TO: DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE “PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION ROCKVILLE, MARYLAND 20652 REAU OF HEALT SOURCES DEVELCF T June 28, 1974 BURE EALTH RESOUR E FMEN ALL COORDINATORS, GRANTEES AND MEMBERS OF THE NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS, AND MEMBERS OF RMP REVIEW COMMITTEES Once again it is a pleasure to bring you the highlights of the National Advisory Council, which met on June 13-14, 1974. As you know, the Council has been enlarged by ten members, Three of the 13 persons invited by the Secretary did not accept due to other commitments, leaving three vacancies. Fifteen of the 18 presently serving members, however, were able to attend the current session, Our new members bring to the Council a great wealth of experience and familiarity with RMPs. You will also be interested to know that we held a one-day orientation session for new members the week prior to the Council, and I believe that this rewarding opportunity contributed to the effective functioning of the Council, which was particularly important because of the unusually heavy work demands placed upon it, Dr. Margulies reviewed the functions of the Health Resources Administration, and indicated that the three Bureaus of HRA conduct intelligence and research activities as well as a variety of programs relating to manpower, facilities and planning. He stressed the importance of having a national statistical base and effective planning authority as we look toward the possible implementation of National Health Insurance legislation. Dr. Margulies pointed out that lacking legislation at the end of a Fiscal Year is by no means unusual. He described in broad terms the various planning bills that have been introduced, and indicated that the present CHP and RMP programs probably would be extended under some form of Continuing Resolution until the passage of proposed legislation, Bills for the National Center for Health Statistics and Health Services Research are expected to pass without difficulty, but the final outcomes with respect to manpower and construction authorities are still uncertain, Dr. Margulies then turned to the functions and responsibilities of the Council, and pointed out that the National Advisory Council on Regional Medical Programs has more authority in the approval of grant awards than most other Councils. The Council has both approval power and veto power. No award can be made without its recommendation and the amount must be within the figure recommended. While it is likely that there will be new legislation before the total RMP funds to be acted upon by the Council will be expended, the Council is responsible for acting on the basis of the existing RMP statute and the Court order, Page 2 Dr. John C. Greene, Director, Bureau of Health Resources Development, discussed manpower legislation. Th: Comprehensive Health Manpower Act, Nurse Training Act, and Allied Health and Public Health Training legislation all expire on June 30, 1974. Senate Hearings on manpower legislation are scheduled for June 24th and a new law is not likely to emerge for some time. It is Dr. Greene's expectation that two bills eventually will replace the present four; one for nursing and one for the other health professions The Congress has also shown increasing concern for the stability of institutions that produce health manpower. This concern has become manifest in various proposals which have been introduced. In spite of differences over capitation, some form of support for health educational institutions will be forthcoming. Mr. Eugene J. Rubel, Associate Director for Health Resources Planning, HRA, reported on the current status of litigation, future prospects for RMP and planning legislation. A settlement has now been reached in the RMP lawsuit. The plaintiffs have agreed that up to $5 million may be awarded under Section 910 provided that none of the funds are used for State administrative or regulatory purposes. The Judge reportedly signed the order on Friday, June 7, 1974, and has given the RMPs 30 days to comment on the proposed Settlement. The Judge has indicated that he will rule expediciously on any comments received. In view of these developments, the exact total amount of funds which will be made available to DRMP for the August Council review will be know when the 30 day period has elapsed, or shortly thereafter. © A House "mark-up" on a new planning bill is expected to be produced shortly, based largely on HR 13995 introduced by Representatives Rogers, Hastings, et. al. Essential features include (a) local Health Systems Agencies serving areas with minimum populations of 500,000 (or as low as 200,000 on a special exception basis); (b) State agencies with a council appointed by the Governor and largely. representing local Health Systems Agencies; and (c} Federal support on an optional basis for any State that wants to undertake rate review activities. A committee analysis of all the planning bills presently being considered has been duveloped by the Subcommittee on Public Health and Environment of the House Committee on Interstate and Foreign Commerce. Copies have been ordered and will be mailed to you under separate cover. In addition to developing a position on planning legiglation, the House Committee has also exhibited an interest in providing substantial amounts of money at State level for continuation of construction. In anticipation of new legislation, several Bureau-level Task Forces have been working on such matters and the geographic designations of areas, and a proposed organization for administering any new authority. Until Congress acts, however, CHP, RMP and Hill-Burton will continue to function as three separate Divisions within the Bureau. © Page 3 Mr. Rubel commended the PMP Ad Hoc Review Committee for doing a good gob of identifying problems requirinc Council attention, He expressed the view that RMPs should be continued through the transition period, but that the Council should exerciee fully its authority to recommend funding levels in each case appropriate to the perceived merit of the Region's application. Dr. Alvin I. Goodman, Program Coordinator, End Stage Renal Disease Program, Bureau of Quality Assurance, HSA, discussed implementation of the program which provides reimbursement for kidney dialysis and transplantation under Section 299(i) of the Social Security Act. The Act was passed in October 1972, and went into effect in July 1973. RMPs in most areas of the country ptill have expertise in the kidney field as well as previous plans that can be used for developing networks, institutional affiliations and required medical review boards. Hopefully cooperative arrangements for implementing the new renal disease program can be worked out between HEW Regional Offices, the currently developing Professional Stardards Review Organizations and the Regional Medical Programs, noting that the latter have extensive previous experience and expertise in this field. Mr. John Reardon, Acting Deputy Director, Division of Emergency Medical Services, Bureau of Medical Services, HSA, discussed EMS matters, noting initially that the RMP Council in the past has been involved with emergency medical service activities. These demonstration activities have shown that a systems approach is sound. The Emergency Medical Service Systems Act of 1973, P.L. 93-154, passed the Congress and was signed into law dn November, 1973. The appropriation provides a total of $27 million which includes $3 1/3 million for research which is administered by BHSR, $6 1/3 million for training which is administered through the HEW Regional Offices, and $17 million for EMS systems. The latter is concerned with feasibility studies, planning, initial operation, implementation of EMS systems, and in addition, expansion of existing systems. A full EMS system includes such elements as medical, surgical and mental health services, transportation, communication training and consumer education. The EMS legislation is aimed at supporting total systems rather than individual components such as the purchase of an ambulance. Section 1207 of the Law prohibirs the use of PHS funds other than those appropriated under the EMS Act for the support of total systems. After appropriate consultation between the Division of Regional Medical Programs, the EMS program and the office of the General Counsel, it has been determined that none of the EMS activities in the current RMP grant applications is in conflict with either the letter of the EMS law or the intent of the Congress. Additional funds have been requested by the Administration for Fiscal Year 1975, and application deadlines will be announced when funds become available. In the meanwhile, an interagency coordinating committee is being established to insure coordination of funding EMS activities and of the development of adequate reimbursement mechanisms. The committee will include, among others, the Transportation and Agriculture Departments, Social Security and the Veterans Administration. Page 4 Dr. John B. Gramlich, one of our new Council members, attended the meeting of the Ad Hoc RMP Arthritis Review Committee, and reported to the Council on that Committee's deliberations, Dr. Gramlich indicated that the Arthritis effort is a truly pilot type of program, the development and philosophy of which might well have profound influence on programmatic thrusts and future legislative action. In the latter case, he pointed out that one of the Committee members had drawn a parallel with RMP efforts in the kidney field in which studies, policies and the development of networks ultimately led to adequate funding under the Social Security Amendments. The Ad Hoc Arthritis Committee essentially had the task of selecting from the $15 million requested in 43 applications to an amount more closely akin to the $4.3 million available under the Congressional earmark. In general the proposals included many of the following features: (a) an inpatient or other central facility with affiliated satellite clinics; (b) strong patient and public education components; (c) some research; (d) major equipment acquisition, usually vehicles and laboratory equipment; (e) frequently, special programs for specific problems such as juvenile arthritis and gout. Before considering the individual applications, the Committee spent almost a full day deliberating on policy issues. (A copy of the policies adopted by the Committee is attached as Enclosure 1.) In summary, the Committee decided to give priority to projects that contributed to a nationally significant program, provided outreach, or served the disadvantaged. Likewise, they agreed generally not to support major equipment purchases, public education, motion picture and videotape production, research, data banks and registries. During the closed session of the Council meeting where specific problems were discussed, Dr. Gramlich extended his comments on the arthritis reviews using specific applications and Committee actions as examples. He also responded to a number of questions from other Council members, and particularly on the method the Review Committee had used to determine priority scores for arthritis projects. As an aside at this point, I, as Acting Director, wish to express my sincere thanks to all the members of both of our Ad Hoc Review Committees, and support Dr. Gramlich's commendation of Dr. Roger D. Mason, of the Nebraska RAG, who did a simply magnificent job as Chairman of the Ad Hoc Arthritis Committee. Before leaving the subject of Arthritis, you will be interested in knowing that the Council recommended for approval 31 applications, of which 27 will be funded under the earmarked funds. In addition, @ouncil recommended that the RMPs having Council-approved projects but which did not receive earmarked funds be authorized to use their own discretionary funds to support the Council-approved portions of the arthritis requests. My report to the Council was short. In view of the extraordinarily heavy work load, I had provided the Council in advance with a written memorandum summarizing major developments since the previous meeting in February. I briefly touched on the items covered in the memorandum which is attached as Enclosure 2. One other item which I did mention, though, was the anticipated Page 5 absences beginning on June 17th of two key DRMP staff members. Both Mr. Cleveland R. Chambliss, Acting Deputy Director, and Mr. Roland Peterson, Chief of Planning and Evaluation, will be away on training assignments. Mr. Peterson will be gone for two weeks at Cornell, while Mr. Chambliss will spend six weeks at Harvard. In Mr. Peterson's absence, Miss Marjorie Morrill has been acting for Mr, Peterson, while Mr. Gerald T. Gardell will be Acting Deputy Director for Mr. Chambliss. Mr. G. Lee Teets will serve as Acting Director of the Office of Grants Management in place of Mr. Gardell. As the final item of business in the open session the Council considered two proposed resolutions suggested by the Ad Hoc RMP Review Committee. These are attached as Enclosures 3 and 4 respectively. The former concerns the development and improvement of reciprocal working relationships between RMPs and CHPs. Dr. Sparkman addressed the Council recommending adoption of the resolution. The council, however, voted against adoption. Council felt (1) that it would be inappropriate for the RMP Council to instruct the CHP program, (2) that the nearness of the July application deadline and the pending legislation tended to make the proposed moot, (3) that the present CHP comments indicate generally satisfactory communications with RMPs, and (4) that the kind of relationships envisioned are built up through mutual trust rather than formal directives. The Council took no action on the second proposed resolution. Some members expressed the view that it was subject to a variety of interpretations and that it would be premature to take action while new legislation is being considered. Fifty-three applications were considered individually. During the closed session, thirty-one Arthritis Center applications were recommended for approval for approximately $4.7 million. Twenty-seven of these can be funded under the earmarked funds. Fifty-one applications for Regional Medical Programs were recommended for approval for approximately $88,7 million. Each RMP proposal was discussed and voted upon individually by the Council. While in the majority of cases the Council voted to accept the recommendations of the Review Committee, there were several instances in which the Council added special conditions or modified the Committee recommended amounts. The applications submitted May > ¢rom two regions were not recommended for approval and the Council was informed that DRMP staff would immediately enter into appropriate negotiations with these regions. Sincerely yours, yo. yt ‘herbert 0, Fe “( Herbert B. Pahl, Ph.D. Attachments ENCLOSURE(: ) ARTHRITIS AD HOC REVIEW COMMITTEE RESOLUTIONS AND GUIDES APPROVED AT MEETING OF MAY 23-25, 1974 The Resolutions and Guides by the Committee are: v 1. Il OUTREACH Resolution: The major thrust of approved pilot arthritis programs shall be outreach. Background: The Committee noted examples of requests for personnel, equipment, and other support for centers which appeared to represent an "overwhelming emphasis on the further development of an on-going center.'' The Committee characterized this as “inreach." It was recog- nized that some support of centers is in order to conduct an outreach program. The center is often the source of reaching out, and upgrad-~ ing of center resources to the degree necessary to initiate and conduct outreach is appropriate. The main thrust, however, should be the improvement of patient access to the health system, and the respective levels of care which it can provide. Facilitation of patient access and entry into the system should be emphasized. The intended thrust of the pilot arthritis program cannot be fulfilled if centers only keep bring- ing patients into the centers. While much should be expected of the larger, established programs, eqyal or greater needs and lessons are present in lesser develcped areas. DATA COLLECTION, AND AUTOMATED REGISTRIES AND DATA BANKS Resolution: Separate arthritis data banks and registries should not be funded. Program statistics should conform to American Rheumatism Association (ARA) standards as these are developed. Background: While it is recognized that specific data is required to plan, conduct, and evaluate pilot arthritis programs, the Committee was opposed to the expenditure of relatively large sums for a variety of lata gathering and analysis activities, especially those proposed to Le automated at many sites, and in different ways. It was noted that the ARA is conducting a study to develop standardized nomenclature and reporting, and these will be published. The support of automated data programs with the limited pilot arthritis funds appears to be premature, and unduly costly in view of the uniform approach to these needs which is being developed. The Committee felt that State Health Agencies would be more appropriately responsible for morbidity and prevalence data. There is pending Federal legislation ' which, if enacted, would more adequately address arthritis data needs. Til. FILM/TAPE DEVELOPMENT, AND PRODUCTION FOR PUBLIC AND PATIENT EDUCATION, AND OTHER INFORMATION PURPOSES Resolution: Those portions of arthritis program applications which request support for the purchase of hardware for film and tape production ahawtdA nat ha Fimdod Tha Cammittee wauld consent to the suoport of software costs if the program is otherwise approvable. The widespread © development of such materials is not considered wise when superior products can be obtained through qualified sources. The Committee recor mends that DRMP and the concerned RMP's cooperate to provide coordinated identification and procurement from central, qualified sources of widely needed film and video tape materials. Background: While the Committee members were personally aware of the capabilities of films and cassettes for patient and other educational activities, it was not considered wise to support the volume and diver- sity of requests made for these purposes. The needs for such materials is Nation-wide, and considerable expertise is required to efficiently produce high quality materials. The high cost reflected in the appli- cations does not appear to be a productive way to employ the limited RMP funds. Previous RMP experience in this area has demonstrated that extraordinary administrative problems are encountered in obtaining first-rate products, even in facilities with sophisticated equipment and expertise. There are a number of institutions which operate high quality audio-visual facilities where equipment presently exists (Michigan was noted). It was proposed that the DRMP might cooperate through concerned RMP's to produce selected video tapes, on subject matter widely sought, through one or two experienced centers. PUBLIC EDUCATION (and fund raising) Resolution: Activities geared solely to public education will not be supported, Background: A number of the arthritis grant applications requested sup~ port for audio-visual equipment, vehicles, printing, publications, and items related to mailing, etc, for purposes of public education. The Committee deliberated on the distinctions between patient and family education, and professional and para-professional training which it viewed as meritorious and appropriate in the pilot program, and public education. The Committee determined that public education was not an appropriate use of the limited RMP arthritis funds. Such activities appear to b. more appropriate for support by Chapters of the Arthritis Found: tion, local departments of health, and medical societies. The Commitcee drew a distinction between undesirable public education, and other desirable types of education by noting the use of vans and other equipment used in British Columbia to provide services to patients, and to extend specific training and education to patients, their families, and local medical and health personnel about arthritis disease treatment. Another example is the dissemination of information about diagnosis and treatment of gout, an eminently treatable disease for which appropriate diagnosis and treatment is not always made available outside of centers. Such activities are appropriate elements of the pilot arthritis grant program. fund-raising activities. Use of Federal funds for this purpose is Specific note was taken of requests for support of overt, or implied @ prohibited. VI. EQUIPMENT (including vehicles) Guide: In view of the one-year availability of the RMP arthritis funds, lease or rental of expensive items of equipment should be seriously investigated before commitments are made to purchase. Background: Activities without firm continuation support may unnec~ essarily commit limited funds to equipment which cannot be effectively utilized when program support ends. RESIDENCIES AND FELLOWSHIPS Guide: The Committee emphasized compliance with DHEW policies with respect to professional training and education. Background: Various applications included requests for support of residencies, fellowships, and other education activities which can-~ not be supported under RMP policies. ENCLOSURE(: ) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION ROCKVILLE, MARYLAND 20852 EAU OF HEALTH RESOURCES DEVELOPMENT June 10, 1974 BUREAU R EVELOPME TO: Members of the National Advisory Council on Regional Medical Programs This letter is intended to bring you up to date on recent events and other important items that I believe you will be interested in knowing. 1. COUNCIL MATTERS: The Secretary has invited 13 persons to fill all vacancies on the Council. Ten of these have accepted appointments and 3 have declined due to other commitments. You already have received a revised list of the Council members. The new appointees include three previous members who have been reappointed as well as a former Review Committee member and a number of individuals who have been active in Regional Medical Programs. I have had an opportunity to meet all of the new members, and I am extremely pleased to have such an experienced group working with us at this critical time. nr, John D. Chase has succeeded Dr. Musser as Chief Medical Director of the Veterans Administration and in that capacity is now an ex-officio member of the Council. Dr. Chase has attended past Council meetings for VA. On May 31st, DRMP held an orientation for new Council members. All but one of whom was able to attend. The orientation covered such subjects as the functions of the Council, the June and August review cycles, the Arthritis Centers earmark, and the history and current status of the program. 2. INITIAL REVIEW GROUPS: All 53 PMPs have submitted applications for the June review cycle, and 46 have indicated that they will submit requests for supplements in July. In addition to the regular RMP applications, 43 applications for Pilot Arthritis Centers have been received and will be considered in June. Although this represents a substantial increase in the Council's normal workload, we have arranged.for preliminary Committee reviews to enable Council to focus on the most pressing issues: Page 2 - Members of the National Advisory Council on Regional Medical Programs An RMP Ad Hoc Review Committee has been formally established to review regular RMP applications. This group met on May 22-24 and thoroughly considered the applications that will come before the Council in June. Applications for Pilot Arthritis Centers were reviewed by the Arthritis Ad Hoc Review Committee on May 23-25. This group, likewise, has been established by the Department as a formal advisory committee. 3. PILOT ARTHRITIS CENTERS: Up to $4.5 million were earmarked for Pilot Arthritis Centers under the Fiscal 1974 Appropriation Act, but following a 5% reduction which also was authorized by the Act, $4.275 million actually will be avail- able. Guidelines for the arthritis centers program were developed after consultation with the National Steering Committee of RMP Coord- inators, the Arthritis Foundation and other consultants in the arthritis field. The special Arthritis program is being managed by Mr. Matthew Spear of our staff. The Arthritis initiative is an entirely new field of endeavor for DRMP, and the staff which screened and summarized applications prior to review by the Arthritis Ad Hoc Committee received an intensive orienta- tion through written literature and presentations by consultants. Because the authorizing legislation is not very specific, the staff reviews identified numerous policy issues which were thoroughly discussed by the Committee in establishing ground rules for application review. Among other things, the Committee took a stand on such matters as (1) purchase of laboratory equipment and vehicles; (2) use of funds for arthritis research, registries, public education and motion picture-pro- duction; and (3) priority for projects involving outreach and/or serving the disadvantaged. : Dr. John B. Gramlich, one of our new Council members, attended the entire Arthritis Ad Hoc Committee meeting as an observer, and will be in a position to comment on the proceedings at the June Council. I would aiso like to take this opportunity to acknowledge the magnificent job done by Dr. Roger D. Mason, who chaired the Committee. Dr. Mason is Chairman of the Nebraska RAG. Unfortunately, he will not be able to attend Council because of a conflict. 4, LEGAL ACTION: A final order in the lawsuit by the National Association of Regional Medical Programs was issued on February 7,.1974, just prior to the last meeting of the Council. Briefly, the order requires that the full amount Page 3 - Members of the National Advisory Council on Regional Medical Programs of Fiscal 1973 and 1974 funds be awarded to RMPs, and that all restrictions imposed under the proposed phaseout be rescinded. Fiscal 1974 funds must be awarded by June 30, 1974. Although Fiscal 1973 funds remain available for one year from the date of the final court order, the order requires that funds be obligated "with such speed as is administratively feasible.” Accordingly, the Administrator, HRA has determined that all released funds will be awarded by September 1, 1974. The Government has filed a request to modify the Court Order to permit some of the released funds to be used to support contracts and grants to organizations other than RMPs under Section 910 of our legislation. This authority has been used in the past for grants for HMOs, the Seattle Cancer Center construction project, various contracts, etc. The plaintiffs and the Government now are in the process of negotiating a settlement, and until the legal question is finally resolved, it will not be possible to determine with certainty the total amount available for RMPs. We expect, however, that funds will approximate $110-115 million. 5. MEETINGS WITH COORDINATORS: On March 18-19, a national meeting of RMP Coordinators was held in Arlington, Virginia. Dr. Endicott, Administrator, HRA, and Mr. Rubel, Acting Associate Director for Health Resources Planning, Bureau of Health Resources Development, were able to attend a considerable portion of the meting. There were full and frank discussions of the uncertainties facing RMPs and the current legislative situation. 6. STEERING COMMITTEE: Since the beginning of the year there have been a number of meetings with the Steering Committee to discuss the arthritis program, the cancer control and hypertension programs of NIH, and the schedule for grant review under the terms of the court order. The Steering Committee met most recently on May 2, 1974, principally to determine the interest of RMPs in organizing local review boards required for the End-Stage Renal Diseas: program currently being implemented under the Social Security Act. 7. DRMP STAFFING: DRMP Staff has continued to decline. Five people in the Grade 13-14 range have left within the past month. At present DRMP has a total of 85 on the rolls, about 60% of whom are in the professional grade levels. The decline in staff is a reaction to both uncertainty about future legislative authority and an agency proposal for decentralizating selected DRMP functions to the ten HEW Regional Offices. The proposed decentrali- zation plan calls for transfer of 40 DRMP positions to the HEW Regional Offices. Recently the Undersecretary has stated that no determination will be made concerning the decentralization of DRMP staff until legisla- tion is passed. Even though a decision on this matter has been deferred, Page 4 - Members of the National Advisory Council on Regional Medical Programs we expect to see a continuing decline in staff as opportunities for alternative employment become available. In order to assure high-quality review of RMP applications, Dr. Endicott has assented to use of former DRMP staff (now working for other HRA compo~- nents) to assist with the May review. The present RMP staff is therefore, being augmented for these reviews by experienced, former staff. 8. REVIEW SCHEDULE AND PROCEDURES: The final schedule through August for review and approval of RMP applications is as follows: May/June Review Cycle: RMP Ad Hoc Review Committee-cme reer rrr t tern May 22-24 Ad Hoc Arthritis Committee----- mere r rrr nnn May 23-25 Orientation of New Council MemberS---cerrer---= May 31 National Advisory Council Meeting----cwser3---H-- June 13-15 RMP and Arthritis Awards-------ecc crs rrr nnn June 30 July/August Review Cycle: RMP Ad Hoc Review Committeer------ ere erent ete re July 17-18 National Advisory Council Meeting---