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CONFERENCE ON REGIONAL MEDICAL PROGRAMS
Washington Hilton Hotel, Washington, D.C.

January 15-17, 1967

THE ISSUE:
SURGEON GENERAL'S REPORT
TO THE PRESIDENT AND THE CONGRESS

Prepared by Staff of the Planning and
Evaluation Branch of the Division of
Regional Medical Programs

This paper is provided as background
to the TUESDAY, JANUARY 17, 1967
General and Discussion Sessions
 

 

PREFACE

The Report to the President and the Congress is set forth as

a specific requirement in Section 908 of the Act authorizing support

for Regional Medical Programs, as follows:

"On or before June 30, 1967, the Surgeon General, after
consultation with the Council, shall submit to the Secretary
for transmission to the President and then to the Congress,

a report of the activities under this title together with

(1) a statement of the relationship between Federal financing
and financing from other sources of the activities undertaken
pursuant to this title, (2) an appraisal of the activities
assisted under this title in the light of their effectiveness
in carrying out the purposes of this title, and (3) recommenda-
tions with respect to extension or modification of this title
in the light thereof."

The purpose and importance of this provision was clearly stated

in the following excerpt from the related Report of the Senate Committee

on Labor and Public Welfare:

“The bill calls for reevaluation of the program and the
submission of a report to the Congress by June 30, 1967. The
Committee views this requirement for accomplishments and
recommendations of further development as an important and
integral part of this legislation. This program provides the
opportunities for major innovations. It is impossible to say
with any precision at this time what the nature, extent and
diversity of these medical complexes will be in the future.

We do know that these developments will be closely watched by

the Congress and by the American people. The Committee does
expect that, as experience is gained, the various aspects of

the program may alter to deal with new problems and opportunities
and to extend the coverage of the complexes into new communities
and situations. The impressive endorsements of the concept of
 

give a basis for launching the program as soon as possible,
but the final form in all its particulars is not, and
cannot be clear at this time. Therefore, the need for
careful and continuous reevaluation assumes a special
importance for this program. The Committee urges that

the program be administered at all times with a view
toward the identification of productive modifications

for submission to the Congress when the extension is
considered in the future."

INITIAL APPROACH

The Report is a staff responsibility of the Division of Regional
Medical Programs. A special Ad Hoc Committee of leaders in the fields of
health, education and community affairs was established to furnish expert

advice*.

The Committee held three meetings between September and November

 

of 1966 to help shape the approach to the Report and identify issues which f
require consideration. In addition, it was considered important to obtain
the experience and insight of a wide variety of people concerned with
Regional Medical Programs through a national conference. One of the major
objectives of the Conference is to provide a forum for this purpose and a
common frame of reference out of which an additional input of ideas can be

secured before drafting the report.

 

*Members of the National Advisory Council: Dr. Michael DeBakey, Dr. Bruce
Everist and Dr. James T. Howell. Other members: Mr. Ray E. Brown,
Dr. George James, Mr. Boisfeuillet Jones, Dr. Charles Odegaard, Dr. Edmund
Pellegrino, Dr. William Ruhe, Dr. Clark K. Sleeth, Dr. Ray E. Trussell,
Dr. Burton Weisbrod, Dr. Robert Westlake, and Dr. Paul N. Ylvisaker.
Special Consultants: Dr. Norman Beckman, Dr. Ward Darley, Dr. Edward
Dempsey, Dr. Kermit Gordon, Dr. Charles Kidd, Dr. Jack Masur, and

Dr. Howard Rusk.

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IDENTIFIED ISSUES
Divisional Staff and the Ad Hoc Committee have identified
certain items and issues. These points are set forth on the following
pages for discussion during the meeting on January 17. In addition,
conference participants are encouraged to identify and discuss issues
and topics not included in this paper.
I. Background of the Report
There will be brief discussion of broad trends in science, .
medicine and education, and social and economic aspects leading to the
enactment of Public Law 89-239. The legislative history will be summarized
including the Administration's proposal (S. 590 and HR. 3140), the
Senate and House Hearings and Reports.
II. The Nature and Purpose of Public Law 89-239
a. Basic Objective and Purpose
Primary objective is to ensure that persons through-
out the country have the benefits of medical scientific advances.
in heart, cancer, stroke and related disease. Attainment of
this objective is impeded by the gap that exists between
scientific advance and day-to-day practice in parts of the Nation.
The fundamental purpose of the Act as formally stated in
Section 900 (b) is: "...to afford to the medical professions
and medical institutions of the nation...the opportunity of

making available to their patients the latest advances in
the diagnosis and treatment of these diseases."
 

b. Prescribed Mechanism for Attainment of Objective

The prescribed methodology is regional cooperative
arrangements among medical schools, research institutions,
and hospitals, with broad based advisory committees to insure
commitment to broad regional needs and guard against the

domination of any individual institution or group.

III. Progress Report

In accordance with the specifications in Section 908, this
Section will report on (1) activities supported under the program,
(2) the relationship between Federal financing and financing from other

sources of the activities undertaken, and (3) an appraisal of activities

 

assisted in the light of their effectiveness.
A. Activities Under the Program
1. Chronology of implementation

a. Bill signed into Law - October, 1965.
b. First Council meeting - December, 1965.
c. Division of Regional Medical Programs established at

NIH - February, 1966.
d. First applications for planning grants received - April, 1966.

e. First awards for planning grants - June, 1966.
£. First applications for operational grants received -

October, 1966.
g. First national conference on Regional Medical Programs -

January, 1967.

2. Basic data concerning applications received and approved; amount
of awards; population served; participating organizations; staffing;

nature and variety of cooperative arrangements; feasibility and

 
 

 

other studies undertaken, etc.
Analysis of Major Planning Activities

a. Organization and staffing of planning unit.
-p. Collection and analysis of data on resources, problems

and needs.
c. Strengthening of communications and relationships among

health resources.
d. Development of feasibility studies and proposals for

priority operational projects.
e. Arrangements for continued planning.
Analysis of Major Activies of Operational Programs

Interregional Developments

a) Multi-State (New England, Mid-West, Rocky Mountain area)

b) Intra-State (New York, California)

B. Relationships of Federal and non-Federal Financing

1.

4.

Q

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Resources made available from non-federal sources for pre-planning
prior to grant awards.

Resources made available from non-federal sources for planning

and operations after grant awards.

Estimates of type of non-federal resources likely to be made
available in the future.

Policies and procedures for assuring diversification of support.

Appraisal of Effectiveness

Methods of evaluation being developed and applied by Regional

Medical Programs.

Data on scope of cooperative arrangements.

Approaches being developed to measure changes in resources and
facilities that will extend "opportunities" for applying

the latest advances.
 

4. Approaches being developed to determine impact of programs on
the diagnosis and treatment of heart disease, cancer and stroke.
5. Examples of "critical incidents" in the development of Regional
Medical Programs.
IV. Problems and Policy Issues Requiring Consideration
This section is most important since recommendations for
extension and modification of the law will arise from the problems and
policy issues which have been identified. Inclusion of an item for
discussion in the report does not necessarily mean that a change in the
law is indicated.

A. Continuation of Program

There is considerable and compelling evidence of the effectiveness

of the Act in bringing about cooperative regional efforts among the major

 

health resources for the purposes specified in the Act. Attainment

of the fundamental purpose of assisting all physicians and medical
institutions to bring the benefits of medical research advances to their
patients appears realistic on the basis of early experience. While current
legislative practice makes it unlikely that a new authorization will not
include a time limit, the Regional Medical Program effort should be
established as a continuing program. Such a long-term commitment is
particularly important in order to enlist the participation of ail

institutions and to provide a sound basis for recruitment of high caliber

manpower.

 
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B. Construction of New Facilities

The original Administration proposals for authority to support
Regional Medical Programs included provision for grant assistance to aid
both new construction and renovation. This provision was amended in the
Congress to limit the definition of “construction” su that only renovation
and remodeling costs were eligible for support. The Report of the House
Committee on Interstate Commerce stated that "the lack of this authority
for new construction should create no serious problems during the 3
years authorized in this legislation and when a request is made for

extension of this legislation in the future, the committee will review

this question again. . ."

Experience to date has identified a number of areas in which
authority to assist new construction is essential to the development
of Regional Medical Programs. Priority needs have been reported for
space in community hospitals to conduct continuing education programs
and to carry on demonstrations of patient care. Most community hospitals
do not include adequate space for educational] programs; acute shortages
of patient care and supporting facilities have required immediate
attention. The same conditions generally make it impossible to meet
the needs for space for continuing education programs through renovation
and remodeling.

During the conduct of feasibility studies and pilot projects,
Regional Medical Progzams have been forced to rent space outside the

hospital for the conduct of educational programs and the use of the
educational staff. This approach is not only costly but -it significantly
reduces the impact of these efforts. It is more difficult for many medical
practitioners and allied personnel to participate. It is impossible for
certain desirable programs to be organized, particularly those involving
demonstrations of patient care.

The issue of matching requirements for construction also needs
further consideration. Reports indicate that many community hospitals
have insurmountable difficulties in raising funds for the construction
of facilities for continuing education. There is a danger that a rigid
matching requirement in this respect will distort or impede progress
toward the achievement of the program's purposes.

C. Relationship of Federal and Non-Federal Funding _

Regional Medical Programs provide, through cooperative arrange-
ments, a broad systematic framework for planning and action. It is
recognized that the Federal grant funds should not finance all the needs
identified in this process and should not take over total support for
the application of all medical scientific advances.

Congress has evinced interest in the amount of non-Federal
resources made available to these programs as an index of local commitment
and support and as a reflection of budgetary realities. It has been
emphasized that diversification of fund support will enhance local
initiative and control.

In reviewing grant requests, primary attention is given to the
extent and nature of local support. Continuing consideration will be

focused on the policies and procedures that are employed locally for

 

 
 

 

 

ensuring diversification of resources for Regional Medical Programs.

It has been felt that a policy placing responsibility at the local level
for assuring balanced, diversified support is more effective and
appropriate approach than a rigid matching requirement, particularly in
view of the cooperative and innovative nature of this new program.

D. Inter-Regional Support Activities

Public Law 89-239 authorizes grants only for the planning
and operations of individual Regional Medical Programs. No consideration
was given during the development of the legislation to other types of
‘grant support.

Reports have indicated that certain resources and activities to
facilitate and support the development of Regional Medical Programs may,
in some instances, best be developed on an inter-regional basis, ©-&->
training of continuing education and other leadership staff, preparation
of teaching materials, standardization of data collection, refinement
of evaluation procedures. The available methods of financing of these
needed services are often awkward and inadequate.

It has been suggested that modification of the Act to permit
grants directly for these "support" activities may be desirable in order
to facilitate the development of individual Regional Medical Programs.
Proposals for such support would have to be directly related to the
achievement of the basic purposes of Public Law 89-239 and would be made

only after review and approval by the National Advisory Council on Regional

Medical Programs.
 

E. Interpretation of Act

A keynote of Public Law 89-239, in both its legislative and adminis~
trative aspects, has been flexibility of approach, The primary purpose of this
approach is to place maximum responsibility on local leadership to develop
appropriate mechanisms, plans and programs. Administrative guidelines and
policies have encouraged local initiative while, at the same time, ensuring
the established statutory purposes are pursued. Instead of rigid national
directives, heavy reliance has been placed upon the review and evaluation of
local program proposals by non-Federal consultant groups, both at the regional
level through the Regional Advisory Group and at the Federal level by an expert
review Committee and the National Advisory Council on Regional Medical Programs.

Specific examples of flexibility of approach are:

1) The fundamental recognition that attention must be given to
developing and maintaining a sound foundation of clinical }
capability upon which more sophisticated programs can be
built. For example, it is recognized that increased
accessibility to the most recent advances in cancer
treatment is ineffective if there are serious gaps in basic
diagnostic and treatment capabilities. Similarly, it is
recognized that "improved diagnostic and treatment capability"
must necessarily include preventive and rehabilitation

activities.

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2) The establishment of new organizational mechanisms to
reflect the cooperative relationships required in the
program. One expression of this development is the
organization of new non-profit agencies to serve as the
coordinating agency for the Regional Program. These new
arrangements can involve a spectrum of new administrative
and fiscal problems that require innovation and inventiveness
for their solution.

On the basis of experiences to date, it appears that flexibility
of approach has facilitated progress toward accomplishment of the aims of
the program. However, reports have indicated that, in some instances,
unreasonably rigid or lax interpretations of the Act and the Guidelines
have complicated understanding and action. The question at issue is

whether portions of the Act or Guidelines need to be clarified or

amplified to insure needed flexibility.

F. Categorical Emphasis

The legislative history of Public Law 89-239 indicates that the
original Administration proposal requested authority to make grants to
encourage programs of regional cooperation among the major health resources
for heart disease, cancer, stroke and other major diseases. The law as
enacted provided for grants to encourage programs of regional cooperation
among the major health resources for heart disease, cancer, stroke and

related diseases.

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The categorical emphasis of the program has been widely discussed.
Some have felt that it is not prudent or practical to develop Regional
Programs on a categorical basis. Others have argued that the efforts of
the program shoulc be exclusively focused on immediate measures to reduce
losses from the three "killer diseases"; they have pointed out that the
highly complex skills and facilities required to apply the recent
scientific gains against these categorical diseases makes it particularly
desirable to organize such efforts on 4 regional basis. Others have
suggested that the scope of the three diseases and related diseases is
so broad that their control necessarily requires attention to fundamental
questions of manpower and facilities. The initial period of program
development has provided opportunities to test these viewpoints through

a variety of experiences.

 

During the planning phase the major activities undertaken by Regional
Medical Programs have involved the establishment of a planning staff, the
initiation of studies to obtain the basic data concerning pertinent
health needs and resources and the development of cooperative relationships
among the major health resources in the region. These activities are
generally generic by nature and consequently have not significantly
involved problems of categorical definition. In most cases, in order to
plan effectively for heart disease, cancer, and stroke, it has been found
necessary to consider at times the entire spectrum of resources available
for personal health services.

However, the emergence of the operational phase of the program will

put a more intensive focus on its categorical purposes. Only projects

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that can be shown to have direct significance for combating heart disease,
cancer, stroke and related diseases can be assisted with Regional Medical
Program grant funds.

The experiences of the Regional Medical Programs will be especially
important in determining what modifications, if any, are necessary or
desirable on this issue in the legislative authorization, The impact
of the categorical limitations on the potential of the Regional Medical
Programs to contribute most effectively to improved health of the people
and the best use of available manpower and facilities needs to be
determined. Similarly, the best ways of facilitating the diffusion of
knowledge concerning the diagnosis and treatment of heart disease, cancer,
stroke and related diseases needs to be identified. These discussions
must take into account the fact that the legislative proposal for extension
of Public Law 89-239 will probably request authorization for the program

through 1973.

 

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