DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE National Advisory Council on Regional Medical Programs Minutes of the Twentv-eighth Meeting 1/ 2/ October 16-17, 1972 The National Advisory Council on Regional Medical Programs convened for its twenty-eighth meeting at 8:30 a.m. on Monday, October 16, 1972, in Conference Room G/H of the Parklawn Building, Rockville, Maryland. Dr. Harold Margulies, Director, Regional Medical Programs Service, presid- ed over the meeting. The Council Members present were: Michael J. Brennan, M.D. . Clark H. Millikan, M.D. Bland W. Cannon, H.D. , Mr. Sewall O. Milliken Mrs. Susan L. Curry Mrs. Mariel S. Morgan Nichael E. DeBakey, M.D. Marc J. Musser, M.D. Mr. Edwin C. Hiroto Alton Ochsner, M.D. anthony L. Komaroff, M.D. . Mr, C. Robert Ogden Mrs. Audrey H. Mars Russell B. Roth, M.D. Alexander M. McPhedran, M.D. George E. Schreiner, M.D. John P. Merrill, M.D. Benjamin W. Watkins, D.P.M. Gerhard A. Meyer, M.D. Mrs, Florence R. Wyckoff Drs. DeBakey, Millikan, Musser, and Roth were present on October 16 only. Dr. DeBakey was present only during the afternoon session. Dr. Merrill was present on October 17 only. A listing of RMPS staff members and others attending is appended. 1/ Meetings are conducted in accordance with Executive Order 11671 ~ and the Determination of the Secretary of Health, Education, and Welfare, thereunder, dated September 27, 1972. Proceedings of the closed portions of meetings, and materials submitted for discussion during such closed portions are restricted unless cleared by the Office of the Administrator, HSMHA. 2/ For the record, it is noted that meinbers absent themselves from ~ the meeting when the Council is discussing applications: (a) from their respective institutions, or (b) in which a conflict of interest might occur. This precedure does not, of course, apply to en bloc actions=-only when the application is under individual discussion. , oe I. II. CALL TO ORDER AND OPENING REMARKS The meeting was called to order at 8:30 a.m. on October 16, 1972, by Dr. Harold Margulies. Dr. Margulies called attention to the conflict of interest and confidentiality of meetings statements in the Council books. Dr. Margulies specifically pointed out that the confidentiality statement applies only to the closed portion of the meeting involved with the review of applications. He also called attention to Executive Order 11671 and its requirements for announcement of meetings and provision for pub- lic attendance and observation. REPORT BY DR. MARGULIES 1. Completion of Council Terms Dr. Margulies noted that Dr. Millikan and Dr. DeBakey were both completing their maximun feasible terms on the Council. Both have served since the beginning of the Program. 2. Quality of Care Conference A Quality of Care Conference has been set for St. Louis during the week of January 22. The meeting will deal with quality of care and quality assurance from a professional | standpoint. It will consist of major presentations and panels, rather than a series of workshops. The meeting is designed to develop a common base of understanding on quality of care issues. Attendance will be kept limited to facilitate moving through the agenda effectively. 3. RAG/GRANTEE Policy Statement The Regional Advisory Group/Grantee Relationships Policy, which the Council considered and endorsed at its June meeting, has been sent out to all Coordinators, RAG Chairmen and Grantees. While this has stimulated some further questions where grantees had not appreciated limitations on their actions, the policy has been generally accepted as reasonable. A March 1 target date has been set for Regions to make adjustments in accord~ ance with the new policy. RPS will provide advice as needed, but does not expect to approve interim drafts generated by the Regions. 4, Discretionary Funding Policy Another policy statement which has been distributed is that on discretionary funding,which describes the freedoms with which RMPs can develop new activities without formalized review and indicates when Rups approval is recuired. whe Discretionary Funding Policy involves a transfer of responsi- bility and of judgment which is consistent with the ae decentralization of RMP functions. Under the policy a Regional Medical Program, which has set out what it pro- poses to do, is given a degree of flexibility during the course of the year and the course of the triennium to pursue its interest-without having to stop in every stage of the process for a pro forma endorsement of activities which have already been endorsed by a previous review. In actual operation, the Discretionary Funding Policy will require discretion both on the part of RMPS and the individ- ual Regional Medical Programs. At this point one Council member suggested that discretionary funding authority possibly should be limited to a specific dollar amount. In response, Dr. Margulies indicated that the new policy provides adequate control over the kind of rebudget- ing that occurs. He further indicated that any amounts rebudgeted inappropriately would be brought to the Council's attention. At a future meeting of the Council, there will be a report on how the Discretionary Funding Policy is being carried out, and the Council can decide then whether shifts being made under the policy are reasonable. Kidney Guidelines At the June 1972, meeting of the Council concern was ex- pressed about the language in the RMPS Kidney Guidelines, specifically with respect to what it meant by a "full-time transplant surgeon." The Council directed RMPS to clarify the point by indicating that we were talking about a kind of commitment on the part of transplant surgeons, rather than something very tightly defined as "full-time." A clarifi- cation has been developed and sent to all the Regions. San Francisco Kidney Meeting At the June Council meeting some concern was also expressed over how kidney consultants were to be made available. The Review Committee had expressed some doubts about the use of a National Panel. These were not shared by the Council. The Council did, however, express a view that there should be a good level of understanding among the consultants as to how they were going to carry out their review functions--both from the technical point of view, and with respect to the overall principles of a network of dialysis and transplant centers to which RMP and the Council are committed. , A two-day meeting was held early in September for over 70 kidney specialists who are on the RMPS Consultant list. The Conference aha was also attended by Dr. Schreiner and Dr. Merrill, representing the Council. Dr. Schreiner indicated that a significant group of specialists attended the meeting and that it provided an opportunity for them to analyze the quidelines and get a common base of information at one time. National Kidney Foundation Award The Regional Medical Programs Service has been selected by the National Kidney Foundation to receive that group's Annual Health Achievements Award. The award will be presented in New Orleans on November 18. Review Committee Functions For the last several months the PMPS Review Committee has had extensive discussions about its functions, vis-a-vis the Council and Staff Anniversary Review Panel. These kinds of questions arise naturally in all review groups as changes occur both in their membership and the patterns of program operation. In order to clarify the situation, PMPS staff has developed a paper on the role of the Review Group with respect to the other RMPS review bodies. The paper was discussed with the Review Committee, which found it-acceptable. One Committee member felt that a chart of the RMPS Review Process would be helpful, but that is a mechanical feature rather than a sub- stantive comment on the functicns of the Committee. The Cormittee does analyze applications in great depth and spends considerable time on site visits and subsequent discussions. In addition to the new functional statement, RMPS has done other things to make them feel more secure in their role. Communi- cations has been improved markedly, for example, by feeding back actions of the Council to the Review Committee. This enables the members to know when there are differences, and understand why those differences occur. Status of RHPS Policv Manual It has been reported to the Council in the past that RMPs is in the process of preparing a looseleaf, cross-indexed policy manual. This has proven to be a rather arduous, time-consuming task, which has been frequently interrupted by the exigencies of day-to-day operations. The manual has now been completed. It will be circulated for comment to Coordinators, RAG Chairmen, grantees, members of the Council, and members of the Review Committee. It will also be announced as available for corment in the Federal Register. 10. Revised regulations for the program are under consideration. They will be redrafted, but they have been held back until the manual could be completed. One of the items that will be included in the manual is a full discussion of Section 910 which, among other things, provides for activities of a National or interregional interest and otherwise broadens the scope of Regional Medical Programs in the fields of health manpower education delivery systems, etc. We have not developed a policy statement on Section 910, largely because this might create the illusion that there is a separate pot of money available for carrying out the authorized activi- ties, which is not the case. Progress on Section 907 Section 907 is that part of the Act which requires the Secretary to prepare a list of hospitals having the most advanced capacity for dealing with the categorical diseases. RMPS is now in the process of developing a list of such hospitals through a contract with the Joint Commission on Accreditation of Hospitals. Under the contract a list of questions and a questionnaire has been developed by a group of experts. The questionnaire covers equipment, personnel, teaching programs and volumes of service deemed to he needed to assure quality of care. No final decision has been made on the nature of the list or its distribution when complete. The final list will not be one that depends upon minimun standards, and this will make it unique. The nature of the final list, however, has not yet been determined. It conceivably could be restricted to an "unique" group of institutions. It could be a more extensive list associated with professional requirements for patient referral, or it could be a much larger list showing the. characteristics of institutions. It is anticipated that information in the questionnaire will also be useful for planning, allocation of resources, and attempts to achieve regionalization. The list, as put together, should be maintained, modified as needed, and made broadly available. As a consequence, RHPS expects to be working with other appropriate HSMHA offices to develop arrangements for the monitoring and continuity of the list. , There was considerable discussion by the Council with respect to the need for judgmental input by Regional Advisory Groups in the Section 907 activity. li. 12. “ge It was moved, seconded and carried that: "After the list is received by this Council, it be distributed to the local Regional Advisory Groups for review and comment, and modification, and returned to this Council before the final list is passed on to the Secretary." (Transcript Vol. 1, page 34.) In subsequent discussion it was made clear that the above action of the Council referred only to the list of facilities and not to the raw data from the questionnaires. MIS and Evaluation Committees Dr. Margulies called on Dr. Pahl to discuss two newly established internal RMPS staff committees--one concerned with Management Information and the other concerned with RMPS Evaluation activi-~ ties. Both of these groups are composed of RMPS senior staff. — The establishment of the two steering committees indicates the very real interest of RMPS in setting a high priority on the better employment of the Management Information System and in improving the usefulness of RMPS Evaluation activities. The MIS group will look closely at the data being collected and its usefulness to site visitors, the Review Committee and the Council. With respect to evaluation, the Council has from time to time been advised of evaluation contracts that have been let and has periodically been informed of results. As the program matures, however, it becomes more and more important to develop an understanding of the accomplishments both of headquarters staff and the individual Regional Medical Programs. The establishment of the evaluation committee is designed to give the evaluation function a considerably higher priority in the future than it has had in the past. It is hoped that increased emphasis on the evaluation function will enable RMPS to involve both the Review Committee and the Council more fully in the formulation of plans. The stepped up evaluation effort is expected to improve the understanding of the program within the Department, and HSMHA, and among the general public. Review Committee Membership Dr. Margulies also called upon Dr. Pahl to discuss changes in the composition of the Review Committee. Three new members have been appointed to the RMP Review Committee. They are: Dr. William Luginbuhl, Mrs. Maria Flood, and Iti. Dr. Grace James. In addition, there have been three recent resignations from the Review Committee: Mr. Jeanus Parks, Sister Ann Josephine and Dr. Edmund Lewis. At this point there was considerable discussion by various members of the Council, principally Dr. Brennan, with respect to the need for greater representation of the categorical disciplines on the Review Committee. As a result of the discussion it was moved, seconded and carried that: "The Council expresses, through the Administrator, its conviction that authoritative scholars, quali- fied in neurology, oncology, and cardiology be included in the membersiiv of the Review Committee." (Transcript Vol. 1, pages 55 and 57.) STATEMENT BY DR, STONE Dr. Margulies introduced Dr. Frederick L. Stone, Interim Deputy Administrator, HSMHA, who read a statement for the Administrator. The statement primarily concerned two subjects: (a) developments relating to categorical disease control programs within the Depart- ment, and (b) the desirability of continued funding by RMPS of certain types of activities. A copy of Dr. Stone's statement is attached. Dr. Margulies asked Mr, Peterson, Director, Office of Program Planning and Evaluation, RMPS, to discuss recently developed statistical data relating to the matters discussed by Dr. Stone. Mr. Peterson stated that roughly two-thirds of the project activi- ties for which RMP support has heen discontinued are being picked up at a reduced level by other local funding sources. In addition, many discontinued projects have been phased out for thoroughly valid reasons. Such projects (1) may have been time limited, (2) may have proved to be undesirable, or (3) may have been determined to be of low priority in relation to available funds. With respect to the funding of categorical activities, there has been a marked percentage decrease in single categorical disease activities and a slight increase in dollars devoted to these, largely as a result of the increase of total funds available to RMPS from 1971 to 1972. In addition, many activities related to the categorical diseases in general are submerged in the "“multi- categorical” classification. , There was extensive discussion of Dr. Stone's remarks by various members of the Council. The following key points were brought out: IV. 1. Firmness in phasing out RMPS funding for particular activities has largely resulted from limitation on the amounts of funds available. 2. RMP staffs need to develop capabilities for economic planning, argument, and presentation to funding bodies. 3. If-NIH controlled programs do not work along with the RMP structure, a new organization similar to RMP will have to be invented. 4, Earmarking of funds for specific categories of activi- ties can be detrimental to the administration of the total program of an PUP, Dr. John R. F. Ingall, Chairman of the National Steering Committee of Regional Medical Program Coordinators, was recognized by the chairman. Dr. Ingall endorsed the Council's comments concerning the need for assistance of RAG and PMPs in the develonment of control programs. He also stated that Regional Advisory Groups had strong categorical protection built in, and indicated that the problem of many RMPs is relating cateqorical interests to the general delivery ‘of health care. He stated that many projects have been continued by other agencies and requested (re: FMS) that HSMHA keep RMPs informed on relevant contracts. In closing, Dr. Stone indicated that he would advise the Administrator of the Council's and others' comments. He also stated that NIH cléarly would not try to stimulate another set of networks--that the creation of "control" programs would be a HSMHA-wide activity in which the Council could expect to take the princinal load. Finally, he pointed out that other HSNHA programs have a certain experience in dealing with the third party navment problem and can furnish technical assistance to RMPs and other organizations where required. SPECIAL REPORTS 1. RMP Relationshins with Health Care Institutions Dr. Margulies called.on Mr. Sam O. Gilmer, Jr. to discuss PMP Relationships with Health Care Institutions. Mr. Gilmer pointed out that recently a number of small and informal conferences have been held with hospital oriented RMP/program staff and with individual hospital administrators. These indicate, as in the past, that there is little institutional commitment to RMP on the part of hospitals. There are exceptions, however. There is a real need to strengthen RMP and RMPS relation- ships with hospitals. Hospital governing bodies generally have not adopted policies clearly stating the relationship of the hospital's service program to the activities of the RMP serving the area. Likewise, there is no commitment on the part of hospital administrators, as a whole, with respect to the importance of RMP or commitment to working with RMPs even though a number of hospital administrators are involved with the programs as individuals. In addition to the informal conferences, a survey of hospital administrative competence within RMPs is now being conducted. Returns indicate that about two-thirds of the RMPs have designated a staff person to handle hospital liaison functions. In closing, Mr. Gilmer cited a number of activities in which hospitals and Regional Medical Pro= grams could profitably participate and particularly called attention to the TAP program of the Joint Cormission on the Accreditation of Hospitals. , Management Survey Activities Dr. Margulies called on Mr. Thomas Simonds, of the RMPS Grants Management Branch, to discuss Management Survey activities. Mr. Simonds stated. that the Management Survey Program was first organized in 1969, At that time survevs were only conducted at the request of the Coordinator or with his agreement. Approximately two years ago the Management Survey Program was reorganized so that all Regions are surveyed by staff on a regular basis. Management surveys cover such items as the adequacy of a Region's written policies, payroll and leave procedures, the adequacy of financial Management and records procure ment and inventory control, as well as personnel policies and procedures. On completion of each survey, preliminary findings are discussed orally with the Region and the final written report includes only material which has been discussed in advance. Survey reports are distributed internally to appropriate units of RIPS, HSMHA and HEW, including the HEW Audit Agency. Copies are furnished to the coordinator, RAG Chairman and grantee institutions. Recommendations of Management Survey reports are used to correct identified deficiences, to assist the operations desk and the Director, and to provide information for con- sideration by site visitors and other reviewers. By the end of November 1972, management survey visits will have been conducted in 35 Regions. Eighteen additional surveys have been scheduled for the 1973 calendar year. -10- 3. Third Party Reimbursement Dr. Margulies called on Mr. Roger Miller, of the Grants Management Branch, RMPS, to discuss a draft of a proposed new HSMHA policy concerning the phasing-in of funds from sources outside the program. - Mr. Miller reported that the proposed policy would require that, to the maximum extent possible, all projects should become self-sustaining community-based operations within a given time frame. In order to accomplish this the proposed policy would require a plan for the phasing-out of program funds and the phasing~-in of other support. V. CONFIRMATION OF FUTURE MEETING DATES The Council discussed,but took no action on, future meeting dates. Several members had conflicts with the dates proposed. VI. CONSIDERATICN OF THE MINUTES OF THE MEETING OF JUNE 5-6, 1972 It was moved,seconded and carried that the minutes of the June 5-6, 1972, meeting be approved. (Transcript Vol. 1, page 134.) VII. CURRENT STATENENT WITHIN THE DEPARTMENT OF FUNDING AND LEGISLATIVE EXTRUSION ACTIVITIES Dr. Margulies reported that the HEW Labor Appropriation Bill was passed and vetoed, Since then a second appropriation bill was passed and again vetoed, There is still no final action on the appropriation or on spending controls. The Department is running on a continuing resolution and there is no basis for speculating on funding levels for RMP. There is, however, very persuasive evidence that in an effort to limit the spending in the Federal budget, restrictions will be placed, wherever possible, on expenditures. There is a good possibility that the level of funding available for RIP during the 1973 and 1974 fiscal years will be reduced. The RMP legislation. expires on July 1, 1973, and there are a number of organizations developing ideas about what future RMP legislation should contain. We have no knowledge, however, of any final position developed by the administration with respect to legislative extension. VIII. REVIEW COMMITTEE DATA PRESENTATION Mrs. Silsbee presented a number of slides that had been utilized on an experimental basis to sumiarize background information from the MIS for the Review Comnittee. She pointed out that IX. ~li- RMPS has considerable information in the Management Information System as well as extensive institutional memory on the part of Staff and older Committee and Council members. Membership in these groups changes, however, and the visual materials were developed in an attempt to bring background information to reviewers in a matter that can be quickly grasped without slowing down the review process. After viewing the visual charts at the September 1972, Committee meeting, Committee members expressed the view that the presenta~ tion had been helpful. They suggested, however, that the information in the charts would be even more useful if made available to site visit team members prior to site visits. Committee members also expressed the opinion that canned visuals could be misleading and that information should be tailored to individual applications to bring out the salient points. Council discussion following Mrs. Silsbee's presentation likewise sounded a note of caution. The Council members expressed the opinion that such material might be presented in a capsulated form which could he misinterpreted by the uninitiated. Several examples were cited of how data accumu-~ lated in broad categories could mask important details. Program staff functions, for example, include both administrative activities and activities of a professional and program nature. REPORT ON MOUNTAIN STATES, INTERMOUNTAIN AND COLORADO Dr. Margulies called on Dr. Milliken, who had particivated in a site visit addressed to the question of territorial overlap between the Mountain States, Intermountain and Colorado/yom= ing RUPs. Dr. Milliken stated that the purpose of the site visit was to decrease the friction that had apparently developed between the RUPs. The three Regions decided to create an interregional Executive Council designed to reach joint decisions regarding programming in overlanved areas, In addition, a policy and procedures document has been developed for coordinating the activities of the three programs. REPORT ON DEVELOPMENTAL COMPONENT Mrs. Silsbee was called upon to report the results of a staff study concerning the develagpmental component and proposed action. At the present time, 35 Regions have been approved for a developmental component; twenty-one have not been approved. XI. -12- of the latter group, eight Reqions have not applied. Two of these are still in the planning stage. Thirteen Regions have applied and have been disanproved--eight of them twice. The Developmental Component was initiated at a time when RMPS was shifting from a focus on "project" to emphasis on "progran." Among other things, the. developmental component appears to have been useful in helping many Regions to strengthen the RAG, program staff activities, forward planning, budget control, and the project monitoring function, At the sane time, there may have been a detrimental effect upon those regions that were not approved. Some disapproved applicants misinterpreted the denial of a developmental component as sicnifving disenchant- ment with specific activities proposed, rather than with their goals or processes. In addition, and most important, those Regions that needed the developmental component most were those that did not meet the standards for approval. Since the developmental component was initiated, RUPS has decentralized vroject review, initiated the triennial system, introduced the review criteria and rating system, and announced the discretionary funding policy. These changes provide Regions with flexibility and recognition, and do other thinos that the developmental component was originally designed to accomplish. RMPS is currently thinking about phasing out the developmental component in an orderly manner and will be seeking the Council's advice on this at the next meeting. MISSOURI SITE VISIT Dr. McPhedran reported on a special site visit to the Missouri “MP which took place on September 15, 1972, The site visit had been recommended previously, bv Council, to relay Council concerns relating to the value of some expensive computer projects and the organization of both the program staff and Regional Advi= sory Group. Dr. McPhedran reported the following: 1. Program staff is beginning to seek solutions to problems in the Region, rather than waiting for project proposals to be initiated by other groups. 2. Program staff is beginning to work on priorities, goals and objectives. 3. The Director of the program has assumed another responsi- bility, on a part-time basis, and is spending currently only 54% of his time with the RMP. XII. ~-132- 4, The Regional Advisory Group needs to add Veterans Administration, CHP and minority representation. 5. The Region needs to create an evaluation section and simplify its review process. At the conclusion of Dr. McPhedran's report there was some discussion of the relationship between the Missouri RMP and the Bi-State RMP in St. Louis. The consensus was that while there were unsettled jurisdictional issues between Bi-State and Illinois, there is no problem between Bi-State and Missouri. REVIEW OP APPLICATIONS A. Albanv Moved: Dr. Ochsner Seconded: Mr. Ogden Accept the Review Committee's recommendations for three- vear funding in the amounts of $1,618,000; $1,783,090; and $1,940,723, Transcript, Vol, 1, Page 165.) B. Bi-State Moved: Dr. McPhedran Seconded: Mrs. Curry Award triennial status, but no developmental component in the amount of $1, 150, 000 for the 04 year with 7% increases for the 65 and 06 years, and conduct a site visit after the next year of operation to review RAG effectiveness, staff relationships, and boundary problems with Illinois. Amounts approved include $50,000 in discretionary funds to make it possible to hire a Deputy Coordinator. (Transcript, Volume 1, Page 171.) Cc. Wisconsin Moved: Dr. Millikan Seconded: Mrs. Wyckoff Accept the recommendation of ‘the Staff. Anniversary Review Panel to increase the approved level for the 06 year to $2,153,624, including $312,881 for kidney activities anda $177,907 developmental component. (Transcript, Vol. l, Page 173.) E. ~14= West Virginia Moved: Dr. Cannon Seconded: Dr. Roth Accept the Committee's recommendation for $1.5, $1.6, and $1.7 million for the first, second and third years. (Transcript, Vol. 1, Page 178.) Central New York Moved: Dr. Schreiner Seconded: Dr. Musser Approval in the amount of $889,000. (Transcript, Vol. 1, Page 185.) ‘ Michigan Moved: Dr. DeBakey Seconded: Dr. McPhedran Approval in the amount of $2.25 million. (Transcript, Vol. l, Page 189.) Hawaii Moved: Mr. Hiroto Seconded: Dr. Komaroff Accept the recommendations of the Review Committee in the amounts of $1,805,488, $1,839,213, and $1,820,577 for the 05,06, and 07 years, respectively, including kidney and earmarked funds for the Pacific Basin. Kidney funds are subject to satisfactory definition of relationships between Kuakini and St. Francis Hospitals. The request for a developmental component was not approved. - (Transcript, Vol. 1, Page 194.) New Mexico* Moved: Dr. Komaroff Seconded: Dr. Watkins Approve for triennial status in the amounts of $1.25, $1.30, and $1.35 million for the 05, 06, and 07 years, respectively. A site visit is to be conducted next year, and no funds are to be allowed for basic training in allied health professions. (Transcript, Vol. 1, Page 206.) ae Council dnereased the amount recommended by the Review Committee because of the Region's success in optaining alternative funding for six of thirteen projects. ~15= I. Northern New England Moved: Mrs. Wyckoff Seconded: Dr. McPhedran Approved in the amount of $850,000 for the 04 and 05 years, including a developmental component and $ 37,500 and $25,400, respectively, for continuation of kidney activities. Triennial status is denied, but should be granted if the Region seems ready for this after a site visit at the end of the 04 year. (Transcript, Vol. 1, Pages 209 and 213.) J. Virginia* Moved: Dr. Watkins Seconded: Dr. DeBakey Triennial status approved in the amount of $1.8 million, including Developmental component for each of three years. (Transcript, Vol. 1, Page 218.) K. Indiana Moved: Dr. Brennan Seconded: Dr. Ochsner Approve the Review Committee's recommendation for $1.2 million for one year. (Transcript, Vol. 1, Page 220.) L. Rochester Moved: Mr. Milliken Seconded: .Dr. Brennan Accept the Review Committee's recommendation for $935,000, including $35,000 for kidney, and noting specifically the Committee's requirement that the bylaws be completed. It was also recommended that the Region be revisited in within six to nine months. (Transcript, Vol. 1, Pages 225-226.) M, Texas** Moved : Mrs. Morgan Seconded: Dr. Schreiner Accept the Review Committee's recommendation for $1,900,000, $2,100,000 and $2,300,000, including the following amounts for kidney: $337,157, $309,640, and $294,640, for the next three years (with the funding for the second and third years contingent upon greater minority involvement in staff and RAG as determined hr further ce iew in nine months. (Transcript, Vol. 2, Pade 6.) a * Mrs, Mars not present in meeting room. *k Dr, Meyer not present in meeting room. Dr. DeBakey absent. * ~16= Mississippi Moved: Dr. Merrill Seconded: Mr. Hiroto Go along with the approval of the triennial application at the funding level recommended by the Committee in the amount of $1,926,984, $2,200,000, and $2, 445,891 for the 04, 05, and 06 years. (Transcript, Vol. 2, Page 11.) Memphis* Moved: Dr. Meyer Seconded: Mrs. Wyckoff . Increase the approved level to $2,000,000, including $100,000 for a developmental component. (Transcript, Vol. 2, Page 13.) Northeast and Southeast Anplications for Interrecional Coordinators Under Section 910. Moved: Mr. Ogden Seconded: Mrs. Morqan Approval of Southeast for three years, and Northeast for two, with funding of a third year for Northeast contingent on satisfactory progress. (Transcript, Vol. 2, Page 67.) Metropolitan New York, 910 Kidney Application Moved: Dr. Merrill Seconded: Dr. Schreiner Defer consideration of the present applications pending a staff visit to studv, evaluate, and honefully to reconcile some of their uncertain aspects. In the interim, the Director, RMPS, is authorized to provide interim funding, if he should find such fundina to be netessary. (Transcript, Vol. 2, Page 79.) SARP Recommendations Continuation applications from the followina Regions which were reviewed by SARP and proposed actions by the Director were called to the Council's attention: California Colorado Wyoning Georgia Maine Dr. Cannon not present in meeting room. -l7- There were no Council comments with respect to these continuation applications, or the proposed actions by the Director. (Transcript. Vol. 2, Page 80.) I hereby certify that, to the best of my knowledge, the foregoing minutes -and attachments are accurate and complete. ‘ Harold Margulies, M.D. Director Regional Medical Programs Service ATTENDANCE AT THE NATIONAL ADVISORY COUNCIL MEETING RMPS STAFF Mr. Norman Anderson Mr. Waddell Avery Mr. Charles Barnes Mr. Kenneth Baum Ms, Marilyn Buell Mr. Richard Clanton Mr. Spencer Colburn Ms. Cecilia Conrath Mr. Joseph De La Puente Ms, Annie Dicks Mr. Alex Dobson Ms. Eileen Faatz Ms, Myrtle Flythe Mr. Gerald Gardell Mr. Sam O. Gilmer, Jr. Ms. Eva M. Handal Mr. Charles Henson Mr. Charles Hilsenroth Mr. George Hinkle Dr. Edward J. Hinman Ms. Dona Houseal Mr. Francis C. J. Mr. Joseph Jewell Mr. A. Burt Kline Ms, Lorraine Kyttle Mr. Walter Levi Dr. Joseph Linehan Dr. Harold Margulies Mr. Rodney Mercker Dr. Bruce Miller Mr. Roger Miller Mr. Ted Moore Mr. Bob Morales Ms, Marjorie Morrill Ms. Mary E. Murphy Mr. Frank Nash Mr, Eugene Nelson Ms. Peggy Noble Mr. Harold O'Flaherty Mr. Joseph Ott Mr. Chris Ottenweller br. Herbert B. Pahl Ms. Jeannie L. Parks Ichniowski October 16-17, 1972 Mr. Mr. Mr. Dr. Mr. MS. Mr. Dr. Mr. Ms. Mr. Ms. Dr. Ms. MS. Ms. Mr. Dr. Mr. Mr. Ms. Mr. Mr. Mr. Dr. Mr. Ms. Ms. Mr. Roland Peterson Michael Posta Laurence Pullen Richard M,. Reese William Reist Leah Resnick Abraham Ringel Jinmy L. Roberts Richard Russell Rebecca Sadin Luther Says Patricia 0. Schoeni Richard Schrot Kathryn M. Sievers Sarah J. Silsbee Shirley Simon Thomas Simonds Margaret Sloan James Smith “Mathew Spear - Doris Staton Jerome Stolov Calvin Sullivan William Torbert Clarence Washington Lee Van Winkle Glenna Wilcom Constance Woody Frank Zizlavsky OTHERS ATTENDING Mr. Edward Bridgforth, Public, Jackson, Mississippi Dr. Dr. Margaret H. Edwards, NCI-NIH John. R. F. Ingall, Public, Lakes Area RMP, Buffalo, New York Ms. Dr. Mr. Dr. Frances Howard, NLM-NIH Frederick L. Stone, OA-HSMHA - Donald N. Young, OGC-HSMHA William J. Zukel, NHLI-NIH OF nme aoe @ Oo : | LU-L6~7/2 Presentation by Dr. F. L. Stone to , National Advisory Council, RMPS oe Dr. Wilson has asked me to express his sincere regret that he is mable to meet with you this morning, but this is his day to defend the HSMHA budget before the OMB, and I am sure you will understand and wish him well. | Before proceeding further, I would Like to emphasize those specific attributes of the Regional Medical Programs that signalize its progress: 1. Its decision-making powers have been decentralized to the final level in most cases; i.e., to the states or sub-regions of states. © 2. Ina special sense it demonstrates revenue-sharing at its best. 3, It has evolved, nationally speaking, into the only reliable tool we have which relates to the professionil at the community level. 4, In these Programs we have, regionally disbursed, the largest pool of talent addressed to health care in our Nation, There are several things he has asked me to discuss with you--and the rirst is I. Priorities: We are well aware of the many pressures which have buffeted the Regic tai Medical Programs ever since they became a part of IISMIIA in 1968--and never has the strain been greater than in the last two years. Under your gui ‘anee, they have made the best of very difficult situations, and their contribution to solving the problems of access to primary comprehensive health care has been remarkable. Their flexibility, imagination, and resourcefulness have © been most impressive. They have found it possible to adjust to new priorities identified by HSMIIA when these came along--the medically underserved, Tridians, 6 . vv migrant workers, urban and rural poor, young children, and the elderly-- and they have been able to place emphasis on ambulant care facilities and the more effective use of allied health personnel. Their ability to enlist the cooperation of the providers and all concerned groups in the regions was most notably displayed in the recent crash program to set up emergency medical 4 y ¥. ‘ whe . seryices, and I believe no other organizations in the country could possibly have done this so rapidly and so well. However, our priorities are also set by the Congress, which in general reflects the will of the people, and it has been inescapably clear that many members of Congress are just as interested today in improving the care of patients with heart disease, cancer, stroke, and kidney disease as they were when the RMP Jegislation passed in 1965. As a matter of fact, the National Caneer Act of 1971 wan passed tu part 4 because the RMPs had not Lalffiled the expectations of those who pled for the RMP legislation in '65 and those members of Congress who over- } . whelmingly supported sj Se they decided to try again. Those members of the health professions concerned with heart disease were not quite so frustrated because they had been deeply involved in the RMPS effort to develop guidelines for optimal care through the Inter-Society Commission for Heart Disease Resources. Nevertheless, they also were ‘deeply distressed as the RMPs withdrew sharply from support in the field of heart disease and urged ecual time with cancer on the Hill. Congress expressed its continuing commitment to improving the lot o: people with cardiovascular, respiratory and blood diseases by passin” ¢ o the National Heart, Respiratory and Blood Disease Bill of 1972. It is no accident that increasing amounts of $20, 30, and 40 M were authorized in both bills for control activitics in cooperation with other Government agencies. - ae tok ; : i 4 ’ * ’ ¥ When Appropriation Hearings came around last spring, members of Congress were hearing bitter complaints from their constituents--doctors and patients concerned about heart disease, cancer, and stroke--who found that many RMP programs in these disease areas were being terminated. They pointed out that the legislation on the books still makes heart disease, cancer, stroke, and kidney disease the major responsibility of - the RMP's, And they are right; it does. Of course, itis perfectly true that if people do not have access to health care at all, they will not have access to care for heart disease, cancer, stroke, and kidney disease either, and therefore the © recent emphasis on access to primary care is totally commendable. What | the RMP's have been able to accomplish in that direction has served to strengthen the base for all medical care across the country. Now, however, Congress has made it crystal clear that it wants the national effort in the control of heart disease, cancer, stroke, and kidney disease greatly intensified and that it will 7 longer tolerate diversion of funds appropriated for those purposes. This time it has authorized special funding for control cfforts in the budgets of the NCI and NHLI and in both cases it has directed that these activities be wy OY. oan . wee i o . 4. carried out ‘in ‘the ‘élosest possible cooperation with other Governnent agencies. The appropriation committees have been generous with the control portion of the NCI and NHLI budgets, but at this point we cannot tell what funds will eventually be released. Partly as a result of Congressional pressure, partly because of the need to achieve better coordination between the various parts of DHEW, and because of the crushing magnitude of the problems of heart disease, cancer, stroke, and kidney disease which constitute at least 70 percent of the content of comprehensive health care, the Secretary has agreed that HSMHA will work closely with the Institutes in the area of disease control--and specifically in the fields of heart disease, cancer, stroke, and kidney disease. As a forerunner of the kind of intense cooperative effort which will henceforth be coordinated by the Institutes, the Secretary launched the National Hypertens?on Program on July 25. Aimed initially at pro- fessional education in the field of hypertension, it will later move on to public education and to the preparation of the health services delivery system to respond to an increased demand for screening, dia~ nosis, treatment, and follow-up. This activity is being served by 2 National Advisory Committee, an Inter-Agency Working Group, and four | task forces made up of members of the National Advisory Committee and: representatives of the NHLI, VA, FDA, and HSMHA. The first will deter- ce net ge stoma CE mine the content of the educational program, define the level above which | $ 7 ON 5 treatment is indicated, and recommend what that treatment should be; the second will plan the professional educational program; the third will plan the public education program; and the fourth, chaired by HSMHA , will evaluate the impact on the health services delivery system and determine the resources needed to respond to the professional and public education programs. Dr. W. McFate Smith, Regional Health Director for Region IX, is serving as the chairman of Task Force IV. This has been a very intensive effort.since July, and has engaged . 1 a large amount of the time of Dr. Margulies, and of Drs. Hinman, Sloan, and Greenfield. Eventually, it must engage the time and attention of this Council and of all the Regional Medical Programs. Dr. Wilson has made a firm commitment that every HSMHA program which can increase its attention to measures affecting the control of heart disease, cancer, and stroke within the limits of present funding ‘and personnel will do so. Depending on the level of funds eventually released, additional contributions will, be made by HSMHA programs to the control of these diseases in cooperation with the NCT, the NHLI, cad the NINDS. The area cf hypertension will take precedence in this cooperative effort, but the others will not be far behind. 7 : so \ What does this mean for the RMPs? Somehow they will have to be’ encouraged to put a larger part of their programs back into the fields of heart disease, cancer,-and stroke, but to-do this as an integral part i ‘ ! s i « . © ad s Vv ¥ \ 5 . ; . . * ‘of comprehensive health care, We wish to protect the gains they have made in the last two years and to reintroduce some of the categorical disease activities in a very special way which will not adversely affect the current noncategorical program efforts. We therefore wish to seek your reaction to the following proposals: 1) That the RMP's be encouraged to retain or redirect a part of © their regular grant program to support those activities which seem most important at the local level in relation to heart disease, cancer, and \, a stroke. t 2) That a special fund be designated for control activities~-the exact amount to be determined by the level of funds finally released to RMPS by OMB_and DHEW--at least a portion of which would be held centrally. Emphasis would remain on getting this to the RAG's as rapidly as possible but with more specific guidelines than has held for some of our past programs. 3) Some part of these central funds may be awarded to the regions by contract after review by appropriate committees of expert consultants for activities which will.follow guidelines developed by RMPS in close cooperation with NCI, NHLI, and NINDS. 4) Quality assurance has been discussed with this council before wut the issue has never been more urgent. Some of these central funds may als« be used to support contracts (a) with national professional organizations for the development of criteria for quality assurance in relation to heart disease, - eancer, and stroke; (b) with individual iustitutions or to groups of institutions to demonstrate various alternatives for the dehLivery of high quality services to patients with these diseases; and (c) with Regional Medical Programs or + ¥ © v3 | . ‘ , national professional organizations to promote the. regionalization of specialized facilities and services. Review mechanisms would have to be worked out; staff would have to be assigned (any additional positions possible? ); and methods of communication of these changes to the regions would have to be developed. In short, RMP's have some new priorities which are really some of the ones they started with, but which now should be integrated into comprehensive health care as much as possible and represent a partnership effort with the NHLI, and NCI, and NINDS, * | . II. Council Policy on Duration of Funding and Phasing Out of Projects The other subject I wanted to discuss with you concerns your Council policy of decremental funding and phaseout aut the end of three years, We all know the dangers of getting trapped in demonstration projects for which it proves impossible to find other sources of support. Obviously, if these are allowed to become fixed charges and continue to proliferate, the situation would resemble Medicare and Medicaid, soaking up an ever- increasing share of the RMPS budget. The Program would then cease to be a developmental one and lose the marvelous, innovative, catalytic role it has played so well, But it was this 3-year termination policy also that gave us special trouble in the Congress last spring. Programs we?» ‘being terminated rigidly because they had had 3-year funding. In some cases little effort was made to help the project directors find other sources of financial support. In some, allegedly promising projects wore terminated abruptly when one or two more years at reduced fimding might have enabled them to become self-supporting. Some of these were sneeeraful | . Succer Ut D v 3 4 ¥ : : . . programs or just beginning to fulfill their promise, and it appeared that the reward for success was annihilation. Whatwe should like to have you consider are some modifications of your policy which would put emphasis on the following: 1) Continue, as I know you do now, requiring new applicants to . indicate how funding will be covered from other sources in 3-5 years. 2) Make awards with decremental fumding when possible. 3) Ask the RMP's to take greater responsibility in helping applicants find other sources of funds. % 4) Apply the policy with flexibility. Not all of our innovations in health care will be acceptable to the funding organizations. There may indeed be some service projects of such value that RMPS should continue funding them for more than three years. If no other alternative fmding can be located then decremental funding should be applied gradually with a maximum of technical assistance to the local program so that we are not in the position of abandoning patients abruptly. 5) Particularly in programs involving children or the elderly, it would be better not to get started on them at all if there is no hope al other funding at the end. But the RMP's will surely lay up credit in .eaven if they cen start programs which bring h2lp to these groups and eventuslly make them self-supporting: | | It has been a keen pleasure for me to participate in your discussions this morning, I trust you have found my reniuks Interesting and thought provoking. Their general thrust will be to add matcrially.to this Council's present responsibilities and scope of activity. 1 will be pleased to try to answer ©} any questions’ that iarise | the ensuihg discussions.