yn BRIEFING BOOK HISTORY OF REGIONAL MEDICAL PROGRAMS NATIONAL LIBRARY OF MEDICINE BETHESDA, MARYLAND 1991 July 24, 1991 i” Leaman \ | TAB TAB TAB TAB TAB TAB TAB TAB Ii IIl IV VI VII VIII RMP BRIEFING BOOK CONTENTS Introductory Statement Chronology of Regional Medical Programs RMP Enabling Legislation Useful Summary Articles Biographical Sketches of Directors of Regional Medical Program Budget History Summaries of Key Reports and Hearings List and Map of RMPs Benes! : | Ma a} s ace wea } ‘ial hia ‘il INTRODUCTORY STATEMENT This briefing book is designed to provide those being interviewed in connection with NLM's history of Regional Medical Programs project, and their interviewers, with basic background information about RMPs. The book will also be useful to journalists, historians and others interested in the hsitory of RMPs. The book was prepared by NLM's History of Medicine Division with assistance from others both inside and outside the Library. This version of the briefing book is a first draft, and comments and corrections are most welcome. Please address these to John Parascandola, Chief, History of Medicine Division, National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894, CHRONOLOGY OF REGIONAL MEDICAL PROGRAMS February 1964 December 1964 January 18, 1965 August 1965 October 1965 December 1965 February 1966 April 1966 February 1967 June 1967 President Johnson delivered his "Health Message" to Congress in which he announced the establishment of a Commission on Heart Disease, Cancer and Stroke. The Report of the President's Commission on Heart Disease, Cancer and Stroke was issued, presenting 35 recommendations including the development of regional complexes, medical facilities and resources. Companion bills--S. 596 and H.R. 3140~--were introduced in the Senate by Senator Lister Hill (Ala.), and in the House by Rep. Oren Harris (Ark.), giving concrete legislative form to the recommendations of the DeBakey Commission. Anthony Celebrezze was replaced by John Gardner as Secretary of HEW. P.L. 89-239, the Heart Disease, Cancer and Stroke Amendments of 1965, was signed. The Commission concepts of "regional medical complexes" and "coordinated arrangements" were replaced by "regional medical programs" (RMP) and "cooperative arrangements," thus emphasizing voluntary linkages. National Advisory Council on RMPs met for the first time to advise on initial plans and policies. Dr. Robert Q. Marston appointed first Director of the Division of RMPs under NIH. He also served as Associate Director of NIH. First planning grants approved by National Advisory Council. Original emphasis of RMPs placed on continuing education, patient-care demonstration projects, and development of new manpower resources. First operational grants approved by National Advisory Council. The Surgeon General submitted the Report on Regional Medical Programs to the President and the Congress, summarizing progress made and recommending extension of the program. J ] i a December 1967 March 1968 March 1968 July 1968 September 1968 October 1968 January 1969 September 1969 FY 1969 Jan-Oct 1970 61 RMPs- designated; only four’ were operational. Companion bills to extend RMPs were introduced in the House by Harley 0. Staggers (W.Va.) as H.R. 15758 and in the Senate by Senator Lister Hill (Ala.) as S. 3094. Wilbur J. Cohen takes over as new Secretary of HEW. Reorganization of the Public Health Service announced. The Health Services and Mental Health Administration (HSMHA) is created; RMPs transferred from NIH to HSMHA. RMPs combined with eight programs of the National Center for Chronic Disease Control to form, within HSMHA, the Regional Medical Program Service. The chronic disease programs included the Cancer Program; Chronic Respiratory Disease Program; Diabetes and Arthritis Program; Heart Disease and Stroke Program; Kidney Disease Program; Smoking and Health Program; Neurological and Sensory Disease Program; and Nutrition Program. Meeting of all RMP program coordinators in Alexandria, VA. Five regional groups established: Northeast, Southeast, Midwest, Southwest and West. P.L. 90-574, extending RMPs for two years, was signed. Changes included -- expansion outside the 50 states; funding interregional activities; permission of dentists to refer patients; permission of Federal hospital participation. Robert H. Finch appointed Secretary of HEW in the Nixon administration. National meeting of coordinators of RMPs and chairmen of Regional Advisory Groups in Warrenton, VA. 44 RMPs were operational. Membership in various Regional Advisory Groups exceeds 2000. Over 400 operational projects were under way. Bills extending RMPs introduced; hearings held. Canal ee ee ee ] June 1970 October 1970 FY 1970 November 1972 FY1973 July 1973 1974 Elliot L. Richardson appointed Secretary of HEW. P.L. 90-515 was signed into law. New provisions: emphasis on primary care and regionalization of health care resources; added prevention and rehabilitation; added kidney disease; added authority for new construction; required review of RMP applications by Areawide Comprehensive Planning agencies; emphasized health services delivery and manpower utlilization. New manpower included "physician extenders" such as nurse practitioners. Of the nine original chronic’ disease programs, the following five were phased out: Cancer, Diabetes and Arthritis, Chronic Respiratory Disease, Heart Disease and Stde, and Neurological and Sensory disease. The RMP Service consisted now only of RMPs, Kidney Disease Program, and National Clearinghouse for Smoking and Health. 54 RMPs were operational. Membership in various Regional Advisory Groups was 2,400. Caspar Weinberger appointed Secretary of HEW by Nixon. Peak year of funding of RMPs, with $140 million appropriated. Emergency medical services were playing an increasing role, receiving larger share of funding. Nixon administration proposes health spending cuts, including zero funding for RMPs in FY1974. Bureaucratic and local support gains a one- year extension. HSMHA is split into the Health Services Administration, the Health Resources Administration, and the Alcohol, Drug Abuse, and Mental Health Administration. RMPs placed in the Health Resources Administration. The National Health Planning and Resource Development Act of 1974, P.L. 93-641, consolidated RMPs with the Hill-Burton and Comprehensive Health Planning Federal programs. t a foo. g ‘asad isi = . - ‘cial’ ‘anal February 7, 1976 1974 In response to a law suit filed by the National Association of Regional Medical Programs, the court ordered the Secretary of HEW to release the $126 million in impounded fiscal year 1973 and 1974 funds to the nation's RMPs. After a transitional period, independent RMP operations ceased. SYNOPSIS OF PL 89-239 (RMP ENABLING LEGISLATION) “Heart Disease, Cancer, and Stroke Amendments of 1965" This act amended the Public Health Service Act by adding on to it the following: "Title IX,-EDUCATION, RESEARCH, TRAINING, AND DEMONSTRATIONS IN THE FIELDS OF HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES" Section 900. "Purposes" a. To establish regional cooperative arrangements of medical schools, research institutions and hospitals, for the purposes of research, training, and demonstrations of patient care. b. To make the latest advances available to the public, through such cooperative arrangements. c. To do so without impinging upon the private health care system. Section 901. "Appropriations" a. $50 million for fiscal 1965. Those funds to be used for grants for universities and institutions for the purposes as outlined in 900 a. b. These grants cover up to 90% of construction costs. Cc. The funds are not to be used directly for patient care. Section 902. "Definitions" Regional Medical Program: a cooperative arrangement among a group of public or private non- profit institutions... 1. . . . in a geographic area to be determined by the Surgeon General. 2. . . . that includes one or more research centers and one or more diagnostic/treatment centers. 3. . . . that includes coordination arrangements of its various components. Section 903. "Grants for Planning and Development" a. The Surgeon General in consult with the National Advisory Council authorizes all grants. b. Fiscal accountability is required of all grant recipients. The applicant(s) must provide an advisory group of experienced members in the health care fields. Section 904. "Grants for Establishment and Operation of Regional Medical Programs" re ee a I bas ee ee This section is essentially a repetition of those regulations in 903, applied here to the formation of a new Regional Medical Program. Section 905. "National Advisory Council on Regional Medical Programs" a. The Surgeon General appoints all 12 of its members, subject to approval by the Secretary of HEW, of this council and serves as its chairman. Two members must be practicing physicians, and there must be one each who is outstanding in the fields of heart disease, cancer and stroke. b. Members serve four year terms and may not serve more than two continuous terms. Cc. The council advises the Surgeon General in the preparation of regulations and of policy matters. Section 906. "Regulations" The Surgeon General is responsible for setting regulations covering grant applications, and covering the coordination of this with other programs relating to the same diseases. Section 907. "Information on Special Treatment and Training Centers" A list of facilities that provide the most advanced methods and techniques is to be made available by the Surgeon General to practicing physicians. Section 908. "Report" This section requires that the Surgeon General submit a report by June 30, 1967, to the President and then to Congress on the following: 1. A statement of financing sources, both Federal and non- Federal. 2. An appraisal of activities after the first year. 3. Recommendations for modification or extension of this title. Section 909. "Records and Audit" a. This section requires that fiscal accountability be maintained. x #4 EXHIBIT XII Public Law 89-239 89th Congress, S. 596 October 6, 1965 ‘An Act Heart Disease, Cancer, and Stroke Amend- ments of 1965. To amend the Public Health Service Act to assist in combating heart disease, cancer, stroke, and related diseases. Be it enacted by the Senate and Flouse of Representatives) of the United States of America in Congress assembled, That this Act may be cited as the ‘‘Heart Disease, Cancer, and Stroke Amendments of 1965”. Sec. 2. The Public Health Service Act (42 U.S.C., ch. 6A) is amended by adding at the end thereof the following new title: “TITLE IX—EDUCATION, RESEARCH, TRAINING, AND DEMONSTRATIONS IN THE FIELDS OF HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES “Purposes “Sec. 900. The purposes of this title are— “(a) Through grants, to encourage and assist in the establishment of regional co- operative arrangements among medical schools, research institutions, and hospitals for research and training (including con- tinuing education) and for related demon- strations of patient care in the fields of heart disease, cancer, stroke, and related diseases ; “(b) To afford to the medical profession and the medica] institutions of the Nation, through such cooperative arrangements, the opportunity of making available to their pa- tients the latest advances in the diagnosis and treatment of these diseases; and “(c) By these means, to. improve gen- erally the health manpower and facilities available to the Nation, and to accomplish these ends without interfering with the pat- terns, or the methods of financing, of pa- tient care or professional practice, or with ‘the administration of hospitals, and in co- operation with practicing physicians, medi- eal center officials, hospital administrators, and representatives from appropriate volun- tary health agencies. “Authorization of Appropriations “Sec. 901. (a) There are authorized to be appropriated $50,000,000 for the fiscal year ending June 30, 1966, $90,000,000 for the fiscal year ending June 30, 1967, and $200,000,000, for the fiscal year ending June 80, 1968, for grants to assist public or non- profit private universities, medical schools, research institutions, and other public or nonprofit private institutions and agencies in planning, in conducting feasibility studies, and in operating pilot projects for the estab- lishment of regional medical programs of research, training, and demonstration activ- ities for carrying out the purposes of this title. Sums appropriated under this section for any fiscal year shall remain available for making such grants until the end of the fiscal year following the fiscal year for which the appropriation is made. “(b) A grant under this title shall be for part or all of the cost of the planning or other activities with respect to which the application is made, except that any such grant with respect to construction of, or provision of built-in (as determined in ac- cordance with regulations) equipment for, any facility may not exceed 90 per centum of the cost of such construction or equipment. “‘(e) Funds appropriated pursuant to this title shall not be available to pay the cost of hospital, medical, or other care of patients except to the extent it is, as determined in accordance with regulations, incident to those research, training, or demonstration activities which are encompassed by the purposes of this title. No patient shall be furnished hospital, medical, or other care at any facility incident to research, training, or demonstration activities carried out with funds appropriated pursuant to this title, unless he has been referred to such facility by a practicing physician, ( [ f “Definitions “Seco, 902. For the purposes of this title— “(a) The term ‘regional medical program’ means a cooperative arrangement among 4 group of public or nonprofit private institu- tions or agencies engaged in research, train- ing, diagnosis, and treatment relating to heart disease, cancer, or stroke, and, at the option of the applicant, related disease or diseases; but only if such group-—~ “(1) is situated within a geographic area, composed of any part or parts of any one or more States, which the Surgeon General determines, in accordance with regulations, to be appropriate for carry- ing out the purposes of this title; “(2) consists of one or more medical centers, one or more clinical research cen- ters, and one or more hospitals; and “(8) has in effect cooperative arrange- ments among its component units which the Surgeon General finds will be adequate for effectively carrying out the purposes of this title, ‘“‘(b) The term ‘medical center’ means a medical school or other medical institution involved in postgraduate medical training and one or more hospitals affiliated there- with for teaching, research, and demon- stration purposes. “(ce) The term ‘clinical research center’ means an institution (or part of an institu- tion) the primary function of which is re- search, training of Specialists, and demon- strations and which, in connection therewith, provides specialized, high-quality diagnostic and treatment services for inpatients and outpatients. “(d) The term ‘hospital’ means a hospi- tal as defined in section 625(c) or other health facility in which local capability for diagnosis and treatment is supported and augmented by the program established un- der this title. “(e) The term ‘nonprofit’ as applied to any institution or agency means an institu- tion or agency which is owned and operated by one or more nonprofit corporations or as- Sociations no part of the net earnings of which inures, or may lawfully inure, to the benefit of any private shareholder or individual. ‘“(f) The term ‘construction’ includes alteration, major repair (to the extent per- mitted by regulations), remodeling and renovation of existing buildings (including initial equipment thereof), and replacement of obsolete, built-in (as determined in ac- cordance with regulations) equipment of existing buildings. “Grants for Planning “Sec. 903. (a) The Surgeon General, upon the recommendation of the National Ad- visory Council on Regional Medical Pro- grams established by section 905 (hereafter in this title referred to as the ‘Council’), is authorized to make grants to public or non- profit private universities, medical schools, research institutions, and other public or nonprofit private agencies and institutions to assist them in planning the development of regional medical programs. “(b) Grants under this section may be made only upon application therefor ap- proved by the Surgeon General. Any such application may be approved only if it con- tains or is supported by— “(1) reasonable assurances that Fed- eral funds paid pursuant to any such grant will be used only for the purposes for which paid and in accordance with the applicable provisions of this title and the regulations thereunder ; “(2) reasonable assurances that the applicant will provide for such fiscal con- trol and fund accounting procedures as are required by the Surgeon General to assure proper disbursement of and accounting for such Federal funds ; (3) reasonable assurances that the ap- plicant will make such reports, in such form and containing such information as the Surgeon General may from time to time reasonably require, and will keep such records and afford such access there- to as the Surgeon General may find neces- sary to assure the correctness and verifica- tion of such reports ; and “(4) a satisfattory showing that the applicant has designated an advisory group, to advise the applicant (and the institutions and agencies participating in the resulting regional medical program) in formulating and carrying out the pis: ica for the establishment and operation of such regional medical program, which advisory group includes practicing physi- cians, medical center officials, hospital ad- ministrators, representatives from appro- priate medical societies, voluntary health agencies, and representatives of other organizations, institutions, and agencies concerned with activities of the kind to be carried on under the program and mem- pers of the public familiar with the need for the services provided under the program. “Grants for Establishment and Operation of Regional Medical Programs “Sec, 904. (a) The Surgeon General, upon the recommendation of the Council, is au- thorized to make grants to public or non- profit private universities, medical schools, research institutions, and other public or nonprofit private agencies and institutions to assist in establishment and operation of regional medical programs, including con- struction and equipment of facilities in con- nection therewith. “(b) Grants under this section may be made only upon application therefor ap- proved by the Surgeon General. Any such application may be approved only if it is rec- ommended by the advisory group described in section 903(b) (4) and contains or is sup- ported by reasonable assurances that— “(1) Federal funds paid pursuant to any such grant (A) will be used only for the purposes for which paid and in ac- cordance with the applicable provisions of this title and the regulations thereunder, and (B) will not supplant funds that are otherwise available for establishment or operation of the regional medical program with respect to which the grant jis made; (2) the applicant will provide for such fiseal control and fund accounting proce- dures as are required by the Surgeon General to assure proper disbursement of and accounting for such Federal funds; Records. “(3) the applicant will make such re- ports, in such form and containing such information as the Surgeon General may from: time to time reasonably require, and will keep such records and afford such access thereto as the Surgeon General may find necessary to assure the cor- rectness and verification of such reports ; and “(4) any laborer or mechanic employed by any contractor or subcontractor in the performance of work on any construction aided by payments pursuant to any grant _under this section will be paid wages at rates not less than those prevailing on similar construction in the locality as determined by the Secretary of Labor in accordance with the Davis-Bacon Act, as amended (40 U.S.C. 276a—276a-—5) ; and the Secretary of Labor shall have, with respect to the labor standards specified in this paragraph, the authority and func- tions set forth in Reorganization Plan Numbered 14 of 1950 (15 F.R. 8176; 5 U.S.C. 1332-15) and section 2 of the Act of June 13, 1934, as amended (40 U.S.C. 276¢). “National Advisory Council on Regional Medical Programs Appointment of members. “Spo, 905. (a) The Surgeon General, with the approval of the Secretary, may appoint, without regard to the civil service laws, & National Advisory Council on Regional Medi- cal Programs. The Council shall consist of the Surgeon General, who shall be the chair- man, and twelve members, not otherwise in the regular full-time employ of the United States, who are leaders in the fields of the fundamental sciences, the medical sciences, or public affairs. At least two of the ap- pointed members shall be practicing physi- cians, one shall be outstanding in the study, diagnosis, or treatment of heart disease, one shall be outstanding in the study, diagnosis, or treatment of cancer, and one shall be out- standing in the study, diagnosis, or treat- ment of stroke. Term of office. ““(b) Each appointed member of the Coun- cil shall hold office for a term of four years, except that any member appointed to fill a vacancy prior to the expiration of the term mend * for which his predecessor was appointed shall be appointed for the remainder of such term, and except that the terms of office of the members first taking office shall expire, as designated by the Surgeon General at the time of appointment, four at the end of the first year, four at the end of the second year, and four at the end of the third year after the date of appointment. An appointed mem- ber shall not be eligible to serve continuously for more than two terms. Compensation. “(e@) Appointed members of the Council, while attending meetings or conferences thereof or otherwise serving on business of the Council, shall be entitled to receive com- pensation at rates fixed by the Secretary, but not exceeding $100 per day, including traveltime, and while so serving away from their homes or regular places of business they may be allowed travel expenses, including per diem in lieu of subsistence, as authorized by section 5 of the Administrative Expenses Act of 1946 (5 U.S.C. 73b-2) for per- sons in the Government service employed intermittently. Applications for grants, recom- mendations. ““(d) The Council shall advise and assist the Surgeon General in the preparation of regulations for, and as to policy matters arising with respect to, the administration of this title. The Council shall consider all applications for grants under this title and shall make recommendations to the Surgeon General with respect to approval of applica- tions for and the amounts of grants under this title. “Regulations “Sec. 906. The Surgeon General, after consultation with the Council, shall pre- Scribe general regulations coverng the terms and conditions for approving applications for- grants under this title and the coordination of programs assisted under this title with brograms for training, research, and demon- strations relating to the same diseases assisted or authorized under other titles of this Act or other Acts of Congress. “Information on Special Treatment and Training Centers “Spc, 907, The Surgeon General shall es- tablish, and maintain on a current basis, a list or lists of facilities in the United States equipped and staffed to provide the most ad- vanced methods and techniques in the diag- nosis and treatment of heart disease, cancer, or stroke, together with such related jnfor- mation, including the availability of ad- vanced specialty training in such facilities, as he deems useful, and shall make such list or lists and related information readily available to licensed practitioners and other persons requiring such information. To the end of making such list or lists and other information most useful, the Surgeon Gen- eral shall from time to time consult with in- terested national professional organizations. Report to President and Congress “Src, 908. On or before June 30, 1967, the Surgeon General after consultation with the Council, shall submit to the Secretary for transmission to the President and then to the Congress, a report of the activities under this title together with (1) a state- ment of the relationship between Federal financing and financing from other sources of the activities undertaken pursuant to this title, (2) an appraisal of the activities as- sisted under this title in the Hight of their effectiveness in carrying out the purposes of this title, and (3) recommendations with respect to extension or modification of this title in the Nght thereof. “Records and Audit “Sec, 909. (a) Each recipient of a grant under this title shall keep such records as the Surgeon General may prescribe, including records which fully disclose the amount and disposition by such recipient of the proceeds of such grant, the total cost of the project or undertaking in connection with which such grant is made or used, and the amount of that portion of the cost of the project or undertaking supplied by other sources, and such records as will facilitate an effective audit. “(b) The Secretary of Health, Education, and Welfare and the Comptroller General of ie ae hea si au USEFUL SUMMARY ARTICLES Robert Q. Marston and Karl Yordy, "A Nation Starts a Program: Regional Medical Programs, 1965-1966," J. Med. Fduc., 42 (1967): 17-27. Paul D. Ward, "The Curious Odyssey of Regional Medical Programs," West. J. Med., 120 (1974): 425-429. Caspar W. Weinberger, "The Guideposts in the RMP Odyssey," West. J. Med., 121 (1974): 158-160. str G Fa Sears Brea eegetitts A Nation Starts a Program: Regional Medical Programs, 1965-1966* ROBERT Q. MARSTON, M.D.j AND KARL YORDYt National Institutes of Health, Bethesda, Maryland This month [October, 1966] marks the first anniversary of P. L. 89-239, the Heart Disease, Cancer and Stroke Amend- ments signed by President Johnson on October 6, 1965. The legislation was hailed by some as a landmark in the history of American medicine. It was strongly criticized by others, both for what it said and what it did not say. Even some of those who supported the legislation in principle still maintained a wary curiosity concerning the imple- mentation of such general legislative language. The philosophical hopes and fears of a year ago have been replaced by actual events, real problems, and iden- tifiable progress. It is appropriate at this time to report on the extent to which the Regional Medical Programs legisla- tion has been implemented. It is estimated that there will be 48 or 49 programs: 45 planning grant ap- plications or declarations of intent have been submitted to date. These programs will actually be defined in large measure through the activity of those people who will make them operative. It is this characteristic of the Regional Medical Programs that makes them a fascinating experiment in federal health policy. Obviously, experience with the devel- opment of these programs is still quite limited, and many of the difficult prob- *Presented at the 77th Annual Meeting of the Association of American Medical Col- leges, San Francisco, October 22, 1966. t Associate Director; Director, Division of Regional Medical Programs. - ft Assistant Director, Division of Regional Medica] Programs. lems being encountered in implementing this legislation are influenced by large issues and historical trends which can be seen only incompletely at any one time and from any one place. While the historian of the future will focus on forces that we can perceive only dimly at present, reflection on the possi- ble impact of the programs brings to mind a view of history presented by Rob- ert Bolt (1) in A Man For All Seasons. His theme is that an examination of the trends and forces will illuminate only a portion of any historical event. What is of interest is the way it happened, the way it was lived. “ ‘Religion’ and ‘econ- omy’ are abstractions which describe the way men live. Because men work we may speak of an economy, not the other way round. Because men worship we may speak of religion, not the other way round.” BACKGROUND There are a number of long-range fac- tors and trends which constitute a com- mon heritage for the Regional Medical Programs and which set the scene for the passage of the authorizing legislation. The most important of these factors is the impact of science on the nature of medicine and medical practice. The dy- namic growth of medical research in this country during the past twenty years and the resulting advances in knowledge form the scientific base which is the beginning point for the program. Following are some of the factors which contributed to the development of the legislation: 17 18 Journal of Medical Education the forty-year discussion on regionaliza- tion of medical services; the evolution of the medical schools with the accom- panying development of great medical centers; and underlying social factors relevant to health concerns, including the rising expectations of the consumer of health services who is increasingly com- ing to expect that modern medical science will have the solutions to his health problems. The legislation was directly influenced by such publications as the Coggeshall Report, Planning for Medical Progress through Education (2); the Dryer Re- port, “Lifetime Learning for Physicians” (3); and the Reports of the Association’s Eighth and Tenth Teaching Institutes “Medical Education and Medical Care: Interactions and Prospects” and “Medi- cal Education and Practice: Relationships and Responsibilities in a Changing So- ciety” (4, 5). However, the actual im- petus for the introduction of the bill was the publication of the Report of the President’s Commission on Heart Dis- ease, Cancer and Stroke (6), which focused on the relationship between sci- ence and service in medicine. The man- date of the President’s Commission did not include the drafting of legislation; that task was performed under the leadership of Dr. Edward Dempsey, then Special Assistant to the Secretary of the Department of Health, Education, ‘and Welfare for Health and Medical Affairs, and Dr. Dempsey’s Assistant, Dr. Wil- liam Stewart, now Surgeon General. The bill that was sent to the Congress by the Administration contained the elements which have proved to be most important to the development of the program over the past year, including the emphasis on the relationship of academic medicine to medical practice, the creation of work- able cooperative arrangements among health resources, and the use of competi- tive grants rather than formula grants. Congress did not rubber stamp the VoL. 42, JANUARY, 1967 Administration’s proposal. Many changes were made in the original bill, primarily as the result of hearings before the House Interstate and Foreign Commerce Committee, chaired by Congressman Oren Harris. By its action, Congress made it clear that this program would be built upon cooperation among existing institutions and that local initiative would play a determining part in the de- velopment of the Regional Medical Pro- grams. The law emphasized the role of the required regional advisory group and the intent that this group be broadly representative of all health interests and include practicing physicians and repre- sentatives of the interested public. The House Committee was impressed with the potential contribution that the Regional Medical Programs could make to the more effective utilization of man- power. Therefore, it stressed the role of continuing education and training in accomplishing the purposes of the legislation. Although the bill as originally written provided authority for new construction, this section was eliminated before the legislation was passed. Finally, Congress authorized the’ pro- gram for three years and made clear its intent that this initial period be an ex- ploratory phase which would constitute the learning experience on which future extension and modification of the legis- lation could be based. Preceding the signing of the legisla- tion, the administrative decision was made that this new responsibility of the Public Health Service would be adminis- tered by the National Institutes of Health. This action emphasized the fact that the Regional Medical Programs concept focused on the relationship and interaction between the development of new knowledge and the provision of bet- ter medical care. In the period preceding and following the final approval of the legislation, Dr. Stuart Sessoms, Deputy “ penee't) poor e 3 he eee f ee my pose A Nation Starts a Program/Marston and Yordy h construction fends | fo can you burid “WEW Convers”? Whats ral iti rally up your sieve? 19 No bweprint. No masterplan? FIGURE 1 Director of NIH, was the focal point for NIH concern with this legislation, as- sisted by Mr. Karl Yordy. Much of the early implementation which will be de- scribed later in this paper occurred under the leadership of Dr. Sessoms, who bore the major responsibilities until February, 1966. On October 6, 1965 there were no ex- perts on regional medical programs, no master blueprints of how a regional medical program would work. During this period, questions from prospective applicants and other interested parties attempted to probe the flexibility of the legislation in order to determine whether or not there was a specific blueprint for implementation (Figure 1). How do you define a region? How many regions will there be? Who can apply? What will be the responsibilities of the appli- cant? What is the exact nature and role of the regional advisory group? Tell me in specific terms what a regional medical program will do and how it will function. The answers, or some would say lack of answers, to these questions reflected the fact that the flexibility of this legislation was deliberate public policy and that this flexibility is central to the concept of a regional medical program. The legislation clearly prescribed that the program be carried out on a regional rather than a national basis. The law represents a vote of confidence in the willingness of the regions to accept the basic responsibility for devising the pro- grams to accomplish the purposes of the law. The flexibility of the legislative provisions highlights this transference of responsibility to the regional. level. A clearly defined national medical program would have led to fewer questions. How- ever, even if workable, it would have meant less opportunity for creativity, fewer opportunities to develop diverse answers appropriate to diverse problems, and Jess assumption of responsibility at the local level. After one year of experience, there is considerable evidence justifying this Jaw’s almost naive trust and faith in the ability of formerly divergent medical interests to cooperate on a voluntary 1 eee; anet 20 Journal of Medical Education _Getober, | 1986 : CHRONOLOGY o OF REGIONAL wEDicAL PrOGRINS be WH 89 Vou. 42, JANUARY, 1967 FIGURE 2 basis in accomplishing important health objectives. , DEVELOPMENT REASSURANCE AND DEFINITION Experience with the program divides naturally into several phases (Figure 2). The first spans the period from the sign- ing of the legislation in October until about February, 1966. During this time, much of the effort of Dr. Sessoms, the authors, and others was spent in pro- viding reassurance to various medical groups concerning the nature of this program as defined in the law. For some still feared that the program would be a federal medical system which would di- vert patients to distant medical centers with no concern for the role of the local practicing physician or hospital. Some of the medical school faculty and admin- istrators feared that their medical centers were being asked to assume the total re- sponsibility in their regions for medical care in the fields of heart disease, cancer, and stroke. Nonaffiliated hospitals feared that they would have no role to play in the program (Figure 3). However, along with the fears and anx- ieties, there was a ground swell of in- terest in the Regional Medical Programs expressed by a very wide variety of health organizations, institutions, and in- dividuals. Meetings were held in regions throughout the country to discuss imple- mentation of the program. The staff at NIH was contacted by literally hundreds of medical organizations and groups ex- pressing interest and support. The Re- gional Medical Programs appeared as a A Nation Starts a Program/Marston and Yordy 21 ; Hoteev ks 2 complexes 2 Sigh) Theyre hot Weil be Suntiowed | Sing re Tel} Us whe Merworks ? Y You m uv men we! $7 Wn % teayrang ; or *Ybedy 2 FIGURE 8 topic for discussion in the programs of a number of major medical professional organizations. In December the Division of Regional Medical Programs was established and its National Advisory Council held its first meeting. REGULATIONS, GUIDELINES, AND OUTLINES The second phase of the program ex- tended from February until April. Spe- cial groups of consultants with expertise in such relevant fields as continuing edu- cation, community health planning, and hospital administration were called to- gether to advise the Division on the implementation of the program. Regula- tions were drafted and proposed. Pre- liminary guidelines for applications and the application forms themselves were developed and widely distributed. Another meeting of the National Advisory Coun- cil was held and a process for the review of applications was developed, consisting of a preliminary review by staff and by a group of ad hoc consultants prior to the review by the National Advisory Council as required by the law. Members of the Council and the ad hoc consultants became increasingly articulate in inter- preting and defining the program in speeches, in their own professional or- ganizations, and in the development of individual regional plans. RECEIPT AND REVIEW OF APPLICATIONS The period from April through June constituted the third program phase. During this time, the emphasis changed from reassurance, definition, and prep- aration to the receipt of applications for planning grants and the review of those applications (Figure 4). No deadlines for the receipt of applications were pub- “Jicized. Instead, it was the Division’s stated intention to hold frequent review meetings so that applications could be considered without undue delay and with- out the development of a crash program. Therefore, the National Advisory Coun- cil met to consider applications in April, June, and August, preceded each time by a meeting of an ad hoc initial review iz a Dey y 22 Journal of Medical Education Vou. 42, JANUARY, 1967 Now aff we fave fo do is walt. FIGURE 4 group representing a variety of back- grounds in health affairs. These groups were able to consider applications with varying approaches to the planning of a regional medical program and reach a consensus on the merits of the proposals in terms of the purposes of the law. Dur- ing this phase, 39 planning-grant appli- cations were received—overwhelming evi- dence of the willingness of regional groups throughout the country to accept responsibility for the development of a planning program. In reviewing the first applications, the Division was able to identify certain areas of emphasis and problems, which were then reflected in the organization of the Division’s staff and development of Division policies. Examples are the consideration given to continuing educa- tion as a major function of the Regional Medical Programs and the proposed large-scale use of systems analysis tech- niques in the planning of specific regional medical programs. As a result, the guide- lines document (7) issued by the Divi- sion on July 1 was based not only on the intent of the Congress and the judgment of the National Advisory Council and other advisors but also on experience in the actual review of planning-grant applications. NEGOTIATIONS AND ANTICIPATION During the final phase of the first year of the program, lasting from June until October, concern was with (a) contin- ued review of applications for planning grants; (b) a rapid buildup of activities in continuing education; (c) preparation for the required Report to Congress in June, 1967; and (d) anticipation of ap- lications for operational grants. In considering the applications, the re- view groups found that a straight “yes” or “no” answer was seldom sufficient to communicate the intent of their actions. Therefore, the National Advisory Council requested that the Division staff dis- cuss with each applicant the action that was taken and the reasons for that action. It was felt that this interchange and discussion between the applicant group and the staff of the Division would contribute to a better understanding on both sides of the nature of the proposal. On many applications the National Ad- visory Council required that additional information be obtained from the appli- cant before the application could be yead watt A Nation Starts a Program/Marston and Yordy 23 recommended for approval and a grant awarded. When the additional informa- tion requested would not affect the basic soundness of the proposal, the Council recommended approval, conditional upon receipt by the Division of clarifying in- formation. If the information to be pro- vided was more substantial, the Council deferred action on the application until it could consider the additional informa- tion supplied by the applicant. On other applications the Council did not feel that it could recommend approval of the ap- plication until substantial revisions had been made in the proposal. In recommend- ing revisions, the Council emphasized the fact that it expected to see the revised application at its next review meeting and that in negotiating these revisions, the staff of the Division would not re- quire that applications conform to a standard pattern. The Council wanted these applications to retain their unique characteristics; but it felt a strong sense of responsibility that the award of fed- eral grant funds could only be recom- mended after satisfactory evidence had been presented that the proposal, what- ever its proposed approach, could reason- ably be expected to result in a plan for a regional medical program that accom- plished the objectives of the legislation. This phase of the program saw the appointment of a blue ribbon ad hoc com- mittee, which has now had 2 meetings to focus on the Surgeon General’s Report to the President and Congress, due June 30, 1967. Also during this phase, ini- tial plans were made for a national meet- ing to be held January 16-17, 1967 in response to a number of requests for such a meeting and also because of the need to get grass-roots opinion for the Report to Congress. At this time, a change in the types of questions which medical groups asked staff representatives became apparent, primarily because increasingly large pro- portions of audiences had actively partici- pated in the development of applications. Actually, many have now given in their regions the same type of talks staff mem- bers were giving a few short months ago. PLANNING-GRANT APPLICATIONS One of the most productive sources of information at this relatively early stage of the program has been the grant appli- cations themselves. ‘They provide pre- liminary insights into the types of ac- tivities to be carried out on behalf of the Regional Medical Programs as well as a rough gauge of the extent to which “re- gional cooperative arrangements” among medical schools, research institutions, hos- pitals, and other health agencies and in- stitutions have developed to date. Forty-three applications have been rec- ommended for approval or are currently under consideration. They cover regions which contain about 80 per cent of the nation’s population. Certain of the major metropolitan centers account for most of the remainder of the population. As might have been expected, multi-medical- center urban areas have had particularly difficult problems in developing the coop- erative arrangements essential to the Re- gional Medical Programs. However, pend- ing applications and discussions with groups in New York, Philadelphia, Chi- cago, and Boston, for instance, have led to the conviction that effective ways will be found of bringing together the many health interests that exist in these urban areas. The applications which have been re- ceived indicate that the initial planning of the Regional Medical Programs will generally include 4 major types of activi- ties: (a) organization and staffing; (0) studies to collect and analyze data on re- sources, problems, and needs; (c) devel- opment of ways to strengthen communica- tions and relationships among the health institutions and agencies of the region; = 24 Journal of Medical Education and (d) preparation of proposals for operational projects. The approaches to the organization and staffing of the programs vary widely. In a majority of cases (26), the formal applicant—the institution acting as the ‘programming headquarters” or “agent” for the region—has been a medical school; this situation is particularly likely when there is only one medical school in the region and that institution is part of a state university system. There have been 4 applications from medical societies, 2 from existing private nonprofit agencies, and one from a state agency. In 10 of the 43 regions new corporations have been established to be the applicant. It has been suggested that these new organizations may be of con- siderable significance for the develop- ment of more effective cooperation among major health resources. In addition to the applicants them- selves, well over 400 other cooperating agencies or institutions are represented in the applications, with hospitals, both affliated and nonaffiliated, constituting the largest group. Among the other key participants are medical societies and state or municipal health agencies. It is clear from the applications that utilization of existing health personnel is planned; experienced senior health ad- ministrators and educators are being sought and found to fill major positions. It is also evident that many of the grantees will be looking to other disci- plines and to other university faculties for assistance. For example, there have been a number of proposals for the par- ticipation of such individuals as sociol- ogists, economists, and communication specialists. In addition, applicants will seek advice and assistance in areas such as computer technology and operations research on a contractual basis, either from universities or from private firms. The surveys which are most commonly mentioned in the applications are con- cerned with the collection of data on VoL. 42, JANUARY, 1967 health manpower, facilities, and special- ized capabilities. Most of the applica- tions include proposed studies of the dis- tribution of and needs for medical and nursing manpower. They also give high priority to problems associated with the shortages of laboratory and other allied health personnel. Most of the applications include plans for continuing education activities for allied health personnel as well as for phy- sicians, dentists, and nurses. The strengthening of communications and relationships among the existing and potential participants in the Regional Medical Programs through a variety of devices is planned. In view of the critical importance of cooperative arrangements in the pro- grams, the following delineation of the membership of the regional advisory groups may provide an initial measure of how effective the programs are likely to be in engendering these arrangements: 1. Practicing physicians and medical center officials each make up about 20 per cent of these advisory groups. 2. Hospital administrators, representa- tives of the voluntary health agencies, other health professionals, and public health officials each account for about 13 per cent of the total. 3. “Public”? members, including law- yers, industrialists, labor leaders, and housewives, account for the remaining 8 per cent. . 4. The state governors have been in- volved, in one way or another, in about one-half of the cases. 5. The state health officer or a member of the state board of health from the staff of related health departments is a member of the regional advisory group in almost every case. 6. Staff members of area-wide hospital planning agencies are members of about one-half of the groups. In all other cases a representative of the appropriate hospital association is named. , | A Nation Starts a Program/Marston and Yordy . 25 Planning Together wesn't go bed, but. ee one aS, Do we reelly Aare 2° werk Together? FIGURE 5 7. The groups have representation from heart associations and cancer societies. OPERATIONAL GRANTS The purpose of the planning grants is to develop operational programs (Figure 5). While continued planning is a cru- cial part of the programs, it is antici- pated that only a few new planning grants will be submitted and that in- creasingly the focus will be on the need for supplemental support for planning and for the initiation of operational com- ponents. A number of applications for operational grants have been submitted or are in preparation. The Division has been deeply involved in the development and clarification of the review and approval processes which will be required for these applications. As a result of this study, it has become apparent that this process must estab- lish 8 new types of relationships: 1. There must be a continuing and spe- cific relationship between the Division staff, the review committee (now ap- pointed on a permanent basis), the Na- tional Advisory Council, and the grantees. The frequent meetings of both the review committees and the National Advisory Council as well as the extensive staff negotiations with applicants represent beginnings in the development of these relationships. The creation of a branch for consultation and assistance under the direction of Dr. Margaret Sloan resulted from a recognition of this need. Further, applicants are being advised to make free use of supplemental applications so that their programs can more easily be developed by incremental] steps. 2. It is necessary to develop flexible but specific involvement of other federal] and nonfederal sources of support, including their review and approval processes. It is recognized that just as the program calls for an integrating and synthesizing activity on the regional level, the Divi- sion has a synthesizing and integrating responsibility to the grantees. In some instances it is clear that specific proce- dures must await the opportunity to work with concrete examples. 8. The review and approval process developed on the national Jevel must be related to the review and approval mech- anisms which exist in the various re- gions. Basic to the goal of establishing the decision-making mechanisms on the local level is the assumption that differ- ent priorities exist in different parts of inal ‘ bi t ma 26 Journal of Medical Education the country. However, neither the Na- tional Advisory Council nor the Public Health Service can delegate its funda- mental responsibility and accountability for the wise expenditure of federal funds. The mechanisms of the review process can be simply described. The regular process will be a familiar one: grants will be received and reviewed by the ini- tial review committee; additional infor- mation will be gained by site visits, which in many instances will be con- ducted by members of both the committee and the Council; and then there will be a recommendation by the Council and the final action involving administrative de- cisions by the Public Health Service. In addition to this regular process the staff will custom-tailor the review proc- ess to meet the particular needs of indi- vidual grants. In many instances this will mean obtaining additional informa- tion on scientific merit or other aspects from the existing expertise in other in- stitutes or bureaus of the Public Health Service or other agencies in the govern- ment to insure that acceptable standards are maintained; and it will also involve exploring the potentialities for support. The development of a decision-making process in each region is a prerogative of that region, and much time and effort have already been devoted to this area by the Division and by applicants through- out the nation. Some factors relevant to evolving effective processes seem to be either easily identifiable or particularly pertinent: (a) The initiation of the first steps in the operational program along with continued planning should represent movements toward the fuller development of the regional program. (b) On the one hand there will be a need to determine the appropriate balance between depend- ence on retrospective data, opinions, and the experiences of others, and on the other hand there will be the need to ini- tiate activities which will themselves pro- vide the basis for future decisions. The VoL. 42, JANUARY, 1967 law anticipates the use of research and ex- periments, and the initiation of activities which, when evaluated, can be modified as indicated. (c) Criteria for specific projects must be developed. The scope and flexibility of this legislation is such that there is no difficulty in listing great numbers of meritorious and needed proj- ects which could be supported. Suggested criteria for setting priorities are as follows: 1, The degree to which the project would assist in the wise utilization of manpower, As one applicant noted, the regional group is not interested in tying up resources with fine projects for which the necessary manpower is not readily available. 2. The degree to which proposed proj- ects involve multiple institutions and types of institutions and, therefore, would lead to more effective development of cooperative arrangements, particularly in the initial steps. 8. The degree to which the proposed project relates science to service. 4. The degree to which the project will contribute to continuing education and training for physicians and other health personnel. . 5, The degree to which latent talent or unique regional resources might be uti- lized more effectively. 6. The degree to which the proposed project represents a critical area which, if supported, will beneficially affect a larger program. A regional medical pro- gram offers the opportunity to bridge gaps and to support new and innovative approaches which of themselves may be only a small portion of much more ex- tensive activities. sO Finally, of course, the fact that this is a broadly categorical program in the area of heart disease, cancer, and stroke must be taken into consideration. The Division has been convinced that as the programs proceed into the opera- tional phase, grantees will be well ad- os RET Mn ee eat ory ty oo is ane . eT OBS woe tome ae ap wt ARN MS were eet Aye ee a Folk: Mee hee AE Ae RL Z tani . RS ase eet pees et eg wha 7 A Nation Starts a Program/Marston and Yordy 27 vised to select those activities which they can see clearly, rather than depending on the development of some master plan in vague and unexplored areas. Therefore, it is anticipated that many will choose those initial steps which will contribute to further refinement of the basic deci- sion-making processes which they have established. As those who are involved in the pro- gram move along this not uncomplicated path, it is worth remembering the way a dean once described the problem of the vice president for health affairs in bring- ing together groups with nonidentical goals. After speaking to the value of such activities, he raised a word of cau- tion in the following way: What do they do? In short they try to hitch mules and cows to the same plow and then drive the rig. What do they try to do? They try to assemble the team, work to- gether, combine assets, etc. To continue to enlarge upon our metaphor of hitching two thousand-pound beasts together without rec- ognizing that the objective of one is to pull and the other to be milked could end with one going unmilked and the other sitting down. Both have highly and equally com- mendable objectives, but working together as a team neutralizes the effectiveness of each. The goal of the Regional Medical Pro- . grams, like that of the vice president for health affairs, is to make the activities of its members more effective in their pursuit of their own goals. CONCLUSION The success of the Regional Medical Programs requires that medical schools as well as all other participants share authority as well as responsibility. Gard- ner (8) made the following statement in his monograph, Self-renewal: The Indi- vidual and the Innovative Society: Every great creative performance since the initial one has been in some measure a bringing of order out of chaos. It brings about a new relatedness, connects things that did not previously seem connected, sketches a more embracing framework, moves toward larger, more inclusive under- standing. The beneficial changes which have been effected by the program twenty years from now will depend upon the extent to which it has stimulated creative per- formances which have contributed to con- stant improvement in the quality of medical service in the nation. REFERENCES 1. Bott, R. A Man for All Seasons. London: Heinemann, 1961. 2, COGGESHALL, L. T. Planning for Medi- Cal Progress Through Education. Evan- ston, Illinois: Association of American Medical Colleges, April, 1965. 3. Dryer, B. V. Lifetime Learning for Physicians: Principles, Practices and Proposals. J. Med. Educ., 37: June, Part 2, 1962. 4. SHeps, C. G., WoLr, G. A., JR. and JACOBSEN, C.(Eds.).“Medical Education and Medical Care: Interactions and Prospects.” Report of the Eighth Teach- ing Institute of the Association of American Medical Colleges. J. Med. Educ., 36: December, Part 2, 1961. 5. Wor, G. W., Jr, and Darey, W. “Medical Education and Practice: Rela- tionships and Responsibilities in a Changing Society.” Report of the Tenth Teaching Institute of the Association of American Medical Colleges. J. Med. Educ., 40: January, Part 2, 1965. 6. President’s Commission on Heart Dis- ease, Cancer and Stroke. Report to the President. A National Program to Con- quer Heart Disease, Cancer and Stroke. (Volume I.) Washington, D.C.: U.S. Government Printing Office, 1964. "7, Guidelines—Regional Medical Programs. U.S. Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, Division of Regional Medical Programs, July, 1966. 8. GARDNER, J. W. Self-Renewal: The Individual and the Innovative Society. New York: Harper & Row, 1965, P. 39. Referto: Ward PD: The curious odyssey of Regional Medical Programs (Government and Medicine). West J Med 120:425-429, May 1974 Government and Medicine es The Curious Odyssey of Regional Medical Programs ch oO , hr PAUL D. WARD, Oakland | ae fe Oo = DURING ITS EIGHT YEARS of existence, Regional Medical Programs (RMP) has developed a history marked by many changes of fortune. No social program enacted after World War I] has exper- jenced the ups and downs, the changes in direc- tion, or the praise and vilification that have be- fallen RMP. Some programs like Model Cities and the Office of Economic Opportunity (OEO) have peaked and then fallen from grace, but none have had the spectacular roller-coaster ride of RMP. Those involved in the program believe RMP has proven its worth and provided many improve- ments in the health care system, but it has also served to test the stamina of those directly in- volved in the program, for it has been like riding the roller-coaster through a wind tunnel with the wind direction changing every few minutes. The changes of fortune have resulted mostly from an unusual number of changes in philosophy at the top level of the Department of Health, Edu- cation and Welfare, the multitude of quarrels HEW has had with Congress, and the intrusion of the Office of Management and Budget into pro- gram decisions (which omB is ill-equipped to enter, especially in the health care field where its expertise barely equals zero). Finally, the courts have entered the scene, with a ruling that the program should be returned to the course charted by Congress and that the funds appropriated by Congress should be made available for the pur- The author is Executive Director of the California Regional Medical Program. Submitted February 22, 1974. Reprint requests to: P. D. Ward, Executive Director, California Regional Medical Program, 7700 Edgewater Drive, Oakland, CA poses of the program. If we could end the story on that note, it would be like the classical novel plot: the beginning, the problems faced in the middle, and the happy ending. But in real life, there is probably more trauma to come. In the beginning, the intent of the legislation was to create a partnership consisting of major segments of health providers, educators, public and voluntary health agencies and other health resources. While these new “cooperative arrange- ments” were to be carried out with an emphasis on heart disease, cancer, stroke and related dis- eases, there was an implicit, though unstated, ac- knowledgement that the potentially confining re- straints of a purely categorical approach to good health care left room for other experimental activities. In any case, the overall objective was to make high quality medical care more uniformly available to every American. For more than three years this view of Regional Medical Programs held sway: Partnerships were developing among medical centers, the health professions and facili- ties designed to provide a single quality of medical care largely of a categorically-linked nature through voluntary cooperative arrangements, and, without interfering with established patterns of medical practice, to disseminate new knowledge to doctors, nurses and other health professionals through programs of continuing education. In the spring of 1970 there were stirrings in the high-reaches of the Department of Health, Education and Welfare. The department issued a set of recommended national priorities for health. Emphasis was placed on the quantity side of med- 425 THE WESTERN JOURNAL OF MEDICINE pees a die eRC rer ee re FS aia at REGIONAL MEDICAL PROGRAMS ical care, with quality relegated to a secondary role. Special effort was to be made to serve the needs of the poor, including particularly the American Indians, urban and rural poor, migrant farm families, children under five and women of child-bearing age who might not otherwise be able to receive appropriate contraceptive counseling. “Primary care” was described by national leaders in favorable terms, and was to be developed for those Americans who, for a variety of reasons, were not able to seek or find necessary medical care in their own communities. Regional Medical Programs had been enacted as Title IX of the Public Health Service Act. With the exception of Medicare, Medicaid and Mater- nal and Child Health, most federal health pro- grams are a part of the Public Health Service Act and are subject to extension by Congress at least every three years. When the Administration in- troduced its bill in 1969 to extend Regional Medi- cal Programs, the emphasis on categorical pro- grams was gone. Primary care and creation of new kinds of health care services were in the ascendancy, and the proscription against inter- fering with traditional patient care patterns had been deleted. Congress modified the Administra- tion’s desires, keeping the categorically-related activities, adding kidney disease, and retaining the restriction against interfering with established medical care practice patterns. Notwithstanding this sentiment, Administration spokesmen con- tinued to speak favorably of RMP’s as the proper vehicle for promoting new patterns of medical . care and new forms of health manpower. Aout this time, however, the practice of “forced carryover” of funds began. “Forced carry- over” is federalese meaning that oMB or the fiscal people in the department embargo a part of the money Congress has appropriated for a program and carry it over to the following year, usually for the purpose of reducing the next year’s appropri- ation. It is a means of whipping a program into line—of warning it to revamp its behavior and purposes, or perish. This revamping always proves difficult for some if it violates the intent of the law, and disturbing to others as they see their commitments to local people who are cooperating voluntarily with the program upset by the change in purpose. Also, it is a sure way to throw conster- nation, confusion, distrust and depression into the working ranks of a program. There is no surer 426 MAY 1974 + 120 * 5 way to reduce the productivity and momentum of any program, if that is the intent. The Administration took the next step shortly thereafter by introducing its proposed budget for fiscal 1972, in which the language called for a “stronger discriminatory policy which will be applied in awarding grants to individual regional medical programs.” “As a result,” the budget language continued, “a sharp retrenchment in grant awards will be made for those regional medical programs which have been the least pro- ductive in order to support selected increases for those regional medical programs which have shown the greatest innovative potential for mov- ing the local health care system toward improved accessibility and quality of care. “The major shift in emphasis by the regional medical programs will be directed toward im- proved and expanded service by existing physi- cians, nurses and other allied health personnel; new and specific mechanisms that provide quality control and improved standards and decreased costs of care in hospitals; early detection of dis- ease; implementation of the most efficient use of all phases of health care technology; and support- ‘ing the necessary catalytic role to help initiate necessary consolidation or reorganization of health care activities to achieve maximum effi- ciency.”? Thus, it was a new direction, with the emphasis on health care economics in place of the legislated purposes of quality and Tregionali- zation. Regardless of the advisability of Regional Med- ical Programs taking on these responsibilities (several of which were new and, many observers thought, inappropriate for RMP), even if they were to have been carried out the budget man- agers were willing to provide only $52.4 million in new money, about half what had been avail- able in 1971. It became more apparent that the Administration expected Regional Medical Pro- grams to concentrate on delivery of primary care, emergency medical services, health man- power development and cost containment, with categorical and continuing education program activities held to a minimum. In fact, the term continuing education was to become one not to be politely used. The authorization for new money as proposed in the President's budget message to Congress carried with it the assumption that the carryover funds, an unprecedented $34.5 million, would beet ye Woe REGIONAL MEDICAL PROGRAMS make a total cf $86.9 million available for RMP fiscal 1972 activities. Yet it had been increasingly difficult as the year passed to persuade the HEW budget managers, and, later, the Office of Man- agement and Budget, to release these carryover funds. The proposed $86.9 million funding level for all of the 56 RMP regions represented a cut of $20 million in one year. As the early months of 1971 passed, the Administration reduced RMP funding levels and it became increasingly proba- ble (if the views of the then-Secretary of HEW Elliott Richardson and his colleagues were as pessimistic as they seemed) that the $34.5 mil- lion would not be awarded for Regional Medical Programs, but would be retained at year’s end to be carried over to fiscal 1972. C corainators of the 56 RMP regions felt that some effort should be made directly with the Sec- retary’s office to argue for the release of more money. Seven representatives of the RMP’s, the American Medical Association, the Association of American Medical Colleges, and the Kidney Foundation met with Secretary Richardson and several of his colleagues in May. The meeting began with a decidedly negative cast, but ended with a renewed interest on the Secretary’s part in the accomplishments of RMP’s and an unstated pledge to seek further responsibilities for Regional Medical Programs. There was no agreement on the release of the $34.5 million, but RMP’s were charged that spring with helping to define “health maintenance,” to set criteria for quality in health maintenance organizations and to develop and set in motion quality control activities. It seemed to the RMp’s then, if not in later perspective, that they bad won their point and the Administration did not, after all, intend to phase out the program. A $10 million supplemental appropriation for RMP’s in fiscal 1971 was heavily endorsed by Congress to help restore some of the momentum lost to the programs through the Administration cutbacks, and the Administration adopted a con- cept of level funding for Regional Medical Pro- grams for fiscal 1972. Toward the end of that election year, however, when it became apparent that Caspar W. Weinberger was to move from his position as Director of the Office of Manage- ment and Budget to Secretary of HEW, RMP co- ordinators began to feel apprehensive about the program. Their gravest concerns were realized when the President’s health budget for fiscal 1974 was published, with Regional Medical Programs slated for oblivion by June 30, 1973. Arguments were heard like drum-fire from Ad- ministration spokesmen that RMP’s had been too closely linked to categorical disease activities and had not really served the needs of people (whereas an early 1973 HEW document covering the pre- vious year showed that more than half of the 9.6 million people directly served through RMP aus- pices had been in primary and emergency care settings), and that RMP projects “have not been carried out according to any consistent theme or set of authorities.” No one in authority bothered to add that it was because of the Administration’s various mandates for change in the program’s purposes and direction that “any consistent theme” failed to exist. As Director of the omB, Mr. Weinberger de- clared that (1) “It is not an appropriate use of federal funds to finance continuing education for professionals generally capable of financing their own education to improve professional compe- tence”; (2) “Originally established to upgrade health care of persons threatened by heart dis- ease, cancer, stroke, kidney disease and related diseases, the RMP’s in recent years sought more to improve access to and generally strengthen the health care delivery system”; and (3) “Dis- mantling the superstructure of the RMP’s will also reduce the competition for the limited staff avail- able with the skills needed to make a contribution to improving the health service system in the U.S.” He added that after an expenditure of nearly $500 million during the life of the program “there is little evidence that, on a nationwide basis, the RMp’s have materially affected the health care de- livery system.” Yet Administration spokesmen had called Rmp the best link government had with health providers. Conpress was yet to be heard from but on Feb- ruary 1, 1973, the Administration sent telegrams to all RMP coordinators, requiring that plans for phasing out operations by mid-year be submitted by March 15. The Administration began im- pounding funds for a wide range of programs, many of them, including RMP, in health. The RMP’s began dismantling their operational and program staffs, and many patients who had been helped by the specialized services brought into be- ing through RMP training and demonstration pro- jects no longer could receive the individualized THE WESTERN JOURNAL OF MEDICINE 427 REGIONAL MEDICAL PROGRAMS and often highly technical aid. Although RMP’s nationally represented in dollars a very small part of the programs that Mr. Weinberger indi- cated he would cut or discontinue, he probably mentioned RMP more often than any other pro- gram in his early 1973 public discussions of the need to reduce federal spending. During this pe- riod Congressional leaders reiterated their intent to keep RMp and other health programs alive. Congress had before it the extension of the 16 programs contained in the Public Health Service Act, the legislative authorization for which ended on June 30, 1973. It was generally agreed that many provisions of the PHS Act needed to be re- vised and the stratagem to renew the Act for one year in order to allow sufficient time for reflection on the revamping of the code was adopted with overwhelming support. The Administration did not favor the blanket one-year extension and Mr. Weinberger took the unusual step of lobbying Congress personally to argue against the bill; but it was passed unanimously in the Senate, by a vote of 94-0, and had an overwhelming 372-1 tally in the House of Representatives. Mr. Nixon signed the measure and it became law in late June. Then began some additional confusions and uncertainties as various levels of the Administra- tion argued that funds could or could not or would or would not be released before June 30. Some $6.9 million in funds was released to the regions on the last day of the fiscal year with the stipula- tion that they could not be spent and the remain- ing impounded funds were incorporated in the law suit filed against the government by the National Association of Regional Medical Programs. The one-year extension of the Public Health Service Act had become law, but since the Ad- ministration had expected that Regional Medical Programs would expire by June 30, except for the necessary tidying up that might carry through un- til February 15 at the latest, there were no plans for the program once fiscal 1974 began on July 1. Consequently there were no directions for several weeks about what was expected. Three of the 56 regions were closed down because the Adminis- tration believed them to have been demonstrably inadequate. Finally, on September 7, a new mis- sion statement was issued outlining five program areas, to which RMP’s were to be restricted: quality care assurance, emergency medical serv- ices, hypertension, kidney disease and develop- ment of new and more effective manpower utili- zation and training programs and assistance to 428 MAY 1974 + 120° 5 comprehensive health planning agencies in carry- ing out the provisions of Section 1122 of the So- cial Security Admendments of 1972. Again, this represented a significant change in the program. As the law suit progressed, it became apparent that the RMp’s had more than a good chance of winning their case. Finally on February 7, 1974, the court ordered Secretary Weinberger to pay the $126 million in impounded fiscal 1973 and 1974 funds to the nation’s Regional Medical Programs. While the Administration could appeal the ver- dict, the court required that the orders be carried out immediately, regardless of appeal. O: the second major point in the suit, namely that the RMp’s be relieved of the mandatory termi- nation date of June 30, 1974, the court found as a “conclusion of law” that “operational activities” of RMp’s “should be permitted to proceed un- hindered” by HEW or the Office of Management and Budget, “and this should be done until Con- gress indicates a contrary intention.” The conclu- sion apparently allows the possibility of keeping selected RMP projects operating through fiscal 1975. In addition to the order on release of funds and a relaxation of the June 30, 1974, termina- tion date for RMP’s, the court lifted the program restrictions imposed by the HEW Secretary in the September 7, 1973, directive containing the “pri- orities and options” section limiting RMP activity to the five major areas. The court found that HEW may legitimately be faced with time and funding constraints because of reduced RMP activity, and that its managers must be allowed to find ways to make the program as effective as possible. “How- ever, they must do so in a manner consistent with congressional, not self-imposed, time and budg- etary limitations.” In addition, the court found, “The defendant administrators may not refuse to accept applications for programs in subject areas that are within the purposes outlined by the statute.” The court also ordered the defendants to “rescind in writing all directives inconsistent” with its order “and notify recipients of such directives” that they are no longer applicable. The February 7 order became effective immediately and the court ordered the government to pay the costs of the suit. If the court order prevails and its intent is obeyed, the RMP’s programmatically can return to their earlier purposes, at least until Congress a teh ae Wem Bee re REGIONAL MEDICAL PROGRAMS acts.on any extension of the Public Health Service Act. In a short span of time, the program’s purposes have been bent and twisted from improving the quality of care to creating new care, to controlling the cost of care, and now supposedly back to the intent of the Jaw. And those same forces which caused the twisting and turning cried the loudest about the lack of “any consistent theme.” The future for the nation’s health programs is in the hands of Congress. The expiration date of June 30, 1974, for most of the Public Health Serv- ice Act is rapidly approaching and it is doubtful if there is time to revamp all of the programs be- fore that date. Some or most will probably be extended for one more year to allow time for hearings and debate. During early 1974 there have been moves to combine the functions of planning, regulation, improvement and implementation of care into one organization at the local level. It is to be hoped we can avoid this pitfall. Planners are not regu- lators by nature or training, and should not be assigned regulatory functions. What we need from planning is a plan which indicates community- health needs—that is, a graphic indication of the deficits and excesses that exist in terms of health care services. Regulation, to the extent that we have it, should give major consideration to the plan when decisions about the health care system are made. But the same people should not per- form both functions if objectivity and justice are a desired result. Nor are regulators and planners the best implementers of services. Implementation requires the skills of those who have had the ex- perience of providing service. Quality determina- tions should be based on provider research and experience. To mix the three functions in one staff and organization is tantamount to placing the legislative, judicial! and administrative function in one unit. Equitable conclusions would be hard to achieve. RMP has proven itself to be the best implementer of services in terms of access and quality based upon provider experience. This re- source should not be wasted. REFERENCES 1. The Budget of the United States Government: Fiscal Year 1972—Appendix. Executive Office of the President, Office of Management and Budget, 1971, p 398 2. The Budget of the United States Government: Fiscal Year 1974—Appendix. Executive Office of the President, Office of Management and Budget, 1973, p 383 THE WESTERN JOURNAL OF MEDICINE 429 A OQUEES RL VEO Nerd RRR Sip tmEN rE eer opPeseane oe ws He pte yes = ‘nae errr ge Roe teste ee lee FHS eT Tae Sige wet oye verwe OO I Pte Ae ot eet Government and Medicine Refer to: Weinberger CW: The guideposts in the RMP odyssey (Government and Medicine). West J Med 121: 158-160, Aug 1974 The Guideposts in the RMP Odyssey CASPAR W. WEINBERGER Secretary of Health, Education, and Welfare THE CHRONOLOGY of the Regional Medical Pro- grams extends through one of the most turbulent decades in the history of American health care. From 1964—when the Report of the Presi- dent’s Commission on Heart Disease, Cancer and Stroke recommended the development of regional complexes of medical facilities and resources— until today, no fewer than 38 laws directly affect- ing the nation’s health care system, not including appropriations legislation, have been enacted. Federal expenditures for the nation’s health have risen from about $4 billion in fiscal 1965 to $24.6 billion for fiscal 1972, with $26.3 billion requested by the President for existing health programs in fiscal 1975. The programs which have been conducted under this legislation, supported by billions of tax dollars, have contributed substantially to improve- ments in the national availability of health facili- ties and health manpower and in expanded access to these resources. The number of active physicians in this country has increased from 280,461 in 1964 to more than 345,000 this year. The number of American medi- cal schools has increased from 87 in 1964 to 114 today. The 1964 problem of scarce hospital beds has now become a problem of how to control the proliferation of unneeded beds and unnecessary duplicative facilities. If we are still confronted by problems in the distribution of health resources, we are at least on the verge of providing the indi- vidual citizen with the means for paying for those Eprror’s Nore: Secretary Weinberger was invited to respond to the commentary “The Curious Odyssey of Regional Medical Pro- grams” which appeared previously in the May issue of this jour- nal. In his response the Secretary places the RMP odyssey in broader perspective and also gives us & glimpse of the future as he sees it. —MSMW Reprint requests to: C. W. Weinberger, The preretary of Health, Education, and Welfare, Washington, DC 20201. 158 AUGUST 1974 + 121 ° 2 resources within his proximity. We can expect this period of accelerated progress in the delivery of health care to be capped by the enactment of some type of national health insurance. If this has been a period of accomplishment, it has also been one of experimentation and learn- ing. We have learned that producing more health manpower and facilities is not necessarily ac- companied by improved geographic distribution of those resources. We have learned that improv- ing the quality of health care says nothing about extending that improved care to those who are physically or financially remote from our centers of medical excellence. And we have learned that the price of an improved health care system is not cheap. Last year, expenditures for health care amounted to 7.7 percent of the nation’s gross national product, compared with 5.2 percent in 1960. The proliferation of approaches to American health problems attempted during the past decade has also shown us that a national policy of simply inaugurating a stream of new programs, each ad- dressing only a part of the total health care de- livery problem, simply adds to the already great federal health bill and postpones or hampers the task of marshalling federal resources into a com- prehensive, coordinated effort. The fact that these lessons were learned over a period of time, and not as of some precise date, eliminates such factors from any neat chronicle of the fortunes of some individual program—whether it be Regional Medical Programs, Hill-Burton, or health manpower—but the impact is there never- theless. Further, especially in view of the pro- liferation of federal programs in the 1960's, a chronicle of the twists and turns of one program GUIDEPOSTS IN RMP ODYSSEY should take into account the total context of fed- eral activity within which those fortunes occurred, whether it included increased competition for federal funds, the development of opportunities for administrative improvements, the availability of alternative programs to carry on the work, the implementation of changed views of what con- stitutes federal responsibility, and the assigning of higher priorities to problems previously sub- merged. Even when these considerations are admitted into the discussion of the history of a particular program, there is room for honest disagreement, variations in interpretation, and shades of opinion. The judicial system is as legitimate an avenue to resolving those important differences as direct approaches to the legislative or the executive branches. Failure to acknowledge that both problems and policies can change and that not everyone will agree with the revised position is to present a dis- torted picture of seeming inconsistencies, contra- dictions, and imagined vendettas. The initial concept of Regional Medical Pro- grams was to provide a vehicle by which scientific knowledge could be more readily transferred to the providers of health services, and by so doing, improve the quality of care provided, with empha- sis on heart disease, cancer, stroke, and related diseases. That this original purpose has been broadened or revised or that some categories have been rescinded was inevitable in light of an im- proved perception of the nature of the nation’s health care delivery problem over the past decade. That the utility of the RMP approach in coping with present problems and priorities has been short of the mark, is neither surprising nor a re- flection on the integrity or competence of the in- dividual RMPs. Despite the value of the relation- ships established by the RMPs over the past several years, the Rmps in their present form were simply never envisioned as a vehicle for addressing the comprehensive scope of health care delivery prob- lems in the manner which we believe will be effec- tive and is required today. From the outset, the RMP has had great diffi- culty in defining a clear role for itself in con- centrating its efforts and resources on even a few, well-selected target areas. At the same time, it has been unsuccessful in reconciling the conflicting and changing emphasis between categorical dis- ease activities and comprehensive health care problems. More than half a billion dollars has been expended via the RMPs in an effort which has neither been true to the program’s initial ob- jectives nor sufficiently flexible to fulfill a more comprehensive mission. As a result of court ac- tion, another $218 million is being directed into this dubious direction. Even with the original strong emphasis of RMP on regionalization there is little evidence—and only with regard to kidney disease—that the RMPs have in many areas produced the regionalized systems of health care originally envisioned at the program’s outset. These is no significant evidence that the RMPs have achieved their goal of getting research ad- vances into regular large-scale practice. The train- ing programs undertaken are typically of limited scope and duration, and there is no substantiating evidence that these have had a significant impact on actual medical practice or in demonstrating improved quality care. A major problem with respect to RMP has been the high cost of maintaining the program, or core, staffs in each of the 56 regions. A significant part of the overall RMP effort and funds has gone to pay for program staff and their activities, includ- ing administration, consultation, project develop- ment and management, and evaluation. Another continuing problem has been the re- lationship of RMPs to Comprehensive Health Planning. In some areas, RMPs and CHPs have worked closely together in a beneficial way, but often their individual roles have been hard to differentiate. It is difficult to have a CHP agency with responsibility for the health planning for an area while another federally-supported program, an RMP, is implementing activities in that same area based on its own planning and priorities. What has frequently happened is that, since the RMP has had funds available to carry out opera- tional activties, its planning has become the de- ciding force of what is done in a given area. This has not always been consistent with broader com- munity and consumer health needs and interests. The opportunity for such conflict may be seen from the fact that of the 56 RMp regions, 34 are exactly coterminous with state boundaries and served by CHP agencies. A solution to this problem has been advanced by the Administration in the form of the proposed THE WESTERN JOURNAL OF MEDICINE 159 8 St RE RR Sab een ess me ter ante ia TE aS aot 7 wot amce P, jaoreiveseome grat a eae ye tae in GUIDEPOSTS IN RMP ODYSSEY = gioetnnata Health Resources Planning Act (S. 3166), which able elements of existing agencies and programs would replace the present RMP and CHP authori- involved in the present fragmented health plan- ties, which expired June 30. The bill has two ning process, the proposal provides for an orderly major purposes: First, to assist the nation’s health transition to bring those agencies into a new align- care system to plan more effectively to provide the ment of Health Systems Agencies envisioned in resources necessary to meet the nation’s health the bill. Hill-Burton, CHP, and RMP programs care needs; and second, to grant assistance to would be eligible to receive technical assistance states to pay part of their costs in regulating from the Department of Health, Education, and proposed capital expenditures and rate increases Welfare to enable them to qualify for provisional for health care. certification as a Health Systems Agency under This proposal provides for a clear distinction be- _ the proposal. The provision of that assistance tween planning and development activities on the could be conditioned upon a reorganization of the one hand and regulatory functions on the other. _ recipient entity or its merger with another entity. We believe that the planning function should rest Of the health planning bills currently being con- at the local level. It is at this level at which local sidered by the Congress, with few exceptions, i problems are best understood and can best be = Most can be characterized by their similarities to te solved. On the other hand, we feel that regulatory | the Administration bill rather than their differ- oes | | i i f F t s te functions should be placed at the state level, rec- | ences. It appears that somewhere in the chron- ys. ognizing that regulation is more clearly a govern- ology of RMP fortunes, the issue has become not Bit ment function. We plan, however, that the state | whether RMP should remain or be terminated, but ¢ Bi regulatory bodies will rely heavily on the local whether RMP is willing to shed its present nomen- aE: planning bodies for advice in carrying out their _clature and limitations and participate in the more i: . functions. comprehensive approach to improving health care a bf Moreover, far from total abandonment of us- which is being developed today. (} if uM t ry i i ml ia % F HS ir ee i 160 AUGUST 1974 + 121 + 2 BIOGRAPHICAL SKETCHES OF DIRECTORS OF REGIONAL MEDICAL PROGRAM 1966-68 Robert Q. Marston, M.D. 1968-70 Stanley W. Olson, M.D. 1970-73 Harold Margulies, M.D. 1973-75 Herbert B. Pahl, Ph.D. Biographical Sketches of RMP Directors Robert Q. Marston, M.D. Robert Q. Marston was born in Toana, Virginia on February 12, 1923. After graduating from Virginia Military Academy in 1943, he attended the Medical College of Virginia, where he obtained his M.D. degree in 1947. Selected as a Rhodes Scholar, Dr. Marston then spent the next two years studying at Oxford University in England with Professor Howard Florey, a Nobel Prize recipient for his work with penicillin. After returning to the United States in 1949, he took an internship at Johns Hopkins Hospital, then spent the next year ina residency at Vanderbilt University Hospital. From 1951 to 1953, Dr. Marston served in the American Forces Special Weapons Project at the National Institutes of Health (NIH), studying the role of infection following whole body radiation. After army service, he took another year of residency at the Medical College of Virginia. Having received a four year Markle Fellowship, Dr. Marston was appointed Assistant Professor of Medicine at the Medical College of Virginia and then Assistant Professor of Bacteriology and Immunology at the University of Minnesota. He returned to Medical College of Virginia in 1959 to assume an Associate Professorship in Medicine, at the same time serving as Assistant Dean. In 1961, Dr. Marston was named Director of the University of Mississippi Medical Center and Dean of its School of Medicine. In 1965 he was appointed Vice Chancellor of the University, while continuing on as Dean. From 1961 to 1966, Dr. Marston served on a consultative review committee for the Division of Hospital and Medical Facilities within the Department of Health education and Welfare (HEW). On February 1, 1966, Dr. Marston was appointed as the first Director of Regional Medical Programs, which was originally located in NIH. He also served as an Associate Director of NIH. Dr. Marston’s tenure as Director of Regional Medical Programs lasted until 1968. On April 1, 1968, Dr. Marston was named Administrator of the Health Services and Mental Health Administration, under the reorganization of the Department of HEW. But in September of that year he resigned that position to accept the directorship of NIH, which he held until 1973. On January 21, 1973, he became Acting Director of the National Institute of Neurological Diseases and Stroke, but left in April of the same year to become a scholar-in-residence at the University of Virginia. Dr. Marston was named president of the University of Florida at Gainesville in January, 1974, holding the presidency for 10 years, until 1984. He remained at the University of Florida as Emeritus President, Emeritus Professor of Medicine and Joint Professor of Fisheries and Aquaculture. | a re a ee ee ee ee ee ee eee ee Among distinctions bestowed upon him, Dr. Marston was named the first distinguished fellow of the Institute of Medicine, National Academy of Sciences. He has served as a member of many health and medical organizations: member of council of the Institute of Medicine, National Academy of Sciences; member of the board of directors of Johnson and Johnson; member of the National Association of State Universities and Land Grant Colleges; fellow of the American Public Health Association; honorary member of the National Medical Association; honorary member of the American Hospital Association. Stanley W. Olson, M.D. Stanley Olson was born February 10, 1914 in Chicago. He earned his B.S. from Wheaton College in 1934 and then went on to study medicine at the University of Illinois, where he took his M.D. degree in 1938. Dr. Olson took an Internship at Cook County Hospital in Chicago in 1938 and remained there until 1940. He was awarded a fellowship from the Mayo Foundation and earned an M.S. in Medicine from the University of Minnesota in 1943. Dr. Olson then served as an Assistant Director of the Mayo Clinic and for the same period, 1947-1950, held a position as Instructor in Medicine at the Graduate School of the University of Minnesota. From 1950-1953, Dr. Olson was Dean of the College of Medicine at the University of Illinois, and Medical Director of the University’s Research and Educational Hospitals. He became Dean of the College of Medicine at Baylor University where he remained in that capacity until 1966. From Baylor he moved to Vanderbilt University, and until 1968, held a Professorship in Medicine along with a clinical Professorship at Meharry Medical College. Dr. Olson was a member of the National Advisory Council for Health Research Facilities within NIH from 1963 to 1967. He served from 1964 to 1965 on a review panel of the Public Health Service which oversaw the construction of medical schools. Dr. Olson was named Director of the Tennessee Mid-South Regional Medical Program in 1967. In 1968 he was appointed as Director of the Division of Regional Medical Programs and continued in this position until 1970. He left this post to take up an appointment as President of the Southwest Foundation for Research and Education from 1970 to 1973. Dr. Olson then joined the College of Medicine Northeastern Ohio University as Provost until 1979, when he became Professor of Medicine and Emeritus Provost. Positions held concurrently by Dr. Olson during his career include: consultant for the State University of New York; member of the Medical Advisory Panel of the U.S. Office of Vocational Rehabilitation Administration, 1960-1965; member of the committee on medical school-Veterans Administration Relations, 1962-1966; member of the National Advisory Commission on Health Manpower, 1966; and consultant on Medical Education, 1979. He has also been Vice-president of the American Association of Medical Colleges, saree eugearge 2 a 1960-1961, and is a Fellow of the American College of Physicians. Harold Margulies, M.D. Dr. Margulies was born in Sioux Falls, South Dakota on February 13, 1918. He earned an A.B. from the University of Minnesota in 1938 and a B.S. from the University of South Dakota in 1940. He studied medicine at the University of Tennessee and was granted his M.D. there in 1942. Later, in 1948, he acquired an M.S. through his work in the Mayo Foundation. Dr. Margulies served his internship at Iowa Methodist Hospital in Des Moines, from 1943-1944. He was a Fellow in internal medicine at the Mayo Clinic from 1944-1945 and also during 1946-1949. Dr. Margulies practiced medicine, having specialized in internal medicine and cardiology, in Des Moines from 1949-1961. He then became professor of medicine at Indiana University. He served overseas in the AID (Agency for International Development) Contract at the Postgraduate Medical Center in Karachi, Pakistan, 1961-1964. He then relocated to Alexandria, Egypt, to be an advisor on Medical Education in the World Health Organization, 1965-1966. Dr. Margulies’s service abroad also included a role as Associate Director of the Division of International Medical Education of the Association of American Medical Colleges and as Director of the AID Contract project from 1965-1967. Dr. Margulies returned to the U.S. and was appointed Associate Director of Socio-Economic Activities of the AMA in Washington, from 1967-1968. He then took the position of Secretary of the Council on Health Manpower for the years 1968-1969. He transferred to the Health Services and Mental Health Administration to be Deputy Assistant Administrator for Program Planning and Evaluation from 1969-1970. It was in 1970 that Dr. Margulies was appointed Director of the Regional Medical Programs Service, a post which he held until 1973. Concurrent positions that Dr. Margulies has held throughout his career include that of consultant in internal medicine for the Veterans Administration, 1949-1961, White House Office of Science and Technology, 1966-1967, and Diplomat of the American Board of Internal Medicine. Among his many distinctions, he is a Fellow of the American College of Physicians and of the American Public Health Association. Herbert B. Pahl, Ph.D. Dr. Pahl was born in Camden, New Jersey, on August 14, 1927. He was educated at Swarthmore College, graduating with a B.A. in 1950. At the University of Michigan he did his graduate work in biochemistry, earning an M.S. in 1952 and a Ph.D. in 1955. a as @ seetiewee RY > oti t quel 5 ial He began his post-graduate career as a Fellow of the National Cancer Institute, and of the Sloan-Kettering Institute, from 1955- 1957. Dr. Pahl then took an assistant professorship at Vanderbilt University in biochemisty in 1957 and remained there until 1960. He entered the National Institutes of Health in 1960 and until 1962 his service there was as the Executive Secretary of the Graduate Research Training Grant Program. He moved to the Special Research Resources Branch and was first its assistant chief and then its chief during 1962-1964. Dr. Pahl continued as chief of the General Research Support Branch from 1964-1966. From 1966-1969 he was the Executive Secretary of the Committee on Research of Life Sciences of the National Academy of Sciences-National Research Council. Returning to NIH, he was appointed deputy associate director of science programs of the National Institute of General Medical Science in 1969. His involvement in the Regional Medical Programs Service began in 1971, at which time he was appointed its Deputy Director. In 1973 he was promoted to the Directorship of the Regional Medical Programs Service and continued in this position until 1975. From 1975 until 1982 Dr. Pahl was staff director of the Committee to Study National Needs for Biomedical and Behavioral Science Research Personnel, which operated within the National Research Council of the National Academy of Sciences. His latest appointment was to the Program Directorship of the Cancer Center Branch of the National Cancer Institute at NIH. He assumed this role in 1984. Dr. Pahl is a member of the American Association for the Advancement of Science. BUDGET HISTORY Troma The budget figures in the table and graph that follow have been taken from Reqional Medical Programs Fact Book (published by the Regional Medical Programs Service in November, 1972). Further research is now in progress to try to confirm and expand upon these figures. We do not yet have data for the period after 1972, when RMPs were being phased out. Miness = ewan ere a diana i APPROPRIATIONS AND BUDGETARY HISTORY (dollars in thousands) Fiscal Fiscal Fiscal Fiscal Fiscal Fiscal Fiscal Year year year year year year year 1966 1967 1968 1969 1970 1971 1972 Authorization $50,000 $90,000 $200,000 $65,000 $120,000 $125,000 $150,000 Amount appropriated for grants $24,000 $43,000 $53,900 $56,200 $73,500 $99,500 $90,500 Actually available for grants - $24,000 $43,934 $48,900 $72,365 $78,500 $70,298 $135 ,000 Amount actually awarded for grants $2,066 $27,052 $43,635 $72,365 $78,202 $70,298 $111,400 (dollars in millions) Appropriations and Budgetary History 210 200 190 - 180 |- 170 + 160 + 150 + 140 - 1390 + 120 + 10 - 1 S8SS3d888 SOW 1 © | RSV SQ Su ALLLLE OY SS S SKK 1966 1967 1968 1969 1970 1972 Fiscal Year exe%] Authorization MAX) Amount appropriated for grants ZZ, Actually available for grants [S