G. TABLE OF CONTENTS -~ QUESTIONS AND ANSWERS

10.

RMP AND THE "HEALTH CRISIS": One increasingly hears and reads about
the "health crisis" facing the nation. How do you see RMP helping to
address and resolve that crisis?

EXPANDED PROGRAM SCOPE: What is the reason for broadening the scope
of Regional Medical Programs beyond the present categories of "heart
disease, cancer, stroke and related diseases?"

KIDNEY DISEASE: Kidney Disease has, I believe, been defined as a

"related disease." What activities have been undertaken through Regional
Medical Programs Service to date dealing with this disease?

NON-INTERFERENCE CLAUSE: Sec. 900(c) of the present RMP legislation
includes a so-called non-interference clause. The Administration's pro-
posal does not, as I understand it. Would you please explain why?

NEW CONSTRUCTION AUTHORITY: The "Report on Regional Medical Programs to
the President and the Congress" referred to the need for new construction
authority for continuing education and certain kinds of other facilities.
Does this need still exist?

MULTIPROGRAM SERVICES: The last extension of RMP provided authority for
project grants for multiprogram services (Sec. 910) -- that is, for ser-
vices needed by, or which would be of substantial use to, two or more
regions. How has this been implemented?

CLINICAL FIELD TRIALS: The proposed legislation provides specific con-
tract authority for the conduct. of cooperative clinical field trials.
What, is the significance of this; and how would such authority be em-
ployed? ;

LISTING OF ADVANCED FACILITIES: The Legislation as originally enacted
(Sec. 907) required that the Surgeon General establish lists of factili-
ties equipped and staffed to provide the most advanced methods and
techniques in the diagnosis and treatment of heart disease, cancer, and
stroke, including the availability of specialty training in such facili-
ties. Has this been done as yet?

_PROGRAM EVALUATION: The last legislative extension of RMP allowed, at
the discretion of the Secretary, that a portion of the funds appro-

priated for grants be available for evaluation of the program. How has
that money specifically been used; and what evaluation of the program
has been made generally?

4

CONSUMER REPRESENTATION: The CHP legislation requires a majority of

representatives on state and areawide advisory councils be consumers.
To what extent is there consumer representation on your advisory groups?

 
il.

12.

13.

14.
15.

16.

17.

18.

19.

20.

21.

22.

23.

BUDGET CUT-BACK: What has been the effect on RMP of the budget

cut-backs in funds this fiscal year and that proposed for next

year in. the President's Budget?

RMP PRIORITIES: We hear a great deal about priorities these days in
health and elsewhere. What are RMP's current priorities.

CORE STAFF AND ACTIVITY: It appears that over half of all the monies
granted to date, and nearly half of that currently available to regions,
is for so-called core staff and activities. In view of the current
tight money situation, wouldn't it be far more productive if a greater
portion were spent for operational projects and activities and less for
core overhead?

HEALTH CARE COSTS: What effect, if any, has RMP had on moderating the
costs of health care? Or has its impact been just the opposite?

COOPERATIVE ARRANGEMENTS: Do cooperative arrangements really result in
improved patient care? If so, how?

IMPACT ON MORBIDITY AND MORTALITY: RMP was designed to speed the
latest advances" in heart disease, cancer, and stroke to the "patient's
bedside." What evidence do you have that morbidity and mortality from
these diseases have been reduced as a result of the program?

DISADVANTAGED POPULATIONS AND AREAS: To what extent have RMP funded
activities helped improve the availability and quality of services for
those residing in areas with limited health resources, such as the inner-
city poor and many rural populations :

~ &

_ PROGRESS IN LARGE URBAN REGIONS: Two years ago , at the time of the last

RMP legislative extension, progress in the large, complex metropolitan
regions such as New York was comparatively much slower., Is this still
the case?

RELATIONSHIPS WITH OTHER FEDERAL PROGRAMS: What have been your rela-
tionships with other Federal programs such as OEO and Model Cities?

RMP-CHP RELATIONSHIPS: How would you describe or characterize the
relationships between RMP and CHP? Has there been either conflict or
real cooperation, or have the two pretty much gone their own way?

REGIONAL OVERLAPS: Is there still a gooddeal of overlap among Regions?

FUNDS TO COMMUNITY HOSPITALS: In the past, some persons have alleged
that the preponderance of RMP grant funds has gone to medical schools,
and conversely, that comparatively little has found its way into
community hospitals. Is this true?

COMMUNITY HOSPITAL INVOLVEMENT: To what extent have hospitals, and I
mean Community and voluntary hospitals, not just the major teaching
hospitals of medical schools, been involved in and benefited from RMP?

™“
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24,
25.
26.
7,

28.

29.

FEDERAL HOSPITAL INVOLVEMENT:. To what degree are VA and other Federal
hospitals participating in and benefiting from RMP?

CONTINUING EDUCATION: How has continuing education of physicians
helped to improved health care?

HEALTH MANPOWER: Has RMP done anything to help develop and train new
types of health manpower?

PHYSICIANS IN RURAL AREAS: Has RMP in any way affected the availability
and distribution of physicians in rural areas (for the better)?

ADL-OSTI CONTRACT: I understand you have a large, two-year contract

with Arthur D. Little which is providing both an evaluation of, and
some basis for, future evaluation of RMP progress. What has it turned
up? nf

CHRONIC DISEASE PROGRAMS: How do you justify and explain the phasing
out of the Heart Disease, Cancer and other Chronic Disease Control
Programs? ,

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RMP AND THE “HEALTH CRISIS": One increasingly hears and reads about

 

the "health crisis" facing the nation. How do you see RMP helping to
address and resolve that crisis? we

Dr. Egeberg in his opening testimony identified two aspects of

the present health care crisis, which warrant reiteration. First,

that health care is provided néither through the public nor private
sectors alone. Second, that we are largely dependent for the pro-
vision of health care on existing resources -- physicians, hospitals,
and other health personnel and facilities -- which are, of course,
limited.

The kinds of changes required in our health care system needed
in order to meet that crisis -- changes designed to insure excellence
of care, for greater efficiency in its delivery, and greater equity
in the distribution of services so that they are far more readily

available and accessible to everyone -- will. require the cooperation

tra

and participation of the private sector. For over 75 per cent of the
care in this country is rendered by it.

Regional medical programs have demonstrated considerable success
in eliciting the cooperation and participation of practitioners and
organized medicine, community hospitals, medical schools, and the many
other health professionals and institutions and organizations. Indeed,
this very possibly has been their major achievement to date.

They now also are beginning to show some potential for bringing

about lorg overdue changes in the health system and the delivery of

care with the participation and cooperation of providers, and between
a -2-

—

providers and consumers, at the regional and Local levets,. RMP, in
short, provides a mechanism and means through which private physicians

and community hospitals and others can play an active and constructive

role in that change process,

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EXPANDED PROGRAM SCOPE: What is the reason for broadening the scope
of Regional Medical Programs beyond the present categories of “heart
disease, cancer, stroke and related diseases?"

The present authority and scope of the program would be broadened
so as to specifically add "kidney disease" and substitute "and other
major diseases and conditions," which would encompass such major pro-
blems as arthritis, epilepsy, and trauma, for the more restrictive
“and related diseases." This is essentially the same as the original
legislative proposal for Regional Medical Programs introduced in 1965.
It has the effect of retaining the categorical focus but removing the
categorical Limitations.

This would allow individual regions to begin to address and work
on other disease problems and conditions which, in terms of their
own regional needs and priorities, may be of equal importance or may

be more susceptible to dealing with, The discretion to do so would

wee .

be that of the regions. Only if and to the extent they see fit and
have locally determined. would the scope of individual programs be
broadened.

We expect, however, that many, perhaps most, would move in that
direction. Few, if any, regions are finding that the cooperative
arrangements approach and the benefits of regionalization are ¥e-
stricted to heart disease, cancer and stroke. To the contrary, the
pay-off from some of the present operational activities is, though

indirectly, far beyond what their categorical orientation and purpose

is. Thus, broadening the program's scope will allow fuller explLloit-

ation of Regional Medical Programs' mechanism and the potential

benefits of regionalization of services.

 
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d

KIDNEY DISEASE: Kidney Disease has, I believe, been defined as a

Wotan Gene
related disease."' What activities have been undertaken through

Regional Medical Programs Service to date dealing with this disease?

The National Advisory Council on Regional Medical Programs has
acknowledged the relatedness of kidney disease. However, recognizing
the complexity of treating chronic renal disease and the enormous cost
of mounting a service program even in a restricted locale, the Council
has recommended that Regional Medical Programs grant funds ‘awarded to
projects in chronic renal disease be limited to support of those pro-
jects which provide for: (1) Training of physicians, nurses, and tech-
nologists for management of chronic renal disease patients, and (2)
regional planning for a coordinated Regional approach to prevention,
diagnosis, and clinical management of renal disease.

As a result of this policy, a total of ul projects, including
training for use of home dialysis, have been approved and funded for a
total of some $400,000 in 8 Regional Medical Programs. An additional
two projects have been approved but not yet funded in two other Regions.
Three projects in three additional Regions are currently waiting on
further interpretation of the Council policy.

With the incorporation of the Chronic Disease Program of the National
Center for Chronic Disease Control, significant additional activities have
been added under the Regional Medical Programs Service aegis. These
include ..... .

* Thirteen (13) programs in various parts of the country to

develop methods to educate patients and their families to

home dialysis and to provide the equipment and actual training.

 
~2-

In Fiscal Years 1967 and 1968 these projects were funded
at a level of $7,150,000; in 1969 at $3,380,000; and the
1970 estimate is $3,604,000.

* A special project to evaluate home dialysis equipment is
also funded as part of the foregoing total.

* Eight (8) university and research centers devoted to pro-

-curement of human organs for transplantation are funded for.

that part of their activities related to kidney transplantation.
In Fiscal Years 1967 and 1968 these were funded at a total of
$150,000; and in 1969 at $1,236,000; and the estimated total for
1970 is $606,000. |

* Eight (8) kidney disease screening, detection and diagnostic
studies are being supported to investigate various aspects of
kidney disease and their relation to end-stage development.
During 1967 and 1968. these efforts’ were funded at $1,590,000

and in 1969 at $688,000. No funds are provided for 1970, however.
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NON-INTERFERENCE CLAUSE: Sec. 900(c) of the present RMP legislation

includes a so-called non-interference clause. The Administration's
proposal does not, as I understand it. Would you please explain why?

In the initial legislation the non-interference clause was most
important. The program was viewed by many aa a direct effort to im-
pose an alien system of care upon the country; a system designed and
operated at the Federal level.

Today the program has a four year history with established pre-
cedent. The Regions now recognize and are confident of the philosophi-
cal base of local identification of problems and decisions as to their
solution. ‘As a result of greater maturity of the program, the Regions
themselves may now wish to experiment with certain changes in health
care delivery practices if this is deemed appropriate and desirable by
their Regional Advisory Groups; and is in the best interests of the
health of the people served. Deletion of Sec. 900(c) would make clear
that locally determined changes are not precluded without in any way
suggesting that these would be Federally mandated. Nothing in the imple-
mentation of the program to date, nor in the attitudes and actions of
those presently responsible for its administration, could give anyone

concern in the latter regard.

 
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NEW CONSTRUCTION AUTHORITY: The "Report on Regional Medical Programs

to the President and the Congress" referred to the need for new con-
struction authority for continuing education and certain kinds of other
facilities. Does this need still exist? -

The need for continuing education facilities remains acute,

Continuing education remains the main force for combating professional
obsolescence and introducing "latest advances" into the health care
system. This activity falls heavily upon community hospitals already
beset by severe budget problems. Thus the ability to meet this need

is of critical importance since Regional Medical Programs are a major
-gource of funding support for medical and allied health professional
continuing education. In both community hospitals and medical schools,
the pressures of rising expenditures for direct patient care have made

it impossible for them to allocate sufficient funds to provide facilities
and space in which continuing education activities could be undertaken.

Therefore, the need highlighted in the Report remains. However, the

present limited construction authority has enabled RMP to defray costs of
alterations and renovations in connection with the conversion of existing
space in community hospitals and elsewhere arising from RMP funded con-
tinuing education activities. And as Assistant Secretary Egeberg pointed
out in his testimony, Federal funding of all construction programs has
had to be cut back in the Administration's fight against inflation. This

combination of factors would argue against the advisability of a broadened

RMP construction authority at, this time.
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MULTIPROGRAM SERVICES: The last extension of RMP provided authority
for project grants for multiprogram services (Sec. 910) ~- that is,
for services needed by, or which would be of substantial use to,
two or more regions. How has this been implemented?

The authority for project grants for Multiprogram Services has
not been implemented. Although the kind of projects which might have
been initiated and the services provided would have undoubtedly been of
teat value in the development of established regions, the decision of
Regional Medical Programs, with the concurrence of the National Advisory
Council, was to give first priority to the funding of at least minimal
operational capacity in all 55 regions. As has been shown, the funds

available to the program since the passage of the legislative extension

which established Section 910 (Multiprogram Services Grants) have been

sufficient only to cover “existing program commitments and to initiate

this single program priority.

Guidelines for Multiprogram Services Grants, and a system of.

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priorities for consideration of program uses of the authority, have been

‘developed by RMPS. As a test of the usefulness of such program services,

both locally and nationally, a general announcement of the program was
accompanied by an invitation for tentative proposals for projects. Some
fifty such proposals have been received and represent a wide variety of
activities which fall generally into two groups: Those which would pro-
vide cooperative efforts among two or three neighboring regions, such as
broad scale clinical studies of certain drugs; and those which would pro-

vice a service of use to many or all RMP programs such as the training

 
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of critically needed and highly specialized personnel, e.g., radiation

therapists, multidisciplinary teams for cardiac surgery, and evaluation

experts.

“on

 

 

 
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CLINICAL FIELD TRIALS: The proposed legislation provides specific
contract authority for the conduct of cooperative clinical field
trials. What is the significance of this; and how would such
authority be employed?

Cooperative clinical field trials are among the most complex

‘research and development activities, particularly in terms of the

organizational elements. They frequently involve careful follow-up
of very large numbers of subjects over long periods of time. The
55 Regional Medical Programs are a valuable organization resource
for mounting such studies. Specific contract authority will permit

the high degree of uniformity in experimental protocol which is

‘vital to the success of such studies, especially where several insti-

tutions or groups would be involved. For the clinical field trials

‘envisaged by this authority would indeed be cooperative, that is in-

volve more than a single institution or group, in keeping with the

. underlying philosophy and general character of Regional Medical Pro-

grams, which is that of "cooperative arrangements."

 
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LISTING OF ADVANCED FACILITIES: The Legislation as originally enacted

(Sec. 907) required that the Surgeon General establish lists of facilities
equipped and staffed to provide the most advanced methods and techniques -
in the diagnosis and treatment of heart disease, cancer, and stroke, in-
cluding the availability of specialty training in such facilities. Has
this been done as yet? ,

The National Advisory Council of RMP realized that before it would be
possible to develop a list or lists of facilities meeting the requirements
of Section 907 it would first be necessary to establish criteria against
which such lists could be developed. Unfortunately, in 1966 no such
criteria existed--none that spelled out what the requirements should be
in a medical facility if it were capable of providing the latest advances
in the diagnosis and treatment of heart disease, cancer, or stroke. There-
fore, the Division has proceeded to make contracts with professional medi-~

cal organizations which could gather together the leading experts in each

of these fields and obtain their agreed judgment on such guidelines.

The "Guidelines for Cancer Care" should be available within a few months.

Those for Heart Disease should be completed in 1971, and those for Stroke
by 1972.

Once completed and subjected to periodic updating, these guidelines

can be used by all hospitals as a basis for assessing their deficiencies

and potential for improvement and by RMPs as a basis for planning on a
regional basis. Various plans for voluntary accreditation and develop~
ment of lists according to these guidelines are now under discussion.
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PROGRAM EVALUATION: The last legislative extension of RMP allowed, at
the discretion of the Secretary, that a portion of the funds appro-
priated for grants be available for evaluation of the program. How
has that money specifically been used; and what evaluation of the
program has been made generally?

Specific evaluation funds relating to this one percent of appro-
priations provision have not been available to the program as yet.
Evaluation, however, has been regarded as an integral and critical
activity of Regional Medical Programs and as such has received con-
siderable emphasis over the past four years. In addition to the
ongoing evaluation activities carried out through the review of grant
applications, progress reports, the studies conducted by the Evaluation
Branch, and the use of site visits, several related activities have
been initiated. For example, almost two years ago, a major contract
was let with the Arthur D, Little Company to develop and test criteria

to measure the effectiveness of Regional Medical Programs. In addition,

the RMPS is supporting training contracts for the development of medical

‘evaluators to work in local Regional Medical Programs, and an Ad Hoc

Committee for the National Assessment of Regional Medical Programs
was established in early 1969. Regional Medical Programs’ involvement
in urban problems is being examined under a contract studying the
strategies and problems of RMP in developing programs for the residents
of the inner cities.

Thus, the legislative extension of 1968, which encouraged the
use of FY70 RMP funds for evaluation provided an additional opportunity
to expand already ongoing evaluation efforts. However, uncertainties

regarding the availability of FY70 grant funds have served to slow
-2-

down the utilization of funds for these activities. The Department
has now tentatively designated $133,700 for RMP evaluation activities
and in anticipation of these "earmarked" funds, we are considering
the support of a major evaluation study concerned with an "Evaluation
of RMPs Role in Changing the Delivery of Health Services," probably
to be. carried out by Harvard University's Center for Health Services
Research. The study will examine the effectiveness of Regional
Medical Programs in improving organizational arrangements for deliver-
ing high quality care.

In addition, the Regional Medical Program Service will sponsor
a National Evaluation Conference to be held in the Spring of 1970
which will bring together the evaluators from all the Regional Medical
Programs to discuss the nature and extent of evaluation in RMP and

to exchange evaluation methodologies and techniques.

ten

 
10.

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CONSUMER REPRESENTATION: The CHP legislation requires a majority of

 

representatives on state and areawide advisory councils be consumers.
To what extent is there consumer representation on your advisory groups?

"The guidelines for Regional Medical Programs stipulates that each
Regional Advisory Group have among the membership representatives of
the public who are familiar with the health needs of the region. The
number of public representatives or consumers on advisory groups has
grown slowly but steadily since the inception of the program. Consumers
played a significant role on the advisory groups during the formative
stages of the program and by December 1966, they comprised 14% of the
total Regional Advisory Group membership. Three years later in December
1969, 18% of the advisory group members were consumers. So, in three
years the absolute number of consumers on the advisory group has grown
greatly and the proportion of consumers has increased by 4%. The rate
of growth of consumer representation hae varied from region to region.
One example of rapid growth is the Regional Advisory Group of the Ohio
Valley RMP. The original advisory group of this region had 4 consumers
among the 33 members for a percentage of 12%. As of December 1969, 30%
of the 37 member advisory group are consumers. Perhaps a more typical
example is the Washington-Alaska RMP which had 14% consumer repre-
sentation on its original advisory group, but now 18% of the advisory
group are consumers. |

The consumers on the 55, Regional Advisory Groups represent a

variety of occupations and interests. The largest segment of consumers

is the business or managerial group which constitutes nearly 40% of

’ the consumer representatives. The next largest category, comprising 2225

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is made up of lawyers, educators and other professional people.
Representatives of labor unions make up another 12% of the consumers
on advisory groups. The remaining 25% of the consumer representatives
on Regional Advisory Groups are civic leaders, housewives, city
councilmen and other individuals.

In line with suggested legislative changes, it is expected that
consumer participation will be broadened. Members of the public

familiar with regional health care problems, financing and organization

will be encouraged to participate, so as to ensure adequate community

orientation.
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BUDGET CUT-BACK: What has been the effect on RMP of the budget

cut-backs in funds this fiscal year and that proposed for next
year in the President's Budget?

The effect of the budget cut-back in FY 1970 has been especially
critical because of the fact that the program entered the fiscal year
with a backlog of $20 million in approved but unfunded applications.
Of this amount, some $2.8 million was for the initiation of the
operational capability in three regions, the rest being for supple-
mental activities in operational Regions, many of which represented
a very critical second stage in the development of well-balanced

Regional programs.

Notification of the reduction in grant funds in the FY 1970
budget to $73.5 million made it immediately apparent that awarding of
initial operational grants to the three Regions in approved/unfunded
status plus the nine similarly approved early in the present FY would

require an amount in excess of the total funds which would remain

after meeting current commitments.

By securing the cooperation of the Regions in the judicious use of
existing funds and careful rebudgeting of unexpended balances among
individual component projects, it appears now that all commitments will
be met and all approved initial operational applications will be at least

partially funded, out of the funds available in FY 1970. This will not

allow a single dollar for supplementation or expansion in any of the

 
41 previously operational Regional Medical Programs nor for the
implementation of a single multiprogram services grant (the
authority for which was provided in the extension of Regional Medical

Programs legislation in 1968).

With the final Region still to be approved for operational
grants, the Program will enter FY 1971 with cumulative funding level
of the existing 55 Regions approximately $4.5 million in excess of
the amount requested in the President's Budget for grants ($79.5

million).
12.

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RMP PRIORITIES: We hear a great deal about priorities these days in

health and.elsewhere. What are RMP's current priorities?
'

The first priority of Regional Medical Programs is to establish
in each of the 55 regions, a viable organization consisting of a com-

petent professional staff and an appropriately representative and

effective system of voluntary advisory groups, which has the capa-

bility to plan and the operational capacity to initiate a program
to improve the existing systems of providing personal health care in

the region, (especially to those who have, or are at risk of having,

heart disease, cancer, stroke, and related diseases).

Of equal importance, and second priority in time sequence only,
is to recognize and strengthen this capability as it is acquired in
the regions, by awarding additional funding if at all possible, and
also by providing a far greater degree of flexibility in the use of
existing grant funds so as to allow for the rapid implementation of
local decisions and to facilitate local cooperative efforts with
other Federally funded programs, as well as among institutions and
agencies,

One important consideration to be taken into account in select-
ing which regions are to be afforded such additional funds and greater
flexibility will be the extent to which their overall programs and
regional priorities are responsive to, and reflective of, national
priorities--priorities as ennunciated by the Secretary, the Department,
and others with respect to health which the National Advisory Council
has deemed as appropriate and applicable to the 55 regional medical

programs.

ae
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CORE STAFF AND ACTIVITY: It appears that over half of all the monies
granted to date, and nearly half of that currently available to regions,
is for so-called core staff and activities. In view of the. current
tight money situation, wouldn't it be far more productive if a greater
portion were spent for operational projects and activities and less for
core overhead?

There has been a tendency to equate RMP core staff and activity

only with program administration. This greatly understates the in-

portance of core which includes planning, project development and
review, and professional and technical assistance and consultation as
well as administration. Moreover, so-called core supports many
central regional resources, such as data systems, evaluation resources,
information networks, and parts of the continuing education systems.

In view of the tight funding situation the functions of the core
staff have become even more important than they previously were.
Rather than being a primary source of funding to improve diagnostic
and treatment capabilities directly, the program must seek to exert
the greatest leverage it can with the funds available. This can best
be done, not with . one or two more operational projects, but by core
staff (1) providing consultant or professional services to local insti-
tutions and (2) serving as a facilitator or convenor of multiple in-
terest groups to solve local problems.

Acting in its convenor-facilitator role, RMP can exercise leverage,
and in some,cases bring small amounts of "venture capital" to bear, to
bring institutions together for both planning and joint operational

activities. Often these activities do not require RMP funds, but can

be assisted by RMP to obtain funds from other sources. One example of
-2-

such activity is provided in Detroit, where complete staff support
for the Model City Health Council Governing Board was provided by
the Wayne State University component of the Michigan RMP; and the
health plan of its recently funded Model City application was largely
developed by the Associate Coordinator and RMP staff at Wayne State.

The technical resource and consultant role is yet another one.
In Maine, for example, core staff is deeply involved in assisting an
area of that Region in which three towns (Livermore Falls, Wilton, and
Farmington) are in the process of deciding upon one joint hospital.
The Maine RMP staff is working on developing the total planning pro-
gram which includes the acute care of the patient with heart disease,
cancer and stroke, the concept of progressive patient care, methods
of patient flow and referral, new methods of construction, and care
payment mechanisms.

; Thus the type of activities carried out by an RMP core cover a
wide diversity of functions, with considerable variation among the
Regions in the balance or emphasis of such activities. It is probably
true that the ultimate success of Regional Medical Programs will be

measured more against its core activities than against a series of

individual operational projects.

 
14.

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HEALTH CARE COSTS: What effect, if any, has RMP had on moderating the

costs of health care? Or has its impact been just the opposite?

The regional scope and character of these programs and the.
involvement of the broad spectrum of health institutions, professions,
and resources within each Region provides a means for taking specific
action to share limited health manpower, facilities, and resources in
maximizing the quality of care and services for heart disease, cancer,
and stroke available to the Region.

The extensive cooperative planning, along with
the process of regionalization -- the linking of health institutions
and resources within a Region ~- helps assure the coordination and
optimal utilization of existing and future resources, and as such has
the potential for eliminating wasteful duplication of activities and
facilities. This improved planning and sharing of resources may well
result in the reduction of the per unit cost, of certain health care

services, . ~-

cent *.

ton

In a great many of the operational activities currently being funded

resources and for the efficiency of their use. Among these activities

 

are: -

- Projects to promote prevention and multiphasic screening for early

diagnosis of heart disease, cancer, and stroke for large populations.

. Projects to promote increased use of less expensive paramedical per-

a
sonnel and new occupations, such as physician assistants.

 
- Projects aimed at making the services of expensive medical care
equipment available to regional and remote hospitals through com-

‘puter monitoring and improved communication systems,

- Projects which emphasize out-of-hospital care, such as home

health care.

« The strong preventive thrust of the activities of the National
Clearinghouse for Smoking and Health with its public information

campaign against smoking.

An increasing number of regions are carrying out studies on the
economics of health care, particularly as it relates to their own pro-
gram activities. Drawing upon economics, operations research, and
other disciplines, such regions as Texas, Georgia, and Rochester are

in this way giving specific.attention to’ some of the interreLation-

‘ship of Regional Medical Programs and the costs of medical care.
15.

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COOPERATIVE ARRANGEMENTS: Do cooperative arrangements really result in
improved patient care? If so, how?

Regional cooperative arrangements create linkages among medical
centers, hospitals, physicians and other health institutions and profes-
sionals in order to facilitate the transmission of knowledge, the sharing
of scarce resources, and the rational planning and development of health
programs. Such linkages are particularly necessary at a time when spedéial-
ization in medicine has served to fragment medical services and inhibit
communications among providers of care, and when the costs of implement- ~
ing technological innovations in medicine cannot be borne independently
by most health care institutions,

To help meet some of these problems, Regional Medica] Programs
are encouraging the development of cooperative working relationships
among practicing physicians, medical educators, medical researchers,
hospitals, public health officials and many other health and health
related organizations and interest groups. These working relationships,
or cooperative arrangements, are already beginning to offer evidence of
progress in helping to knit together the various autonomous elements of
the health care system for the benefit of those patients affected with
heart disease, cancer, stroke and related diseases. For example, in
the Tennessee Mid-South region, newly established coronary care units
in several small rural hospitals have been electronically linked to
Vanderbilt Medical Center for the transmission and diagnosis of EKGs and

a

other physiological signals. Patients in these rural areas now have the
15.

Continued -2-

benefit of the medical center's expertise, In the Intermountain
Region, university-based neurological specialists are making’ sched-
uled visits to rural hospitals to conduct consultative clinics with
attending physicians.

In addition, many Regional Medical Programs are helping develop
linkages among several hospitals in an area for the direct benefit of
their patients. For example, in Maine, a "Regional Blood Bank" is
handling 200 pints of blood per month for six of the region's hospitals
in one area of the state. Previously, a few of these hospitals were
running their own individual blood banks, on a less than optimal
basis. Regional Medical Programs helped them develop a blood bank
with sophisticated equipment and enlarged storage capabilities which
now provides broader and higher quality services.

Cooperative arrangements can help avoid unnecessary duplication of
expensive facilities by the ‘process of community involvement in the plan-
ning and decision-making of Regional Medical Programs. Such a process
brings together the medical, health and community leaders to consider
jointly the health needs of the region and develop a consensus on how to

meet the needs in the most efficient and effective manner for that parti-

cular community.

 
16.

2/6/70

€

IMPACT ON MORBIDITY AND MORTALITY: What evidence do you have that

 

morbidity and mortality from these diseases has been reduced as a
result of Regional Medical Programs?

It is still too early to adduce definite evidence that Regional
Medical Programs and the activities specifically being carried out by
them have produced any decrease (or other changes) in morbidity or
mortality from heart disease, cancer and stroke. The majority of the
55 regions have been operational for just a little more than one year;
only four have been operational for as long as three years. It takes
longer than this to affect changes and accumulate the data reflective
of any that may have occurred.

Since it is too early to assess the program in terms of ultimate
impact and pay-off, improved care and health status, program assessment
to date must be largely in terms of the RMP organizations and planning
process which have been established, the regional cooperative arrangements
among health institutions and providers that have been created, and the
enhanced diagnostic and treatment capabilities beginning to be brought
about through the efforts of the 55 regions. The means by which more
comprehensive and improved care is being achieved and hopefully the health
of those patients receiving it is benefited.

True, we do have some preliminary and highly. tentative evidence in
a few isolated instances. For example, preliminary data reported by the
North Carolina RMP in connection with a coronary care network in a rural,
mountainous area in the western part of that state, indicates a 67% re-
duction in mortality from acute myocardial infarctions among the first

300 patients who had this service available to them.

 
-2-

Not only is it too early to make any generalizations along these
lines, but I would hasten to add that unfortunately it is rarely possibl
to measure and attribute changes in the health of a population to simple,
"individual causes. There are many things affecting health other than
improved care. The air we breathe, the food we eat (or overeat), and our
genetic heritage to cite but a few. Not only are there many variables
which must be taken into account, but sometimes we are mystified as to
what to attribute certain rather dramatic changes to. Witness the steady

decline in recent years of stomach cancer in men.

 
17.

2/7/70

DISADVANTAGED POPULATIONS AND AREAS: To what extent have RMP funded

 

‘activities helped improve the availability and quality of services

for those residing in areas with limited health resources, such as
the inner-city poor and many rural populations?

Regional Medical Programs have participated in both planning and
operational activities aimed at improving health resources for inner
city residents and rural populations.

. In the area of planning, the New Jersey RMP has been vitally
involved in planning with all community segments for improving health
services for the urban areas of Newark, Trenton, and Hoboken. It has
provided Urban Health Coordinators to work directly with their several
Model Cities programs to plan the health component of the program.
This support and the attention and time provided by the staff of the

RMP is expediting the development of improved urban health services.

Participating in community planning and at the present time in a

major operational activity, the California RMP has played a major role

“in developing a plan to meet health needs of the disadvantaged

population of the Watts-Willowbrook district of Los Angeles. Again

in California an operational program is attacking the health care
delivery system in yet another way by the use of mobile multiphasic
screening for the early detection and identification of health problems
among the urban poor and ndgrant agricultural families in San Joaquin
County. There are eight other similar operational disease screening
projects in other parts of the country with an approximate Regional

Medical Program funding support in excess of $2 million in this area

of disease prevention for disadvantaged populations and areas.

ae

 
18.

2/7/70

PROGRESS IN LARGE URBAN REGIONS: Two years ago, at the time of the
last RMP legislative extension, progress in the large, complex
metropolitan regions such as New York was comparatively much slower.
Is this still the case?

There has been and still continues to be a wide variation in the
character and stage of development of these programs in the metro-
politan areas, Although it is generally true that as a group they
have lagged behind in the organization of the core program, initiation
of operational projects, and level of funding, many of these regions have

overcome the initial organizational problems which deterred their

early progress and growth.

In large, complex metropolitan regions such as New York City,
Philadelphia, Cleveland, St. Louis, Boston, and Chicago, the rate of
development has been slower because the mechanisms required to pull
all the elements together for a more directed effort have been quite
difficult to align and organize. To some extent, this has been
expected because the large cities are-~for a number of reasons~-more
complex in their makeup and are subjected to numerous competing demands
and priorities over and above those faced in the health field. Asa
consequence, these regions have had to stimulate the pulling together
of a great multiplicity of resources to bring about a better utilization
of available professional manpower and facilities. This has required
a considerable amount of time' and effort and in some, much more time

and effort are required still.
Notwithstanding the complexities, however, RMP has made some
progress in the area of urban health in several metropolitan areas;
namely, the Watts-Willowbrook section of Los Angeles, Indianapolis,
Washington, D.C., Nashville and Newark. Considerable amount of
planning has been done in a number of the larger cities and supported
directly by Regional Medical Programs. Some of these plans have

already emerged and have been forwarded for review and funding by OEO,

Model Cities, and other HSMHA programs in addition to RMPS.
19,

| 2/7/70

RELATIONSHIPS WITH OTHER FEDERAL PROGRAMS: What have been your
relationships with other Federal programs such as OEO and Model
Cities?

In several Regional Medical Programs, relationships with other
Federally-funded programs involve both planning and operational

activities. One of the best illustrations of planning assistance is

with the Model Cities program.

. The New Jersey RMP is closely coordinating its planning
activities with Model Cities in that state. Three
staff persons are assigned as full~time Urban Health
Coordinators within the designated Model Cities of
Newark, Trenton and Hoboken to develop the health
ens of the Model Cities plan. Each, working with
the elected citizens’ health panels,’ has identified the
priorities for health services and developed an opera-
tional framework for action, which was submitted as part
of the total Model Cities operational plan. Their success
has led to requests for five additional such Coordinators

for assignment to the newly-designated Model Cities.

There are strong cooperative efforts between the RMP and
Model Cities in Richmond, California where the sharing of
the salary of an Urban Health Coordinator should soon lead

to the development of grant applications in community health

for possible sponsorship by Model Cities and RMP.
In Detroit, complete staff support for the Model City
Health Council Governing Board was provided by the Wayne
State University component of the Michigan RMP; the
health plan of its recently funded Model Cities contract
was largely developed by the Associate Coordinator and

RMP staff at Wayne State.

Such relationships as these are gradually developing in a series
of other Regions, with the form of consultation, committee interaction,
or joint planning varying depending on the complexity of the local
situation and the state of development of both the Regional Medical

Program and the Model Cities agency.

An example of RMP cooperation with OEO involving operational

assistance is to be found in Nashville, Tennessee where a demonstra-

att e

tion project. has been established to test and evaluate the impact of

early diagnosis of heart disease, cancer and stroke within the

confines of a Comprehensive Neighborhood Health Center. Here, health
evaluations and utilization studies are being made on a defined
population group within a prescribed inner-city area. This demonstra-
tion project is being coordinated cooperatively between Meharry Medical

College, OEO and the Tennessee Mid-South RMP.
20.

2/6/70

RMP-CHP RELATIONSHIPS: How would you describe or characterize the
relationships between RMP and CHP? Has there been either conflict
or real cooperation, or ave the two pretty much gone their own way?

‘The relationships between Regional Medical Programs and Compre-
hensive Health Planning agencies are quite varied, ranging from close
cooperation to exploratory discussions. General cooperation such as
overlapping membership between Regional Advisory Groups and the CHP
State Health Advisory Councils are evidenced in 53 of the 55 regions.
Furthermore, 23 regions have undertaken common data collection acti-
vities with the state CHP agencies and 14 have indicated a sharing or
joint participation in special planning studies. In this regard the
state CHP agency and the RMP have defined common subregional areas
for planning and operations in 6 regions,

Relationships with areawide comprehensive health planning agencies

have been somewhat slower in developing, in large part perhaps because

ee,

the majority of the 114 current Ly funded areawide agencies have been

in operation for less than a year. In that connection, it is signi-

ficant that 11 regions have assisted actively in the development of
areawide agencies and in 4 actually provided some developmental funds.
Evidence of the potential for close working relationships between
RMP and areawide CHP agencies is that 26 of the regions have over lapping
membership between the Regional Advisory Groups and the Areawide Advisory
Committees. In Memphis, the membership of the 314(b) agency advisory ..

’
group, (Mid-South Medical Center Council),and the Memphis RMP advisory
group are the same,

A number of regions have established local advisory or action

groups. These groups review projects, assess local needs, encourage

 
-2-

project development and generally coordinate RMP activity at the local
level. The Georgia RMP, for example, has established some hospital-
based local action groups throughout its region. These groups send
all proposed operational projects to the areawide CHP agency for
approval, if one exists.

Even closer coordination, collaboration and possibly consolida-
tion have begun in several places. The governors of South Dakota
and Vermont have been exploring ways in which the relationships be-
-tween RMP and the state CHP agency might be formally structured. The
Program Coordinator of the Nassau-Suffolk RMP is also serving as the
acting Project Director of the Nassau-Suffolk Comprehensive Health
Planning Council; and a formal relationship between the two there is
being studied.

For the most part there is no concrete evidence of overt conflict
or suspicion between the two programs at the state, regional, or local
level. Rather, general cooperation, tentative involvement and avoid-
ance of any open conflict characterize the relationship between RMP

and CHP.
21.

2/6/70

REGIONAL OVERLAPS: Is there still a good deal of overlap among Regions?

There are approximately 13 cases in which two Regions both have
some responsibility for developing activities within a certain geogra-
phical area. Discussions among neighboring Regional Medical Programs
have resulted in both planning and the development of operational pro-
jects which cross regional boundary lines and thus are designed to
capitalize as much as possible on regional resources to meet local health
needs. It is sometimes best for individual hospitals and groups to
participate in different aspects of several programs, such as the con-
tinuing education program of one Region and the medical library program
of another.

The definition of regional boundaries is regarded by most Regions
as a flexible determinant of regional activities, rather than as a fixed,
geographic limit for activities. In placing responsibility for deter-

mining boundaries at the regional level, it was felt that local planning

groups could best determine the relative weight of criteria to be used..

Generally a Region aims at being an economically and socially
cohesive area, taking into account such factors as population trends and
patterns of growth; location and extent of transportation and communication
facilities and systems; and presence and distribution of educational and
health facilities and programs. In defining medical trade areas, the
attempt is made to follow appropriate existing relationships among insti-
tutions and existing patterns of patient referral and continuing education.

Thus some 36 Regions have defined themselves as essentially coterminous

- with one. or more States, while the other 19 are essentially parts of one of

more States. _

 
-2-

The definition of regional boundaries has not changed significantly
since the Regions first delineated their boundaries for planning pur-
poses. Of approximately 9 Regions making changes, most were a matter of
adding or subtracting specific counties because of areas of overlap with

adjacent Regions.

 
22.

2/6/70

FUNDS TO COMMUNITY HOSPITALS: In the past, some persons have alleged
that the preponderance of RMP grant: funds has gone to medical schools,
and conversely, that comparatively little has found its way into
community hospitals. Is this true?

Since the beginning of Regional Medical Programs, the medical
schools have functioned as one of the significant organizers and re-
sources for the RMP's development. Commonly the center of the "medical
trade areas" along whose boundaries the fifty-five regions were formed,
the schools provided a natural resource for the establishment of the
RMPs and for the conduct of their activities. Historically, the medi-
cal schools and their affiliated hospitals have been the recipients of
the greatest part of RMP grants funds, but this situation is now begin-
ning to change. While this is still true in many of the regions, particu-
larly in those which are in their initial operational phases there has
been an increasing emphasis on the community hospital as a local resource

as operational programs mature. The community hospital is recognized as

one that is better able to accomplish the foremost objective of the RMP-—

"to strengthen and improve the personal health care system in order that

the quality of care received by individuals may be constantly improved..."

 

Clearly, the community hospital, being oriented to the care of the indi-~
vidual, provides the setting which can best carry out programs which will
fit the needs of the community. |

In examining the progress of several regions which have been opera-
tional two years or longer, one can discern what seems to be a trend away
from the medical school and toward the community hospital. The hospital

is becoming more involved in Regional Medical Programs and consequently
~2—

it is receiving a greater share of the funds. The RMP of Kansas typifies
this trend: the University of Kansas Medical School was the primary .
recipient of funds and central resource when the RMP in that state went
operational almost three years ago. At the present time, community hos-
pitals are taking a much more active part in nearly every operational
project in the region, and twenty hospitals are sponsoring or co-sponsoring
six of the fifteen projects.

The Regional Medical Program of Albany, New York, is another case in
point. The RMP here was established by the Albany Medical College and has
been operational since the spring of 1967. A quick look at the opera-
tional projects of this region is enough to discern that efforts to increase
community hospital involvement have been fruitful: of Albany's ten projects,
four are sponsored by community hospitals, only one by the college medical
center. In seven projects, forty-eight community hospitals are the recip-

as *

jents of RMP funds totaling approximately 110,000 dollars.
23.

2/6/70

COMMUNITY HOSPITAL INVOLVEMENT: To what extent have hospitals, and I

 

mean Community and voluntary hospitals, not just the major teaching
hospitals of medical schools, been involved in and benefited from RMP?

In the early stages of RMP, there was concern on the part of the
Congress that there was insufficient community hospital involvement in
the various regional programs. At this point, however, it is evident
that community hospital involvement is increasing and that the hospital
is becoming a center for program activity, both at the division level
and in the regional programs. RMPS has designated a senior staff member
with primary responsibility for strengthening relationships with
community hospitals, and a joint invitational conference was held in
June 1968 for the American Hospital Association and RMPS.

Community hospital impact is also being felt in the regions--while
total membership on the Regional Advisory Groups has almost doubled
since December 1966, the number of hospital and hospital association
representatives on the RAG's has increased by 135%, and now comprises
12% of the total membership as compared to 8% three years ago. Community
hospitals are also represented on other planning and policy and decision-
making bodies of the RMP organization-about 18% of the combined member-
ship of planning committees and area and local advisory groups is
community hospital representation.

Almost a third of the nations 6000 communi ty hospitals are repre-
sented on regional, area, and local advisory groups, planning committees,
regional task forces, and the various other decision-making groups.

Community hospitals comprise about a third of all institutions and organi-

‘gations represented on these bodies.

 
—-2-

A number of local hospitals, hospital associations, and hospital planning
councils have been or are presently conducting planning and feasibility
studies for the various RMP's. Of the 96 subcontractual studies cited by
_the regions, 14 are being performed by community hospitals and 11 by hos-
pital associations or planning councils.

Community hospitals play an important part in operational activities
within the regions. About 1700 hospitals are participating in operational
projects, comprising 70% of all institutions and organizations involved
in RMP.

Over a thousand of these hospitals are considered primary participants—
either sponsoring the project, receiving RMP funds or serving as the location
of all or part of the project. Project sponsorship is probably the most
indicative of active involvement, since it entails overall administrative
responsibility for the conduct of a project, including, in some cases, the
disbursement of RMP funds; dpproximately 160 community hospitals are
acting as sponsors or cosponsors of operational projects.

. Eight community hospitals in the Ohio Valley RMP are jointly
sponsoring a project concerned with establishing a full-time
Director of Continuing Professional Education in each of the
hospitals; eight additional hospitals are participating in the
project in other capacities.

. The Georgia RMP has undertaken a statewide cancer project which
is sponsored by nine community hospitals and the Emory University
School of Medicine, its teaching hospital. When the project is

fully implemented, it is anticipated that excellent services and

facilities will be available within a reasonable distance of the

 
home of every cancer patient in the region.

There is no doubt that community hospitals have derived benefits from
their association with RMP. In many instances the hospital has been able to
obtain equipment and services which would not have been financially possible
without RMP support; and many hospitals have been able to upgrade their staffs
through RMP continuing education programs. Moreover, RMP has fostered the
development of relationships among community hospitals which previously had

little knowledge of or involvement with one another.
24,

2/6/70

FEDERAL HOSPITAL INVOLVEMENT: To what degree are VA and other Federal
hospitals participating in and benefiting from RMP? .,

Federal hospitals, especially Veterans Administration hospitals,

_are becoming increasingly involved in planning and decision-making

and operational activities of Regional Medical Programs. This |

increased participation is largely due to the fact that the law
governing RMP was amended in October of 1968 to permit Federal hospitals

to be reimbursed for participation in RMP activities.

There are a total of 72 VA hospitals presently involved in
activities in 39 regions, as compared to only 37 hospitals in 28 regions
a year ago. Forty-six (46) have representatives on regional planning
and decision-making bodies (regional, area, and local advisory groups,
planning committees, etc.) and 38 are participating in operational
projects, Twenty-six (26) other Federal hospitals, both PHS (13) and

military (13), are also involved in operational activities.

* The VA Hospital in Tuscaloosa, Alabama, is conducting,
with RMP funds, a training program in "reality orienta-
tion technique" designed to improve the care and rehabili-
tation of older patients with cerebrovascular disease and
stroke, The training is directed toward a broad spectrum
of health personnel in the Alabama region with special

t

‘attention to those working in nursing homes.

 
* The California RMP is supporting an operational project in

the San Francisco area (AREA I) for the comprehensive éare

of patients with hypertension. Sponsored by the San Francisco

Medical Center, the project involves 9 other hospitals
throughout the country, including the Fort Miley VA Hospital.
It is a major teaching hospital and the primary Veterans'
facility in the Bay Area. A demonstration clinic for con-
sultation and care of patients with hypertension has been

established there under the auspices of the California RMP.

The Washington/Alaska RMP has been instrumental in develop-
ing the Alaska Health Sciences Library at the USPHS Alaska
Native Medical Center in Anchorage. When the Library was
established by the Hospital in 1967, there was only one
medical library in the entire state; and until RMP support
became available in early 1969, the Center Library operated
on a very limited and inadequate scale. At this time, |
however, the Library is fully staffed and has advertised its
services to all physicians and dentists in the state. A

recent survey shows that 38% of all private physicians in

Alaska already have used the Library.

 
25.

2/6/70

CONTINUING EDUCATION: How has continuing education of physicians
helped to improve health care?

Over 50 per cent of all operational grant funds awarded have
been for continuing education and training activities which address

themselves quite directly to the primary purpose of RMP, the improve-

“ment of health care. Another 32 per cent have been awarded for -

demonstrations of patient care. Many of these projects have an
educational component.

The ultimate standard of effectiveness resides in the measure-
ment of changes in health care. Limitation of present evaluation
methodologies are such that quantification of the direct effect on
patient care is not generally feasible. However, on an individual
basis, it is sometimes possible to identify the specific impact of
an education program. This is exemplified in the case of the

California physician in a small community hospital who successfully

. treated six cases of cardiac arrest as a result of the skills devel-

‘oped in an RMP-sponsored course at the Pacific Medical Center. This

RMP-trained physician, with his colleagues and in cooperation with
the local heart association and junior college, in turn offered
courses for nurses and allied health personnel in coronary care.
With trained supportive personnel from this program, the hospitals
were able to provide critical 24-hour surveillance of myocardial

infarction patients in intensive coronary care units.
-2-

Whereas the direct relationship between continuing education
activities and patient care changes often defy exact measurement,
a component of effectiveness, such as the program's ability to
reach the desired audience, is more readily assessed. By June,
1969, over 16,000 physicians had been trained with RMP funds in
the 55 regions. | Also trained with RMP support were well over 38,000
personnel whose services are supportive to those of physicians and
thus contribute to the total quality of health care,

Another component of effectiveness is the quality of educational
design and instruction. Regional Medical Programs Service, in an
attempt to improve the quality of physician instruction and of evalu-
ation in educational programs, has initiated five contracts in as
many universities (University of Illinois, Ohio State, University of
Southern California, University of Washington, Michigan State) for
long-term courses leading to. advanced degrees, as well as providing

“funds for workshops and short-term training courses, Graduates are
“now found in RMP staffs throughout the country.

Regional Medical Programs also have been instrumental in signi-
ficantly improving the planning aspects of continuing education pro-
grams. They have involved institutions and health professionals
in a team effort so that the programs planned are more relevant,
duplication has been avoided, patient care needs and practitioner
needs have been dominant in the setting of objectives, and the best
possible resources of the region are utilized. They increasingly

are serving a coordinating function as well. The West Virginia RMP,

 
-3-

for example, is cooperating with the state medical society in study-
ing ways to devise statewide.programs based on the patient care review

mechanism.

 
2/6/70

26. HEALTH MANPOWER: Has RMP done anything to help develop and train new
types of health manpower? .

RMP has funded a few operational projects for the training of

new types of health manpower.

k

Georgia RMP. Grady Memorial Hospital in Atlanta trains "medical
specialty assistants" to work in medical and coronary intensive
care units. The two-year program accepts high school graduates

or medical corpsmen. me

‘-Indiana RMP. Flanner House in Indianapolis offers a 6-8 week

course for the training of screening technicians and community
health organizers. Trainees live in the community, have less
than high school education and are generally unemployed or under-
employed. |

Washington-Alaska RMP. Spokane Community College, Spokane, has

aoe »

. just completed a two-year training program for cardiopulmonary

technicians.

Maine RMP. Maine Medical Center offers a 16-week training course
for registered nurses to become pediatric nurse associates.

North Carolina RMP. Extension of the 24-month physician assistant
program at Duke University. This proposal has been approved by

the August DRMP National Advisory Council but is as yet unfunded.

In addition to the operational projects mentioned above, many regions have,

4

as part of their "core" activities, been supporting planning studies, and

meetings of representatives from universities, junior colleges, clinical

resources and professional associations to discuss needs, training resources

 
-2-

and placement, etc. of new types of health personnel. Some RMPs have

published survey findings.

 
276

2/6/70

PHYSICIANS IN RURAL AREAS: Has RMP in any way affected the availability
and distribution of physicians in rural areas (for the better)?
Regional Medical Programs most significantly affect the avail-
ability and distribution of physicians in rural areas through helping
create a more intellectually stimulating environment. More readily
available continuing education opportunities, and greater accessibility
of colleagues in the medical center made possible through RMP, helps
overcome two often repeated objections to rural practice. Increasingly,
through the process of subregionalization, circuit riding courses and
the use of communication technology, among others, the distance is
lessening between the rural practitioner and the medical world outside.
The Washington-Alaska RMP reports that a total of 11 physicians
have started practice in the rural communities in central Washington
sime the start of one of its continuing education projects in the
summer of 1967. This project is based in the subregional medical

center of Yakima, a city of 44,000 ringed by 10 isolated communities.

A regular exchange of teachers and practitioners goes on between the

Seattle Medical Center and Yakima and between the latter city and its
surrounding small towns.

The 11 new physicians include a cardiologist sent by the. Washington-
Alaska RMP to Yakima for a teaching consultation seminar. He decided
to stay to practice. A University of Washington affiliated pathologist
who moved to Yakima early in'1969 stated:

"The ambitious continuing education programs here have created

such a stimulating atmosphere that I felt I could move from a

University Center to this remote community without any profes-
sional penalty at all."

 
-2-

Speaking of a coronary care preceptorship program, one family prac-
titioner said:

"Tt has already changed the type of myocardial infarction care

in our area. It stimulated other physicians to seek out similar

courses and awakened the dormant education programs among our
nurses,"

The use of communication technology has made accessible the most
recent medical information in many rural areas. The Dial Access
System in North Dakota has been enthusiastically received by rural
practitioners; and the Alabama RMP-sponsored Medical Information
Service provides direct telephone communication between the inquiring
practitioner and the specialist at the University Medical Center in
Birmingham best qualified to answer his questions, In the Inter-
mountain region, characterized by widely scattered small hospitals,

52 hospitals participate in its Network for Continuing Education,
Medical grand rounds and physicians" conferences are broadcast weekly.

Regional Medical Programs have also brought to rural practitioners |
‘ppportunities for greater emphasis on disease prevention through
screening projects. Two such projects are occurring in 4 rural
counties of Florida and in Southern Tennessee, Large segments of

medically indigent in these two rural communites will be among those

screened for cardiovascular. disease as a result.

 

 
28.

2/6/70

ADL-OSTI CONTRACT: I understand you have a large, two-year contract
with Arthur D. Little which is providing both an evaluation of, and
some basis for, future evaluation of RMP progress. What has it turned
up?

We expect a final report from this two-year effort in the summer

of 1970. The work is still in progress. We have received various in-

terim reports orally and in writing, so it is possible to indicate the

lines along which the contractors are working. Some of their tentative
findings are as follows:

* RMP can and often does contribute to the regionalization of
health services. The regionalization processes it can employ
are varied, but more often than not, many steps are required;
first, to develop relationships between two or more institutions,
professions or communities, then to create subregional networks;
and, finally, to broaden and deepen these networks by associating
them with other networks--all to serve tangibly to improve the
quality of care, or its availability. :

* RMP starts with specific, tangible projects, not ‘usually with a
"“srané design." "Grand designs" in RMP experience so far have
not in most cases, speeded things up, because these plans have
usually been expressed so early in the process of regionalization
that they were perceived as either threatening or irrelevant by
too many of the people whose voluntary cooperation and enthusiasm
was necessary. “Whether a "grand design" is useful in RMP appears

to depend on whether people reach a point where they want such a

plan.
-2~

* RMP has no power to enforce any preconceived pattern of

regionalization. How regionalization begins and progresses

in

on.

the early stages (the first few years) depends accordingly

The energy and enthusiasm of voluntary participants.
preexisting conditions: the conflicts, needs, patterns

of care, and institutions that were there before RMP.

RMP core staff skill in identifying and encouraging energetic —
people, and in helping to develop useful processes and pro-
jects (facility sharing, encouraging more referrals, and
consultations, e.g., to improve early diagnosis, promoting
appropriate institutional mergers, developing continuing
education networks, etc.) . .

The skill of the Program Coordinator and the success of
Regional Advisory’ Group and Directors Gi£ any) in making RMP
accessible to all interested parties without becoming the

captive of any of them.

RMP in most cases acts as a broker, a convenor, and a facilitator.

When it is effective, it helps to catalyze the efforts of others.

RMP is forced into this role (1) by P.L. 89-239, with its

emphasis on voluntary cooperative arrangements, (2) by the need

for such a catalyst in many parts of the country, (3) by the

t
fact that RMP resources are relatively very small (e.g., one

tenth to half a percent of national expenditures for health care

 
-3-

and only a few percent of expenditures attributable to diagnosis
and treatment. of the categorical diseases). 2
Evaluation of RMP. Because there is wide variation in the
starting conditions of the regions, and because of the relatively
high degree of local autonomy demanded in the law, as well as
other aspects of P.L. 89-239 mentioned earlier, the contractor
believes that the regions (and accordingly, the program as a whole)
must be evaluated in terms of regional RMP effectiveness in its
primary role: that of facilitator-broker. The ultimately
necessary evaluation of the program's detailed impact on the
health of the people cannot now be accomplished because of the
delay between cause and effect. Furthermore, it is rarely, 1f
ever, possible to measure and: attribute changes in the health of
populations to simple, individual cases. But the plausibility

of specific projects-and their progress toward reaching either
planned or perceived goals can be estimated. More important
still, the skill and effectiveness with which RMP's in the various
regions have carried out a process of involvement, planning, and
achieving genuinely useful health care regionalization can be
examined and substantially judged against the back drop of the
conditions under which a region started and the resources avail-
able to it. | |

RMP appears to be able to enlist the participation of practicing

physicians, and to provide them with an acceptable opportunity to
-4-

act in concern with members of other health professions and

the general public. The contractor pelieves that this ability,
though still partly unrealized in fact, is a great asset to RMP,
and an absolute precondition to any voluntary effort to achieve

regionalization.

am
29.

2/6/70

CHRONIC DISEASE PROGRAMS: How do you justify and explain the phasing
out of the Heart Disease, Cancer and other Chronic Disease Control
Programs? :

‘Regional Medical Programs was established to deal with the pro-
blems of heart disease, cancer and stroke and improve the care of
those suffering from, or threatened by, those diseases. To.do this,
it was authorized to make grants for planning, research, training,
and demonstrations of patient care; through fiscal year 1969, nearly
$150 million in awards have been made to the 55 regions for this
purpose. Of that for operational activities, about $23.5 million
has been in the area of heart disease; almost $7 million for cancer;
$7.7 million for stroke; approximately $5. million for related diseases;
and over $30 million for activities of a multi-categorical nature.

A program review of the several Chronic Disease Control Programs
indicated that there was very considerable overlap between them and
Regional Medical Programs as to the training, development, demonstra-
tions, and other activities being carried out. It was felt that these

could be carried out more effectively, and in a manner that would be

more consonant with regional needs and priorities, by Regional Medical

Programs.

Thisis why they are being phased out. Those several programs where
there was Little overlap, or not the case, are not being phased out.

These are the Kidney Disease, Nutrition, and Smoking and Health Programs.
. t