this Committee in support of the original enabling legislation. Today I come before you in support of the extension of this program which represents one of the greatest opportunities in the history of medicine to prevent death from these dread diseases. and to prolong good and useful life for our people. May I summarize briefly a few points concerning the program asa whole. and that portion dealing with cancer in particular: (1) A magnificent beginning in planning, and to a smaller extent in operations has already been made in this very short period of time. The Regional Medical Programs already show convincing evidence that for the first time in American history the various components of a given region of the country concerned with the health of our people can and will work together toward the achievement of a goal which has never been so broadly defined. (2) The goal of the Regional Medical Programs, in a few words, is the pro- vision for every man, woman and child suffering from any of these dread and related diseases, of all that is known as well as all sophisticated technical proce- dures for the prevention of death and the prolongation of good life. Fundamental to the achievement of these goals are developments in data collection and the per- fection of better methods of delivery of medical care, as well as improvements in continuing education for the physician and education of the public. Making use of these invaluable tools, then, the Regional Medical Programs, in the case of cancer, are beginning to create meaningful relationships between community hospitals and those parts of the region where are located the medical schools, teaching hospitals, and research institutions concerned with cancer. The com- munity hospitals must be strengthened by increasing the number of members of their staffs, specially trained in the various aspects of diagnosis and treat- ment of the many different diseases we call cancer, and the addition to their technical armamentarium of such special technical devices as radiotherapy units. and other diagnostic and therapeutic equipment. In the medical school complex there will be concentrations of specialists in the many phases of cancer research, diagnosis and treatment to give expert assistance 143 to any doctor in the region in behalf of his patient. In such complexes where a critical mass of expertise is to be found, primary responsibilities will include continuing education with the help of technical equipment in the modern idiom, demonstrations of new techniques for diagnosis of treatment, and consultation services to the community hospitals and all doctors in the region, in addition to the conduct of research designed to provide solutions for problems in cancer which can not be satisfactorily handled on the basis of present knowledge. (3) It has been estimated by experts that if we could make available to every patient with cancer in the country today all that is known concerning diagnosis and treatment, we could save 100,000 of the more than 300,000 who will die of cancer this year. This is without new knowledge emanating from research labora- tories. It is a goal that can be achieved by the full development of these Regional Medical Programs in the field of cancer alone. (4) As was the case with the Hill-Burton program, and also the Health Fa- cilities Research Construction Program of the National Institutes of Health, in- vestment of Federal money will be sure to eall forth investment from the private sector. You will be interested I am sure in une experience in a part of our Country which has serious need for improvements in the field of cancer, The commodity of Anchorage, Alaska, in response to the needs identified by the Washington-Alaska Regional Medical Program for high energy radiation treat- ment facility closer than Seattle, Washington, is now conducting a fund raising campaign. Solicited private funds will be used to construct housing for the equipment, which will be purchased by the Regional Medical Program. The treat- ment center will be operated as a regional resource by the Providence Hospital, as planned and approved by local and regional advisory groups. The decision to support the activity involves cooperative arrangements at another level also, for the National Cancer Institute conducted a site visit which gave assurance of the sound scientific and professional basis of this project. I heard just before coming here that the Anchorage Building and Construction Trades Council, com- prising some 14 unions have taken on the construction of the building as a project, contributing more than one half of the total cost from this one source alone. RECOMMENDATION The time for increasing the support for these Regional Programs in Heart Disease, Cancer and Stroke has come on the basis of the truly splendid start that has been made. The upward trend of needs—almost double each year— is apparent as more programs reach the stage of actual operation. In fiscal 1967 only 4 programs were operating; in 1968, 20 more will reach that stage. Even to make possible the universal application of such a simple and established technique for detection of cancer of the uterus at the Papanicolaou smear, is an expensive procedure, but one that will be followed by the saving of thou- sands of lives of women each year. We should emphasize, too, that many seg- ments of our system—in ghettos, rural areas, or old-age homes among others, hare little or no access to modern scientific health technologies. We are aware that particularly at this time priorities must be established and that choices must be made. It is our purpose today merely to point out the great good that will come if there is support of programs which have already demon- strated their ability to achieve the goals defined by the President’s Commission on Heart Disease, Cancer and Stroke and put into law by the Congress of our Country on the recommendation of this Committee. From the time of the iden- tification of these goals in P.L. 89-239, the Regional Medical Programs have captured the imagination and raised the expectations of the general public and the health provisions alike. Those who have studied the needs of this program most carefully recommend that the ceiling for the national program as a whole should reach the level of more than 500 million dollars within 5 years, and should certainly not be lower than 300 million dollars for 1971 if we are to utilize to the full the strength which has been mobilized in the varous regions of the coantry in behalf of the health of our own people. ; I close these remarks confident in the belief that the leadership to the Con- gress offered by your Committee will permit these Regional Medical Programs to make a truly great contribution to the health of all of us. Mr. Rocrrs. Thank you very much, Dr. Farber. We are indebted to _ you for being here and giving us your opinion on this program. 144 Let me ask you, for instance, with the Children’s Cancer Research Foundation, can you give us-any example where a new treatment, perhaps, has been disseminated through a regional medical program ? Dr. Farser. Yes, Mr. Chairman. The Children’s Cancer Research Foundation, if I may speak of something with which I have been concerned for the last 21 years, is really a prototype of the Regional Medical Center program. It is a private Foundation, assisted from the private sector and receives research funds from the National Can- cer Institute and help from the American Cancer Society. It is sup- ported by the entire New England community. It provides expert care and diagnosis and treatment for children with leukemia and all forms of cancer, for any child sent by a doctor in the entire region. The doctor takes care of the patient at home and gives the tremendous moral and medical support required by a family which has a seriously ill child at home. The foundation provides the techniques and equipment which are much too expensive to be in a doctor’s office. It carries out all these expensive services without professional charge to the patient; at home the patient is the private patient of his private doctor. In 21 years, Mr. Chairman, I have never had a complaint from a single doctor in this region. We have had remarkable cooperation, and the community as a whole has cooperated to support something which they considered absolutely necessary for the comfort, the well- being, and the mental peace of the family, as well as for the health of the child. Mr. Rogers. Have we had any real breakthroughs in this area, in the treatment of leukemia in children ? Dr. Fanser. Mr. Chairman, there has been very great progress. It was 20 years ago last November when the first chemical that could control leukemia, at least temporarily, was administered to a child for acute leukemia. There is no cure for acute leukemia, but atients live good lives for several years, instead of a few weeks or a iew months. And there are alive a few hundred patients, adults and children, about 1 percent, I estimate, of all the patients with leukemia treated, who have lived good lives for 10 to 15 years without evidence of the disease. This is not a cure, in my opinion, but this is very heartwarming evi- dence that we are in the right direction in the use of chemicals, and many supportive programs, such as latelet transfusions and so forth. Lf we can keep good life going, the next forward step in research may come in time for that child. We have other tumors in adults as well as children, which have re- sponded to surgery, radio therapy, and chemotherapy. In one case of cancer of the kidney in children, we are now above 80 percent. in long- term survivals because of the addition of chemical, in this case an anti- biotic, to modalities of surgery, and radio therapy. We have accom- plished what seemed impossible 20 years ago. Once spread to the lungs had occurred in this kind of tumor, there was a matter of 3 to 6 months of life ahead. We are now able, in about 60 percent of the children who have had spread of this cancer to the lungs, we are able to have complete destruction of the tumor using small amounts of radio ther- apy and an antibiotic. Life has continued in the longest patient for 18 years with no evidence of the return of the tumor. 145 There are many examples that could be given from the splendid in- stitutions in the country and in other parts of the world where great- est advances have been made. The word “cancer” does not apply to a single disease. It includes many different diseases, which may be un- related, all of which are called cancer, so we may have to answer your question instance by instance as we record success. Mr. Rogers. I think that is encouraging, and I think it is well for us to spread on the record some of these examples, so where you have a technique that is successful, this can be spread quickly through a re- gional medical program—at least that is the theory—that it can get to the local doctors and hospitals. And although we may not have the necessary treatment there, it can be arranged for and the treatment prescribed. Dr. Farper. We hope these regional programs will provide for the community hospital the expertise and the equipment which will take care of the vast majority of patients with cancer, leaving for the cen- ters the new problems which require far greater outlay in equipment and manpower. Mr. Rocers. Thank you. Are there any questions? Mr. Kyros. I want to join with you in welcoming Dr. Farber here. Mr. Nexsen. I was interested in your statement that many patients have gone as long as 13 years with no evidence of recurrence. Is there any specific number of years that the medical profession assumes to be past the danger point in radiation treatment of a tumor? Dr. Farper, This varies from tumor to tumor, In the ease of the kidney tumor I mentioned, I have experience for more than 40 years with this kind of tumor. If there is no recurrence or evidence of tumor 2 years after initiation of therapy, we may as- sume with a high degree of certainty that the patient will remain in good health. In the case of other tumors, cancer of the breast, for ex- ample, although most patients will remain well if they have been well for 10 years, all of us—Dr. Carter, too, I am sure—have seen patients who have had recurrences 18 to 20 years later. , So we must give a different answer for each kind of tumor. Mr. Netsen. I had in mind a case that I am well aware of, that hap. pens to be my son who had a brain tumor. It is now 5 years since the radiation treatment was given, and he has been in very good health since this operation was performed. . T am always watching, of course. This was 5 years ago, and it would seem he is in very good health at this time. ; Dr. Farzer. I am sorry to learn you have this personal experience, Mr, Nelsen. I would say the story you give is encouraging. If there is no evidence of tumor after 5 years, this looks very hopeful. Mr. Rocers. Dr. Carter? Mr. Carrer. I want to say thank you for an interesting and informa- tive—and I started to say “persuasive” presentation, but instead of that, I am going to say that so far as I am concerned, I am a believer and am fully persuaded in what you say. Thank you. Dr. Farser. Thank you very much, Dr. Carter. Mr. Sxvpitz. Doctor, Ihave one statement. 146 You made the statement, I believe, that if we could make avail- able to every man, woman and child the evidence that we have on cancer, 100,000 lives would be saved this year or any year. Is this correct? Dr. Farser. That is correct. Mr. Sxusrrz. Of course, I recognize the task we have in trying to get to every individual, but don’t we have a central clearing agency Sf some sort where information is collected ? Dr. Farser. Yes, we do, through the National Cancer Institute and the American Cancer Society, but the problem is complex. May I mention a few of the complexities? First, we must have the patient come to his doctor early. This is No. 1. The American Cancer Society particularly has had a great educational program for many years in the attempt to have patients come much earlier than is now the case. Tf we could apply the cytologic diagnos- tic test, for example, to every woman today, we could save thousands of lives, literally thousands, because here is a form of cancer of the uterus which can be cured by surgery, or radiotherapy. But if we can’t get the patient examined properly and regularly, we cannot save lives. There is a further point that should be made. It is that there is a lack of facilities in many of the community hospitals of the country where there are good men and well trained men and devoted doctors, but without expensive facilities and without all of the supportive therapy that is extremely costly, one cannot do as much for the patient as we hope to do when these regional medical programs bring support to every community hospital that is connected with every center, and every center connected with every other center. There are many reasons of this kind, but if this country decided today that it was worthwhile saving these 100,000 lives by bringing the financial support and the administrative relationships that would be required, these lives could be saved. My. Sxcprrz. Maybe I misunderstood you. I thought you were say- ing that one of our first problems is trying to bring about an aware, ness in the individual of what the danger signals are, and if they could recognize them, and then get to the proper place for proper medical attention, they would be saved, AmIright? Dr. Fanner. That is point No. 1. Part of it is what the individual satient will do, and part of it ig what the doctor will do. But if these patients come to hospitals which do not have facilities, the doctor, who is already tremendously overburdened with the tremendous amount of good that he is doing in general practice, will be unable to give the optimal treatment, because the facilities are lacking, because of the expense of sup ortive therapy, because of the number of ex- perts In many fields of medicine, surgery, and laboratory science, are not available for the patient. But if a patient should receive everything that is known today, he will stand a far, far better chance in such a place than he can otherwise. Mr. Sxvpirz. Thank you, Doctor. Mr. Rocers. Thank you very much, Dr. Farber, for your excellent testimony. 147 Our distinguished colleague, Congressman Kuykendall, will in- troduce the next witness. We are pleased to have our colleague with us at the committee here and are delighted that you will introduce our next witness. STATEMENT OF HON. DAN KUYKENDALL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TENNESSEE Mr. Kuyxenpaw. Thank you, Mr. Chairman. It is a real privilege to be with the subcommittee for a few moments, and a_ particular privilege to introduce a man who for several reasons, I think, is peculiarly qualified to testify on this particular bit of legislation. I think he is qualified for several different reasons. First, if not foremost, is the fact that our city and area of Memphis is very much a regional city, probably more so than any major city outside of the crowded area of the eastern seaboard, where within 125 miles of our city we have five States. And we have run into problems of Hill-Burton, because of implications of not getting benefits from a regional concept. We proudly announce that Memphis is a major medical center around our fine university. And Dr. Cannon himself is one of the outstanding surgeons and, maybe more particularly pertinent to this hearing, one of the major contributors to medical education in the whole Nation, having been one of the leaders in the field of medical education for quite some years. So it is a privilege to introduce my fellow Memphian, a good friend and a leading educator, Dr. Bland Cannon, of Memphis. Reluctantly, I have to leave now, and go to my committee. Mr. Rocers. We understand. Dr. Cannon, we are pleased to have you and welcome you to the committee. I understand you have an associate, Dr. Henry Brill. Dr. Cannon. Yes. I would like to ask Dr. Ruhe, Dr. Brill, and Mr. Harrison to accompany me to the witness table. Mr. Rogers. We welcome all of you to the committee and will be pleased to receive your testimony. It is my understanding, Dr. Can- non, that you are representing the American Medical Association in giving your testimony. STATEMENTS OF DR. BLAND W. CANNON, MEMBER OF COUNCIL ON MEDICAL EDUCATION, AND DR. HENRY BRILL, MEMBER OF COM- MITTEE ON ALCOHOLISM AND DRUG DEPENDENCE, AMERICAN MEDICAL ASSOCIATION; ACCOMPANIED BY BERNARD HARRISON, DIRECTOR, LEGISLATIVE DEPARTMENT, AND DR. WILLIAM RUHE, DIRECTOR, DIVISION OF MEDICAL EDUCATION Dr. Cannon. That is correct, Mr. Chairman. Iam a practicing neurological surgeon and a member of the Ameri- can Medical Association’s Council on Medical Education. With me to present the views of the American Medical Association on H.R. 15758 is Dr. Henry Brill, of Brentwood, N.Y. Dr. Brill is chair- man of the AMA’s Committee on Alcoholism and Drug Dependence. 148 Mr. Bernard Harrison is director of AMA’s Legislative Department, and Dr. William Ruhe is director of AMA’s Division of Medical Education. . The three parts of H.R. 15758 affect three programs of special interest to the American Medical Association. I will comment on the first part which relates to the extension of the regional medical pro- ram. The second part proposes an extension of the program for grants or health services for migratory workers. The third part proposes a new program for alcoholic and narcotic addict rehabilitation. Dr. Brill will provide the subcommittee with the association’s views on the latter two subjects. STATEMENT OF DR. BLAND W. CANNON Dr. Caxxon. One hundred and twenty-one years ago, as & result of the concern of the profession with problems relating to the quality of medical education and health care, the AMA was founded. Since that day in 1847, organized medicine has encouraged methodologies of health care which it believes will best provide improved health care for all patients. The increased longevity which the American people enjoy today is a tribute to medical advances and their ap lication to the health care of the American people. The American physician today is prepared to render the best medical care in the svorld because he is a product of a constantly improving pattern of the finest medica] education and research; because his opportunities for postgraduate education are un- excelled anywhere; and because he has been armed with matchless and ever-advancing diagnostic and therapeutic techniques. T have made the previous statement, Mr. Chairman, because it should be clear that while we constantly strive for improvement so that what we have today will be better than yesterday, and what we obtain to- morrow will still be better than today, we must not lose sight of the remarkable accomplishments that have been made in health care by our medical educators, medical researchers, and practicing physicians. In July 1965, when ‘Dr. James Z. Appel, who was then president of the association, appeared before the full Interstate and Foreign Com- merce Committee to testify on the bill to establish the regional medical program concept, he voiced the association’s concern with certain pro- visions of the bill then before the committee. Because of the amend- ments made by the committee, much of our concern was quieted. RMP began auspiciously and, since that time, continues to promise a hopeful uture. But there are still some who would like to see the regional medical program as an instrument by which the organization and delivery of health care to the American people could be changed in some revolu- tionary manner. Importantly, this does not appear to be the view of those in the administration charged with the implementation of Public Law 89-239. Dr. Dwight L. Wilbur, president-elect of the AMA, in addressing the conference-workshop on regional] medical programs on January 18, 1968, noted that on an earlier occasion Dr. R. Q. Marston, director of the regional medical programs, had said that RMP faces the challenge of influencing the quality of health services without exercising Federal 149 or State governmental control over current patterns of health activ- ities. Dr. Wilbur then said: If the program in fact is clearly one designed to catalyze and to facilitate the development of better programs than now exist to serve patients and their physi- cians, it will undoubtedly receive enthusiastic cooperation from the medical pro- fession and related groups. Such support is evidenced by the participation in RMP by some of our outstanding physicians and by constituent medical societies of the AMA. In five of the 54 regions, a State medical society is the program grantee. These are Georgia, the District of Columbia, Nebraska, Min- nesota and Pennsylvania. In many of the other regional programs, the state medical society isan active participant. ~ JF We view with favor the early progress of RMP, its ability to build on existing patterns of medical care (sometimes adding new features or changing old ones as local demands and resources make possible) and the local flexibility which allows the program to make a real con- tribution to the health care of our nation. At the same time, we recognize that the concept of the regional medi- cal program is still in its very early stage of existence and that it is dif- ficult to appraise the program. We do not know, for example, how much this-pregram adds to the sttess on an already’ overtaxed supply of available medical: manpower. There is some concern that the‘pro- liferation of Féderal:health programs substaitially contributes to the rise in health care costs. For this reason, we are pleased that H.R. 15758 provides for an evaluation of the program. We ‘would suggest, however, that the evaluation begin July 1, 1968, rather than July 1, 1970, since evaluation ‘should be an integral pirt of the planning. We also suggest that the subcommittee consider further amending section 102 to provide that the evaluation Shall be made by a nongovernment agency. ; ; me, Sections 103, 104, and 106 contain provisions which we believe to be salutary. Section 103 provides for the inclusion of the territories under RMP; section 104 makes combination of regional medical program agencies eligible for planning and operational grants; and section. 106 adds a new provision under which grants could be made to public or nonpofit. private institutions for services needed by, ‘or which will be of substantial use'to, any two or more regional medical programs. We recommend the adoption of all three changes. - . , ‘As to other amendments, we recommend that the subgommittee delete the open-end authorization for funds for the 4 fiscal years end- ing after June 30, 1969. In view of the fact that we are still dealing with a relatively untried program, we believe it would be wise to limit the authorization to such sums as this subcommittee may determine - to be reasonable, rather than to provide for “such sums as may be necessary for the next 4 fiseal years.” Further, with the same concern, we urge the subcommittee to extend the program for a total of 3 years rather than the 5-year extension provided in the bill. Both of the pre- vious witnesses have mentioned 1971 as a landmark in the activation of the program. , Finally, we note that section 105 provides for an increase in the number of Advisory Council members from 13 to 17. As this change is made by the subcommittee, we would suggest the further amend- 309-653 O-68—8 | 150 ment to provide that four members of the council shall be practicing physicians. The current law requires that only two be practicing phy- sickans. In view of medicine’s involvement with RMP, we believe that having @ minimum of four practicing physicians would be helpful tothe Advisory Council and tothe RMP program. Mr. Chairman, 17 conclusion, let me 8a. that RMP has stimulated favorable reaction from the medical prot i isti guished medical leaders are participating 1n the regional program and many State and county medical societies are cooperating in the planning of the activity. On the whole, we feel that the programs hold much hopeful promise. With your permission, Mr. Chairman, I would now ask Dr. Brill to continue the association’s statement with comments on the remain- ing provisions of HLR. 15758. r. Rogers. Thank you, Dr. Cannon. 154 Mr. Rogers. Mr. Skubitz? ; pte Sxvusirz. Dr. Carter raised a question that I had intended to ask. I am wondering whether we shouldn’t limit these authorizations to 1 year. When we authorize for 8 and 4 years, the departments do not have to appear before us and justify their program, or tell us what they have done. They are through with us. Would you oppose 1-year authorizations? f Dr. Cannon. I think that 1-year commitments could create dif- culties. Mr. Sxvsrrz. This doesn’t stop the agencies from planning for 4 or 5 years. It means they are to come back and report to us and tell us what they are doing. Dr. Cannon. There may be difficulties in effecting the program, in hiring personnel, and many other things, but we wouldn't be op- posed to your annual evaluations and appropriations. I mean, that is a decision for your committee. Mr. Sxvsrrz. I don’t think the committee wants to abandon the pro- gram. But this is the committee that listens to the testimony. I think it is important for the agencies to come back and tell us what they have done and justify the money they need for the next year. Otherwise, the departments are on their own. We have no control. Dr. Cannon. We are tremendously pleased and have commended this committee for its perceptivity in organizing this program into a meaningful piece of legislation. We still have that confidence in your judgment. Mr. Sxvszrrz. I notice, for example, in this particular bill there was an authorization for $100 million in 1967. This makes it appear that the program is starting to level off at this time. It doesn’t make sense to me. Thank you, Mr. Chairman. Mr. Rocers. Thank you very much. Dr. Cannon, I notice you still express some concern that this pro- gram might be used to bring about some change in a revolutionary manner in health care of the American people. Is this widely felt in the medical community ? Dr. Cannon. I think that there still exists an aura of concern, be- cause some might interpret the legislation to mean that it can effect the standardization of health care. 13d Mr. Rocers. I thought we had dispelled that in writing the bill. We made every attempt to in this committee. I recall the concern when the bill came out of the Senate. It would have put up medical com- plexes where patients could be referred, and so forth. But we changed the concept oF the program in this committee, as you may recall, and, I hope, dispelled this idea. And I would hope the American Medical Association could dispel that viewpoint. Dr, Cannon. I think the amendments have been very gratifying, but the shock wave initially was rather great. And, as you know, this is something that we have had to gradually overcome. Mr. Harrtson. May I comment, Mr. Chairman, that as indicated by Dr. Cannon in his statement, that because of the amendments made by this committee at the time it passed on this bill, the fears and concern of the association were somewhat quieted. And while there still remains some concern, we have seen much hopeful promise. We have been very much appreciative of the work done by this committee in the adoption of the initial program. Mr. Rogers. Thank you. I notice you express concern on page 3—you don’t know yet how much this program may add to the stress of an already overtaxed sup- ply of available medical manpower. It was my concept in the original legislation, and from hearing testimoney, that rather than add a burden to manpower, this would perhaps serve as an easing of manpower, because the theory was that you could quickly get to the doctor in his own locality the latest treatments, the information of the latest treatments, and so forth. And teams could be brought in from the university centers to work with them in a cooperative spirit, where it didn’t take the time of the local man to have to go someplace for 2 weeks in the summer to do the continuing education that we carry on now. Communications would be improved, and this was, I thought, a hopeful way of helping to ease the manpower problem rather than put a burden on it. What is your feeling on that? Dr. Cannoy. I think your point is well taken. The average practic- ing physician is somewhat in a box for time. He bounces around and -ean’t really break away from an educational experience. However, many men, as you know—I would say most. of them— are dedicated to continuing self-education. What I had reference to here was the number of personnel, the demands on an already scarce commodity has been increased, and the utilization of those people who are trained in medical care to admin- ister programs, to particitape in them, to teach, to set up units. We don’t have any specific figures, but we are concerned. Mr. Rocers. I am interested in having information along this line, because J would see it operating just the opposite, and I would hope it would. Dr. Cannon. May I ask Dr. Ruhe, who is director of our Division on Medical Education, to comment? Mr. Rocers. Yes. Dr. Rune. I believe what you said will ultimately be the case. In the planning and early operational stages, however, it has been neces- sary for all of the regions to accumulate rather large staffs of profes- sional people to administer the program and to direct it. 156 As I recall, and I am not certain this is the exact number, but I recall one of the larger regions estimated that it would need approxi- mately 90 professional people, Mr. Rocers. All doctors? Dr. Rune, Not necessarily M.D.’s, but persons at that comparable degree level, in order to carry on the administrative work and the direction of the program. Thus, one of the immediate effects has been a rather considerable increase in the competition for—that isn’t per- haps the right word—but in the available opportunities for employ- ment of professional people at the administrative level. We have noticed this already. I think it has been noticed in the medical schools which have been actively involved in the regional activities. It has been necessary for them to add additional faculty and administrative personnel in order to discharge their responsibili- ties under the program. These people have to come from somewhere. They were not in great supply before. A number of them have come out of practice, and while we feel ultimately this may result in more efficient utiliza- tion of health care services, we think there is an immediate effect here in providing some competition for manpower in the health field. This is, I think, the basis for this statement. Mr. Rocers. Well, now, what I wondered was this: For instance, I envisioned the fact that you would carry on a continuing education program, perhaps through television, where you have an expert in a medical center giving instruction to your local hospitals in a certain treatment that may have just come out; so that you don’t have to send instructors out to each hospital, or have each doctor come in and take that time to come to the medical center. But the communication is one of the means that you are going to cut down on the use of man- power, I would hope. Is this envisioned ? Dr. Rune. Yes; it is. Mr. Rocers. So there are so many things where I think you would be saving’ the time of the local doctor; so you don’t have to have five doctors where one doctor may do the work of two doctors—for in- stance, where he performs his exam and wants a reading on an X-ray, and he sees something that is wrong, but he can get it in the medical center where it comes back immediately with a communication on the diagnosis. Isn’t that going to save him time and enable him to see more patients ? Dr. Rune. J think in time it will. Mr. Rocers. Right; and this is what we are concerned with, getting the health to the people, and this is the reason this program was en- visioned and adopted, I think. Mr. Carrer. Mr. Chairman, will the gentleman yield? Mr. Rocers. Yes. Mr. Canter. I want to say something in behalf of the general prac- titioner in this case, if you plase. I don't think we should sell him too short. He is a man who is known by the fruits of his labor. If he doesn’t produce, certainly his practice is going to fall off, and he does take part in schools. He goes as a member of the Academy of Gen- eral Practice. He is required regularly to go to school. 157 Our universities, too, in cooperation with the medical associations, do provide aid and visiting physicians who come to our hospitals throughout rural America to teach us, and we are glad for this. The general practitioner in most cases, if he is efficient and effective. he has developed channels of communication with universities, and surgeons and dignosticians who can be of help to him. ; Most of our community hospitals, I would say, have a qualified radiologist who read their films from time to time. So we have most of these programs already. They have already been developed by private initiative, forced by the necessity of doing the best type of work. And I should say that most general practitioners do these things. This program, as I see it, is to complement the program which is already existing. Mr. Rocers. | am not trying to run down the general practitioner. I think he has done a grand job. We want to help him to do a better job for the American people. I agree with you. I think he has done a great job. We want to help him do a better job with this program. This is a program, really, for the doctors, so I would understand why the American Medical ‘Association would support it. It is really baci-ally for the doctors, to be helpful to them i» civing good treatmer.. Dr. Cannon. Mr. Chairman, may I comment on your statement ? Mr. Rogers. Yes. Dr. Cannon. Tusis is, in essence, why we believe in the expansion of the Advisory Council. We believe it is wise iv inke two new members from . .z practicing profession. Mr. Rocers. [ think it is a good suggestion 2. lak we sho: d have practicing people, and I don’t think we are ¢."' ng enough hospital people in there, either, Dr. Cannon. I think we are getting too many ccueators. This is natural at first, and we need them. But we have overlooked in this p:agram, to date, I think, bringing in a more active participation by practicing physicians and by hospital administrators, and some of the people who are actually involved with providing some of these services and where the critical units should be. We need a more practical approach in the implementation of what is a good program in theory, and I think your suggestion is good. I might state that I think the only group that requires continuing education is your group of general practitioners; does it not? Your specialties don’t require continuing education. Perhaps they will. This will be good. Dr. Cannon. By our negative reward system, they require it. Mr. Rocers. I am sure all the doctors try to keep up as best they can. itis not easy. T can assure you this committee is not going to go for open-ended funding. We have made it a practice, as has been expressed by my colleagues here. We will set a certain sum to be authorized, and our normal procedure has been a 3-year program. 159 Mr. RoceErs. We have a distinguished colleague from Illinois, who may know about the Chicago problem. Congressman Springer is here, our dis- tinguished minority leader on the committee, and he may have some questions. Mr. SprinceEr. Just one or two, Mr. Chairman. Doctor, were you any part of the AMA structure at the time we passed the heart, stroke, cancer bill? Dr. Cannon. If “structure” is an all-inclusive term, I certainly was. But I was not one of the spokesmen at that time. I am aware of the statements that were made. Mr. Sprincer. Well, never will T accept the testimony of anyone who comes before this committee as an expert on a program until I am more than satisfied. The gentleman from Florida and I kept this thing within what we thought were reasonable boundaries at that time. It came over here from the Senate with one and a half days of hearing at $970 million, almost a billion dollars to’start a program, and I have never seen such an array lined up for that bill, and L almost swallowed it, until I went home and thought about it. Then I just began to make some investiga- tions to find out what should be done. And despite all the mean things that were said about the distin- guished gentleman from Florida, and me, too, during that time, that we were keeping that pill from coming to the floor, we finally got it out at $320 million. We didn’t let it out until they agreed in the other body that they would pass our bill. If my figures are correct, we are almost at the end of 3 years, and out of what they called a piddly little $390 million, they have been able to spend $85,200,000 to date. . Lam coming back to this for one reason only, and that is that you are - now asking for $65 million for the fiscal year 1969, and nothing has been said, 1 take it, Mr. Chairman, with reference to any possible re- maining 2 years.. Mr. Rocers. It has been said, and they are submitting the figures. Mr. Sprixcer. Iam glad to see that. I come back again to my colleague in saying that at the time you were speaking on this before, your people doubted that this program could be undertaken. They went on and pointed out why, terms 0 personnel available and so on. _ ; T am glad that what you said and what I said and Mr. Rogers said, and a few others on this committee, has come true. Only it has come even more true than we anticipated. This is about the only time we hare overevaluated a program. This was a program that I supported energetically, once J thought st was within some reasonable means. But I merely point this out, that Lam extremely skeptical of anyone ‘who comes before us with figures unless they can be justified. This was, may Isay, what] considered to be the best testimony in the country. But you ought to go back and see that testimony, from Dr. DeBakey on down. It was presented before this committee, to justify a program for a billion dollars, which turned ont 3 years later to have spent $85 million. 160 I just want to put that on the record, because I think it ought to be brought out here that what we get in the way of landslide testimony here is a selling job and snow job claiming that something can be done immediately. Mr. Sxusrrz. Mr. Chairman, will my colleague yield? Mr. Sprincer. Yes. Mr. Sxvusrrz. Was $320 million authorized and $320 million appro- priated ? Mr. Sprincer. Fifty-nine and 200. Mr. Sxvusrrz. But how much money was appropriated ? Mr. Sprincer. $85,200,000. Mr. Sxvusrrz. That is all they spent. How could they spend any more if more wasn’t authorized ? Mr. Sprincer. The fact is they didn’t spend all that was appro- priated. They appropriated more than $85 million. Thank you, Mr. Chairman. Mr. Rocers. Thank you. I do think it might be brought out at this point that I would com- mend the administration of the program in the fact that they haven’t just gone out and spent money. So I think this is rather com- mendable, that they have held up some 8 million on last year because they felt they were not at a stage to spend it. So this is commendable, and I would want to put that on the record, too, that we don’t want them, just because we may authorize something on it may be appropriated, that expect them to go out and spend it unless they are at that point where it could be done effectively. So I think whether we reach goals that we may have set: is not neces- sarily the determination on the spending of the money. We want to make sure that it is appropriately spent and even though the goals may have been set above that. So J think the administration of it has not been in error in that regard, r. Rune. May I comment on that? I think we would support this fact. We have been reassured and encouraged by the way this program has been administered. I think in defense of the program, one thing can be said, that in the early stages, very careful attention has been given to the planning and the preparation for the operational stage of the program. This has been one of the things which has kept the expenditures down at the present time. But as the program gets moving into the operational phases, I think it is reasonable to expect that the costs would increase greatly. We feel that the program has been administered very well, and with restraint and good judgment. . My. Rocers. Thank you. Mr. Sxuprrz. That brings me back to the question I raised a few moments ago, the necessity of limiting these authorizations and having the agencies come back and present their case and prove their point. Lf we authorize for 3 years, they don’t have to come back. From that moment on they go before the Appropriations Committee—— Mr. Rocers. This is right. Dr. Rune. There is one problem in that, if I may. That is, from the standpoint of the region which is attempting to recruit personnel, if 161 there is any question whether the program is going to be continued for the indefinite future, it would be extremely difficult to get good people to change their careers and come into this program. Mr. Sxvsrrz. Doctor, you sound like a Government bureaucrat. We hear the same statement time and again we must have a 3- or 4-year program, or we can’t get the people. But for some reason, the Gov- ernment has no trouble hiring people. Mr. Rocers. It may be the doctor is looking at what happened to the Congress on only a 2-year contract, and he is disappointed. [Laughter. ] Mr. Elarrrson. I would like to comment on Mr. Skubitz’ question, The association would generally support, if it was the committee’s good judgment, an authorization for a single year which would re- quire the program people to come back and give the committee an opportuntiy to examine the program again. iF that was your judge- ment, and we would support that movement. Mr. Sxupirz. You had better stay with the chairman. I am the low man on the totem pole. , (Laughter. ] Mr. Rocers. As a matter of fact, Mr. Skubitz, you might be inter- ested to know that we did a special study on HEW and recommended yearly authorizations. Mr. Sxvsrrz. I am glad to hear that. Mr. Rogers. We haven't been able to move it in committee yet Thank you very much. Your testimony has been most helptul Dr. Cannon. Thank you, Mr. Chairman. Mr. Rogers. Our next witness is Dr. William Likoff, immediate past president, American College of Cardiology, from Bethesda, Md. Weare very pleased to have you with us, Dr. Likoff. STATEMENT OF WILLIAM LIKOFF, M.D., IMMEDIATE PAST PRESI- DENT, AMERICAN COLLEGE OF CARDIOLOGY; ACCOMPANIED BY WILLIAM D. NELLIGAN, EXECUTIVE DIRECTOR Dr. Laxorr. I am pleased to introduce William Nelligan, executive director of the college. I appreciate the privilege of appearing before this committee to present the views of the American College of Cardiology regarding bill H.R. 15758. The goals and philosophy of Public Law 89-239, the progress recorded by the regional medical program during its short life and the future promises embodied in this endeavor are pertinent to your cur- rent considerations and, therefore, prompt this testimony. Medical science in this country is favored by superb talent, com- petence, and abundant resources. This committee, however, is par- ticularly aware that the distribution of these assets, specifically in terms of patient care, is shamefully uneven. The basic goal of Public Law 89-239, the authority for the regional medical program, is to bridge this unequal gap between science and service and to provide an - efficient health care system which will assure the transmission of the best in scientific knowledge to all people of this country suffering from heart disease, cancer, and stroke, or struggling to avoid these catastrophies. 162 The concept regulating the regional medical program is remark- ably simple and in the best tradition of this country’s genius for effec- tive action. It holds that modern medical advances can be made available to all people when needs are identified at a regional level by individuals involved in regional affairs and when available re- sources and manpower are properly exploited through cooperative arrangements linking discovery with learning and application. Critical analysis of the activities of the regional medical program uncovers an unusual record of accomplishment toward that goal over a relatively short period of time. Federal funds have stimu ated the planning for a health care system in approximately 50 regions encom- passing about 90 percent of this country’s population. Operational programs have been activated in 11 additional regions. Solicitations for planning and operational grants for areas not yet involved are being constantly prepared and reviewed. The speed with which Public Law 89-239 has exercised its impact and the wide area of its maturing influence is most impressive almost denying the complexities of establishing a new administering organization and staff within the Public Health Service and the difficulties in assembling for planning and action representatives of diverse scientific and con- sumer groups in a myriad of local communities. The first dynamic engagements with the problems of organization, defining regional needs in health care and interrelating local resources for their correction have revealed a number of specific facts. Those who have worked in the field developing a program for a specific region, almost without exception sense that institutions and men representing medical, paramedical, and consumer interests welcome the challenge and opportunity to serve. They are applying themselves unstintingly to the search for sound administrative structures and for effective voluntary cooperative arrangements which will assure the success of the program. They share a positive view about the likelihood of obliterating the void now separating the conversion of knowledge to service. They appreciate local needs and they are creative in their plans to meet them. From early experience it also appears that the funding provisions of the act are adequate and that the Public Health Service is awarding these funds judiciously and in keeping with the needs and sonhistication of the applications from the petitioning regions. However, and in contrast to some of the statements made to this point, the community is extremely sensitive to the limitations imposed by the fact that the program has not been established on a continuing basis. The paradox of contesting with long-term needs and long-range objectives under the umbrella of a short-term act is uncomprehensible. It impairs the harnessing of manpower; it constricts programs to the immediate; dedication is diminished; promise is aborted; potential threatened. In a frank acknowledgement of clear fact, Public Law 89- 939 has evoked the type of robust response that deserves the assurance of continuing support and inclusion of logical areas of involvement not heretofore embraced, At least a portion of these are recognized in H.R. 15758, Certainly the provisions to involve areas outside of the 50 States is consistent with our traditional obligations; those improving imple- mentation through interregional cooperative, those seeking involve- ment of Federal hospitals and providing for construction funds are necessary logistically and functionally. 163 The American College of Cardiology enthusiastically endorses the objectives and philosophy of the regional medical program because they embrace an unchallenged need and seek to use forces which require only release and coordination. We support the planning and opera- tion of every regional program where we possess manpower and resources. The college is certain the program will elevate the health of the Nation. It pleads for a favorable action on bill H.R. 15758. This amend- ment to the Public Health Service Act extends and expands the medical regional program to a new and amplified potential and hope- fully to the status of the most distinguished medical program con- ceived in our time. I am grateful for the opportunity of expressing these views. Mr. Rocers. Thank you very much, Doctor. We appreciate your testimony. Did your associate have any statement ? Mr. Newxican. No, sir. Mr. Rocers. Doctor Carter. Mr. Carrer. No questions. Mr. Rogers. Mr. Skubitz? Mr. Sxunrrz. No questions. Mr. Rocers. I might say that the committee, in adopting a 3-year program rather than a 5- or 10-year program, feels that this is one way for this committee to carry out its responsibilities to the Congress and the American people, because otherwise we have no review of the program. Dr. Lrxorr. I understand that philosophy, Mr. Chairman, but I do wish to tell the committee, and particularly Mr. Skubitz, that we in the field have found it difficult to construct long-range, vital orga- nizational programs and planning in view of the uncertainty from time to time of the funding required to support these ventures. Something we plan for a decade ahead cannot be accomplished on 2-year appropriations. How you get Government workers under these conditions, I don’t know. We are having difficulty. Mr. Rocers. I am sure it would be desirable to set programs for as much time as we wanted with as much money as was wanted, but we have to equate the economy of the Nation. But this is the committee's function, and that is what we will do. We are grateful for your testimony in support of this legislation. It will be helpful to us in our consideration. Our next witness is Dr. Clark Millikan, of the Mayo Clinic, who will appear and give testimony for the American Heart Association, Inc. Dr. Millikan, we are delighted to have you here. and will be pleased to have your testimony. If you would like to put your statement in the record and just sum up for us, it would be acceptable, or if you prefer, read it. STATEMENT OF DR. CLARK MILLIKAN, CHAIRMAN, COUNCIL ON CEREBROVASCULAR DISEASE, AMERICAN HEART ASSOCIATION Dr. Mrxian. Mr. Rogers and members of the subcommittee, it is not only an honor, but a responsibility, to take part in the construc- 164 tion of the continuing legislation. I would prefer, actually, to just make some comments. a Mr. Rocers. That will be done. Without objection, Dr. Millikan’s statement will be placed as part of the record following his remarks. Dr. Mitrixan. I represent the American Heart Association, being chairman of the association’s council on cerebrovascular disease. This program has turned out to be a unique opportunity, and a practical, recognizable entity for cooperative and collaborative ar- rangements, not only between the university centers and practicing physicians but between government and nongovernment agencies and personnel. ; The Heart Association, for instance, has taken an extraordinarily active part all over the Nation, not only at the level of regional advi- sory committees but in smaller community affairs. Last week there was a meeting in New York at which over 400 volunteers were present, and one of the firm decisions arrived at at that meeting was to en- courage further the participation of Heart Association personnel, which can bring a great deal to the implementation and the purposes of the past bill and the new bill. This exemplifies the kind of feeling and the loyalty, for instance, that is being generated by the very wise provisions of this act, and we heartily endorse the continuation of these basic principles, in- cluding the business of originating ideas at the loca] level and having administration remain at the local level. Commenting about the matter of the finances, $65 million is a sug- gestion for fiseal 1969, and as is brought out, there is to be some holdover. You are aware that there are now actually about 11 operational pro- grams, aid within the next few months there will be a total of 30 to 35 operational programs. It is extraordinarily important to consider that we are thinking in terms of a graph of continuity here. And ag this program develops effectively, gaining momentum, it is mandatory that we not put a fence in front of it at any point in time with the attendant loss, in possible instances, of personnel. This whole program relates to people, whether at the administra- tive end or the practicing physician end, or at the patient end. And if we do something which cuts back the momentum 1n the year 1968 to 1969, we have lost more than 1 year of progress, and so I would emphasize the need for the continuity of fiscal support for this whole business. Now, .on the matter of construction money, that has come up in reference to the new bill. It would seem highly important that there be authorization for this. As Dr. DeBakey mentioned and Dr. Farber added, there are areas of activity for which new construction funds will undoubtedly be necessary at the level of 2, 3, or 4 years from now, which should be evaluated at that point in time. It does not need to be done now in terms of assigning an amount of money. But it should be looked at precisely later on. . * But the cardiac intensive care unit, or a stroke unit, or a matrix which requires space—that is not the issue at the moment. But for adequate planning in the future there should be the authorization 165 for the potential of including new construction somewhere in the course of time. Now, a comment in the area of stroke, because this is the area of my particular interest. The American Heart Association has been much interested in stroke and has formed a council on cerebrovascular disease and has been active in promoting teaching and spreading the word in communities. I believe that RMP offers us an opportunity to produce a greater matrix where we are really going to do something about stroke. You are aware of the need for treatment in terms of acute facilities for rehabilitation, reentry of the patient into the community, but we are now beginning to accumulate data which, if we can get the infor- mation to the population and to the hysicians, will significantly affect stroke prevention. And this is the kind of thing that RMP is designed to do, among other things. One of the most interesting items that is coming on the agenda now is the word “hypertension,” or high blood pressure, and we now have definite epidemiological evidence through programs which have been supported and originated by you people that hypertension is as im- portant in stroke as it is in heart disease, certain categories of heart disease in particular, and that via the detection and treatment of hypertension, we may cut significantly down on the incidence of stroke. The Heart Association is designing programs to interrelate to RMP and provide screening and detection mechanisms to find these people. Some 20 percent of hypertensives are not even detected at this point in time. In relationship to the very important subject of hypertension, the regional medical programs offer an excellent matrix for the evaluation of antihypertensive drugs. As programs for screening, detection, and diagnosis of high blood pressure are constructed, funds should be avail- able for evaluation and comparative trials of drug agents; includin drugs already known and those which will come out of developmenta laboratories. These are simply summaries of some of the comments that are in the formal record. I don’t want to belabor these issues, but to me, we are dealing with the national resource, the health of our people, and we couldn't be discussing a more important subject. I congratulate and commend you on all of the things that you have done, and in this particular frame of reference your wisdom in guiding RMP has been unique. (Dr. Millikan’s prepared statement follows :) STATEMENT OF DR. CLARK MILLIKAN, CHAIRMAN, COUNCIL ON CEREBROVASCULAR DISEASE, AMERICAN HEART ASSOCIATION Iam Dr. Clark Millikan, Chairman of the American Heart Association’s Coun- cil on Cerebrovascular Disease. Representing the Association I welcome the op- portunity of testifying in support of ELR. 15758, the five-year extension of the Regional Medical Program (P. L. 89-239). As one of the organizations instru- mental in promoting the original Regional Medical Program in 1965, we are pleased with the significant contribution it has made to the application of new medical knowledge to the diagnosis and treatment of heart disease and stroke. We are particularly pleased that the Regional Medical Program has provided, as intended, an effective vehicle for governmental and non-governmental co- operation in combatting the three diseases taking the greatest toll of life in 166 American society. Maximum responsibility has been on local leadership and regional cooperative arrangements. Heart Associations across the country have been active on almost all Regional Advisory Committees planning programs, gathering data on health manpower requirements and analyzing available health facilities and services. We expect continued participation during the five years of the proposed renewal as the em- phasis of the program shifts from the planning to the operational phase. Last week in New York City 400 American Heart Association volunteers and staff from across the nation planned ways in which we cap improve our pro- gram. One entire discussion group was devoted to the interrelationship of the Regional Medical Program and the American Heart Association. We discussed the ways in which the relationships between Heart Associations in the various states and the governmental agencies in their areas could be reinforced. It was decided at this national meeting that part of our future program would be to encourage our membership to take every available advantage of Regional Medical Programs, so that Heart Associations would be playing their maximum role to the maximum benefit of their communities. The original law provided over a three-year period increasing grants of from $50,000,000 to $200,000,000 for the fiscal year ending June, 1968. We note that H. R. 15758 specifies $65,000,000 for fiscal 1969 and ‘“‘such sums as may be neces- sary for the next four fiscal years.” We are aware that nearly $35,000,000 of unobligated funds are available in addition to the $65,000,000 provided in this bill for the next fiscal year. However, we would prefer that specific funding for fiscal years 1970 through 1973 had been included in this bill to assure the maxi- mum growth of this successful program. If the $65,000,000 for fiscal 1969 is appropriated and authorized, we under- stand 30 of the 54 Regional Medical Programs will be receiving their initial operational grants and 14 will be in their second or third year of operational grant activity. It is to be expected that in the following four years operational requirements will increase; yet the legislation under consideration here today leaves the program to the unknown quantity of annual Congressional appropria- tions after fiscal 1969. We have some reservations as to the wisdom of this ap- proach since long-range planning is essential to the success of this program. One final word as to funds, we stress the minimal necessity of the full $65,000,000 requested in H. R. 15758 for 1969. Among the promising developments in the Regional Medical Program of par- ticular interest to us has been the recent emphasis on extending the development of coronary care units and the necessary trained personnel to hospitals not now having these life-saving facilities. It is our understanding that the Regional Medi- cal Program has many applications for funds for this purpose. We thoroughly applaud the establishment of these life-saving facilities in every hospital caring for coronary artery problems and hope that in the future even more funds will be available for coronary care units. As the Chairman of the American Heart Association’s Council on Cerebro- vascular Disease, I can speak with particular knowledge of the constructive pur- poses the Regional Medical Program has and will continue to serve in mobilizing professional attention and funds for community-wide stroke detection programs and treatment. Teaching units in many medical schools have shied away from involrement with the stroke patient. As part of the planning and operational grants of the Regional Medical Program, new interest in this problem has been stimulated in a constructive way. This promising development must be en- couraged in the next five years of the Regional Medical Program and adequate funds supplied for this purpose. Section 103 of the bill extends the Regional Medical Program to areas outside the United States which should be the beneficiary of this program. We..endorse the inclusion of Puerto Rico, the Virgin Islands, Guam, American Samoa and the Trust Territories of the Pacific Islands. Value to citizens of the states within the United States should not be hoarded but shared with areas not part of, but historically connected to the United States. Additionally, the American Heart Association endorses the use of grants for two or more Regional Medical Programs, as proposed in Section 910. This provision will permit the economical development of teaching films, videotapes and other educational materials for use by several regions on a national basis. This pro- vision also permits the kind of flexibility the American Heart Association has always envisioned for this program. 167 The inclusion of referals to Regional Medical Program facilities by practic- ing dentists proposed in Section 107 is of particular importance. Deutists can play an important role in preventing the recurrence of rheumatic fever and bacterial endocarditis if aware of this opportunity. Their inclusion along with physicians in this program is therefore of significance to the alleviation of some forms of cardiovascular disease. In relationship to the very important subject of hypertension, the Regional Medical Programs offer an excellent matrix for the evaluation of anti-hyperten- sive drugs. As programs for screening, detection and diagnosis of high biood pressure are constructed, funds should be available for evaluation and com- parative trials of drug agents; including drugs already known and those which will come out of developmental laboratories. Finally, the American Heart Association endorses the inclusion of federal hospitals (Section 107) in the total operation of the Regional Medical Program. The broadest possible range of community medical facilities enlarges the scope of health services to the public contemplated in the original purpose of the program. Despite one reservation expressed at the beginning of this testimony, the Ameri- can Heart Association strongly recommends the enactment of H.R. 15758. Mr. Rocers. Thank you very much, Dr. Millikan. We appreciate your testimony, and I would agree with you that stroke is an area where we need to do great work, and much needs to be done to improve the health of the people in this area. I think it has been overlooked a great deal from the testimony I have heard. Dr. Carter? Mr. Carrer. No questions. Mr. Rocers. Mr. Skubitz? ; Mr. Sxustrz. Doctor, the point I am trying to get across is, I have no objection to a continuing program. But I want the agency to come forth each year, justify what they have done and prove how much additional money is needed. | . Maybe $65 million is sufficient for 1969, but who is to say how much we need in 1970 or 1971 without the Department coming before us and reviewing the program. Maybe we need $200 million next year, in 1970. And maybe the year following we may need $300 million in- stead of $100 million. ; . T don’t know. What I want is for the Department to come in and justify its request from year to year. If it can’t justify them, then I see no need of carrying the program forward. . Dr. Muiran. May I ask a question? Are you addressing yourself to just filing the authorizations, or the amount $ Mr. Sxusirz. The amount. oo . . Dr. Mirurxan. I believe these are different things, i, essence. It seems to me that the record is now being written on the justification of this program, and that we are seeing significant changes in the interrelationships between the laboratory and teachers, on one hand, and the practicing physician community, on the other hand, which are going to accrue to the benefit of patients all over the Nation. Mr. Sxvsrrz. I don’t think there is much doubt about that. I am sold on the program. . Dr. Mriirman. It seems to me that if the question is how much money is to be allocated per year, that is really in the province of the com- mittee, as you deliberate how you esta lish mechanisms to find out about this. ; . _. Mr, Sxvsrtz. My point is, though, that if we authorize $200 million for 1970 and $300 million for 1971, the Department does not have to 168 come before this committee anymore. It goes to the Appropriations Committee. ; Mr. Rocers. Mr. Kyros? . Mr, Kyros. Dr. Millikan, I found your testimony most interesting, not only in support of the program, but particularly what you say about money. And, again, as a man who has just come to Congress In the last year or so, it surprises me to see doctors come before this com- mittee and ask for this money and for the continuation of programs. T used to think that doctors in the American Medical Association took a different view. I am in full agreement with your position as it is expressed here. Dr. Miuurman. Thank you. Mr. Rocers. Thank you very much. Tt is my understanding that one of our witnesses has a 3 o’clock plane to catch back to California, and if the committee would bear with us, if we could hear nis testimony now, it would be helpful. Dr. Lester Breslow, professor of health administration and chief of the division of health services, School of Public Health, University of California, Los Angeles. Dr. Breslow, we appreciate your helping the committee, and we will be pleased to receive your testimony. If you would like to file your statement for the record and make appropriate comments, we wou be pleased to follow that procedure. STATEMENT OF DR. LESTER BRESLOW, PRESIDENT-ELECT, AMERICAN PUBLIC HEALTH ASSOCIATION Dr. Brestow. Thank you. I am appearing before you as _vesident- elect of the American Public Health Association. I would lik: 29 make some remarks based on the written statement which has been gi. iitted for the record. ; Mr. Rocers. Your statement will be made a part of the record fol: lowing your remarks. Dr. Brestow. The effective organization and utilization of the +.- sources that we now have, and the unique contribution of the orig’ :. cooperative arrangements, are made possible by this program. The unique contributions are to extend the excellence of the medici.! centers out into the communities, and to accelerate the progress that is being mace. I think it is unfortunate that the American people still do not realize the advances that are being made against heart disease, cancer, and stroke, and the point of this program is to accelerate progress. When we speak about regional cooperative arrangements, it is im- ortant to note that these are developing as a two-way street. The extension of expertise is not only from the ‘medical centers out into the community but also from the point of view of the practicing doctor, from the community hospitals, back to the medical centers, They then begin to appreciate the real problems physicians are up against in the day-to-day handling of medical problems. This is a truly cooperative arrangement and a two-way street, with motion in both directions. I would like to say a few words about the progress that is being made in California. From the outset, the California program has 169 sought. to effect. cooperation between the hospital associations, the medical ‘associations, the medical schools, and the State health depart- ment, Cancer Society, and Heart Association. There has been estab- lished a network of good communications, now, through area commit- tees around every medical school and extending into every area of the State. Consequently, effective working bodies around many of the community hospitals and practically in all of the counties in the State are tied in with medical centers. A couple of advances are being made. We are going to submit, on April 1 and 2, for consideration by our national site review, 14 pro- posals for operating grants in California. Among these will be a proposal to establish coronary care unit service in the coastal areas of California, a stretch of several hundred miles of small communities. If this program is approved these units will work with the university medical center in San Francisco, in order to extend this whole program out to the periphery of the State. In the southern part of the State there is a proposal that would bring together the medical faculties of two of our universities there. This proposed program also would bring the medical faculties of these schools in contact with the practicing physicians in the Watts-Willow- brook area, in the center of Los Angeles—a scene of past violence and serious problems. The medical faculties of these schools would work along with the county and hospital administrators of the region who would then develop a postgraduate medical education program with concentration on heart disease, cancer, and stroke. I mention these two projects merely to emphasize to the committee that this program is going to bring better care to persons not only in the medical centers but also into those parts of the State which have been relatively neglected in the past, such as the ghetto areas in the cities and the rural areas over the great stretches like in California. Thank you, Mr. Chairman. (Dr. Breslow’s prepared statement follows:) PROFESSOR OF HEALTH SERVICES ADMINIS- SraremenT oF Dr. LESTER BRESLOW, UNIVERSITY OF CALIFORNIA AT Los ANGELES TRATION, SCHOOL OF PUBLIC HEALTH, Mr. Chairman and members of the Committee, I am Lester Breslow, Professor of Health Services Administration in the School of Public Health at UCLA. I have previously been the State Health Officer for the State of California. I have come today to speak in support of H.R. 15758 and particularly that section of the bill which would extend the authority for the Regional Medical Programs. In my professional career I have long been concerned with the need for a more effective organization of our vast health endeavor, and I view the Regional Medical Programs as having great potential for making a very important con- tribution to this objective. In recent years this Committee has heard a great deal of discussion about the current difficulties of our health-care system. For this Nation, these problems are not always the lack of health resources but rather the effective organization and utilization of the many resources with which we are blessed, including our resources of talent and knowledge as well as capital, equipment, and personnel. In passing this legislation three years ago, the Congress expressed a public feel- ing that the benefits of medical science were not being applied uniformly enough to all segments of our population. This expression was part of a growing recogni- tion within the health field that the present complexity and specialization of health care requires exploration of improved patterns of organization. The legis- lation carried through with this concern by placing emphasis on the development through the Regional Medical Programs of “regional cooperative arrangements” 309-653 O-68—9 170 among the health personnel and institutions on a regional basis as a necessary prerequisite to accomplish the objectives of reducing the unnecessary toh from these diseases. . he Regional Medical Programs pecome then an exciting new venture in the development of an improved health system—creating new relationships and ca- pabilities while preserving and puilding upon the great strengths of our existing institutions, agencies, and personnel. The history of past efforts at creating a regionalized approach to health serv- ices provides ample evidence that the task set for the Regional Medical Programs will be difficult and progress at times will seem slow. There have been previous beginning efforts at regionalized health activities in various parts of the country, some of which were described by this Committee in the report on the original legislation three years ago. Now the pressures of an increasingly complex health enterprise and the rapid advances of medical science and technology have added a considerable urgency to the need for regionalization in the health field if our people are to benefit fully from these advances. The pressures generated by the rapid rise of health-care costs and the increasing urbanization of our society add to this urgency. The Regional Medical Programs are beginning to show some effectiveness in providing part of the answer to these problems. The activities of the Regional Medical Programs are helping to define the opportunities for improving the excellence of the health services within each region and the contributions that each element of the region’s health resources can make to that excellence. The programs are establishing a permanent framework within the regions that be- comes a two-way street whereby the expertise in the great medical centers becomes more readily available to the practitioner and institution at the com- munity level, while at the same time the definition of community health needs and the involvement of community resources ig made more relevant to the spe- cialized capabilities of the large centers. I have seen this process at work in California where we face a more complex task than most of the regions because of the great size of the region. This is the largest region with about 20 million people, and the development of the Regional Medical Program is following a somewhat different pattern than other regions, reflecting the commendable flexibility of the legislation in allowing each regional program to develop according to the particular pattern most suitable for that region. The amount of cooperation involving all of the medical schools, the medical profession, the hospitals, the public health agencies, and interested public in California has already made an invaluable contribution to the development of the essential basis for cooperative action. Even before the Califorina Regional Medical Program has received any operational funds, the progress of the program during this planning phase and the establishment of much improved lines of communication among the many elements involved constitute substantial progress. In the interest of time, I would like to submit to the Committee a fuller statement of the accomplishments to date under the California Regional Medical Program. (See attachment A.) I think there is still a long way to go in developing the program in California when the progress is measured against the magnitude of the task. By that same measure, however, we in California are very pleased that the necessary initial steps in the development of the program are now well underway. I believe that the Regional Medical Programs for heart disease, cancer, and stroke are a very important eomponent of the development of health care on @ regional basis in this country. With their emphasis on medical excellence, the involvement of medical centers, the practicing physicians, and the hospitals, the programs are a necessary part of the effort to bring the best in health care to the American people. Regional Medical Programs, however, can only make. their full contribution in concert with the many other activities devoted to that goal. The scope of the challenge is too proad to be totally accomplished by any one program. The development of effective interrelationships among the Regional Medical Programs, Comprehensive Health Planning, and the wide variety of other health programs—Federal, State, and local—will be essential. I believe that the development of cooperative relationships among many diverse interests already underway through the Regional Medical Programs is a basis for hope that this cooperation can be extended to a broader level and that the effective inter- relationships will be developed in ways appropriate to serve the diversities of the various areas of the country. 171 As an essential component of this broad effort, the authority for the Regional Medical Programs should be extended and support should be provided for theix continued development. Thank you very much for this opportunity to appear before you today. [ATTACHMENT A] STATEMENT OF LESTER BRESLOW, M.D., ON THE CALIFORNIA COMMITTEE ON REGIONAL MEDICAL PRocRAMS, Marcu 27, 1968 The California Regional Medical Program has been funded for only 15 months and althongh it would be premature to claim that lives had been saved, never- theless, it can be said with confidence that the stage has been set for the pro- vision of greatly improved health care services for heart disease, cancer, stroke, and the disorders related to them. Just this week a study was launched by the California Health Data Corpora- . tion to gather information on the origin of every patient admitted during the entire week to every hospital in California. The study, never before undertaken on so large a scale, will show where each patient came from, what his diagnosis was when he was discharged from the hospital, and other information. While these may seem little more than a set of dry statistics, the results should reveal with great accuracy the kinds of medical services needed for Californians and others cared for in the State. Other data gathering studies, which are expected to lead very shortly to operational programs, will be described later. From the very beginning, planning for the California Regional Medical Pro- gram embraced all the major medical and health interests in the State. The Cali- fornia Medical Association, spokesman for the State’s 23,000 practicing physi- cians; the California Hospital Association, representing virtually all of the 600 short-term acute general hospitals in the region; the California State Depart- ment of Public Health; the California Heart Associations; the California Di- vision of the American Cancer Society; the deans of all of the eight medical schools in California, and the deans of the two major schools of public health were joined by eight public representatives of the consumer. Together they con- stitute the legal advisory committee for the region and are known formally as the California Committee on Regional Medical Programs. The Committee has met many times, has gained strength, grown gratifyingly more confident of it- self as an entity and has increasingly been able to resolve differences amicably. As for operational programs, we are looking forward to a two-day site visit in California on April 1 and 2 by a review committee of the National Advisory Council for Regional Medical Programs. They will examine the merits of 14 operational proposals generated by local community interest in five of the State’s eight planning areas, and by the California Heart Association, These first op- erational proposals are heavily weighted toward continuing education, and in- clude some promising innovative experiments. The greatest single topic of interest among these early operational proposals concerns coronary care units, reflecting a growing consensus throughout the Na- tion that such units, properly equipped and with highly-skilled doctors and nurses to run them, can bring about a dramatic reduction in deaths due to myocardial infractions and other cardiac emergencies. Four of the 14 proposals deal with the training of physicians and nurses and the equipping of coronary care units, One proposal would offer nurse training in several communities throughout North- western California, stretching from the Bay Area to the Oregon border along the Pacifie Coast, and would include intensive training for physicians at the San Francisco General Hospital, under the tutelage of University of California cardi- ologists. Similar proposals would be offered through several hospitals in the highly concentrated Los Angeles basin and include the beefing up of the intensive coronary care unit at the Los Angeles County General Hospital. A joint proposal by the University of Southern California and the University of California at Los Angeles would join with the Charles R. Drew Medical Society and others to establish a postgraduate medical school in the Watts- Willowbrook ghetto area of Los Angeles. Internship and residency programs would be generated along with inservice and postgraduate training for doctors, nurses and allied health professionals, close relationships with the faculties at USC and UCLA and detailed planning to meet heart disease, cancer and stroke needs in the area. At Roseville, a community of 20,000 citizens 18 miles northeast of Sacramento, the University of California Davis Medical School has encouraged local physi- 172 cians to establish a “living laboratory” involving the whole community. Contin- uing education, training for licensed vocational nurses and other paramedical personnel, stroke treatment, handling of central nervous system malignancies, establishment of a tumor board, selected multiphasic screening and community education programs are involved. . The California Heart Association proposes a substantial expansion of its suc- cessful student research projects, bringing highly qualified science students into cardiovascular research laboratories. In Los Angeles, special training in angiography—the visualization of the blood yessel system with the aid of radioactive dyes—would be presented for practicing and qualified radiologists. Two proposals—one for the Sacramento Valley, the other for the lower San Joaquin—would make use of videotape recording units which would be moved from one hospital to the next, covering several score hospitals. The units would be accompanied by medical television tapes, for instruction of each hospital's staff members, and each local staff could record its own grand rounds, lectures and demonstrations, then, by playing the lesson back, improve its own teaching skills. The California Heart Association proposes a substantial expansion of its suc- pitals in the State, would be expanded to other regions. The development of simple learning languages in a computer program available for undergraduate, graduate and postgraduate instruction to several regional medical program areas would be encouraged in another proposal. The Loma Linda University School of Medicine has a highly intriguing pilot project based on a third-generation computer, and proposes to expand its library services to practicing physicians throughout its vast service area. The computer demonstration would test the feasibility of using @ remote display, very much like a television set, on which a physician in a community hundreds of miles from the school could, by picking up the telephone, hook into the computer and ask it to analyze the electrocardiograph readings peing taken on the patient lying by the physician’s side. The computer analysis would be done in real-time, and the answer would return in 2 or 8 minutes. Such 4 project might provide needed services to small, remotely located hospitals and communities now lacking medical specialists. These 14 operational proposals are under immediate consideration. Several others, submitted in the March, 1968 quarter, will be briefly detailed in a moment. All have been developed following planning activity: which began in January, 1967. The first rear’s planning activity involved, among other things, the lay- ing down of a data pase from which operational proposals are being projected. Construction of the data base has gone through two phases. In the first phase simple, readily available data were arranged in forms most useful for planning in each of the eight areas of California. Demographic data were acquired from the State Department of Finance. Mortality data were gathered from the State Department of Public Health. Also from the State Health Department, with added information from the California Hospital As- sociation, came material for a complete hospital roster for each of the Cali- fornia Regional Medical Program areas. Finally, the first phase of data acquisi- tion entailed analysis of less readily available types of information involving, for example, transportation and the many varieties of morbidity data. During the second half of the first planning year, six planning studies were undertaken on a region-wide scale. All were approved by a data needs subcom- mitee on which each of the California Regional Medical Program areas was represented. Each study aimed at relatively deeper penetration into some aspect of the data base needed for planning. At the same time each pointed clearly to the shape of operational proposals in the making. . Patient origin study.—This study, reseribed priefly in the opening paragraphs of this statement, will include important material for morbidity analysis, partic- ulary if the survey can be repeated at intervale. At the same time, the survey in is first round is expected to yield information needed for transportation and facil- ities planning in conjunction with the rendering of optimal care for heart disease, cancer and stroke patients. Training facilities inventory—Many of the ideas for operational ‘projects, which began to take shape jn the first planning period, concerned manpower needs and the possibilities of training programs for key health services, in addition to physician services. It was found, though, that ‘little information had been gathered on the simple question of what training facilities now exist. 173 The California Regional Medical Program, therefore, contracted with the Survey Research Center at UCLA to make an analytic region-wide survey of existing training facilities for health service manpower of all sorts, The survey, besides being an inventory of facilities, includes analytic details as to capacities, present enrollments, expansion possibilities, curricula and new programs. It will serve as a basis for second-generation studies and operational proposals in the man- power field. Physician referral patterns.—The Stanford Research Institute, in cooperation with the California Medical Association, is completing interviews with a random sample of physicians throughout the State on the subject of referral patterns for patients with heart disease, cancer and stroke. Here, too, material never gath- ered before’is being acquired. Questionnaires already completed contain valuable material of two kinds, As a basis for improved delivery of medical service in cases of heart disease, cancer and stroke, referral patterns, both as to physicians and facilities, are being discussed. And, the needs seen by family physicians, and other physicians of first reference, are being recorded and analyzed for the first time in this context. Registries—A cooperative undertaking involving the System Development Corp. of Santa Monica and the UCLA School of Public Health is doing feasibil- ity testing for possible registries in stroke and heart disease. California has al- ready had rich experience in the development of a tumor registry, covering roughly a third of the hospital beds in the State and providing cancer incidence data of unique significance. The System Development Corp. study is, therefore, moving on to a preliminary examination of registry construction in stroke and heart disease. At the same time, the Director of the California Tumor. Registry is cooperating with the California Regional Medical Program in connection with cancer registration and follow-up. Use of medical scoiety review mechanisms.—On a trial basis, local medical orga- nizations in three California counties are cooperating with the Regional Medical Program to determine the value of local medical review mechanisms—generally associated with claims review in health insurance programs—for case identifica- tion heart disease, cancer and stroke, review of prevailing community stand- ards and practices in management of such cases, and possible development of postgraduate medical education and other programs. In each case, the county medical group has agreed to cooperate with the appropriate university medical center in the review. Specialized resources in hospitala.—The sixth and last of the first-generation California planning studies is based on questionnaires sent to all the acute, gen- eral hospitals in the State, through the cooperation of the California Hospital Association. The hospitals are reporting whether or not they have various items on a detailed roster of specialized resources or facilities needed for treatment and overall management of patients with heart disease, cancer and stroke. This material, too, has not been gathered before, and is expected to highlight ma- terial lacks, oversupplies or maldistributions. At the same time, the study will bring manpower training requirements to a sharper focus as California’s Re- gional Medical Programs enter their operational phase. All these data gathering studies have been integrated into the 14 operational proposals described earlier. They have also been incorporated into the five op- erational proposals and the two additional requests for funds especially ear- marked by Congress, submitted by the California Committee on Regional Medical Programs during the March, 1968 quarter. This second set of proposals includes the expansion of existing clinical cancer diagnosis and treatment, soctal service consultation, radiological physics, nuclear medicine and computer retrieval of pertinent data to 26 hospitals in northern California, a coordinated year-round general practice residency, intensive coro- nary care training for physicians in small hospitals, and the establishment of a medical library and information service network. The first of the projects seeking earmarked funds involves a sixth area in California—Orange County, the planning for which has been assigned to the University of California at Irvine—proposing a pediatric pulmonary demonstra- tion center. It would be only the fourth of its kind in the Nation. The second project would expand and improve an existing hypertension program of the UC San Francisco Medical Center. Taken all together, these first operational proposals can be seen as the begin- ning broad outlines in the development of a region-wide comprehensive blueprint, 174 whose cohesion and effective potential for vastly improved health care services are emerging, almost on a day-by-day basis, ever more clearly. Mr. Rocers. Let me ask this. Is your program getting to the ghetto areas? Could you give us a quick rundown on that? Dr. Brestow. One program that is being considered—I perhaps should not prejudge the issue—is the proposal which has been devel- oped by USC and UCLA faculties. It would transfer the medical expertise developed by these two centers, in the field of heart disease, cancer, and stroke, to the Watts-Willowbrook area. It is in this area that the county plans to build a new hospital with the aid of Hill- Burton support. The aim of this program is to build around that hospital, bringing in the practicing physicians sn the community, a program of postgrad- uate education, emphasizing heart disease, cancer, and stroke. We think this will have a remarkable effect in mobilizing the services of that portion of Los Angeles to provide better care. Mr. Rogers. Thank you, and I am delighted to see you have given us a statement on the California program, which we will go into in detail. Mr. Kyros? Mr. Kyros. No questions. Mr. Rocers. Dr. Carter? Mr. Carrer. I am delighted to know you are making all these services available for the Watts area. I wonder what you are doing for the areas around Watts. Dr. Brestow. Our programs extend into the Watts area and also around the Watts area, not only throughout the metropolitan region of Los Angeles, but in the mountainous areas, and so forth. Other projects-——— Mr. Carrer. I believe in those surrounding areas we are liable to have more heart attacks and strokes. {Laughter.] Mr. Rocers. Thank you very much, Dr. Breslow. We appreciate very much your coming here. T understand that we will try to hear one more witness here. Reverend Works, you and Dr. Price, I understood, were going to have to get away. Could you come forward, then? We. will be pleased to hear your testimony. Mr. Macdonald, your Congressman, wanted to come and introduce you, but the committee knows of your work, and we are delighted to have. youu here with us, and Dr. Price. And if you would like, we will make your statements part of the record, without objection and they will appear following your re- marks. And if you could then summarize for us the points that you think wolud be important, this would be helpful to the committee. 193 Mr. RoceErs.' ; . . The next witness, Mr. Nathan J. Stark, group vice president for operations, Hallmark Cards, Inc., Kansas City, Mo. STATEMENT OF NATHAN J. STARK, CHAIRMAN, MISSOURI REGIONAL MEDICAL PROGRAM Mr. SrarK. My operations have nothing to do with medicine. Mr. Rocers. I am not so sure. Don’t you give get-well cards or something ? Mr. Starx. I have been accused of that. I am pleased to have this opportunity to be at this hearing on regional medical programs. I am, as you note from the title, a non- expert in the health field. ‘\ businessman interested in health programs is my category. As I listen to all these experts, many of whom I have heard of, and several of whom I have known, I asked myself the question, “What am I doing here?” But perhaps this is the new look in the nonprofessional’s view of the health field. I think that the need for citizen participation has been rather un- familiar to most of those in many parts of the health field, but I believe it is fast becoming consumer oriented. My credentials in the health field are as president of the Kansas City General Hospital and Medical Center, and as chairman of the Missouri regional medical program, and it is to this latter role that I wish to address my remarks. My statement will be restricted to the Missouri program, since this is the one I am most familiar with, and it may be typical, or may be typical of what other programs are. 194 The final focus of our program is on the cooperative delivery and planning of the best possible health care to patients suffering from heart disease, cancer, stroke, and other related diseases, regar less of economic, educational, or geographical status. The program utilizes maximum local planning and initiative with regional emphasis upon coordinaion of efforts and review of the qual- ity of endeavors. Policy is set by a council representative of the public and professional leadership with advice from all groups in the region who have a bona fide interest in the delivery of health care. Because of the stated intent of the program which was to improve care by increasing the effectiveness of present systems, attention in the Missouri program was directed to early detection of disease, method- ology for systems to provide maximum economy and effectiveness, and initially 2 small number of models of delivery systems, planning for a service to a specific population of people without regard to the exact place in which that service might be rendered, but with empha- sis on delivering the care as close to the patient’s home as is consistent with economy and quality. In other words, we are people oriented. Primary emphasis has been placed on the development of supportive services which utilize the newest in scientific technology. This includes a variety of services which can be furnished both to the physician and to the patient quickly and economically at any time anywhere in the region. The present testing of computerized interpretation of EKG’s for physicians in rural areas is a precise example. For screening purposes, and for the first time in history, the private practitioner participating in the model system has consultation for heart disease immediately available to him at every hour, 168 hours a week, at an estimated cost of less than $3 per interpretation. Each interpretation can be backed up by a dial-a-phone lecture reference source, recorded on tape and also automatically available at all hours at the cost of a phone call. These backup lectures will develop on a demand basis in accord with experience. A model of delivery systems is found in the Smithville project. Here building upon an existing rural system, maximum effort has been placed by the local advisory group and the State university medical school upon a sophisticated consultation and referral program. In Smithville, the system extends into home care utilizing all avail- able ancillary and auxiliary personnel. Faculty members of the uni- versity teach and consult with the local staff. Financial assistance was given with a specific terminal date, at which time the system of care is projected to be self-supporting. ‘The program provides for careful change of quality of care as a result of intensified support. 7, It is the plan of the Missouri program to establish and terminate final support for all demonstration projects in this manner in order to provide the opportunity for cooperative programs with a maximum of communities in the region. Supporting services and later innovations will continue to be made available on a financially self-supporting basis to these cooperating communities so long as these are found to be mutually helpful. A final facet of the program is the interdisciplinary research group in the university who are studying intensively the delivery system 195 for health in the region, scientific devices which are needed but lack- ing at present, a communication facility which possibly could be adopted for purpose of the program. The research group functions as a medical experiment station draw- ing together the talents of all university disciplines which can con- tribute to the definition or solution of health care problems. Of the 21 bioengineering projects now active, I should like to men- tion two. One result of this research has been the development of a diagnostic chair, which simplifies the takin of a heart tracing. The chair reduces the time required for an EKG from about 20 minutes to less. Another piece of equipment developed by the engineers and the physicians working together is an electrolytic unit which has proved extremely helptul in speeding the healing of leg and body ulcers for the diabetics or patients who must be in bed for long periods, and these compact units can be taken home. ‘An added feature is an alarm system which reminds. the patient to keep the bandage properly dampened. Future programs could be summarized as the design of more model delivery systems in cooperation with the public and health profes- sional involving finally the entire region, continued concentrated study of appropriate services designed to be self-supporting, the assistance to programs in providing for treatment of disease and rehabilitation of patients suffering from these categories of disease, and last, a translation of new ideas into action on behalf of the patient or the potential patient. This is indeed an exciting, though wearing, time to be involved in health affairs. The regional medical program, to my mind, offers one of the best means for achieving optimal health for all people, who are in effect the real beneficiaries of regional medical programs. I would certainly urge the support and the continuation of this program. Now I have here an organization chart of the Missouri regional program which I would like to offer for the record. Mr. Rocers. The committee would be very pleased to have that, and it. will be made a part of the record at this point. (The document referred to follows :) Muissourt REGIONAL MEDICAL PROGRAM ORGANIZATION 1. GOAL SETTING (a) Policy is set by representatives of the public and the practicing profession upon advice from: Medical schools. State departments related to health. Voluntary organizations. All health professional organizations. (A total of more than 50 people read and comment upon each Proposal.) (b) Planning is for a selected population of people regardless of where they may ultimately receive their care. This permits maximum use of communication mechanisms already established between the many involved groups. (ce) Planning and operations are kept administratively separate. 2. ORGANIZATIONAL PATTERN The Project Review Committee consists of the head or his delegate from the schools of osteopathy and medicine, the Division ef Health, Director of Welfare and Director of Mental Diseases. This committee serves as an advisory body to the Council on all proposals. 196 An Advisory council, nominated by the Project Review Committee and ap- pointed by the Governor, serves as the governing body. The 12-members serve staggered terms, no person’s service to exceed six years. Members may not be drawn from University staff. : . The Liaison Committee is composed of elected or appointed representatives sent by each state-wide voluntary or professional organization which has applied to and been accepted by the Council. The 24 members serve as 4 reaction panel on all projects for Council. ; The University of Missouri serves as trustee for funds for the Missouri Regional Progrant. 8. SPECIAL URBAN ORGANIZATION For the Kansas City area a special Metropolitan Liaison Committee has been formed, Members include five local citizens and two representatives from each of the Advisory Councils of the two regions (Kansas and Missouri) which overlap in the Kansas City area. This committee also serves in an advisory capacity to the two Regional Councils for all projects which fall within the six county urban area of Kansas City. A special, local planning force has been assigned to Kansas City by the Mis- souri regional program. No matter how a region is described, ultimately it must interact with other regions. Modifications of the Kansas City committee have been developed with three of the other adjoining regional programs and similar plans are under dis- cussion with a number of other regions which also adjoin Missouri. Mr. Sranx. I submit for the record three separate publications of the Academy of General Practice as evidence of cooperative efforts between the practicing physician and the program, Mr. Rocers. We will receive those for the committee file. Thank you very much. Dr. Carter? Mr. Carrer. I just want to compliment this gentleman upon the paper that he has delivered here today, and to say that I think it is a very healthy sign when men of his evident ability take part in such programs as this. Thank you. Mr. Rocrrs. I would like to second those sentiments. I think it is excellent, and we do need more and more people to involve themselves in the health field other than just the scientific community, and I won- der if you could give us an example—you say the design of more model delivery systems. What is your thinking there? Mr. Srarx. Two that I have specifically in mind: One would be the Smithville project located in a rural area about 15 miles from Kansas City where they are designing a program for the first time to give complete continuity of care from the time the patient is seen in the diagnostic stage through the treatment stage and then into the rehabilitation stage. Another one is that taking place in Springfield, Mo., at the com- munity hospital. A cardiovascular program is in force where they are treating the cardiac patient and also training nurses and doctors in the care, treatment, and rehabilitation of cardiac patients. This is a part of the current operational grant and is working out very well. There are six or seven programs in operation, or being proposed now, in community hospitals. Mr. Rocers. Thank you very much. We appreciate your being here today. Our next witness who has a 4 o’clock plane, I believe, is Dr. Amos Bratrude. We appreciate your presence here today. Your Congress- 197 man, Tom Foley, spoke to me on the floor and said he wanted to be here to personally introduce you to the committee and regrets he can- not be. He is in committee himself. STATEMENT OF DR. AMOS BRATRUDE, WASHINGTON MEDICAL ASSOCIATION, AND ASSOCIATION OF GENERAL PRACTITIONERS Dr. Brarrupe. I was sent here today by the Washington Medical Association, and I have the blessing of the Association of General Practitioners. I am Dr. Amos P. Bratrude and am in general practice in Omak, Wash. I have a common failing with all people who have moved West, and that is our adopted home has become very important to us, and so you'll excuse me if I give you a few words about Omak. It is a rather typical western community of about 4,500 people. The prime industries are logging, apple orchards, and cattle. The biggest single event of the year is the Omak stampede with what we consider, a world-famous suicide race. It is a nice community and my 9 years there have been very pleasurable. I am married and have four children, and asa father am beginning to experience the rigors of a teenage daughter. I was raised in the Middle West. My father was a general practi- tioner in a small town by the name of Antioch, Il]. Upon deciding where to practice, there were several things I was sure that I wanted. I wanted a community with a hospital in it. I have always been very interested in general practice but could see no reason to choose a com- munity that was large enough to have a well established specialist group. I wanted to choose a community that I felt had some promise. of growth so that I could eventually have the type of medical practice that I was interested in. This: namely, is a group of three, four, or five doctors who are quite interested in the practice of medicine. but also want to be free to pursue academic and recreational activities. I am now the senior man of a four-man group, and the reason that I can be here today is that I have three excellent partners that are cover- ing for me. Those were the practical reasons for choosing Omak. The emotional ones are that the country just immediately appealed to me. I enjoy hunting and fishing and being outside, and all these things were avail- able. We have been 15 months in a new hospital with 32 beds, and a staff of seven physicians. Of course, four of these are of our group. It is quite interesting to me to go to various meetings and seminars and hear people discuss the problems of a small hospital. Invariably these People consider anything from 100 to 150 beds to be a small hospital. onsequently, their discussions of problems that might occur there have no bearing at all on what happens in a hospital of 32 beds. I had always been quite interested in the broader problems of medicine, and when the opportunity came to me from the Washington-Alaska regional medical program I welcomed it. I would be the first to admit that I had a rather biased viewpoint when I joined the Washington-Alaska regional medical program board. Thad been raised of fairly conservative parentage and had a decidedly jaundiced opinion of the role I thought Government was playing in medicine, It is quite surprising to find out at the first advisory com- 198 mittee meeting that most of us had the same feeling. Then it was inter- esting to see the change in everyone as the meeting progressed. It seemed that most of us had very definite, but very erroneous ideas of what the regional medical program would be and how it would work. It was explained in the first session in May of 1966 that the regional medical program was not oing to be a vehicle to transport the patient to “supercenters” but rather was going to be a vehicle to transport knowledge, technique, and assistance to the local level to improve patient care in places such as Omak. I, of course, was very suspicious that this was just the bait to lure us into the trap. 1 have now com, pleted approximately 90 months on this committee, and Iam convinced that at least the Washington-Alaska program has not altered from this ideal; that is, to attempt to improve the level of care for victims of heart disease, cancer, and stroke and related diseases into local com- munities. I was also prejudiced in another area as I approached the work on the regional medical program. T am in a very rural commu- nity. I think it is wonderful to have great research projects and a large amount of what we call ivory tower medicine. But I also feel there is a tremendous amount of medicine that has to be practiced on a day-to-day basis to help the people receive proper care. I also had many preconceived ideas about physician education pro- grams that I felt were fairly worthless. I have taken these prejudices and conveyed them into ideas for our group, and am afraid I have helped to sidetrack certain programs I felt had little practical value. Y do want to say that I feel there is a definite place for complicated research projects, and without them many of the advances we enjoy today would not be here. But I feel, as the only general practitioner on the Advisory Committee, that I have wasted very little time ar- guing for the aspect of medicine because many about me are. In regard to specific problems that were present in the practice of medicine in north-central Washington these are some. There are certainly many other problems which deal with rural areas, and many of these would fall in the categorical areas of the heart, cancer, and stroke program. We are looking forward to taking advantage of the coronary care unit training programs that are cur- rently being established by our RMP and are looking forward to many other benefits from it. I think the point that I would like to make so strongly is that the RMP has offered the first opportunity gor local medical communities to feel that it is worthwhile to get in- vole and interested in because their opinions and problems are being sought. There certainly has been a considerable change in stance of the average physician in regard to Government in medicine. Just a few years ago no cooperation would be offered, and if preferable no inter- ference would be tolerated. Today we find the average physician understanding that the Government will be involved in medicine and that a cooperative venture of some kind would be most desirable. The RMP with its emphasis on regionalization has, I believe, caught the fancy of the medical communities of the United States. As I travel to various meetings with colleagues who are scattered across the coun- try, I find that quite often they have many favorable comments con- cerning the aims and goals of this program. I think that if this pro- 199 gram were to be significantly curtailed or even dropped, you would find a considerable disillusionment in the medical profession. I think most of us feel there is a strong chance that the RMP is going to offer all of us help and cooperation, not interference, from the Government on our local medical problems. I think that if it were possible to establish a long seriod, such as 5 years, the RMP could then do sig- nificant future planning and the medical community would know that the program was here to stay. I have certainly enjoyed the experience of coming to Washington, D.C., and appearing before this committee. Thank you very much for the opportunity. Mr. Rogers. Thank you very much, Dr. Bratrude. Your testimony is the type I think the committee needs to hear, from a practicing physician. We are delighted that you took time to present this testi- mony to the committee. Dr. Carter? Mr. Carrer. I certainly want to congratulate the gentleman upon his presentation. He is one of the men who applies the tools which have been given him, and in addition will evaluate and use what other tools are given him by our regional groups. I am impressed by his paper, and the depth of what he says. I am happy to have such a young physisian before us today. Mr. Rocrrs. Let me ask you: You say you are the only general prac- titioner on the Advisory Committee for your region, or is this a subregion ? Dr. Brarrcpe. I am the only one for the Washington-Alaska meet- ing. We have six practicing specialists from various disciplines; in addition, of course, to many physicians in the universities. ; Mr. Rocers. But there are six out of 830 whom you would classify as practicing physicians! Dr. Brarrupe. Seven, counting me. Mr. Rocers. How many hospital administrators do you have? Dr. Bratrupe. Two. ; Mr. Rocers. Do you think this is a good ratio? ; Dr. Bratruve. It is difficult to put everybody there. We have six or seven lay people, we have two nurses, we have a dentist ; and by the time you are done, we really aren't heavily laden with the medical school people. . . Mr. Rocers. Would it be more of a problem getting away if you were not in partnership? ; . . Dr. Bratrupe. I would like to speak about this a bit. I think the concept of the practicing physician is changed somewhat. As we are trained today, we are totally convinced that we have to stay current; and I think, as we set ourselves into practice, many of my colleagues in our county are in independent practice, such as Bill Henry, one of the doctors there. He feels it is important enough, and has educated his patients enough that he gets away for courses. I believe that group orno group, this is the way it.is going to be in the future. . Mr. Rogers. You don't think it can be brought down to the hospital level ? Dr. Brarruve. I don’t mean that. We have hospital staff meetings, and visiting professors who come for seminars, and the gentleman 200 from Missouri, some of his programs sounded outstanding. When you think about help that you need—it is 3 o’clock in the morning and you have a cardiac problem; you don’t need a seminar, you need someone to give you some help. It sounded like this aspect of his program was very exciting. Mr. Roczrs. Thank you so much. We appreciate the benefit of your advice. Mr. Rocrrs. Our next witness is Dr. Chambers, Medical Associa- tion of Georgia, Atlanta, Ga. It is a pleasure to have you here, and we know of you through your good friend, Congressman Jack Flint of Georgia. Dr. Crzaspers. | would like to submit a copy of this journal for the record. Mr. Rocers. Without objection, we will accept the journal for the files. (The publication referred to, “Journal of the Medical Association of Georgia,” April 1967, was placed in the committee files.) Mr. Rocers. You may proceed, Dr. Chambers. STATEMENT OF DR. J. W. CHAMBERS, REPRESENTING THE MEDICAL ASSOCIATION OF GEORGIA Dr. Caspers. Mr. Chairman and members of the committee. Tam in private practice of medicine in La Grange, Ga., associated with a fee for service group practice. La Grange, Ga., is asmall city of 25.000 population in a county of 50,000 population. There is one hospital in our community; it has approximately 220 beds and is an accredited hospital. I appreciate the courtesy of this committee in hearing a voice from the “grassroots support” of ELR. 15758. It is my belief that the health professionals in our region consider the original legislation, Public Law 89-239, as important as any that has been passed by the Congress in many years, and we feel that it deserves continued support. Our interest in this program, however, began before Public Law 89-289 was passed. This was evidenced by discussion among repre- sentatives of the Medical Association of Georgia. Emory University School of Medicine in Atlanta, the Medical College of Georgia in Augusta, the Georgia Heart Association, and the Georgia Division of. the American Cancer Society. These discussions were expanded during 1966 to include the representation from the Georgia Hospital Asso- ciation, Georgia Department of Public Health, Georgia Medical Asso- ciation, Georgia Dental Association, Georgia Pharmaceutical Associa- tion, Georgia Division of Vocational Rehabilitation, Georgia State Nurses Association, Georgia State League for Nursing, Georgia De- artment of Family and Children Services, Community Council of ‘Atlanta Area, Inc., and the Planning Council of Metropolitan Savannah. Tn addition, the Georgia Nursing Home Association and knowledge- able and interested Jaymen were included. From such discussions, 209 involving these diverse groups, a plan was developed for the organiza- tion of a regional advisory group composed of approximately 125 knowledgeable and interested persons broadly representative of our region. Evidence of the interest of the physicians of Georgia in the regional] medical program has been shown by the fact that the entire April 1967 issue of the journal of the Medical Association of Georgia was devoted to the Georgia regional medical program. This is the journal I asked to be put in the record. Although the program had only officially begun on January 1, 1967, the responsibility for leadership by physicians was already keenly felt. In fact, the Medical Association of Georgia was unanimously elected by the regional advisory group to serve as applicant, for the Georgia region. May I quote briefly from an editorial entitled “A Unique Oppor- tunity for Leadership,” which appeared in the April journal. The regional medical program for Georgia provides the membership of the Medical Association of Georgia a unique opportunity for leadership in “pro- moting the science and art of medicine and the betterment of the public heaith.” However, the role of leadership can only be effectively assumed as physicians understand the program. The legislation which established this program was the result of the report of the President’s Commission on Heart Disease, Cancer, and Stroke, commonly called the DeBakey report. However, Congress gave thoughtful consideration to many medical leaders and organizations before passing Public Law 89-289 jn October 1965. As a result. this law provides for local medical programs which can and will be developed by people in the areas involved for the people in the areas to be served. This is inherent in the legislation through the lan- guage of “cooperative arrangements,” and “without interfering with the pat- terns, or the methods of financing. of patient care of professional practices, or administration of hospitals.” The regional medical program for Georgia has been planned carefully by Georgia people in a truly cooperative atmosphere during the past 15 months. This can best be judged by the membership of the program's Georgia advisory group. The program is practical and will provide the tools for every practitioner to improve not only his own medical capabilities but also to improve the quality of medical care provided for each and every one of his patients. This is a challenge for each member of the Medical Association of Georgia and may well be our greatest opportunity in our time for exhibiting responsible leadership. Another factor which we feel recommends the extension of the regional medical program is the already demonstrated marked im- provement in communication and dialog. not only among teachers, medical schools, and practitioners, but also among all of the health professions in the region. In short, we have begun what we believe to be successful treatment of the “town gown” syndrome in our region. The long-range effect of this will he improved care of patients. The original program plan for the Georgia region takes into account that new knowledge from the medical centers must flow to every area of the region and equally important. the knowledge and needs of the practitioner and others in the small towns must flow to the medical centers. Still another recommendation for the extension of this program, we believe, has been the demonstrated mechanism for developing a pro- gram of public education to stimulate lay people to want and to seek good medical care. There are many economically disadvantaged people 309-653 O-68—10 210 whom we hope to educate to want adequate medical care, but there may be just as many medicall deprived people totally unrelated to economic circumstances. Included in this group are many of our most talented and capable citizens who simply 50 not seek medical care that could be classified as adequate. Finally, Mr. Chairman, we believe that the key to the success of the regional medical program in Georgia is the involvement of community hospitals. This, no doubt, is true in every re ion in the country to a reater or lesser extent. Very early in the development of plans for the Georgia program, the regional advisory group recognized that the vast majority of physicians, nurses and others involved in the regional pro- gram relate themselves to one or more hospitals. Therefore, each hospi- tal in the region has a vital role in the program and in the future of medicine. This includes the large hospital, the small hospital, and the hospital in the medical center, and the hospital remote to the medical center. At the present time there are about 19,500 hospital beds in Georgia distributed among 178 general and limited services hospitals of all sizes. Over 3,000 physicians serve on the staffs of these hospitals. To emphasize the role of hospitals in the program, it is lanned that each hospital will become a central focal point through which the objectives of the regional medical program will be carried out. Every hospital will become a teaching hospital. This does not imply that medical students and house staff need to be present; but, it does imply that physicians, nurses, dentists, pharmacists, administrators, members of the public, and all of the allied health professionals shall organize themselves into an educational program. Each hospital has been asked to submit the names of a group of persons to serve as a local advisory group to the regional medical program. It was suggested that a physi- cian (as chairman), a hospital administrator, a nurse, and a member of the public be the minimum number to comprise each designated group. T his local advisory group may be as large as the local hospital or community desires, but it must be named by and through acceptable administrative mechanisms. These groups of local hospital representatives are functioning well. Of Georgia’s 178 hospitals, 121 have appointed local advisory groups. This represents approximately 90 percent of the general hospital beds in the region. It is pertinent to this presentation that the chairman of the local advisory groups met in Atlanta on Sunday, March 24, 1968, for a day of planning and discussion. According to the registration, 87 hospital representatives were present. Similar meetings, as approved in the program plans for Georgia region, will be held at least twice during each calendar year. This method of affiliating local direction at the grassroots with the overall program of health planning is,-in our opinion, a sound and effective approach. Although health planning has been going on in our region for many years, this is the first time that representatives from all interested groups have deliberated together in an attempt to coordinate their health care planning into a unified plan for progress. Both interest and participation of the practicing hysicians, local hospitals, and medical schools have been excellent. Close communication with other agencies, organizations, institutions, and Government programs is 211 assuring complete coordination of all activities in the area of health in the Georgia region, and the purposes of Public Law 89-239 are being achieved. Thank you again, Mr. Chairman, for this opportunity. Mr. Rogers. Thank you for an excellent statement. I notice that you say 87 hospital representatives were present at your last meeting out of what? Some 178? Dr. Cuamaers. Potentially 178. Of that number 121 have already set up the local advisory groups. The ones who have not are primarily the extremely small hospitals, Mr. Chairman, maybe as few as 15 to 20 S. Mr. Rocers. But you feel the major hospitals in the State have? Dr. Cuampers. We have 90 percent of the beds covered. Mr. Rogers. Even though they don’t attend the meeting, they have signed up for this? ; Dr. Campers. Yes. These same ones are not the ones who were at previous meetings, necessarily, but this percentage is a pretty good attendance, for a region our size. Mr. Rocenrs. Is the region too large? Dr. Cuampers. No, we do not think so. We are beginning to get sub- regionalization now. This is what we hope to accomplish. r. Rocers. How long have you actually had the region formed ? Dr. Cuampers. Our program, Mr. Chairman, actually began Jan- uary 1, 1967,so we are only about 15 months old. Mr. Rogers. You present a very encouraging picture. . Dr. Cuanmers. We feel we have acoomplishe a lot in 15 months, sir. If the committee would be interested, sir, I would be glad to leave a copy of the operating rules and regulations of our programs, Mr. Rocrrs. I would like very much to have that for the committee files. Thank you very much, Dr. Chambers. 218 Mr. Rocers. Our last witness today is Eugene Sibery. May I say we will make your statement a part of the record, follow- ing your remarks. Now, if you would give us your comments, 1t would be helpful. STATEMENT OF D, EUGENE SIBERY, EXECUTIVE DIRECTOR, GREATER DETROIT AREA HOSPITAL COUNCIL Mr. Super. I shall paraphrase the important items, so that I shall not make a 15-minute commentary on a 7-minute formal statement. Mr. Chairman and members of the subcommittee, I am D. Eugene Sibery, executive director of the Greater Detroit Area Hospital Coun- cil. I also serve as chairman of the American Hospital Association’s Council on Research and Planning, and I am the president of the As- sociation of Health Planning Agencies. I was the acting coordinator of the Michigan regional medical program during its initial, organiza- tional period, and now serve on that program’s regional advisory group. I am here today to speak in support of title I, H.R. 15758, to extend the authorization for regional medical programs for heart disease, cancer, and stroke. As a health planner involved with the coordinated planning ac- tivities of a hundred hospitals in one of the Nation’s most heavily 219 urbanized areas, I am strongly attracted by the potential of regional medical programs and impressed by their progress. The strength of these programs stems from the spirit of voluntary cooperation which underlies them, and which was written into the law largely by your committee 3 years ago. This voluntary, cooperative approach to problem solving isn’t as swift as a more direct approach might appear to be, but I hope that you will be persuaded that it is far more sure. Regional medical programs are becoming strong and successful forces in our society because they challenge the ingenuity of the par- ticipants. They are becoming strong and successful forces in our so- ciety because they exist to meet specific local problems, not problems that have been rendered sufficiently vague to be labeled national prob- lems. And finally, regional medical programs are becoming strong and successful forces in our society because they are based upon plans and decisions made by those who must carry out the plans and decisions, and by those who will be affected by them. The last point—broad-based involvement for cooperative plan- ning and action—is the paramount reason regional medical programs will ultimately succeed in the inner cities of America. It is a program that health planners have long awaited, a program to draw together the hospitals, physicians, public health agencies, and all of the other elements necessary to provide efficient, effective, and economic health services, It is also a program which must incorporate the opinions and thoughts of the public to be served by these health resources, and this too is a terribly difficult task. The population of our inner cities is de- pressed in mind and spirit, handicapped by lack of education and opportunity, and all but overwhelmed by poverty and need. This must not deter us. Without the cooperation and the support of these people, no program can succeed. ; . The development of regional medical programs has seemed slow in the inner cities, but there has been progress. It’s not unlike the con- struction of a building. Until the foundation is laboriously dug and built, and the main structure begins to rise, progress 1s not apparent. Regional medical programs have been digging their foundations with a process of careful planning, and the structures beginning to merge— the operational programs—will be all the sounder and stronger for this every effort. Briefly stated, from the national view, the progress of regional medical programs has been dramatic. Less than 2 years ago, there were no regional medical programs; today there are 53 organized and at work. . . There is one further reason why I view the period of planning as* so essential. The experience gained in this program—I wish to stress this point—for heart disease, cancer, and stroke can serve as a guide to make it far easier for other health programs to meet the needs of our country’s entire population, including our urban areas. Significant changes in the traditional methods of delivering health care must be effected. I believe with active and meaningful involvement of all health professionals, the regional medical programs will provide the mechan- ism for the health professionals to markedly improve the patterns of organization and distribution of health care. 220 I believe our experience in Michigan is not atypical. I do think it is important for us to understand the soundness of the program which is under way, the marshaling together of, resources, the inno- vation which characterizes all of the planning activities in the founda- tion for the program which is being well laid at this point in time. To help these programs, I would certainly hope that a great deal of emphasis will be placed on the need for the efforts under compre- hensive health planning programs and the cooperative regional ar- rangements developed under the Regional Medical Program Act, to be compatible and in conformity. I think they are complementary with respect to goals and activities, and I think at the local level we must do everything possible to be certain that these are not in conflict, but in fact do cooperate and sup- port each other. T do believe there is a real need, as the statement indicates, for limited construction funds, and I would hope that as a part of the introduc- tion of my formal statement in the record that you would also include the appended article entitled “Hospitals and Regional Medical Pro- grams, a Plea for Coordinated Action,” which was in the December 1967 issue of Hospitals magazine. This was written by my good friend, Dr. Robert Evans, and I think amplifies eloquently on the point that I would make, that there is a real need for limited construction dollars. Mr. Chairman, I certainly hope that this bill will be supported by your committee and will be adopted. I think the progress so far is sound, because we have gone cautiously. I believe the operational pro- grams will speed the day that we will get to every area in Michigan, to every citizen in Michigan the benefits that this program was de- signed to bring. I should be pleased to answer any questions you might have. It has been a pleasure to appear. (Mr. Sibery’s prepared statement follows :) STATEMENT OF D. EUGENE SiBeRY, EXECUTIVE Director, GREATER DeTroir AREA Hospita, Counciz, Detroir, MicH. Mr. Chairman and members of the subcommittee, I am D. Eugene Sibery, ex- ecutive director of the Greater Detroit Area Hospital Council. I also serve as chairman of the American Hospital Association’s Council on Research and Plan- ning, and I am the president of the Association of Health Planning Agencies. T was the acting coordinator of the Michigan Regional Medical Program during its initial, organizational period, and now serve on that Program’s Regional Ad- yisory Group. I am here today to speak in support of Title I, H.R. 15758, to extend the au- thorization for Regional Medical Programs for heart disease, cancer, and stroke. As a health planner involved with the coordinated planning activities of a hun- ,ared hospitals in one of the Nation’s most heavily urbanized areas, J am strongly attracted by the potential of Regional Medical Programs and impressed, by their progress. The strength of these Programs stems from the spirit of voluntary cooperation which underlies them, and which was written into the law largely by your com- mittee three rears ago. This roluntary, cooperative approach to problem solving isn’t as swift as a more directive approach might appear to be, but I hope that you will he per- suaded that it is far more sure. Regional Medical Programs are becoming strong and successful forces in our society because they challenge the ingenuity of the participants, They are becom- ing strong and successful forces in our society because they exist to meet specific local problems, not problems that have been rendered sufficiently vague to be 221 labeled national problems, And finally, Regional Medical Programs are becoming strong and successful forces in our society because they are based upon plans and decisions made by those who must carry out the plans and decisions, and by those who will be affected by them. This last point—broad-based involvement for cooperative planning and action— is the paramount reason Regional Medical Prograins will ultimately succeed in the inner cities of America. It is a program that health planners have long awaited, a program to draw together the hospitals, physicians, public health agencies, and all of the other elements necessary to provide efficient, effective, and economic health services, It is also a program which must incorporate the opinions and thoughts of the public to be served by these health resources, and this too is a terribly difficult task. The population of our inner cities is depressed in mind and spirit, handi- capped by lack of education and opportunity, and all but overwhelmed by poverty and need. This must not deter us, Without the cooperation and support of these people, no program can succeed. The development of Regional Medical Programs has seemed slow in the inner cities, but there has been progress. It’s not unlike the construction of a building. Until the foundation is laboriously dug and built, and the main structure begins to rise, progress is not apparent. Regional Medical Programs have been digging their foundations with a process of careful planning, and the structures begin- ning to emerge—the operational programs—will be all the sounder and stronger for this early effort. Briefly stated, from the national view, the progress of Regional Medical Programs has been dramatic: Less than two years ago, there were no Regional Medical Programs; today there are 58 organized and at work. There is one further reason why I view the period of planning as so essential. The experience gained in this program for heart disease, cancer, and stroke can serve as a guide to make it far easier for other health programs to meet the needs of our country’s entire population, including our urban areas. Significant changes in the traditional methods of delivering health care must be effected. I believe with active and meaningful involvement of all health professionals, the Regional Medical Programs will provide the mechanism for the health pro- fessionals to markedly improve the patterns of organization and distribution of health care. I believe our experience in Michigan is not a typical. With the $1,294,449 grant awarded the Michigan Regional Medical Program almost a year ago, the Fed- eral Government has essentially pought a blueprint for the initial stages of action. Most tangibly, this initial blueprint is a 504-page document, our first operational grant request, which defines what we must do and commits us to doing it. It is not a sterile plan devised in some ivory tower. It represents a realization that previously fragmented health resources can unite to provide the best possible patient care for heart disease, cancer, and stroke, a realization held by the scores of men and women who live in the real world and who have contributed and will continue to contribute to this planning task. It represents our entire Michigan countryside. From my point of view as a needs of my metropolitan area, 0 Regional Program is the series E n gre number of groups and institutions engaged in health planning and providing health services in our Region. I hope that the staffs and Advisory Groups of all Regional Medical Programs share my zeal for coordination of activities in this regard. Specifically I believe Regional Medical Progranis and Comprehensive Health Planning programs, both authorized by legislation enacted by the 89th Congress, are quite complementary and mutually supportive of their activities and goals, Every effort should be made by the staffs of these two programs, at the local levels, to ensure this cooperation and coordination exist. ; To help make these Programs more effective, I urge your approval of Title I, HR 15758, with one change: Give the Regional Medical Programs limited authority for construction to meet regional needs as stated in the Surgeon General’s Report on Regional Medical Programs to the President and the Con- gress, and as eloquently amplified in an article entitled, “Hospitals and Regional Medical Programs: A Plea for Coordinated Action”. This article appeared in the December 16, 1967, issue of Hospitals magazine. It was written by my good friend, Dr. Robert L. Evans, Director of Medical Education at the York (Penn- sylvania) Hospital, and immediate past president of the Association of Hospital health planner concerned with the total health ne of the most important facets of this Michigan 222 Directors of Medical Education. Dr. Evans assisted me in preparing my testi- mony for today, Mr. Chairman, and I would like to request that his article be inserted in the record of this hearing. I hope, gentlemen, that Dr. Evans’ article will convince you of the need for Regional Medical Program construction Authority. Thank you; that concludes my statement. [From the Journal of the American Hospital Association, December 1967] HospITALS AND REGIONAL MEDICAL PROGRAMS: A PLEA FOR COORDINATED ACTION (By Robert L. Evans, M.D.’) To say that in the last three years our medical care system has been subjected to close scrutiny, deep concern, and an incomprehensible quantity of advice is both trite and insufficient. Since early 1965, our medical care system has existed in a holocaust of suggestion, pressures for change, and internal and external examination, which has involved the President of our nation on one hand and volunteer drivers of our neighborhood ambulance clubs on the other. Organizations representing every level of medical care and medical education in our voluntary system and virtually every executive and legislative branch of our national, state, and local governments have had their say—and are still talking. Beginuing with the Coggeshall report in 1965 and progressing through the DeBakey commission, the AMA task forces on education and care, the Millis commission, the pending reports of the N: ational Advisory Commission on Health Manpower and a similar Commission on the Cost of Medical Care, our system, its yoluntary hospitals, organized medicine, medical colleges, and the role of our federal and state governments have been studied by so many groups and individ- uals that often there have seemed to be more pacteriologists than bacteria com- posing the culture. There are no indications that this trend will stop. There should be no desire for the cessation of these activities unless they are threatened with the mumps of minisculity, from which they may emerge sterile. Cood health is now a fundamental right, together with life, liberty, and the pursuit of happiness. Examination of the system that ensures this health is now in the public domain. LEGISLATIVE ACTIVITY Complementing the studies and investigations has been a host of bills repre- senting the greatest activity in social legislation our nation has ever experienced. This began with the legislation encompassing hospital and medical care for the aged and indigent, followed by the various health career training acts, and more recently has included the programs for planning on a regional nonpolitical base and on a nonregional, political base (Public Law 89-239 and Public Law 89-749). This legislative onslaught is aimed at producing better health for the citizens of our nation, although in some respects it replaces properly aimed rifle fire with poorly. aimed shotgun charges. No one can predict with any degree of accuracy the eventual effect of the activities of the mid-1960s on our voluntary care sys- tem—indeed, to attempt an intelligent appraisal is a staggering and incomprehen- sible task. This paper is concerned with only a small and comprehensible portion of the studies—the planning legislation—that portion concerned with the Regional Medical Programs of the National Institutes of Health, continuing education in medicine, their relationships to our hospitals and medical colleges, and their governmental support system. Beginning in the 1930s, but accelerated productively by World War II, two parallel governmental funding systems have had a vital impact on medical care and knowledge: (1) billions of dollars of federal support and additional millions of voluntary foundations support have gone into basic biomedical research, and (2) additional billions have gone into hospital and facility construction. While expenditures for research were producing almost indigestible quantities of new knowledge designed to be productive in the prevention, diagnosis, and treatment of disease, other monies in smaller quantity were developing a vol- untary system of hospitals and other community facilities that are structurally 1 Robert L. Evans, M.D., is director of medical education, York (Pa.) Hospital, and president of the Association of Hospital Directors of Medical Education, 223 modern and usually competent. New medical knowledge has been produced largely in major medical college research and teaching hospital complexes, but the majority of health care has been delivered to our people through a distinctly Separate system of community medical institutions. Communication between medical education and research centers and com- munity health care delivery centers began to deteriorate before and during eos War II. It has become increasingly ineffective through the 1950s and Unquestionably, the federal system of research support has been productive in terms of knowledge, but it has served, through the tender trap of “soft money,” to enhance greatly the difficulty in communication between the teach- ing and research centers and the community hospitals. Patterns of human be- havior dictate that an individual infected with the virus of discovery—whether through financial or personal suasion—and whose job and family support are functions of continuing success in discovery, will lose interest at a rapid and predictable rate in the more mundane functional application of his discoveries, except as such application might further prove his theses. Understandably, as the Midas touch of research support produced more full-time faculty members who received their major support from investigation rather than teaching, less and less of their time became available to transmit and validate information from the medical college to the functional arm of the medical care system. These rretudes are both inevitable and defensible within the system that has produced them, At the receiving end of this sclerotically deteriorating pipeline of communica- tion between educational centers and care centers, other disruptive forces were at work. Most of the governmental support to our voluntary medical care system, as represented by our community hospital, is directed at bed needs, Provable demographic studies, leading to indicated increases in bed capacity, produce the highest priority of funding in hospital construction. Very little support has gone into the creation of diagnostic or treatment facilities unless they are im- mediately defensible by bed capacity. Almost no support has gone into nonpa- tient care and supportive facilities of an educational, evaluative, or analytic nature. Accrediting bodies stress in ponderous manner the necessity for smooth operation and recording of the administrative and business functions of a hos- pital and its medical staff, but pay almost no attention to the actual quality of the staff, or to any system of assuring the continued quality of the staff in terms of updating of knowledge and techniques. The exceptions to this insistence on administrative and directive function have occurred in relation to two active forces: (1) incidental to approval of graduate programs (internship and residency), the American Medical Associa- tion’s Council on Medical Education does insist on minimal standards of graduate education and on evidence of departmental educational activities in those de partments operating approved programs; and (2) the American Academy of General Practice for some years has had an established minimum requirement in continuing education for its membership, which the academy itself recognizes ag a minimal figure. ‘ EMPHASIS ON BUSINESS FUNCTION The predominantly lay boards and lay administrators of our voluntary hospital system frequently have contributed further emphasis upon bed capscity and direct bed support. It is a paradox that individual hospital board members, who are involved in corporate structures that place tremendous emphasis on continu- ing education in management techniques, psychology, and evaluation for their management personnel, neither insist upon, nor are oriented toward, the same emphasis on comparable continuing education activity in the medical staffs of the hospitals that are their community charge, The development of this orienta- tion is again both understandable and defensible within the system that has produced it. . Businessmen tend to regard hopsitals as businesses and to stress their business function to the administrative group. Government and accrediting bodies under- Standably have been reluctant to impose continuing education requirements on the medical profession. Many examples around the country show that when the necessity for continuing education and its basic purposes in relation to medical practice are explained in a clear and knowledgeable manner, most board members and administrators are quick to recognize its import, but still may assign 224 it a low funding priority in an overall system that directs insistent light upon pricks, mortar, systems, and machines. ATTITUDES OF MEDICAL STAFFS Hospital medical staffs have been both active and passive in adding plaques to the sclerotic communications pipeline. The measurable shortage of physician man- power tends to confine their immediate thought to the care tasks at hand, which are all too time consuming. Physicians have tended to regard the medical col- Jeges, which spawned them, as sophisticated purveyors of a type of intellectual exercise that is impractical in terms of temporal, physical, and emotional pres- sures in the community setting. With some justification, they look on medical college faculties and functions as consuming inordinately large nuinbers of phy- sicians, in both intern and resident programs and staff positions. Their plea to the medical colleges too frequently has been based on what they believe to be a clearly demonstrated need for house staff in the operation of their hospitals and for passive spoon-fed, time-consuming continuing education programs. That these pleas have fallen on deaf and unsympathetic ears is understandable in view of the content of the pleas and the nature of the institutions and in- dividuals to whom they are directed. Although many other factors have contributed to a lessening of effective com- munication between the sources of our knowledge and the institutions of its appli- cation, those discussed would seem to pe the most important and relevant to the effects of federal support on the individuals and institutions at each end of the “nowledge to application” transport system. Suddenly, into this potpourri of understanding, misunderstanding, interest, and disinterest has come a tremendous force for motivating change. After decades of providing major fund support for both medical research and medical care institutions, the federal government, representative of the consumers of our product, recently has discerned that much of its investment in research has been unproductive because the information, techniques, and skills produced in the research centers have not been transmitted effectively to the operational arm of the medical care system—the community hospital and its medical staffs. Whether the failure of effective transmission is due to simple lack of infornia- tion transfer is open to serious question, even though it is a convenient theorem. Campbell Moses, medical director of the American Heart Asociation, identifies the real problem as validation of knowledge—that is, inability of the practitioner to aceept and adopt new knowledge or technique until he has had the experience of “seeing” it used and using it under direction. Perhaps the “information gap” is really a “validation gap,” but probably it is both—certainly the therapy for either lies in continuing education. Forces within government also are beginning to recognize that much of the support assigned to the construction of community medical care facilities has been less than totally effective in producing efficient and knowledgeable delivery of medical care. Funding instead bas produced an overemphasis on inpatient care and medical staff direction and administration. to the detriment of a coordinated system of patient care involving logical division of inpatient and outpatient activities, and to the detriment of the continuing updating of physician know]- edge, techniques, and skills. With the recognition of its less-than-complete success in the past, the consumer group, represented by the Regional Medical Programs, the National Institutes of Health, and their parent body, the Department of Health, Education, and Welfare, have come up with a very efficient ‘and almost certain to be effective mechanism to correct some of the past inadequacies. - A “SHOTGUN WEDDING” Stated simply, medical care and medical education, the two ends of our sclerotic pipeline for the transmission of knowledge and understanding, are about to be subjected to one of our more common social relatiouships—the inevitable progression from the spurned proposition, to the proposal, to the engagement, and finally to the marriage. Considering the divisive factors above, this is certain to be a stormy junction, but it ig just as certain that it will be consummated and productive, for it is a “shotgun wedding.” The people of our nation are holding the shotgun. It is loaded with cash—the greatest motivator in our society. of 225 a moment, the disinterested and apathetic governmental father of the research years has become the kindly, interested, but extremely firm, future father-in-law. (That he may become an overbearing tyrant is possible, depending upon the success of the courtship. ) The imminent wedding is complicated by the fact that we are not quite certain who is the bride and who is the groom. If educational ability, facility, and personnel are the measure of virility, then the medical college system must be the groom. It is doubtful that the father will listen for long to any disclaimers of ability of the groom to effectively support the bride without further prodding or promise to help with support. It also is doubtful that any disclaimers on the part of the bride (the medical care delivery system) as to her ability to assume educational or analytic duties in the household seriously will affect the future of the marriage. . Similes aside for the moment, let us consider this union between medical education and research and medical care and examine the factors necessary for its success, Three areas require close scrutiny: (1) the depth of the quality, the ability, and the personnel of our educational and research facilities; (2) the sophistication, the quality, the ability, the personnel, and the functional pattern of our medical care institutions; and (3) the question of facilities support and construction subsequent to a productive union of the educational and research institutions and the medical care institutions—perhaps recognizable ag the eventual arrangements for housing the family. The medical college system at present is rich in all three areas, Over the last four decades, it has built up a large cadre of educationally oriented indi- viduals, in spite of research emphasis. The very nature and primary task of the medical college system provides it with adequate classroom, audio-visual, instructional, and other material aids to education. Its hospitals are equipped for the most sophisticated care—a significant portion of it on a research or re- search-connected basis—and are largely modern and relatively well staffed. Although the medical college certainly will need some additional support to help it in its new role as the resource of both content and some instructional ability for the transmission and validation of knowledge, it is relatively well equipped to cope with its role as educational breadwinner. The distaff side—the com- munity hospital, which will consuine and utilize the educational paycheck—is much less adequately prepared. WONUNIVERSITY HOSPITALS The nonuniversity hospitals divide into those that have graduate educational programs and those that do not. A recent survey conducted by the Association of Hospital Directors of Medical Education shows that although graduate teaching hospitals are much smaller in number, their total bed capacity and total number of staff physicians are approximately equal to the total bed capacity and total medical staff physicians of the hospitals that do not conduct teaching programs. The same survey indicates that even among those hospitals conducting graduate programs, less than 50 per cent have minimally adequate teaching facilities and less than 10 per cent have the services of trained educators, evaluators, or sociologists available, even by consultation. There is little difference between the two types of nonuniversity hospitals in most of the important parameters we shall measure. The major difference seems to be that those hospitals conducting graduate programs may be a little further advanced in educational philosophy. Their staffs, however, frequently are com- posed largely of physicians who do not actively participate in the teaching pro- grams, and their educational facilities, with a few notable exceptions, tend to be little different from those present in hospitais that do not eonduct graduate pro- grams. Consequently, for the purposes of this discussion, the two types of non- university hospitals may be discussed as a common entity. The fact remains that the emerging strident necessity for the nonuniversity hospital is that it assume its proper role ag the center of continuing education for the physicians and allied health personnel of its area. Most nonuniversity hospitals are modern, quite sophisticated, and relatively well equipped to render medical care. When one compares them with the medical college hospital, the difference in the area of medical care is a difference between acceptable sophistication on the part of most nonuniversity hospitals and proper ultrasophistication on the part of the medical college hospitals. This is a tolerable and appropriate difference. 226 INTOLERABLE DIFFERENCE The difference between the university and community hospitals in educational facility and ability, however, is so great as to be intolerable, even under present loads in continuing education in the nonuniversity hospital. These community institutions have their ultimate direction residing in the hands of boards and administrations who, in a proper and dedicated fashion, represent the voice of the community in the operation of its medical care facilities. Very few of the medical staffs and educationally oriented physicians in these hospitals have been able to impress upon their boards and administrators the overriding im- portance of continuing education to the competence and survival of our medical practice system and its hospitals. Some of the blame for this failure to impress directive bodies must reside in the medical staffs, who have not made a coordi- nated effort to educate and thus produce a change in the attitude and behavior of their boards and administrations. Similarly, with fault resting in medical staffs as well as directive bodies, non- university teaching hospitals have tended to look upon graduate (intern and resident) education programs as tolerable and interesting because they appear to raise the level of medical care, and because they provide additional hands with which to supply that medical care. However, even in relation to graduate education, it has been difficult to bring boards and administrators to spending patient care income on educational facilities, or to supply within the hospitals physicians whose base purpose is graduate or continuing education as opposed to the delivery.of medical care. With the rapidly rising cost of hospitalization, and the clamor this rise has produced, one certainly must have sympathy with our hospital boards and administrators in their reluctance to utilize patient care funds for educational facilities and personnel, even though the dollars spent on education are the best purchase the patient might make. The concept is sufficiently abstract to make direct continuity of purpose and decision difficult to achieve. PROPOSALS AND PRACTICALITIES In addition to being the subject of studies and recommendations by various commissions and individuals, our medical care and education system has been exposed to many different proposals in relation to continuing education. One hears of universities with and without walls, nationwide closed circuit television, application of the national educational television network to medicine, two-way radio, television tape, and a host of other novelty approaches. When one digs peneath the veneer, he is forced to the inescapable conclusion that, in spite of all of these proposals and gimmicks, the only practical place to educate the prac- ticing physician in a continuing and productive manner is in the milieu in which he works, treats his patients, and earns his living—his hospital. While it is true that in leading a horse to water, one may not force him to drink, the horse is a great deal more likely to drink if the water is under his nose constantly. While the universities and their medical centers may be the central nervous system om continuing education and of the Regional Medical Programs, there cannot be must doubt that the nonuniversity community hospitals will be the muscle of these programs. No portion of the knowledge produced by the billions of dollars spent in basic research in the last 40 years can be productive until it is in the hands of the individuals who care for the majority of the people of our nation—the physicians of our community hospital medical staffs. The people of our nation—our consumers—in the form of Congress. have spoken in a loud and clear voice. . . The basic purpose of the Regional Medical Programs is to translate knowledge into understanding and thence into medical care, in a cooperative. regional, and efficient manner. Thus, the basic and initial form of the activities of the Regional Medical Programs must be reparative education in bringing physicians and other health professionals up to date. This must be followed by continuing education to maintain their competence. Once education is well under way, attention may be paid to providing the facilities in which the newly understood knowledge, techniques, and skills may be applied in a coordinated manner. It is senseless to build the facilities until the system of education that will assure their proper usage is established and functioning, with the explicit purpose of making the billions of dollars they have spent in research productive in the care of our people. 227 HOSPITALS NEED HELP At this time, the educational muscle of the nonuniversity hospital system is so weak that it is difficult or impossible for it to handle its presently assigned tasks in education. If it is to become the cornerstone and functional arm of the Regional Medical Program, then the nonuniversity hospital needs a great deal of help. This help must be twofold: (1) an informational campaign that stresses the importance of an educational foundation to underlie all patient care ac- tivities so that the boards, administrators, and medical staffs of our hospitals assign proper recognition and importance to the educational activities of their institution; and (2) direct financial support to establish the skeletal frame- work of facilities and personnel necessary to support the educational functions. The first of the requirements for help to the nonuniversity hospital in educa- tion is well under way. The publications of the Regional Medical Program divi- sion of the National Institutes of Health place eonstant stress on this area. Programs within other portions of the government are designed to stimulate the medical colleges and organized medicine to a more active recognition of continuing education as unquestionably the most important portion of the spec- trum of undergraduate, graduate, and continuing health profession education. Accediting organizations and institutional groups, such as the American Hospital Association, should play a more important role in the stimulation of interest in the educational function of hospitals; they are just beginning to evidence interest in this activity. The Association of Hospital Directors of Medical Education, composed of key individuals in stimulating and directing continuing education, continues to increase its voice, competence, and activity. Continuation and expansion of these initial activities on the part of all the interested groups and organizations will assure proper emphasis to a function that will produce more good patient care in the future than any other single area of endeavor. The second need, that of funding support, becomes increasingly important education. The initial direction of as more emphasis is placed on continuing funding in the Regional Medical Programs and in the comprehensive com- munity planning programs properly has been toward the commitment of monics for integrated planning of an approach to the problem of opening the com- munications pipeline between medical education and research and medical care. Once these groups have planned to communiente effectively, we still are faced with the problem of a bride and groom who are geographically separate, and who, therefore, must be provided with the means to communicate appre: priate to their desire to do so. FACILITIES AND EQUIPMENT Funds must be provided for educational faciiltics and equipment fn non- university hospitals. Facilities include most importantly, auditorium and con- ference room space and their accoutrements, library facilities and materials, audio-visual materials and departments, and areas specificlly designed for edu- cational demonstrations in patient care. These require brick, mortar, and equip- inent funds, which most hospitals simply cannot supply from monies currently or as a result of their available in their communities, the Hill-Harris program, patient care efforts. These are the very basic facilities that all hospitals must have to adequately perform their task in educating their staffs and personnel. They are multiuse facilities and, thus, can serve for the continuing education of allied health professionals as well as physicians. Design and construction of facilities may occupy a considerable period of time ; Concurrently, however, funding thus, their funding should be of first priority. 1 should be available to ensure proper and complete utilization of these educational facilities. To make these new facilities really functional will require two addi- tional factors: (1) investigation and measurement to assure the most produc- tive content of the programs they will house; and (2) adequate numbers of educationally competent personnel to assure the productive application of the identified curriculum content and the facilities. Two of the greatest problems for individuals with practical experience in continuing education are curriculum design and content and the motivation of the practicing physician who is the student. These two factors are inextricably interwoven with a need to know patterns of medical care and physician func- a 228 tion. The area where need for information and the presence of misinformation is most apparent is in the field of function—the activities of physicians in the delivery of medical care and the identification of their needs and motivation in relation to continuing education. : There is sore need for support within the nonuniversity setting for the measure- ment and evaluation of continuing education to assure its efficiency and perti- nence, Additional need relates to the measurement and evaluation of the physi- cian’s performance, so that he can be helped to become more efficient and produc- tive in the delivery of medical care. In short, we should be attempting now to identify what we should teach and what changes in behavior we are trying to bring about through continuing education. ESTABLISH REGIONAL UNITS It would seem of great importance that within each of the Regional Medical Programs there be one or more nonuniversity hospital granted funds to construct and staff units to measure and devaluate systemically patient care and its delivery, thus to assist in determing need, content, and motivation in continuing education. These units should be staffed by physicians, educational personnel, and sociologists. Because each region by definition is singular in quality, it is probable that each region will have sufficiently different needs to require dif- ference in approach and measurement techniques. To establish just one or two national institutions or units involved in this type of research would be inefficient and insufficient. This investigative function cannot be carried on in the university setting, for we are studying a nonuniversity organism. Once identification has been begun of need, content, and pertinence in relation to continuing education, it will be necessary to ensure that sufficient educationally oriented, able and motivated individuals are present within each community hospital (or available to it) to ensure productive usage of the information gleaned and facilities added. This assurance, in the form of trained personnel, might vary across a spectrum encompassing highly skilled, formally trained educators in the larger and more complex hospitals, to individual staff members who have had the opportunity to receive additional understanding in educational philosophy, skills, and techniques in smaller hospitals and communities. One might regard these individuals as the “marriage counselors” of our simile. They are vitally important to a marriage that has little solid foundation in previously existent love or mutual respect between its partners. Only after the establishment and support of competent and productive con- tinuing education programs should attention be turned to large-scale support of patient care facilities. While such devotion to competence in continuing edu- cation, orientation, and ability would somewhat delay the construction of actual physical facilities for more omplex and sophisticated patient care, the delay would serve to ensure that these faciilties would be properly utilized by physi- cians, Some programs could be coordinate and concurrent. Caring for patients is, after all, the primary purpose for the existence of our entire medical care system. A PLEA FOR ACTION In summary, this presentation is a plea for a cogent and logical progression of activity in relation to Regional Medical Programs. perhaps the most impor- tant portion of the socially oriented legislation that has arisen in recent years. By simile, it is a request for good, sound premarital discussion and orientation by the groom and the father-in-law to ensure that the bride of our “marriage” has the knowledge and. the necessary appliances and counsel to keep house properly. . Community hospitals and their health professionals must be properly prepared to accept and use the knowledge that will pour from the perviously sclerotic communications pipeline. The medical care system must have initial funding support for identification of educational need and provision of educational space and personnel. Such funding will prepare it for the proper and productive utilization of the health care system and facilities to be established in the future as the result of coordinated regional and community planning for the delivery of medical care. To paraphrase Winston Churchill, “We are not at the end, nor the beginning of the end, but perhaps we are at the end of the beginning.” It is of vital impor- tance that we be sure that this “beginning” represents a solid foundation for a productive and functional future. 229 Mr. Rocers. Thank you. We appreciate your being here. Are we getting enough representation from hospital administrators, from local people involved with the delivery of services in the councils ? Mr. Sreery. From my vantage point I cannot generalize. I would say that because of my American Hospital Association responsibility, I hear some say we do not have enough hospital involvement. Others say it is fine. Hospitals are certainly welcome to participate. Generally, I believe they are eagerly invited to participate, so I don’t have much sympathy for those who say they have not had an op- portunity to be an integral part. I think that our experience in Michigan might help you to see that this is not just a continuing education program for our medical schools, but in fact is a program that was designed to develop truly cooperative regional arrangements, and it took us many months to develop a working mechanism for the three medical schools to co- ordinate their efforts and communicate because they had never done this in a similar way before. I think the very fact that I as executive director of a hospital council was asked to take the initiative in trying to draw together the program and develop the grant application is a good indication that in our State at least the hospital role was well identified. Thank you very much. Mr. Rocers. Thank you. Your testimony has been most helpful. This concludes the hearing for today. The hearings for tomorrow will be held, I understand, in the main hearing room, which is on the first floor, room 2123, and so the committee will now stand adjourned until 10 o'clock tomorrow morning. (Whereupon, at 4:15 p.m. the committee adjourned, to reconvene at 10 a.m. Thursday, March 28, 1968.) 298 Houss OF REPRESENTATIVES, Washington, 0.C., March 26, 1968. Hon. JoHN JARMAN, Chairman, Subcommittee on Public Health and Welfare of the Committee on Interstate and Forcign Commerce, U.S. House of Representatives, Washing- ton, D.C. Dear Mr, CHarrMan: Hearings are currently being held by your Subcommittee on H.R. 15758, a bill to amend the Public Health Service Act so as to extend and improve the provisions relating to regional medical programs, to extend the au- thorization of grants for health of migratory agricultural workers and to provide for specialized facilities for alcoholics and narcotic addicts, which was introduced by the distinguished Chairman of the Committee on Interstate and Foreign Com- merce, the Honorable Harley O. Staggers. Because of the increasing involvement jn medical programs in the Pacific by the relatively young University of Hawaii School of Medicine, I would like to take this opportunity to comment specifically on Section 103 of the bill, under the subtitle “Inclusion of Territories.” 299 This section apparently is designed to extend the regional medical programs to Guam, American Samoa, and the Trust Territory of the Pacific Islands, as well 4s to other areas. The extension of such programs would promote the acquisition and dissemination of medical knowledge and skills throughout U.S. territories in the Pacific. Medical research and training in which the University of Hawaii School of Medicine is presently engaged in several cooperative ventures in these Pacific areas, would be strengthened and improved. The result of all this is that the people in these areas would receive the full benefits and assistance of Ameri- can medical science and technology. For the foregoing reasons, I strongly urge that Section 103 be retained in the measure that is reported out by your Subcommittee. 7 ae. requested that this letter be included in the record of hearings on H.R. JID Aloha and best wishes. Sincerely, Spark M. Matsunaga, Member of Congress. AMERICAN HospiTaL ASSOCIATION, Washington, D.C., March 26, 1968. Hon. Harwey O. Sraccers, Chairman, Interstate and Foreign Commerce Committee, House of Representatives, Washington, D.C. Dear ConcressMAn Staceess: This statement expresses the views of the Ameri- can Hospital Association on H.R. 15758 which amends the Public Health Service Act so as to extend and improve the provisions relating to regional medical pro- grams, to extend the authorization of grants for health of migratory agricul- tural workers, to provide for specialized facilities for alcoholics and narcotic addicts, and for other purposes. REGIONAL MEDICAL PROGRAMS This Association strongly supported the development of the Iegislatlon which resulted in P.L, 89-239. We were pleased that certain recommendations, which we felt were essential to the most effective development of the program, were incorporated in the law. We have continued to follow carefully and with great in- terest the progress of the program. The past two years appenr to have been spent in the main in the establishment of regional programs and in thelr planning, The operating stage of the program is really only just beginning with a Hmited number of projects having been approved to date. Though good planning Is highly ersent{al it is te be hoped that the program will move forward rapidly in Its application. We have always believed the purpose of the bill is to establish a bridge between the science of medicine and its full application to the care and treatment of patients. In the coming months, therefore, it is to be hoped that the programs developed will be felt by the public in terms of a broadened application of knowl- edge in the treatment of these diseases covered under the program. We urge the Comniittee to authorize the full amount requested for the program for the fiscal year ending June 30, 1969. . The Association has continued to feel that implementation of the intent of the law would necessitate a full involvement on the part of hospitals and their medical staffs. This will necessitate not only the participation of the medical schools and the larger teaching and community hospitals but the smaller hospitals spread throughout the nation which provide a focal point for medical care and treatment in smaller communities. We have been disappointed at the extent of involvement of hospitals and particularly the minimal participation of these smaller community hospitals which is so essential if the program is to have meaning to the public at large. Therefore, the American Hospital Association will undertake a number of steps which it is hoped will result in a much wider involvement of hospitals. We have also noted that very little emphasis has been given thus far to preventive care and long-term patient care and we intend to stimulate leadership on the part of the hospital field in fostering such a broad approach to the regional medical programs, We will continue to work closely with the administrators of the program and to work for the fullest participation of the hospital field. 300 We recognize fully the merit of thorough planning as a basis for the develop- ment of regional medical programs. Such plans, of course, must involve the facilities, personnel and services pertaining to the illnesses covered under the program. However, the Congress under P.L. 89-749 initiated comprehensive health planning thereby establishing planning mechanisms throughout the nation to be involved in over-all health care and to specifically include health facilities, services and personnel. It is obvious therefore, that rather complete duplication of planning now exists between the two programs and from reports which we receive we are just beginning to witness the confusion resulting from this conflict and overlapping. If health planning, which we strongly, approve. is to be developed in an orderly manner, any overlapping and conflict must be resolved. At present the existing provisions go far towards encouraging com- petitive activities for domination of the field. We recommend, therefore, the Congress take action to eliminate the existing overlapping and confusion by requiring that the cooperative regional medical programs developed under P.J,, 89-239, and the results of the planning developed under P.T.. 89-749 be in conformity. HLR. 15758 proposes to increase the membership of the advisory council from twelve to sixteen members. In order to facilitate further the closest possible coordination between this program and the comprehensive health planning pro- gram, we would urge that additional representation of council members he required to include individuals directly engaged in area and state wide planning activities. ye are pleased to note that the bill, as in the original Act. does not propose to authorize funds to be appropriated for construction purposes. The program is of such magnitude that we believe the funds should be expended for the operational phages of the bill. Further, we feel it would be unwise to duplicate the construc- tion authority now provided for in other acts. The bill requests clarification so that grants may be made to agencies and institutions for services which will be useful to two or more regional medical programs, There are various services which can be developed most efficiently and effectively for larger areas than would be encompasged in a single region. We believe, therefore, that the authority to make grants as suggested here is desirable. MIGRATORY AGRICULTURAL WORKERS The bill proposes to extend the program of grants providing for health services to migratory agricultural workers for an additional two years. We strongly sup- ported the original legislation and later urged an increase in the program so As to permit payment to hospitals for care provided migratory workers and their families. Our recommendations were made after a study of the problem of migratory workers in considerable depth. We found that hospitals in various parts of the country were providing care under emergency circumstances and with very sizable costs for services and for which no reimbursement was avail- able. We were, therefore, very pleased that the Congress provided funds which could be paid to hospitals for inpatient care. The major portion of the funds which have been made available go for the provision of public health services and preventive medicine with a very modest amount being made available to pay for inpatient hospital care. We urge, there- fore. that the funds to be provided under the bill be increased to at least $15,000.- 000, with $5,000,000 of this amount being allocated for rei mbursement of hospitals providing inpatient care. Because of limited funds, the administrators of the program have necessarily restricted payments to hospitals under the program to areas which had an over-all public health program for migrants. Therefore, no provision has been made for assistance to migratory workers in transit or in areas of the country which had no over-all public health program for migrants. The increased au- thorization which we have recommended should enable the administrators of the program to provide inpatient hospital care to migrants wherever it is needed. Further, we recommend that the program be authorized for a period of four years instead of the two years called for in the bill. We have no comment at this time on other provisions of the bill. We would appreciate your making this statement a part of the record of these hearings. Sincerely, . KENNETH WILLIAMSON, Associate Director. 301 NATIONAL TUBERCULOSI8 AND RESPIRATORY DISEASE ASSOCIATION, Nev York, N.Y., March 20, 1968. Hon. Hariey O, StTaccers, Chairman, Interstate and Foreign Commerce Committee, House of Representatives, Washington, D.C. DEAR Mr. Sraccers: The National Tuberculosis and Respiratory Disease As- sociation wishes to express its support for continuation of Regional Medical Pro- grams as provided for in H.R. 15758. Although Programs have been largely de- velopmental, reports of progress throughout the country indicate that the majority will shortly be initiating operational activities. Reports indicate an earnest desire on the part of persons concerned with this Federal programm to fulfill the purposes of the legislation; namely, that the American publie receive improved medical services through coordinated and more efficient delivery of medical and paramedical skills and talents. Authorization for funds must be adequate to meet the growing needs of the Programs in the next few years if they are to achieve their goal. The momentum of this Federal program, which involves relationships with many agencies and groups, is accelerating as operational activities are due to begin. Readiness to perform will be affected by the amount of Federal funds available. Therefore the Committee should consider whether or not the authorization of $65 million for fiscal 1969 is large enough to permit implementation of the extensive plans developed over the past few years. . The NTRDA is particularly eager that Regional Medical Programs be sue- cessfully launched into operational activities because of the great need to improve services for chronic pulmonary disease patients. At time of appropriating funds for fiscal 1968, Congress specified that between one and two million dollars of the RMP appropriation for that year be devoted to chronic respiratory disease programs. The NTRDA had requested such action by Congress because of the critical situation in diagnosis and treatment of these diseases, particularly emphysema. Incidence of emphysema has so accelerated that it has become the second most frequent disease for which benefits are granted to workers who are retired for disability prior to age 65, at an annual cost of about $90,000,000. Other diseases of pulmonary insufficiency, such as chronic bronchitis, are widespread and responsi- ble for much illness and restricted activity. Deaths from emphysema have been doubling approximately every five years in the recent past and along with asthma and chronic bronchitis now represent the tenth cause of death in the United States. The seriousness of the chronic respiratory disease situation impelled the Public Health Service and the National Tuberculosis and Respiratory Disease Association to convene a Task Force in the Fall of 1966 to discuss how the contro} of these diseases could be improved. The critical needs in medical services for patients became a focus for much of the discussion and led to ene of the Task Force’s major recommendations; namely, that provision be made for pulmonary function laboratories, respiratory-care units, home-care, and rehatillitation pre grams, Data indicate that the lack of such resources is widespread, Many comniainity hospitals are even without the necessary apparatus to take care of serioneds PI respiratory disease patients. Organized home-care programs catet ty euds a small percentage of our general hospitals, while outpatient clinles which can play a full role in rehabilitation and counseling of respiratory discase patients t i -existent. Behe Ca a totte practitioner is particularly at a loss to help patients a chronic respiratory disease except for recommending hospitalisation ; at al illness becomes critical. The average general practitioner fa the victina one adequate education because of the recency in the rise of eee ttine a nd to the type of supervision needed to protect patients from acute naible cannot be maintain their physical condition at as optima’ f icrel As poxsille ri in most communities under existing con ; g ett ty obvious that direction and supervision of high quality chronic respiratory is ; i dical schools and medical centers disease programs must be provided by me 1 “nt to the tom. Demonstrations of patient diagnosis and treatment must be brough : iti inui ducation courses offered by these munity practitioner through continuing e cat fer the most institutions and facilities. The Regional Medical Programs offer : 302 expeditious way to achieve this goal. Interest in improving programs for chronic respiratory disease patients exist in many areas and it is our belief that this interest will generate development of such programs. TB-RD associations will help stimulate interest in such programs, utilizing their background of experience in promoting better patient services. In the past, many associations have supported medical education in pulmonary disease, and have demonstrated the need for screening surveys and diagnostic and treatment services. TB-RD associations were influential forces in communities for many years in promoting more adequate services for tuberculosis patients. In the same way, associations have been in a position to witness the dearth of help for emphysema and chronic bronchitis patients today and because of this, they will be good community partners to the RMP in seeing that the urgent needs of respiratory disease patients are met. The American Thoracic Society, the medical section of the National Tubercu- loxis and Respiratory Disease Association, has provided leadership in medical standards and research in tuberculosis and other respiratory diseases. Staff of our organization will continue to work closely with the Division of Regional Medical Programs to promote high standards of diagnosis and care for chronic respiratory disease. The NTRDA is pleased with the proposal in H.R. 15758 to expand the number of Advisory Council members from twelve to sixteen. At the time Congress speci- fied that attention be paid in Regional Medical Programs to chronic respiratory disease, it also requested that one of the members of the National Advisory Council have competence in this particular medical field. Expansion of Council membership will provide more scope for ensuring representation of the various areas of medicine which are of necessity involved in the many activities of Regional Medical Programs. We question if evaluation of Programs, as provided in Section 102 of the bill, should be performed solely by the Secretary. It would seem more satisfactory for both the Department of HEW and the public, to require that such evaluation be done by outside groups. We are certainly in support of extension of grants for health services for migratory workers and our only reservation is that these seem very minimal amounts considering the high rate of disease in this segment of our population. Tuberculosis rates are high in these people because of their low economic status and because their living conditions favor spread of the disease. We support provision of funds for construction of special facilities for inpatient and outpatient treatment of alcoholism. Alcoholics have a high rate of tubercu- losis, and extensive difficulties have arisen in recent years in hospitalizing many of these persons in community hospitals, including tuberculosis hospitals. Some of these difficulties would seem to be obviated by the provisions suggested. How- ever, recognition of the high rate of tuberculosis in alcoholics is essential in planning adequately for treatment facilities. It gives us great pleasure to record our support for extension of Regional Medical Programs. Sincerely yours, , JAMES BE. Perkins, M.D., Managing Director. AMERICAN DENTAL ASSOCIATION, Washington, D.C., March 27, 1968. Hon, JoHN JARMAN, “ Chairman, Subcommittee on Public Health and Welfare, Committee on Interstate and Foreign Commerce, House of Representatives, Washington, D.C. Dear Mr. JARMAN: Pursuant to the announcement of March 18, 1968, the American Dental Association wishes to submit its views on H.R. 15758, the Health Services Act of 1968. The Association’s brief comments will be limited to those provisions of the bill which would extend and improve the Heart Disease, Cancer and Stroke Amendments of 1965 and the Migrant Health Act of 1962, as amended. As part of its commitment to improving the total health of our people, the American Dental Association is sympathetic to the goals of H.R. 15758. / The dental profession has particular and long-standing concern with respect to oral cancer and some forms of heart disease. Additional research into the pre- 303 vention and treatment of these disease manifestations is needed and can and should be included in the regional medical programs authorized in H.R. 15758. When the Heart Disease, Cancer and Stroke legislation was under consideration in 1965, the Association submitted to this Committee details regarding the inci- dence of oral cancer and the low survival rate of victims of the disease. At that time, attention was directed to the need for more research into the specific causes of oral cancer and the methods of treatment and rehabilitation of patients who suffer from it. . The Association is pleased to note that considerable progress is being made in this field and that members of the dental profession and several dental schools are participating in the programs that are being developed. The Association also is pleased with and supports fully the amendment included in H.R.15758 which makes it clear that a practicing dentist as well as a phy- Sician may refer a patient to a facility engaged in research, training or demon- stration activities which are supported by regional medical progam funds. With respect to the provisions of the bill extending the migrant health pro- gram, the American Dental Association recognizes the need for increasing the availability of dental care for migrant workers and their children, The Associa- tion supports the extension of the program but agrees that ag soon ag feasible, this activity should be included in the regular public health programs of states and communities, The American Dental Association appreciates the opportunity to present its views on this legislation and respectfully requests that this letter be included in the record of hearings. Sincerely yours, JouN B. Witsow, D.D.S., Chairman, Council on Legislation. UNIVERSITY OF Hawatt, ScHOOL oF MEDICINE, Honolulu, Hawati, March 18, 15068. Re H.R. 15758. Hon. Hariey O. Sraccers, Interstate and Foreign Commerce Commitiee, House of Representatives, Washington, D.C. DEAR REPRESENTATIVE STAGGERS: House Resolution 15758 includes a paragraph on “inclusion of territories” which would bring Guam, American Samoa, and the Trust Territory of the Pacific Islands within the scope of the Regional Medical Program. The Medical School of the University of Hawaii is involved in medical research and teaching in many areas of the Pacific. We have been asked by the health administrators in American Samoa to develop an affiliation between the new Lyn- don B. Johnson Tropical Medicine Center and the University of Hawali School ot Medicine. The same applies, but at a somewhat more preliminary stage, with the health administrators of the Trust Territories, with special regard to the hos- pital that will be built on Ponape. These programs will be mutually advantageous as we will provide continuation education for the medical and nursing stafts, and they will provide facilities for research and certain aspects of education for our faculty and students. I would urge your support of the paragraph fn question because this would facilitate the cooperative ventures described. : -ours, pincerely yours Wrnosor C. Cuttino, M.D., Deas, 304 . Tampa, Fua., March 20, 1968. Congressman PAuL G. RoGers, House of Representatives, Washington, D.C. Dear CONGRESSMAN Rocers: We have just started our Florida Regional Medi- eal Program and not too many physicians are yet aware of its great potential for improving the quality and efficiency of medical care through improvements in communications and in continuing medical education. The Regional Medical Programs must develop into ongoing operational proj- ects and therefore the administrations bill to extend and slightly modify Regional Medical Programs is highly desirable. This ig the type of congressional legis- lation the physician in practice and in education will favor. Cordially yours, H. Partrre Hampton, M.D. U.S. GOVERNMENT PRINTING OFFICE ; 1968 O—309-653