REPORT FROM THE DIVISION*

Stanley W. Olson, M.D.
Director
Division of Regional Medical Programs
Health Services and

Mental Health Administration
Bethesda, Maryland

*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.

 
The office I now hold, Director of the Division of Regional Medical
Programs, is one to which Dr. Robert Marston lent such great distinction ~
as he guided the Division through its first formative years. Under his
leadership, Regional Medical Programs received wide acceptance, and a
functioning Program was launched in a remarkably short time. We in the
Division of Regional Medical Programs, and you who carry major responsibility
for the 54 programs now covering the country, are faced with the difficult
task of managing an ever-increasing load of responsibility. We must guard,
as Dr. Marston has done, against the emergence of bureaucratic ‘rigidity |
We must continue to foster, instead, the spirit of innovation and

creativity.

Most Regional Medical Programs were faced with the difficulty, at
the outset, of judging how best to approach the complex task of achieving
voluntary, functional, regionalization. The Division of Regional Medical
Programs and its National Advisory Council wisely resisted the temptation
to establish a model which could be adopted by those Regions for their
planning. The all-too-easy solutions offered by experts in systems
analysis organizations were also rejected. Instead, leaders in each of
the developing Regions began to cope with the unique relationships
peculiar to their own area. Initial planning efforts were directed
toward the creation of a climate of cooperation within which regionalization
among traditionally independent, autonomous elements of our pluralistic

health care system could proceed.

 
-2-

I am no more inclined to prescribe a national pattern or model for
‘the Programs than those who have guided it so well in its beginning years.
It is possible now, however, to describe some of the locally derived
features that characterize those Programs which are meeting with success
in achieving regional objectives. This is information which I believe
will prove useful to all Regions, and will assist them to formulate

better solutions to their own problems.

I should like to describe the elements that characterize successful
Regions:

Success in this, as in every large-scale, practical endeavor, has
been unequal and progress has been uneven. And while it is true that no
single Region has as yet achieved full regionalization, some are clearly
more advanced than others. The success of the more advanced Regions
can, I believe, be attributed largely to several significant, common
characteristics, specifically, leadership by the program coordinator,
organized commitment of the health power structure, sound program concept

and design, effective implementation of program, and evaluation of progress.

The first of these critically important attributes is strong, dynamic
leadership. Progress in regionalization frequently comes through the
leadership of a single individual, the Program Coordinator. This is not
to say that leadership must be "singular.'"' Clearly, a larger leadership
element than that of the Program Coordinator or of any other single
individual is required; but the ability of the Coordinator to mobilize
the larger leadership within the Region is often determinative of its

success. He exercises personal leadership to secure organized institutional
-3-

commitment, as well as individual support, for Regional Medical Programs,
support which is essential if the Program is to wield-the influence
required to bring about significant change. I should like to comment on

some of the observed actions of effective Coordinators.

Coordinators secure the confidence of leaders in the medical centers
in their Regions, or practicing physicians and hospital administrators,
and gain their understanding and support. They establish contacts with
key health leaders of the Region to evoke from them a working commitment
for Regional Medical Programs. They acquire information of the health
characteristics of the Region, its resources, its problems, its politics

and its style of getting things accomplished.

The successful Coordinator exhibits his leadership by attracting
a competent and respected staff. He develops an organizational framework
to perform the functions of administrative planning, implementation and
evaluation. His core staff is diversified and includes physicians,
nurses, hospital administrators, education and public information
specialists, allied health personnel, experts in behavioral sciences,
and others. Such professional diversity among the staff contributes to
a rounded and balanced program. The Coordinator typically is full time.
Undertakings of the magni tude of Regional Medical Programs do not flourish

under part-time leadership.

A number of universities and medical centers have assisted in the

recruitment of able Program Coordinators (and of other key staff members)
-4-

. by offering academic and staff appointments. Such appointments facilitate
access to the academic and clinical resources of the medical center and

to the faculty.

Those institutions which have sponsored Regional Medical Programs are
not likely to find individuals with all the capabilities described above.
They can, however , select with care individuals who have administrative
ability and have had experience in dealing with health care problems both
in the medical center and in the community. Having appointed the
Coordinator, they have a responsibility for maintaining a continuing
relationship with him. He will welcome all the guidance and support he

can obtain as he negotiates for the involvement and commitment of the

groups described above.

The Division of Regional Medical Programs, too, has a responsibility
in this regard. The staff of the Division has discussed ways in which
it can provide relevant information to Coordinators as they and their
staffs and their Regional Advisory Groups address the task of securing

funds through the grant application route.

We are prepared to structure a series of three to four-day seminars
in Bethesda for groups of Coordinators to discuss in depth with them the
organization of the Division of Regional Medical Programs, its administration,
its resources, and its grants review and management procedures. We hope
also to use this seminar as a medium through which Coordinators may
supplement their knowledge of Regional Medical Program activities

throughout the country. This undertaking, which will necessarily be
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experimental at the outset, will be carried on under the guidance of
Dr. Richard Manegold and his staff, and we shall be prepared to initiate
the first of these seminars as soon as we have requests for participation

from a group of six to ten Coordinators.

Beyond that we are making plans now to experiment with a "war games"
approach to teaching the techniques of long-range planning. Dr. George Miller
and his staff at the University of Illinois College of Medicine have agreed
to put on a program of this kind as a substitute for one of the irregularly
scheduled sessions on medical education, probably in June 1969. We shall
make announcement of the course as soon as the details of the program can
be formulated and distributed. In the discussion sessions that will be
held during this Conference we should welcome any comments or suggestions

you may have about either of the above proposals.

Organized Committment of the Health Power Structure: The successful
Coordinator recognizes the critical elements in the health power structure
and the order of priority in which they must be brought together,
actively involved, and committed. The key groups with which he deals
include the following:

Medical Centers and Medical Schools - These have provided much of the
initial Program impetus. A close relationship between them and the Program
must continue because medical centers constitute a reservoir of professional
expertise and competence that must be drawn upon for the transmission of
new knowledge and techniques. They have considerable potential for

serving as a "change agent" and they are a highly specialized resource
-6-

. for obtaining quality health care. This is not to say that medical schools
can or should control the Program. To the contrary, continued exercise of
control by this or by any single institution or group will impede and
retard the involvement and commitment of other key groups. But without
medical center involvement and commitment, there is little chance that the

Regional Medical Program can succeed.

Another important group includes practicing physicians - and by
extension, State medical societies and their component organizations.
It is essential that practitioners be involved in Regional Medical Programs.
Not only are they the first point of contact with the health care system,
but many significant improvements in the quality of care and in the health
status of a population can be achieved only through their direct efforts.
But simply "involving" individual physicians is not enough. Organized
medicine -- State medical societies and their component organizations --
must participate in the Regional Medical Program decision-making process.
In terms of the health power structure, organized medicine represents the
collective voice of physicians. We have seen instances where failure to
involve these groups in decision-making has created obstacles to program

advancement.

 

A third and equally important group includes hospitals. They

represent the major institutional focus for health care in this country.

Diagnosis and treatment are increasingly hospital-oriented and hospital-based.

Moreover, the hospital represents an important interface with the community
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which surrounds it and represents both the providers and consumers of
health care. The involvement and commitment of the hospitals, therefore,

must be broadly structured to include the administration, medical staff,

and trustees.

Fourth, Official and Voluntary Health Agencies - It may be easy to
overlook these groups or to wait for them to ask for participation and
then to expect from them only a nominal contribution. Such a policy is
short- sighted and self- defeating.

State and local public health agencies play a significant

role in the provision of health care. No Region can afford
to ignore or proceed without the understanding and backing
of city and State health officers, many of whom have the |
ear of a Governor or a Mayor. Moreover, the statewide and
areawide comprehensive health planning agencies, which will
play an increasingly important complementary role in
structuring the health care system, are by law related to
State and local governments -- often through their health
departments.

. Voluntary Health Agencies such as heart associations and
cancer societies have a real contribution to make. They
have built up a commmity organization which can be a
source of education, support, and leverage within the
commnity. This apparatus can be made available to
Regional Medical Programs to sponsor training and to

assist in other operational projects.
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The Regional Advisory Group is the voice of the health power structure.

 

Public Law 89-239 established it as an essential component of a Regional
Medical Program and defined its responsibility in the same broad charter-like
terms that characterize the other components of Regional Medical Programs.
The Guidelines issued by the Division of Regional Medical Programs described
the responsibilities of the Regional Advisory Groups in more precise terms.
In this discussion of the elements that characterize the more successful
Programs, I should like to describe how Regional Advisory Groups are
relating to sponsoring organizations and to comment on the specific
functions they perform. Some Regional Medical Program sponsors look

upon the Regional Advisory Group as a body which the law requires be
established but whose function is a nominal one, that of approving
operational grant proposals. It may be looked upon as a force which
threatens the role of the sponsoring organization. Not infrequently the
chairmanship of the Regional Advisory Group is retained by the chief
executive officerof the sponsoring organization as a means of controlling
this aspect of the Program. The fear may exist (although evidence to
support this fear has been notably lacking) that Regional Advisory Groups
may exceed the policy-making functions assigned them in the law and in

the Guidelines and seek administrative control of the Program. We are
pleased to note that many sponsoring organizations clearly recognize

that the Regional Advisory Group must become the dominant organization
expressing policy on behalf of all cooperating health interests in the
Region. One such institution -- the University of Washington -- has
identified its role as that of administrative trusteeship, which means

that it will exercise the obligations imposed upon it with respect to

a1.

Adminictrativwea naliciac whiten at tha anna #20 2 te
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Regional Advisory Group to assume an ever more significant role in

guiding and directing the policies to be followed as the Regional

Medical Program develops.

It clearly takes time for a Regional Advisory Group to become
organizationally mature, to come to grips with important policy problems,
and to begin resolving them wisely. Where Regional Advisory Groups are

functioning actively, one find that they have a membership that comprises
the leadership of the major health interests and power groups of the
Region (i.e. medical centers, practicing physicians, organized medicine,
community hospitals, and other groups). Not only are they geographically
representative, but they include strong public representatives who have ~
significant regional influence and social and economic "clout".
Where they are exercising 4 real trusteeship, the groups have a significant
and substantive voice in setting policy. They determine the overall
scope, nature and direction of the Regional Medical Program and establish
priorities. They provide a forum for the forces of change as well as for -

the traditional health power structure.

It is too early to determine whether those Regional Advisory Groups,
which are functioning under the chairmanship of the chief executive officer
of the sponsoring organization, will in fact become a representative
voice of the many elements of the health power structure in the Region.
This arrangement at least has the saving grace that its actions are

closely coordinated with those of the sponsoring organization.
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those who provide care. Categorically oriented, it has a strong technological
bent -- the latest advances in heart disease, cancer, and stroke and related
diseases, but it is concerned with linking as well as strengthening health
resources, a linkage which is the essence of regionalization. A Regional
Medical Program requires a wholeness of program that cannot be achieved by

an aggregation of loosely related projects; it fosters innovation and change --
not in the relationships between physician and patient, but in the

relationships among providers of health service.

‘Thus, Regional Medical Programs emerges on the American health scene
as a voluntary mechanism that depends upon the organizational behavior of
health-related institutions -- a "coalition politics" of health, if you will.
This is as mich a part and parcel. of Regional Medical Programs as is the

substance of the information related to the latest advances in heart disease,

cancer, and stroke.

Against this background which represents the broad national policy
establishing Regional Medical Programs, let us look at some of the specific

patterns we see emerging.

Mariy Regions are in the process of developing a "grand design" that
will permit them to proceed with specific projects, each of which will
fit into the larger pattern. This process is not unlike the one we are

using to create the Interstate Highway System for our country.
- 12 -

Initially, some Regions have placed greater emphasis on action,
others on planning for action, but the following tactics have been fairly

common to all Regions:

Their planning may best be described as "consensus" planning,

that is, once leadership has emerged and organizational

involvement has begun, certain immediate needs and problems

were so obvious that they could readily be agreed upon. Similarly,
_ there were available certain kinds of ready solutions, such as

coronary care units and continuing education programs, which also

could be agreed upon as ‘mechanisms for initiating operational

activities.

The more advanced and successful Regions have moved from the initial
consensus planning to the establishment of long-range planning. This has
been expressed by the creation of categorical and other task forces, of
special committees at the regional level, at the subregional or community
level or even local action groups within the community. The achievement of
this kind of layered planning contributes to better understanding at all
levels and provides a mechanism for achieving widespread involvement and
commitment. Properly done, it requires a great deal of organization and
supervision from the core staff. As these planning groups address themselves
to specific problens of diagnosis and treatment for heart disease, cancer,
‘stroke, and related diseases, the need for an adequate data base becomes

ever more apparent. The data available is often fragmentary or lacking
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and Regions are then faced with the decision as to whether they should
begin to collect the data they need. It is well recognized that we have

as yet no adequate national system to collect the data required for
effective management of health care. Scattered and sporadic efforts to
collect data will not solve the national problem; not only is the
information derived from diverse sources not comparable, but data which

is not continuously updated prevents its most effective use -- to tell us
how well we are succeeding. Without such a mechanism, the cross-sectional
data obtained by local groups have only limited value. Scanty as it is,
however , such data as is available must be used by planning groups to

make appropriate analyses and to derive as much benefit as possible from it.
Regions are reluctant, and properly so, to set up elaborate data collecting
mechanisms. We continue to look for the early development of this

critically important national health tool.

Regions developing their strategic plan may begin with a realistic
assessment of the elements peculiar to the Region, including such things
as resources, gap areas, regional ecology and traditional attitudes within
the Region. We see emerging in certain complex multi-medical, center
Regions, a geographic or functional division of responsibility with specific
areas assigned to each medical center. Division of geography tends to
delineate responsibility more clearly; it permits those areas, which for a
variety of reasons may be able to move ahead more quickly, to do so --
the pace of all is not determined by that of the slowest element. It is
too early to tell whether such division within the Region will, in the

long run, advance the program.
In the more successful Regions one sees this in terms of a subregional effort

and identity based on referral patterns corresponding roughly to what might

be termed "health market areas."

In sum, we see that Regions are:
Making cooperative arrangements the guiding principles for action.
Encouraging and even Suggesting projects and Proposals that fit
that strategy, |

- Promoting efficiency in terms of regional health manpower and
“other resources,
Fostering interagency relationships and communication,

Striving for adequate program balance,

Two examples: We can cite one Region which has adopted as its
Strategy the establishment of a series of hospital-based centers of
excellence for heart disease and for cancer throughout its Region.

It hopes Subsequently to add facilities for excellence in stroke also.

In another Region the Strategy has been described as a series of
related thrusts. The first of these thrusts concerns approaches to
improving the effectiveness and efficiency of patient care at the local
level. The second concerns the development of working partnerships
between key hospitals and one of the university medical centers leading
to the creation of a "third faculty." The joint appointment of. full-time

chiefs of service in selected hospitals would be made by agreement between

 

me
ore

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the hospitals and the medical center. A third thrust is concerned with .
smaller hospitals which often cannot support the implementation of many
of the recent advances in diagnosis and therapy. A proposal has been made

to develop selected services on a centralized basis, and alternately to

strengthen other specialized services on a decentralized basis.

Effective Implementation of Program - Given leadership, the involvement

and commitment of key health groups (including the effective functioning

_of the Regional Advisory Group), and a carefully thought out regional

strategy or design, there remains the problem of formating operational
activities for implementation of the Program. It is in the implementation |
or action phase where the impact of Regional Medical Programs may best be .
seen. .

The more adequate the implementation, the greater its impact will be
in terms of overall Program visibility. Properly achieved, this visibility
will encourage local identification with the Program on the part of the

medical centers, the hospitals and the physicians in the Region.

Decisions as to what kinds of operational activities to undertake
have, in the main, been governed (consciously or unconsciously) by a
short-range strategy aimed at demonstrating success and achieving visibility.
These general tactics have characterized even the most successful Regions.
On the other hand, just as initial consensus planning must be superseded
by long-range planning, so the initial tactics and "off the shelf" solutions

must be superseded by the development of long-range projects.
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The initial operational projects not only provide evidence of regional
strategy, but reflect regional cooperative arrangements. They are not
just isolated projects aimed simply at expanding and advancing the diagnostic
capabilities of individual institutions, physicians, and other health resources.
But they illustrate realistically how cooperative arrangements among medical
centers, hospitals, and physicians can be implemented. - —_

One sees, for example, as in Louisiana, four hospitals in the same
community pooling their resources in cooperation with the State Heart
Association and one of the medical centers to establish a single, high quality,
coronary care demonstration and training unit. This unit is designed to
improve the care ‘of all patients with myocardial infarction in that area.
Instances such as this provide the real test of regional cooperative
arrangements. When individual institutions are, in effect, required to
give something up, or to do things differently than they have in the past,
one may judge whether these institutions are truly willing to move from a
competitive approach in the solution of health problems to a cooperative one.

In the Washington-Alaska Region, we see the example of a high- energy
radiation source > planned for one of the Anchorage hospitals. No longer
will patients - in that vast subregion have to travel to Seattle or elsewhere
for such treatment. . Planned and approved by both local and Regional
Advisory Groups, the radiation unit will be operated as a regional resource.

In a funded operational project of the Georgia Regional Medical Program,
the faculty from two medical centers will travel to institutions participating

‘in the development of hospital-based centers of excellence. Consultants

will see patients with practicing physicians in those hospitals and will
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utilize the consultation mechanism to promote the continuing education
of both physicians and allied health professionals.

Similarly, one already sees in the early operational proposals
of many successful kegions, an indication of concern for and attention
to program balance. Needs in stroke and cancer are being addressed
as well as those in heart disease, which appear to be more readily
identified and dealt with. Areas of prevention and rehabilitation are
not being ignored. There is functional balance among research, training,

continuing education, and patient care demonstration activities.

Evaluation of Progress

 

We come finally in our consideration of the characteristics of
successful Regions to the subject of evaluation.

Adequate data is, of course, essential to proper evaluation. AS
noted before, we are badly handicapped by the lack of data concerning
the quality of care. We suffer especially froma lack of data concerning
the ambulatory care of patients. We know next to nothing about quality
of care provided in physicians' offices. We are plagued, too, in evaluating
Regional Medical Programs because we are not entirely sure what our
"product" is. It may, indeed, be true that in Regional Medical Programs ,
as some say about television, "the medium is the message."

If we are having difficulty in evaluating our efforts, we are surely
not alone in this respect. Nor should we be prevented from moving forward
simply because our evaluation techniques are not as clearly defined as
we should like them to be. If one considers such as a venerable social

institution as education, we find that it has served us well for centuries
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even though many observers today believe it has a faulty evaluation
system. Success in education has been judged by measuring the amount of
retained knowledge. This way of measuring success has influenced teaching
and learning techniques for a very long time. Those techniques are being
changed as we begin to reach agreement that it is more important to judge
the change in behavior of students than to measure the amount of knowledge
that can be reproduced on an examination.

But the existence of difficulties and problems in no way minimizes
the -importance of evaluation for Regional Medical Programs. To the contrary,
evaluation is critical to our effort and much more attention must be paid
to it in the immediate years ahead. .

In almost one-third of the Regions we find neither evaluation staff
nor consultants in this field, and only one-half of the Regions have
developed an organized approach to evaluation. Some have highly-developed
efforts. For example, the North Carolina Regional: Medical Program has a
Division of Planning and’ Evaluation, headed by a prominent medical sociologist
and a competent staff. It is making a major effort to incorporate
evaluation as an integral part of the overall regional effort. The
evaluation division of that Region works closely with the executive committee
and the Regional Advisory Group and will seek to determine the progress of
the Program in meeting its stated objectives. In making this analysis, the
effectiveness of each project in changing the status of health care will
‘be ascertained. In addition, it will be the function of the Region's
Division of Planning and Evaluation to work closely with each project

director to assure the inclusion of evaluation procedures.
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A Look at the Future

Let us now turn from what we have been doing, and look to the future

of Regional Medical Programs.

| To begin with, we might look at the immediate future. Clearly, we
are moving from a circumstance in which there has been a surplus of funds
(at times an embarrassing surplus) to one in which the reverse will be
the case. Based on applications in hand, we can predict that the aggregate
demand for grant funds will exceed our appropriations in the fiscal years
1969 and 1970; and beyond that, the amounts which the Review Committee
and the National Advisory Council will likely recommend for approval will
also exceed the available funds.

This matter was discussed in.depth by the National Advisory Council
at its meeting in August of this year. The Council has indicated it will
continue to judge programs and operational grant applications on the basis
of quality. They have rejected the principle of a distributive mode for
the allocation of funds based on population or geography. Inevitably,
this policy will lead to a backlog of approved but unfunded applications.
I know of no better way to bring to the attention of the members of the
Congress the requirements for adequate funding, than to present such a
record. This is particularly necessary because in the past the Congress
has expressed impatience with the slowness with which the Programs have
developed, and with the disparity between the amounts of funds authorized

and appropriated and the amounts actually spent.
- 20 -

These policies recommended by the National Advisory Council bear
directly on the application and approval process at both the national and
regional levels. It does not appear possible to provide applicants with |
an appropriate review within a three-month period. A review of multimillion
dollar grant applications requires critical analysis by our own staff,

a site visit by a team of consultants and staff members, analysis of the
project by the Review Committee and finally, consideration by the National
Advisory Council. Applications which are well organized and lend themselves
to orderly review will ordinarily be acted upon within four months after
application deadline. In general, they will be acted upon in the order
received.

Beginning with the next fiscal year, the number of annual review
cycles will be reduced from four to three. The deadline dates for submitting
| applications, tentatively, will be August 1, December 1, and April 1;
but you will be given definitive information on this matter.

We are attempting to define the appropriate input of each group to
the review process. We shall expect the staff in its review not only
to summarize the proposals but to express judgments which can be clearly
identified as staff judgments. We are looking critically at the function
of the site visit teams in order that the contribution of this important
group may become more effective. You may expect that the procedures
with respect to site visits will change as we attempt to identify the
" specific contribution this group can make. We are asking the Review
Committee to make an objective scientific and technical evaluation of

applications rather than to make value judgments. This latter function
21

is properly the responsibility of the National Advisory Council.

During the developmental phase of the Program, minimal standards
were set by Council as a means of insuring quality and insuring also that
every Region would be encouraged to begin the task of regionalization.

As we enter a period in which. funds exceed requests, Regions will be
judged competitively.

We shall look to the Regions acting in their own self interest to
improve the quality of their applications. Evidence that the applicant
is moving in the direction of the longer range goals and objectives which
it has set for itself in its strategic design will have great weight.
Individual project proposals will be reviewed to determine how they
relate to the Region's own grand design. Review groups will look for
the relationship of individual projects not only to the overall Program
concept but to each other. They will expect clear descriptions of what
is intended to be accomplished, set forth in specific and, where possible,
quantifiable terms, to insure that evaluation of progress and success
will be undertaken. (In a program such as this with its emphasis on
innovation, both sociological and technological, we must expect some
projects to fall short of expectation. What is not tolerable is failure
to distinguish between effective endeavors and those that lack effectiveness
in improving care. We must learn to make such distinctions and to alter
or abandon projects based on these judgments.)

We shall look for evidence that the application has been given a
discriminating and qualitative review at the regional level so that only

those projects are sent forward which (1) have merit, (2) are capable of
- 22-

implementation, and (3) are clearly related to the Region's _ strategy.
for regionalization.

We shall look for better information about the role of. the Regional
Advisory Groups, not only with respect to how they review and evaluate

specific proposals but how well they function in setting the overall

direction and scope of the total program.

The degree to which many applications have failed to reflect accurately
the actual degree of development achieved within Regions is perhaps best
indicated by the experience of site visit teams. Their reports have
frequently materially altered or reversed the preliminary impressions

obtained from the written applications by staff, Review Committee members,

and Council.

Other Issues

I should like now to comment on two major issues relating to Regional
Medical Program objectives that have been interpreted as imposing divergent

pressures on the regions. They are the problems of the cities and

continuing education.

The first issue relates to the matter of how Regional Medical
Programs may serve an effective function in improving the care received
by the large population groups in our cities and especially that received
by our poor and disadvantaged groups living in the ghettos. The complex
problems our cities present, pose a national crisis of the gravest order.
| The health of the poor who live in the cities is of deep concern to

Regional Medical Programs. True, we suffer from several constraints
- 23-

as we attempt to deal with this problem. Facilities are needed, but we
have no authority to use funds for construction of facilities. Neither
may grant funds be used to pay for the cost of medical services or the
cost of hospitalization. Nevertheless, there are major contributions
which Regional Medical Programs can make but which can be made only if

we understand the nature and mechanisms to be employed in Regional Medical
Programs, and understand also the nature of the problems faced by our
cities in improving health care for the poor.

The long-established system for the health care of the indigent is
now in the process of major change. Over the next seven to ten years
more dollars can be expected to be placed at the disposal of the indigent
to purchase their care. The process for doing so is only now being
structured and we are in that unhappy period of transition when the old
system is being allowed to deteriorate and new solutions have not yet
become effective. The problem with us today is that many of the poor
have neither an adequate indigent type of service nor funds to purchase

their own care.

If there is any group which should be in the fore in creating a new
system of health care for the urban poor, it is the providers of health
care. Regional Medical Programs are functioning organizations specifically
designed to link the providers of care together for the purpose of
collectively improving services to patients. These Programs can and should
contribute significantly in planning general health services for these

populations because it is only in this fashion that we can come to grips
- 24 -

specifically with the problems of heart disease, cancer, and stroke.
Regional medical Programs can assist in the improvement of health service
activities through projects that supplement elements of both old and new
systems aimed specifically at the urban poor. To do this, Regional Medical
Programs must enter into cooperative arrangements with the many local and
Federal programs already addressing themselves to health problems of the
urban poor. But regions must first be able to function as Regional Medical
Programs. We recognize that the complexities involved in developing
regionalization in urban areas have delayed the development of regions
in the very areas where their services may be most needed. This is a
matter to which I have already given a great deal of my time and to which
I am prepared to devote more of my personal efforts. |

The second issue is that of continuing education. From the beginning
there has been some degree of controversy about the role and significance
of continuing education in Regional Medical Programs. There were some
who saw continuing education as the whole program. Others saw very little
purpose to be shia by supporting the kinds of ineffective continuing
education programs which rely mainly on 1 information. transfer, which reach
relatively small numbers of physicians and which appear not to change the
behavior of physicians to any significant degree.

I am convinced that continuing education is the most significant
single component of Regional Medical Program activity. What is at issue
‘4s not whether we should support and extend continuing education but what

kind of continuing education-we should encourage. Efforts of Regional

 
- 25 -

Medical Programs in this field must improve both the knowledge and skill
of physicians, nurses, and other providers of health services. They must
encompass a variety of innovative techniques which will involve them in
an active rather than a passive role. These efforts should result in
behavioral changes leading to improved diagnosis and treatment of the
patients they serve. Further, our continuing education efforts and
activities mst be structured in a way that promotes the cooperative
linkages upon which the ultimate success of Regional Medical Programs
will depend.

Having identified these two issues which would seem to be polarized,
as are so many national issues today, on the needs of the cities versus
the needs of the rural areas, I should like to reject firmly the notion .
that we are unaware of the health needs of the rural poor or. the importance
of including them as beneficiaries of a system of voluntary functional
regionalization. Equally, I should like to reject the notion that physicians
in the urban areas are not in need of continuing education simply because
of their proximity to the centers of learning. In our larger cities
many physicians practice independently, without hospital appointments,
and are subject to none of the influences which are of major benefit to
all physicians who do conduct a substantial part of their practice in an
organized hospital setting. We can ignore neither these physicians nor

the patients they serve.
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In the presentation I have just made,some of the factors leading
to the establishment of successful Regional Medical Programs have been
described. Special problems such as those encountered in the larger
urban areas have also been identified. We have shared with you some of
the management problems associated with a very large and complex grant
program. |

But we are wide of the mark if we regard Regional Medical Programs
simply as another Federal program which uses grant funds to implement
a specialized objective. The categorical restraints in PL, 89-239 are
Clearly recognized. But equally recognizable are the legislative actions
which have broadened the program to include additional related diseases
and to use the Regional Medical Program mechanism for such activities as
clinical trials.

The true significance of the Regional Medical Program effort can be
understood only if we recognize that a test is being made, nationwide,
to determine whether the quality of health services can be continuously
improved by means of voluntary, functional regionalization. We are |
engaged in resolving an issue of critical significance to the future of
the American health care system -- a system which in the aggregate involves
the life and welfare of 200 million persons -- a system in which more
than $50 Billion is invested anmually.

The best estimates we have of the cost of a fully established
regionalization program suggests that we may require $400 to $500 Million

annually. If these figures are realistic we should be planning the
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structuring of a system that will involve every element of the health
care process. We are called upon to perform this task at a time when our
country is beset with severe economic problems. We are faced with the
necessity for establishing our national priorities at a time when there
are many urgent problems to be solved, each of which requires large
sums of money. Regional Medical Programs are under real pressure, therefore,
to. present evidence that this Program does indeed have the potential for
improving the quality of health care that its advocates have held out.
Ours is a program that has its primary impact on the providers of
care rather than on the public directly. We depend, therefore, on those
professionally involved in health care to interpret the success of our
efforts. They in turn must communicate their understandings of the value
of the Program to the Public and to the Public's representatives in the
Congress.
We are only now beginning to see the results of our efforts over
the past two and one-half years. The limited evidence we have of the
validity of the Regional Medical Program process must be used as feed-back
into the system to guide our own further planning efforts. It mist be
used to inform the groups most directly interested in Regional Medical
Programs about its effect on health care. It must also extend the

base of cooperation upon which Regional Medical Programs ultimately will

depend.