A & DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE , HEATH SERVICES AND MENTAL HEALTH ADMINISTRATION ROCKVILLE, MARYLANID 20252 . ¢ REGIONAL MEDICAL June VW, 1972 PROGRAMS SERVICE | oa Dear The following is a summary of the highlights of the major issues and discussions of the May 11-12, 1971, meeting of the National Advisory Council. Although the minutes of this meeting will not be formally approved until the Council meets in August, this summary has been prepared to infcrm you of the essential actions of the Council which affect policy. Council actions concerning projects and programs have been or will be reported in the usual manner. Of immediate interest is.the Administration's 1972 Appropriations Request, which would hold RMP grant funds (exclusive of construction) at $70 million (the fiscal year 1971 apportionment) through fiscal year 1972. In the House hearings the decision to maintain this level was questioned clogely. No House mark-up has been announced and the Senate Committee may not hear testimony on the bill until September. Interest in National Health Insurance remains high on all sides. The number of bills before the Congress on this subject continues to grow, but as yet there scems to be no clear trend toward the support of any one proposal. , The concept of Area Health Education Centers, greatly stimulated by the Carnegie Foundation repert, is now exbodied in two bills before the Congress. One plans administrative responsibility for Area Health Education Centers in the Regional Medical Program, the. other would result in assignment of responsibility to the National Institutes of Health. Page 2 The: Area Health Education Center is as yet not fully defined, probably will be a community~based, prant-eligible agency, built ‘around health care tustitutiohs and practitioners, affiliated with health educational and training institutions, including a university health science center, The AHEC would be a natural and important concern of the Repional Medical Program. In turn the Regional Medical Program will under any circumstances be associated with the center, because of their common interest in enhancement of health care services. RMPS is cooperating closely with other HEW efforts to develop Health Maintenance Organizations. There has been established a national clearinghouse in RSMHA to keep records and oversee all HMO activities, but the basic responsibility for their development is in the HEW Regional Offices. MPs will be especially useful in the early phases by assisting in the convening of those who must meet together and by obtaining for them necessary consultation and other required supporting material, They will be of value later in the establishment of an effective health care system particularly by assisting in HMO efforts to monitor the quality of care being provided. RMPS has the specific responsibility for developing guidelines and criteria for the monitoring of quality and for developing a concept and guidelines for health maintenance. The Civil Service Commission has established prades for Physician's Assistants, most of whom will be employed by the Veterans Administration. The Director of RMPS serves as a member of an executive committee advising the Commission of the qualifications to be established for the grades GS 7, 9, and 11. MPS continues to have with NCHSR&D a keen interest in Physician's Assistants development and will partici- pate in the further definition of PAs, their functions, their legal status and their limitations. There have been a number of recent developments in the Regional Medical Programs Service: . A. An expanded focal point for services to Council and Review Committee is being developed. The charter of this Office of Council and Committee Affairs will be circulated when the reorganization plan is completed. B. The Operations Division is developing four geopraphically organized "desks."". Each of these will provide a spectrum of services for a designed group of Regional Medical Programs. Each will be served by designated liaison personnel of the Professional Division. Automation, Since Oppo Not beca serv way e the Last Council meeting, the Equal Employment rtunity program in KNPS has been developing rapidly. only because it {s an apency of government, but also use its missfon is to the whole citizenry, Ri@S cannot e Regional Medical Programs effectively if it in any discriminates against minorities or women. Not only in RMPS, but in all the RM?s, both Equal Employment Oppo majo will rtunity and minority group access to health care are roconcerns. Evidence of adherence to these concepts be sought in all program reviews. Dr. Michael Brennan, Chairman of the Council's Subcommittee on . reported the following as the Committee's considerations and recommendations concerning automated multiphasic health testing as an RMP investment: ad A. VAC proj The of t acqu "Aut the util For feat "The the the ment, Heal Scie and 1. this time eleven Regional Medical Programs have funded ects that feature sutomated multiphasic health testing. purposes of these projects present a fair representation he purpeses for which patient health status data are ired, | omated Health Testing is very costly. The influence of projects in which it appears on regional deployment and ization of health care services is highly unpredictable. these reasons Council re commends that no new projects” uring automated health testing be funded. Council further recommends that the Director, RMPS, and appropriate Regional Medical Programs, coordinating with Nattonah Center for Health Services Research and Develop- Community Health Services, the National Center for th Statistics, the National Institute of General Medical nces and other interested agencies, institute consultation iovestigation to: Provide market and financial analyses and advice to avoid loss in post-grant operations of projects currently funded by Regional Medical Prozgrans; Build into RMP and other projects baseline data, defined goals and measures of progress for cohorts of persons whose initial multiphasic tests were positive, negative and refused, among such populations as urban and rural poor, - ae employees’ groups, hespital and clinic patients, to help resolve debate about the effects of multiphasic testing on | quality of and access to health care services and the regional deployment and utilization or health care resources; Page 4 3. Utilize systems gnalysis and all available epidemiologic , information to stimulate natural histories of diseases and identify those for which secondary prevention might be feasible and acceptable, In cost; and 4. Conduct multi-variant analyses of the results of multi- phasic testing to investigate the possibility that it could improve diagnostic application of the tests." COUNCIL ACTION: The Council unanimously adopted the above recommen-_ ations of the Subcommittee en Automated Multiphasic Health Testing. In this regard, please note that the recommendation in Section B establishes a new policy for Regional Medical Programs Service. I reported briefly on a limited test by which our site visitors or Review Committee have ranked Regional Medical Programs in terms of their overall effectiveness. ‘This type of activity will become in- creasingly necessary if changes in levels cf available grant funds are to be accommodated in a selective fashion rather than across- the-board additions or reductions for all programs. A, The Professional Judgment Comparison . To date very broadly conccived criteria of effectiveness have been employed in the review of our grants. At the last meeting of the Review Committee the programs of fifteen Regional Medical Programs were considered. After the formal actions were completed, the members of the Review Committee agreed to try informally to rank those programs for overall effectiveness. The: procedure con- sisted simply of distributing the fifteen Regional Medical Programs into "quartile" groups; the results were highly consistent. There were several instances of identical quartile assignments, and in ‘almost all cases the differ- ences in assignments were not more than one quartile apart. This informal, no-record exercise was conducted as an extension of the entire review process and appeared to be workable. . B. The Grading Comparison Another approach to comparison of Regional Medical Program effectiveness can be made by erading or scoring the per- formance of each on an absolute scale. This approach has not been given a full trial. Earlier this year numerical grading was used in a limited way on several site visits to Regional Medical Programs. ‘The results of these trials have shown less consistency among the graders than did the Review Committee's comparison of the fifteen regions. Page 5 C. kffects of Ranking Regions in the long run, aduinistrative actions and advisory group recomendations which result from such determi~ nations of relative merit primarily will affect the least and most effective Regional Medical Programs. Dr. Vernon FE. Wilson, Aduinistrator, HSMUA,. discussed with the Council events and trende that have dmplications for the future. A. Consumer interest in quality determination It is not unlikely that the basis of advisory council actions as well as the actions thenselves will become public records. Increasing consuger group interest in program processes reduces the latitude for unsupported judgwent. This Council seriously should consider develop~ ‘ment of a rating system as a basis for its decisions on grants. The interest of carecr consumer advocates in this field is rooted in a widely held opinion that pro- fessional judgments should be openly determined and in- telligible to the lay mind. po There is need for a system.that the consumer advocates can understand and apply to reach the seme results as does the Council. There is also a widespread misunderstanding of RMP by people who seé it.as an implement of Federal control of health care. It is also said that RMP performance is spotty, does not yield true naticnal coverage, and that RMP is not as closely related to the universities. as it should be. We see the flaws in these arguments, but their proponents are not easy to convince. In RMP the Federal government has a good channel for working with the providers, but the relationship is not — always easy to clarify. We must continue to emphasize the process and not only the content of RMP in our judg- ments. The need is for a foundation of understandable judgments on which credibility can grow. B. Two bills to establish Area Health Education Centers have been placed before the Cengress.. One would place the authorization Title IX (RNP) of the Public Health Service Act; the other, which is the Administration's Bill, would place the authority in the National Institutes of Health. We must be prepared for either eventuality, and in either case both the RP and the Manpower bureau of the NIH will find their activities affected by the program. The Department's proposal is being presented as part of the - proposal for extension of the Health Manpower Act. C. The Willard Committee report has been circulated among a limited number of administrators and advisors, but has not ‘been published. The document was kept brief by design, end some of its concepts are rather broadly stated. Some of its ideas already have been incorporated in testimony pre- sented before Congressional committees, and more will be ‘presented, for example, in testimony on Section 314 of the Public Health Service Act. - Miss Cecilia Conrath, Chief, Continuing Education and Training, RMPS, spoke on Council and RNP policies and ebjectives concerning health — , manpower. At the turn of the century, 80 percent of health workers .‘were M.D.'s, now 84 percent of health workers are not M.D.'s. About 70. percent of health workers are women; many of their jobs are characterized by: low pay, little requirement for independent judg- ment, special turnover and dropout problems, entry at the high school _ level, and re-entry through established training, or re-training. One of every two health vorkers entered with lese than three years of college education. | One of every five had less than full high school educaticn. Many jobs are routine, narrow in scope, and severely limited in opportunities for advancement. Refresher training for re-entry of dropouts, once enthusiastically advanced as 4 means of relieving shortages of help has not succeeded as hoped . ... too many of the trainees limit their availability to part-time or intermittent work. _RMP is going to be involved in manpower problems because it is the logical channel for provider concerns. With regard to our relationship to CHP and NCUSR&D, I stated that it is important that RMP retain its identity and avoid assumption of CHP responsibilities. It ig also important that RMPS and NCHSR&D . work more fully together. The basic guide to RMP development now and in the coming yeers will be found in the Federal health strategy. If it is to be of maximum service to this country RMP will work with Page 7 increasing effectiveness through al] of the mechanisms which are available--CHP, R&D, Tocal organizations, ete.-~to maintain or improve the quality of health care while enphasizing increased accessibility, better distribution of manpower, greater’ pro- ductivity of the health system and increasing efficiency in the delivery-of services. ‘ I trust you will find this summary useful. Starting with the August Council meeting, we shall mail these highlights to you within 2-3 days after the meeting. : Sincerely yours, Yun! t pe fee AAG ; 7 i) Harold Margulies, M.D. Director . NATIONAL ADVISORY COUNCIL ? “ | Meeting May 11-12, 1971. € RECOLMENDATIONS FOR ACTION 4 , _ ARIZONA REGIONAL MEDICAL PROGRAM — RM 00055 5/71 (Supplemental) © | ¢ G No additional. funds are recommended for this Regional Medical ‘ ¢ : Program at. this time. The request for additional core support is specifically disapproved. The Region may rebudget available funds into any of the: projects in line with its own priorities. This action coincides with Review Conmittee recommendations. BI-STATE REGIONAL MEDICAL PROGRAM -- RM 00056 5/71 (Supplemental) G Additional direct cost funding in a reduced amount is recommended as follows: Ist ycar - $16,750 2nd year ~ $15,850 3rd year ~ $15,850 While the Region may rebudget available funds into either of the soe two projects included in this application, Council considers Project #16 - To Develop a Model” for Testing Physician Continuing Education ~ innovative and Project #15 - A Public Education Program A on Harmful Effects of Cigarette Smoking - was considered low priority. This action coincides with the recommendations of the Review s Committee. \\ -2- @ CALIFORNIA REGIONAL MEDICAL PROGRAM ~ PM 00019 5/71.1 & 5/71.2 (Supplemental) . Region may rebudget available funds into Project #41 ~ Patient Monitoring - - ¢ “(Area I), in line with its own priorities. ‘ 9 Council defers consideration of Project # - Cooperative Planning Effort of Regional Medical Prograns and Model Cities for Training in the Allied Health Professions - Aréa I - pending program site visit of June. 1971. . og ; © This action differs from Review Compittee recomendations only in relation to Project # . IOWA REGIONAL MEDICAL PROGRAM - RM 00027 5/71 (Supplemental.) ©. Additional direct cost funding is recommended for the Iowa RMP as follows: lst year ~ $43,500 2nd year ~ $35,272 — 3rd_ year ~ $36,719. @ Region may rebudget funds into any of the projects included in the application except for Project #19, Renal Failure Management Training, in line with its own priorities. * . . ~ @- This action differs from the recommendations of the Review Committee but incorporates the recommendations of the Ad Hoc Panel on Renal ° Disease. KANSAS REGIONAL MEDICAT, PROGRAM ~ RM 00002 5/71. - (Triennial) o This Region is approved for triennial review with direct costs funding recommended as follows: “yy Ist year ~ $1,800,000 2nd year ~ $1,800,000 3rd year ~ $1,800,000 : ‘ee KANSAS RMP CONT. © The request for devclopmental funding is disapproved. © Project #40, Development of a Comprehensive Nephrology Program, is approved in line with the recommendations with the special [review by a renal specialist and the site visit team. ; : nt i . , : ‘ : G This action coincides with the recommendations of the Review . | ‘ Committee. * MAINE REGLONAL MEDICAL PROGRAM ~ BM 00054 5/71 (Supplemental) e Additional direct funds are recommended for this application . as requested: $27,696 | fe { i This action coincides with the Review Committee recommendations. e MISSISSIPPI REGIONAL MEDICAL PROGRAM — RM 00057 5/71 (Anniversary) G 2 No additional funding is recommended for the Mississippi RMP at this time. ’ The request for developmental funding'is not approved. 7 . ca The Region may rebudget available funds into the projects in . ‘ the application, including Project #17 - Renaj_ Disease Program — in line with its priorities... A program site visit is recommended to help this Region's core . a staff, RAG, and Planning Group’ focus priorities on health needs of Mississippians; staff assistance is also recommended. ny ~ “ ‘ +8 . ¢ a . ea: This action coincides with the recomendations of the Review Comittec. | - and incorvorates the advice of the Ad Hoc Panel on Renal Discascs. -4- MISSOURI REGIONAL MEDICAL PROGRAM ~ RM 00009 5/71 (friennial) ” © x * . This Region is approved for tricnnial review at the following direct € . ~ cost levels: Ist year - $2,500,000 2nd year - $2,012,000 3rd year ~ $1,825,000 The request for developmental. funding is disapproved. r s fhe recommendations of the Review Committee regarding funding -allocations among the major program elements should be ‘conveyed . to the Region. ‘ This action differs from the Review Comaittee only in the level of funding recommended for the first year. Council felt that ode $300,000, rather than $250,000, would provide for more orderly phasing out of the computer and bioengineering activities. MOUNTAIN STATES REGIONAL MEDICAL PROGRAM — RM 00032 5/71 (Triennial) © This Region is approved for triennial review with direct cost funding levels as follows: ist year ~ $1,741,000 2nd year ~ $1,511,000 3rd year - $1,366,000 nr te “s we The request for developmental funding is approved. a « Funding for Project #3R - Mountain States Tumor Institute - is ’ soy approved for two additional years only. The interest in forming a separate Nevada RMP is recognized; at . 4 such time as.an application is received and acted upon, the funding recommended for the Mountain States RMP will have to be “y ky . . reviewed also. “ “ @ 6 oy MOUNTAIN STATES RMP. CONT. so This action coincides with Review Conmittec recommendations. NASSAU/SUFFOLK REGIONAL MEDICAL, PROGRAM ~ RM 00016 (Triennial) oe oO Q NEBRASKA REGIONAL MEDICAL PROGRAM ~ RM 00068 5/71 (triennial) Ga @ ee” ‘Operational status is approved for the RMP. i j Wve years direct cost funding is recommended as follows: ‘Ist year ~ $829,755 Qnd year ~ $868,408 3rd year ~ $908,043 bee , . t ° A site visit should be made to review progress during first year. sN , First continuation application should be reviewed by Committee and Council with idea of increasing funding level if progress permits. | This action coincides. with recommendations of Review Committee . except that Council did not develop a policy on computerized EKG as requested by Committee. Council requested a staff paper ‘on this subject for consideration at a later time. Therefore, the Region is not prohibited from utilizing its funds. for this activity if program priorities so dictate. Status as a separate RMP is approved for Nebraska. ‘ ae ~ “ . - ‘ . Three years direct cost funding is recommended as follows: + Ist year - $790,070 2nd year ~ $790,070 3rd year - $440,653 Region should be advised of serious concerns about direction of . a . . program. 8 A site visit should be made to assess’‘progress during next year. “ * “ a % NEBRASKA RNP CORT. © First year continuation application should be reviewed by Committee and Council. . : This action coincides with Review Committee recommendations except for level of funding recommended for third year. Council feels * a ‘ e *.. , ‘s ‘ . , that Region must provide ‘more substantive information, about plans to utilize funds during third year. ¥ ? NORTH CAROLINA REGIONAL MEDICAL PROGRAM - RM 00056 5/71 _(Cfrfennial) Co re) 9 This Region is approved for triennjal review with the following direct cost levels reccimmended: ist year ~ $2,049,000- 2nd year - $2,049,000 3rd year - $2,049,000 * “fhe request for developmental funding is approved. A specific exception is made to Council policy regarding support of basic education for Project #32 ~- Career Ladder Nursing Education. The funding level does not take into ‘consideration funding for Project #28 - A Proposal for the-Care of Patients with Chronic “4 Uremia-which is deferred for further technical review. ~ tf . This action coincides with recommendations of both the Review ‘Committee and the Ad Hoc Panel on Renal Diseases. NORTHEASTERN OHIO REGIONAL MEDZCAL, PROGRAM ~ RM _00064 5/71. (Anniversary) — ° Funding is recommended at the ‘committed Jevel, $786,187, for one additional year... . "y “y NORTHEASTERN. OUTOQ RMP CONT. The Region may rebudget available funds into any of the proposed new projects, except Health Careers in Ohio, in line with its own priorities. © RMPS staff should explore with this Region, as well as other | . te . ' ‘Regions serving Ohio residents, ways to provide a more effective, efficient organization for regional medical « 7? : e programming in Ohio. Council believes it may be necessary “too have at least two RNPs serve the State, but a unified RMP should also be explored. Site visits should be made as necessary. . This action differs from Review Committee recommendations in that an alternative other than one Ohio RMP is suggested and that the ‘number of site visits may be negotiated. NORTHWESTERN OHIO REGIONAL MEDICAL PROGRAM -- RM 00063 5/71 (Anniversary) G Funding is recommended at the following direct cost level for one ee tne year only - $687,304. “" 7 This. recommendation provides for continuation of core and on-going \ . activities at present rate of expenditures; however, Region may rebudget available funds into new projects in. line with its own priorities. ° . RMPS staff should explore with this Region, as well as other Regions . , . “yy 7 serving Ohio residents, ways to providp a more effective, efficient _ % organization for regional medical programming in Ohio. Council o NORTHVESTERN OUTO F2P CONT. 1 . believes it may be necessary to have at least two RMPs serve the ‘ State, but a unified RMP should also be explored. © Site visits should be made as necessary. 7 o The request for developmental funding is disapproved. ’ + a Qa This action differs from Review Committee recommendations in that . * r . an alternative other than one Ohio RMP is suggested andethat the number of site visits may be negotiated. OHIO STATE REGIONAL MEDICAL PROGRAM ~ RM 00022 5/71 (rtennial) wy i The request for triennial review status is denied; funding até the committed direct cost level is recommended for one year only as follows: $714,075. G The request for developmental funding is disapproved. | © The region may rebudget available funds into projects included in this application, with the exception of Health Careers in Ohio (core), Project #29 - Home Dialysis Program and Project #30- Program for Hypertension Detection, in line with its own priorities. ¢ 4 © RMPS Staff should explore with this Region, as well as other Regions serving Ohio residents, ways to provide a more effective, efficient - organization for egional medical programming in Ohio. Council ‘ believes it mihy be necessary to have at least two RMPs serve the State, but a unified RMP should also be explored. . . “sy ; oo . “y ee © Site visits should be made ag necessary. OHO STATE RMP CORT. y . ae This action coincides with Reviesr Committee recommendations. PUERTO RICO REGIONAL MEDICAL PROGRAM - RM 00065 5/71 (Anniversary). “1 + ¢ : ° wa > . f _ © Fuading is recomaendcd for Region's sécond operational year at the following direct cost level: $989,762 PUERTO RICO RMP CONT. ’ oO The request for developmental funding is disapproved. > € © Region may rebudget available funds into any project included in. this. application in line with its priorities. ~~ | @ (This action coincides with Review Committee recommendation. ‘ ee: SOUTH CAROLINA REGIONAL MEDICAL PROGRAM - RM 00035 5/71 _(friennial) a . ' 0 Region is approved for triennial funding, at the following direct cost levels, pending favorable site visit report on Project #55 - Chronic Renal. Disease Education and Service Progran, lst year - $1,550,000 2nd year -- $1,550,000 3rd year ~ $1,550,000 ! i* I! : j © Request for developmental funding is approved. ! — oo, ® | © Region may rebudget funds into projects included in this application in line with its own priorities, except for those activities precluded by Council policy; i.e., Project #52 - Health Manpower and Fellowships . and #46 ~ Hematologic Malignancies segeee “ly a a © This action incorporates advice of Review Committee and the Ad Hoc j - | * : = & Panel on Renal Diseases. a SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM - RM 00059 2/71 & ALT (Deferred . Supplement) G Approval of $100,000 supplemental funding is reconmended for one year with following conditions: ¢ that .the’ Region engage effective leadership on its core staff; © that the Region study and make nicessary changes in the RMP ee organization to assure -@ viable Regional Advisory Group, viable 2 ¢ . * ‘ 2 : . medical center involvement and a viable grantee, -~ jl - . SUSQUEHANNA VALLEY RMP CONT. . 2 » . ©that RMPS make available sufficient, experienced staff resources to assist Region in its study and subsequent no ; program changes. © The request for developmental funding is disapproved. , : + G This action essentially coincides with recommendations of the Review Committee. aes TRI-SUATE REGIONAL MEDICAL PROGRAM - Ri 00062 5/71 (Supplemental) | @ . Action on the application for funding a New England Facilities for Fnd-Stage Kidney Diseese is deferred, pending Council ef study on technical site visit report. G ‘This action coincides with the recommendations of the Review “Committee and the Ad Hoc Panel on Renal Diseases. WESTERN PENNSYLVANIA REGIONAL MEDICAL PROGRAM ~- RM00041 5/71 (Triennial) ©. Approval for triennial funding is recommended at the following direct cost level: . ~.. Ist year - $1,450,000 2nd year-- $1,450,000 3rd year ~ $1,450,000. @ The request for developmental funding is approved. " ‘@ Funds for Project #14 - Renal Disease - are disapproved as recommended by the Ad Hoc Panel on Renal Diseases. Py } @. Region may rebudget available funds into any project included in the application provided they are consistent with Council. policy., aa nay a -12- @ WESTERN PENNSYLVANIA RMP CONT. ~.. © ‘Council notes that the Region has not presented specific plans € by project for some of the funds requested in the second and - third years of the triennial period. If RMPS staff should find a disproportionate share of the funds proposed in the second and third years are for activities not previously a studies by Council, the application should be reviewed by * , Council at that time. ? C) . This action essentially coincides with recomaendations of Review Comnittee. RPS /GRB B/llf74 “4 y