REVIEW OF ISSUES AND RELATIONSHIPS*

Donald R. Chadwick, M.D.

Deputy Director

Division of Regional Medical Programs

Health Services and Mental Health
Administration

 

*Presented at the Conference ,

of Coordinators of Regional Medical Programs
September 30 - October 1, 1968

Marriott Twin Bridges Motel

‘Arlington, Virginia

 

This copy reproduced from original manuscript for immediate
distribution to Conference participants. Final copy of all papers
will be published and made available as soon as possible.
Regional Medical Program Authorization Bill in Congress

Congressional action on the RMP extension bill is nearly completed,
and the major decisions have been made by the Senate-House Conference
Committee. We have kept you iriformed on the progress of this bill through
the News, Information, Data publication. In summary, the new Bill extends
the legislation two years and authorizes funds, provides that up to one
percent of the funds can be used for evaluation, includes areas outside
of the fifty States, such as Puerto Rico, the Virgin Islands, etc.,
changes certain wording regarding participating agencies, increases the
membership of the National Advisory Council from twelve to sixteen,
permits funding of services to two or more RMPs, permits dentists to

refer patients, and permits participation by Federal hospitals.

The differences between the Senate and House versions of the
Bill involved the length of the extension and the amount of funds
authorized. The Senate version provided a three-year extension at levels
of 65, 140 and 200 million. The House version provided a two-year
extension at 50 and 100 million. The resolution in Conference provides
a two-year extension at 65 million for fiscal 1969 (the Senate version),

and 120 million (a compromise figure) for fiscal 1970.
"The bill as passed by the House authorized a total of
$50 million for the fiscal year ending June 30, 1969, and $100
million for the fiscal year ending June 30, 1970, for regional
medical programs for heart disease, cancer, and stroke, and
related diseases. The Senate amendment authorized $65 million
for the fiscal year ending June 30, 1969, $140 million for
the fiscal year ending June 30, 1970, and $200 million for
the fiscal year ending June 30, 1971, for this program.

The Conference substitute authorizes $65 million in
appropriations for the fiscal year ending June 30, 1969, and
$120 million for the fiscal year ending June 30, 1970.

Although the authorization contained in the conference
substitute is limited to a 2-year period, the managers on the
part of the House wish to emphasize that this program,
although a newly established one, has already proved its
value, and should be considered as a permanent program,
subject, however, to periodic congressional review and
legislative oversight. The managers on the part of the
House agreed to a 2-year limitation in order to provide
an opportunity for the 91st Congress to review the operation

of the program."

It is not certain at this time exactly how much money will be
available for this fiscal year. Action by the Congress on the appropriation

has not been completed. If the amount which is contained in the Senate
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appropriation bill is passed, a total of 99 million dollars will be
available, including a carryover of 36 million dollars from 1968.
There are, however, two factors which can reduce that amount. One
would be a lower figure agreed upon in the House-Senate Conference; .
the other would be a reserve placed on funds by the Administration

in order to meet the requirements in the legislation which established

the ten percent surtax. In any case, we will keep you informed.

Several important developments should be mentioned. in regard
to the passage of the RMP extension bill. As Dr. Manegold will discuss
with you later this afternoon, it looks as though we are going to be
faced with another earmarking of funds this year--a minimum of five
million dollars for studies of the effectiveness of Atromid-S in
lowering the frequency and severity of myocardial infarctions. The
Senate Committee, in our authorization bill report, expressed concern
that "enough emphasis is not being placed on clinical research, with
‘ particular emphasis on the evaluation of various important therapies
which show promise of reducing morbidity and mortality.'' They go
on to point out that the RMP mechanism is ideal in their view for
carrying out broad field trials of the efficacy of various drugs, and
they refer to the field trials of the Salk vaccine. I'd like to quote

you their concluding paragraph on this point:

"The Committee, therefore, in full agreement with the
position of the House, urges officials of the regional medical

programs to encourage clinical field trials to fulfill the
AA tee atte

intent of the Report of the President's Commission on

Heart Disease, Cancer and Stroke. The Committee realizes
that plans for such programs must develop out of the thinking
of State and local regional advisory groups. However, the
testimony received indicates that these local groups are
eager to conduct such field trials, but they need encourage-
ment and technical assistance from the top administrative
officials of the regional medical programs. This encourage-

ment and technical assistance should and must be provided."

Clearly, the Atromid-S earmark and previous earmarks in the
Regional Medical Program are symptomatic of things that we can expect
in the future. It's important to emphasize that the Congress has given
us very Clear signals that they expect this kind of program to be carried
out under regional medical programs. It's up to us, those of us here
in the Division and all of you in the 54 Regional Medical Programs, to
figure out how we can carry out these programs so as to strengthen,

rather than damage, the regional programs.

Another item that appeared in the Senate Committee Report on our
authorization bill was a reference to kidney disease activities under
regional medical programs. There was no earmarking of funds, but the
Committee did say that they “heard testimony which confirmed that there
is sufficient relationship between kidney disease and heart disease to

include kidney disease within the scope of regional medical programs

as a 'related disease.'" They also went on to say that "Regional Medical
Programs offer an appropriate and effective framework for the exploration ©
of the best approach on a regional basis to the great challenges presented
by the prevention and treatment of acute kidney disease. The Committee
wishes to encourage the use of the regional medical program mechanism

for this exploration of how to deal most effectively with the ravages

of this disease. .- " Thus, the Committee is telling us that planning
for taking care of the kidney disease problem is an appropriate activity
in regional medical programs. ‘This does not seem to us, however, to call
for change in the previous policy of regional medical programs not to

support service programs such as hemodialysis therapy.

Merger of Activities of National Center for Chronic Disease Control and
Regional Medical Programs

As part of the recent reorganization, a major portion of the
National Center for Chronic Disease Control was moved over to form, with
the Division of Regional Medical Programs, a new organization called

- the Regional Medical Programs Service.

A consideration.of the origin and functions of the Chronic Disease
Center shows, I think, the logic of this move. Indeed, the principles
and concepts which led to the formation of the chronic disease program
are quite similar to those that led to the regional medical programs.
Both involve an attempt to find ways to foster and promote the application
of the latest research advances in the care of persons suffering from
chronic diseases like heart disease, cancer and stroke. Indeed, certain
program elements of the chronic disease program had their origin as

elements of the National Institutes of Health in order to promote
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application of research findings.

The Division of Chronic Diseases, as it is now called (and
this interestingly reflects a reversion to the name used prior to the
last reorganization of the Public Health Service), includes eight |
categorical programs, most of which are disease categories. These are
cancer, chronic respiratory disease, diabetes. and arthritis, heart
disease and stroke, kidney disease, neurologic and sensory diseases,
the nutrition program, and the National Clearinghouse for Smoking and
Health. The mission of this Program has been to foster the development
of improved methods for the prevention and control of chronic diseases
and to promote application of these methods. ‘The developmental effort
has been carried out through the contract mechanism, by supporting
projects to develop, test and evaluate improved health services related
to the categorical diseases. An example or two may serve to clarify

this function.

Soon after research developments in hemodialysis for end-stage
renal failure made long, continued dialysis therapy feasible, centers
were supported throughout the country by the Public Health Service
through grants for carrying out dialysis in the hospital. It was
immediately apparent that something needed to be done to reduce the
cost of this procedure in order to make it available to the large
numbers of persons needing such treatment. The Kidney Disease Control
Program, therefore, in 1967 initiated a contract program to test the

feasibility of home dialysis. Twelve institutions received contracts
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to train patients for home dialysis and to gather and supply the

necessary experience data on which to evaluate this technique. This

Study is currently in progress.

A somewhat different exampie is the coronary care nurse training
program initiated by the Heart Disease and Stroke Control Program. Back
jn 1965 and 1966, when more and more coronary care units were being
established, it was apparent there was a need for training programs to
prepare the nurses for their responsibilities. Ten programs were
developed under contract to serve a5 models for the kind of training
program that was necessary and to begin to supply at least a small
proportion of the need. Some of these programs are phasing into

Regional Medical Programs.

The relationship with Regional Medical Programs, I think, is
fairly obvious. Both Programs are concerned with fostering the application
of new improved techniques for health services. The one, Regional Medical
‘Programs, is concerned primarily with organizational framework and
cooperative arrangements whereby this application will take place. The
other is concerned with the content of the individual health services. |
Dr. Olson presently heads a task force which is looking at the way in
which these efforts can best be carried out and coordinated in order

to achieve the objectives in a way which will be mutually supported.

The two Programs represent a somewhat different approach. In
the one case, the ideas and proposals are developed peripherally and

reviewed and approved centrally. In the other case, the ideas are
developed at the Federal level, usually with the advice of expert
“committees, and carried out peripherally through contracts. We must
develop ways in which these two efforts can be carried out in order to
be mutually supportive. The situation is perhaps somewhat analogous

to the matter of Congressionally earmarked funds.

In sum, we feel that this is a very important favorable new
development .and we will be looking for ways in which the Division of
Chronic Disease and the Division of Regional Medical Programs can work ..

together to achieve common goals.

Relationships Between Comprehensive Health Planning and Regional

Medical Programs

I am sure you are all concerned and involved in the relationship
between Comprehensive Health Planning and Regional Medical Programs. An
effort is under way at this time within the Health Services and Mental
Health Administration to clarify this relationship. I can't say that all
the i's are dotted and all the t's crossed, but a fairly clear, and I

think workable, delineation seems to be emerging.

Both programs are concerned with improving health care. Two
elements can be identified in this effort--one involves the setting and
the resources available for care--the other involves the substance, the
quality, of care. It seems clear that planning agencies are primarily
concerned with the first of these two elements. Comprehensive Health

Planning is the mechanism for determining the needs for health facilities
and health personnel,. for finding out how to meet these needs, and
setting the appropriate plans in motion. It is quite appropriate
that the consumers of health care play a prominent role in this kind

of planning.

The second element, the substance of care, or the quality of
care, is clearly the area of concern of regional medical programs. The
whole thrust of the cooperative arrangements in regional medical programs
is to assure that high quality care is available, that mechanisms are
set up whereby the latest research findings in health services will be
quickly added to the armamentarium of physicians who have the responsi-
bility for primary care of patients. Thus, physicians and other health

personnel are the prime constituency of regional medical programs.

Background on Arthur D. Little-OSTI Health Policy Research Contracts
with Division of Regional Medical Programs

. In early August we advised each of you by letter of a health
policy research study relating to Regional Medical Programs being
undertaken by Arthur D. Little and the Organization for Social and
Technological Innovation. As that letter indicated, the purpose of
this Study is to assess the present status of the total program,

progress to date, and its actual and potential impact.

The genesis of this Study, and its desirability, dates back

nearly a year. A number of us, and particularly those in Planning
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and Evaluation who had had a major role in pulling together the
required Report on Regional Medical Programs to the President and the 7
Congress, felt it would be desirable to have a group of experienced,
perceptive, outside observers look at the program--a multi- disciplinary
group that could bring a special set of talents and abilities to the
task and that might lead to fresh and perceptive insights of Regional
Medical Programs easily overlooked by those of us involved in its

day-to-day administration.

As a result, an ad hoc group of key Division staff - developed
the specifications and screened the 96 firms which expressed interest
in doing the work. Eventually, five firms were selected and requested
to submit proposals. That submitted by Arthur D. Little, Inc., and
the Organization for Social and Technological Innovation, as a sub-
contractor, was judged as best by the ad hoc ‘group and a contract was -.
awarded in late June. Both of these organizations are experienced in

health matters and have a staff of high caliber.

Four major areas are highlighted for analysis under the Study.
These are: |
(1) Regionalization - A history of past regionalization efforts |
in relation to the development of Regional Medical Prograns
and a descriptive report of the organization components and
operations of the program with emphasis on cooperative

arrangements, regionalized involvement and decision-making. —
(2)

(3)

(4)

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Evaluation Indicators for Regional Medical Programs - A
description of accomplishments from the point of view of
the Regions, a survey of evaluation techniques in use or
available, and descriptive statements which suggest the
utility of projects in moving toward the goals of the
program. An important product of this aspect hopefully
will be criteria which give the Division insight into
the ways it should be looking at the progress of the |
Regions and give the Regions insights into evaluating

their own programs.

Economics of Regional Medical Programs - The object
here is to express the behavior of RMP in economic and
financial language to permit the future development of
cost and benefit analyses. Projections of future costs
and the relationship of the Program to health care costs

generally will be identified and described.

The Relationships and Commmnications Flow Between the
Division and the Regions - The consultative and |
supportive role of the Division will be reviewed
along with the regions' perception of this relation-
ship. It is hoped that suggestions will be made
leading to a better two-way flow of information and

consultation.
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Let me emphasize that the purpose of this Study is not to
- evaluate individual RMPs, but rather to gain a better tnderstanding
of the nature of the regionalization process we have set in motion

and how to improve it.

In the initial phase of this Study, the ADL-OSTI group visited
several regions including Iowa, California, Western Pennsylvania, and
Georgia, and have talked with many of the people in the Division and
other parts of the Public Health Service including Dr. Shannon,

Dr. Marston, Mr. Lewis and Mr. Yordy. They also have been reviewing
applications and related materials on hand in a Division in order to
gain a better understanding of the Program and its operations preliminary

to moving ahead in the substantive areas I briefly outlined.

You may well be contacted in ‘connection with this Study as it
proceeds since the contract envisages an in-depth study of several
Regions. Selection of these Regions will be made in consultation with
the Division and the Regions specifically concerned. Your support and

cooperation, needless to say, will be appreciated.

In concluding, let me note that Roland L. Peterson, Acting
Associate Director for Planning and Evaluation, is the Project Officer
for the Division on this contract, and that Dr. Phillip Donham is the

case leader for. ADL-OSTI on this Study.