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ISSUES AND CONCERNS - I*

Marc J. Musser, M.D.
Program Coordinator
North Carolina Regional Medical Program

*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.
Each of the serles of meetings we have had here In Washing-
ton since January, 1967 has come to be a landmark In the evolu-~-
tion of Reglonal Medical Programs. Each has concentrated upon
the compelling circumstances at 6 particular point tn time-~----
“from the InIttal stage setting efforts to amplify the altruistic
goals which the program was capable of accomplishing through the
perlods of:

Conceptual Ization of the Interrelationship of the

planning and operational phases,

The much needed exchange between regions of project

design and objectives,

And now the constructive sharing between the Division

and the Coordinators of the Issues and concerns that

have emerged as we have been more and more Initimately

confronted with the realities of the situation and

have had to concentrate more of our time, energy, and

Ingenulty upon the mechanics of making the right things

happen.

From the standpolnt of the record, There can be no positive
evidence of the Increasing Involvement of the Regions tn health
atfalrs and the growlng substance of operational activities-----

natlonwide, than Is provided by These landmarks.

Central to the success of thls accomplishment has been the
splendid cooperative arrangement between the Division and tha
Reglons. This has been a forthright, mutually supportive, and

declsive relationship - a "Tell it as ‘it Is" affair that has kopt
out goals In sharp focus and has expedited our progress toward thelr
accomp|$éhment.

it Is Indeed remarkable that In such a short pertod of time we
should have reached this point In the promotion and realization of
a concept that has been espoused for several decades but seemingly
could not be Incorporated In the complex and diffuse health system
which has grown up more or less {Ike Topsy In our soclety. Not only
did Publ te Law 89-239 come along at Just the right time, but also
bacause of Its nature It was able to attract the support of people
with the degree of perception and dedication necessary to assure its
implementation. The existence of these circumstances has been
appreciated Increasingly as we have learned that It ts much easler
to talk and legislate about cooperative enterprise for coordinated
planning and the most effective and economic utilization of resources
than It Is to accomplish all The details necessary to assure Heke
reality and durability. As the Issues and concerns Increase in number
and complexity, the need for the right answers becomes more and more
acute.
| Several months ago the Division sent a questionalre to each
coordinator asking him to Indicate the Issues and concerns which Ia
his region seemed to be the most compel | ing. These have been consol I-
dated and | have been asked fo summarize them. ®y and large, the
Issues and concerns reported can be divided Into three categories:

those relating to events and activities on the Washington

stage, those having to do with Interreglonal relationships,
and those relating to Intraregional activities. Pervading
each of these categories, however, Is the Interrelationship

between the regions and the Division.
THE REGIONS AND THE FEDERAL GOVERNMENT

The reorganization of the Public Health Service and the real ign-
mont of health programs within HEW has, of course, been matter of
concern to everyone. Probably there Is no group of health adminis-
trators In the United States more keenly aware of the need for better
communications and coordination between these health programs-----
particularly as they operate In the fleld---than the Regional MedIl-
cal Program Coordinators. No other group relates as Initimately
to The broad array of health professionals and health Interests.

Hopefully, the organization of the Health Services and Mental
Health Administration will be able to Interrelate Regional Medical
Programs, Comprehensive Health Planning, Chronic Disease Control,
Vocation Rehabilitation, Health Services Research, and Mental
Health so that thelr mutually supportive and complementary features,
can be more effectively utilized in the Interests of Pubilc health.

A great deal of this has to be worked out at the State or regional
level; add some states have made considerable progress in this
direction. However, since It appears that everyone takes his cue
from what goes on In Washington It would be Immensely helpful If
® prototype cooperative arrangement between these programs within

the Administration were more clearly visible so that field
representatives would have a stronger motivation to share problems
and expertences and work together.

There are other federal health Interests outside HEW that well
might be brought Into this cooperative arrangement. Reglonal MedI-
cal Program efforts to contribute to the Improvement of the health
care of the poor have establ Ished contact with the programs of HUD,
O£0, Labor, Commerce, Just to mention a few. Efforts to generate
education and training programs have created a nead to know more
InitImately the sources and nature of support outside RMP. The
Importance of a mechanism for better coordination of all of these
programs becomes more clear when If Is recognized that all of them
tend to be directed at and Involve the same groups of people------
be they health educators, commun! ty or. regional health planners,
practicing physicians, or allfled health professionals. At feast
In our region more and more of these groups sre turning to the RMP
for advice as to where to go and what to do, and we are finding
this an Increasingly difficult chal lenge.

The Increased experlence with Reglonal Medical Program actl-
vitles and their ramifications has led to several concerns relating
to the executive and legislative branches of the government. One
of these has to do with the stabllity and longevity of the Program
and the growing need for some assurance of both. The need springs
trom the pragmatic realization that the full accompl Ishment of
objectives Is a long torm affair, that our hard won cooperative

arrangements and the benet its therefrom can only be secured at this
early stage of the game by our Integrity and ability to produce,

and that the recognition, confidence, and support we have attained
at a regional level can disintegrate In the face of a threatened
short Itfe, or Increasing evidence of modification of concepts and
-administrative policltes that would deprive reglons of their preroga~
tive for determining the nature and modus operand! of their programs.

Tha greatest asset to acceptance at a local level has been The
assurance of local determination, local decision making, and local
administration. There are many with whom the coordinators and their
staff deal every day who still don't beileve this Is really true
and are continually on the alert for any Indication of bureaucratic
Intervention.

This ts espectally true of practicing physicians. Their full
commitment to the Regional Medical Program ts of critica! Importance,
now and for the future. Fortunately, we have been able to obtain
a large measure of this because of the sound principles upon which
the Program Is based. Interestingly enough the Intensity of committ-
ment to the Program seems to run paraltel to the intensity of feeling
about the princtpabed Recently a key physician In our Program
summarized the state of affairs very succinctly, "Regional Medical
Program has been acceptod In Its original Intent, and as such Is
good. WIth conceptual changes and If allowed to be infiltrated it
will dle aborning. Be assured | will turn 180° for what little

that Is worth."

Perhaps pertinent to this consideration Is the Issue raised

-Se
by one of the coordinators ~ local planning vs. nationa) planning.
Thus far, the bulk of planning at the Diviston level has been In
support of the neads of the Regions, and this has been good. Con-
cern has been expressed, however, that over-enthustasm or Impatience
might tead to centrally concelved projects which might appear to
compete with loca! Inttlative. Untortunately, the earmarking of
certain funds by the Congress last year wos Interpreted by some

as an example of this, and thereby a folr number of fles wore
strained.

Indeed there Is 4 need for frequent oxchanges and Joint
planning between the regions and the Olvislon tn regards to issues
problems, mechanisms, and needs. We also need to share know! edge
of what Is working and what Isn't. As we become more tnvoived tn
registries and reporting systems the value of uniformity of basic
data becomeSobvious. The leadership which the American College
of Surgeons is takIng In working out with coordinators, the
NCT and the Division staff a concept of cancer registries which
might be adopted nation-wide, Is a fine example of how some of
these things can be accomplished In an appropriately cooperative
Manners

Finally, It Is Important that neither the legislative nor
the administrative branches of our government lose sight of the
fact that for tho first time In the history of our country, the:
health professionals and the health Interests areAetnd together

¢o make our health care system more cohesive and more effective,
not by legislation or with large Stee ot money, but by pursua~
sion, good Judgement, common sense, and a challenge to local Initla-

tive

INTERREGIONAL RELATIONSHIPS

The anticipated need Is now materlal izing to refine concepts
and procedures for interregional zctivities and relationships. This
Is reflected tn an Increasing enthusiasm for Interregional meetings.
Some of these are on-golng; more are being planned, and It Is itkely
that many of the questions and Issues will be resolved between the
coordinators. Some will require decisions at a Division level.

There fs a growling need for exchange of more detalied planning
and operational Information between regions, especially adjacent:
regions. This creates problems of supply and demand. No Ideal
solution exists at the moment. There Is a falr movement of annual
reports, operational grant applications, and project proposals, but
the very volume of most of these negates thelr practical utility.

A while back, Ed. Friedlander concelved the Idea of a brief, but .
complete, profile of each region's program - - something that could
be perlodically updated to assure currency. A sdtisfactory format
for this hasn't been worked out thus far, but If still seems a good
Idea. Also, it has occurred to me that broader use could be made
of the splendid project summaries Martha Phillips and her staff
prepare.. These could be Incorporated In the profile of a region;
also they could be regrouped on a disease category or subject basis
and made avallable whenever there {s a need to know what Is going

on nationally.

7
For exampia, many regions have concerned themselves with the
care of the acute coronary patient. Perhaps there are twenty-five
to thirty projects dealing with one aspect or another of this problem.
It would be most helpful to a planning group to be able to review the
essential features of these projects, and also, when such Informa-
thon becomes avaliable, to have some assessment of a project's effec-
tiveness. Presently there Is no way to get this Information untess
one corresponds with every region. And yet It seams to me the avall-
ability of this information for bibillographic purposes would contri~
bute materially to Improved project design. The Sclence Information
Exchange has provided a service of this type for some years.

Yesterday 8 group of directors of hypertension projects met to
consider the feaslbliity of a uniform systom of data collection and
reporting. They also had an opportunity to discuss thelr plans and
share experiences. Perhaps this witl become an Increasingly attrac-
tive mechanism for interregional communications and coordInat ton of
activities.

The problem of Information exchange will be compounded as
regional programs grow and become more complex. If Indeed we are
preaching the availability of the "latest advances" we need to
practice It within the family.

The destrabiiity has been expressed of Interreglonal or,
when appropriate, national I tbraries for support materlals, such
as audiovisual alds, etc. and also of a multi-reglonal speakers

bureau. In this latter regard It would be helpful If such o
bureau were coordinated with other organizations that provide
speakers such as the American Cancer Soclety and American Heart
- agsoclation.
Efforts at reglonal ization have generated planning activi-
ties which cross the borders of adjacent Regional Medical Programs.
Mostly these reflect the identification of hospital service areas
or the ¢irming up of long standing functional relationships between
communities. There seems to be no reason why these porder adjust-
ments cannot be accomplished between the regions Involved. Some
dit¢icutties might arise when funds from other than the RMP, such
as county or state funds, sre required. Our experience has Indicated
that county commissions are extremely careful with thelr money. Also,
there may be some problems with reports and statistics, particularly
those comptied on a state basis.
Concern ts growlng over the coordination between RMPs, espec-
dally those serving the same geographical area, Interregional
programming, and the mechanisms for handling Interregional projects.
Much of this depends upon core staff Interrelationsbips. The forth=
coming guidelines for the Implementation o of Section 910 of the new
RMP law (HR 15758) may clarity this to some extent. However, a
number of potential problems can be foreseen. One coordinator has
-found that the attitudes of public officials or official agencies
are not always conduc ive to Interreglonal planning, particularly
between states. Also, If Interraglonal projects must compete with- -

tn a region with the other projects which the region has generated
{ndapendantly, and particularly If tight money causes advisory
councl!s to have more and more rigid criteria for determination

wf project priorities; they might fare less well than they deserve.
Thus, It may be necossary to establish a separate funding mechanism
for Interreglonal projects.

The growing need tor Interregional activities necessitates 6
serlous review of core staff organization and tunctlons. Produc~
tive Interregional relationships will relate directly to staff Input --
and few If any of us have made provisions for this In our present
staff organizations. Other unanticipated demands upon core staffs
have accentiated the problem. Mony of these demands require the
avatiabliity of skills and knowledge which are not readity avali-
able. One possible machanism for the resolution of this situation
Is the avatlability of consultant services between reglons and the
sharing of staff members with spectal skifis.

We have had an Interesting experience In this regard. A year
ago we ‘began to make consultative services avaliable to community
hospitats In the areas of design, equipping, and operation of
Coronary Care Units. This was done In collaboration with the med I-
cal schools, the North Carol ina Medical Care Commission (HIE i-Burton)
and the Duke Endowment, whlch long has acted In an advisory capacity
to hospitals, As this service became more popular, It emerged that
one of the major needs was for expert architectural and engineering
consultation. It turns out thet there are no available guidel Ines
for the proper design of: these units and for the elimination of the

various hazards which can be of catastrophic consequence. The part-
time architect-engineer whom we retained, In conjunction with The
Medical Care Commission, and who now has acquired a considerable
smount of expertise, has been able to properly advise hospital
authorities, and In so doing he has saved them well In excess of
$100,000.00. So Important has thls service become that we are In
the process of employing the architect tull time providing him with
further opportunities to expand -his knowledge and expertise, and
among other dutles, to have him prepare the guide {Ines and stan-

one which are necossoryy, 4 f |

An expanded role also Is forseen for the Ilason officers of
the Division since they can be Immensely helpful In the resolu-
tion of: many of the problems relating to Interregional planning:
and operations. |

(MTRAREGIWWL ACTIN TIES

Probably the major concern within regions ts the accomp!ish-
ment of an optimal degree of cohesiveness among participants In
program planning and operations. More and more this has become
a core staff responsibil Ity, and yet a willingness to cooperate
on the part of participants fs essential.

A varlety of factors contribute to this problem. One Is that
the participants have ‘not had much expertence working together, and
at least at the onset have beer Inclined to fall back upon thelr
more firmly estab! shed patterns of operation when they contemplate
the nature of thelr Regional Medical Program Involvement. Thus

the medical schools, not accustomed to service responsibility at

a community level, have tended to preter. To conduct educational
and demonstration activities within their walls and to maintaln
Independent planning staffs. This attitude prevails more strongly
at a departmental level than In the Dean's Office. Community
hospital boards, administrators, and staffs have found it difti-
cult to think in terms of regional services, even though they have
depended for years upon. reterrals from within thelr service areas.
They also are intensively preoccupled with their own needs and
problems. State and County medical societies, curlously, seem to
have been exciuded from a large number of organized health planning
efforts In the past and consequently find It difficult to suddenly
be In the malnstream. The universities, community colleges, tech-
nical Institutes, State Boards of Higher Educatlon, or Divisions of
community colleges, though Involved In health education have not |
coordinated thelr efforts and thus find It difficult to look at the
total array of health nanporenl thin a region. State health agen-
cles, particularly Boards of Health, first were caught In the con-
fuslon of a change In their federal funding from categorical to
block grants, and then tn trying to decide how they might relate to
both Regional Medical Programs and Comprehensive Health Planning.
Slowly but surely, however, these and other groups are be-
coming more comfortable In this new situation and are beginning to
work more effectively together. However, expertence Is demons-
trating that meaningful participation per se requires a sustained
investmont of timo and effort by particIpants which they are not

organized or statfed to provide. Thus there emerges & certain

’
"cosi of togetherness" which hasn't yet been specifically Identifled
tn dollars and cents but which the realities of the situation require
be recognized.

Cructal to the productivity of these new tles Is the avall-
abliity of & competent and adequate core staff. There must be some
mechanism to bring plans or concepts Into reality, to manage the
countless number of administrative detalls necessary to assure
smooth operation, continulty and evaluation, and to Interprete
these properly to the Advisory Councll.

More and more, the position of the Reglonal Medical Program
becomes thet oi a way station between the medical schools and
medical centers on the one hand and the system of delivery of
health service on the other, Interposed for the purpose of cata-
lyzing stronger and more meaningful tles, of trying to determine
how sclentifie knowledge and resources can be used more effectively
tu meet patient care needs. Concern with patient care needs rapidly
leads to an Identification and understanding of those Individuals,
organizations, and agencles which in one way or anovher are Involved
in ministering to them. Concern with the medical schools, medical
centers, and other academic Institutions allows for e sharper Iden-
+iftlcation of the resources avaliable and those that must be
developed . Only with these two bodies of Information can effective
and coordinated operational activities be generated.

it Is not beyond the realm of possibit ity that thls unique role
of the core staff will become one of the major Reglonal Medical

Program contributions to the Improvement of our health care system.

«| 3~
- Much of all this points up the Increasing complexity of core
statt functions. As these ere more clearly Identified, their
documentation would be particularly helpful In better ecqualat ing
advisory councl!s, planning groups, participants, and project
directors with the mechanics of Regional Hedical Program operations.

Money, of course, Is and always will be an issue.

One concern hos to do with the projected fiscal potential of
the Reglonal Medical Programs. More specifically, this could be
expressed by asking what can we expect to be able to support three,
five, and ten years from now. -

Clearly, the longer renge potential will depend upon what the
program produces--~~how woll It attalns the objectives of Public
Law 89-239--with appropriate concern for economics, organization
and administration. The shorter range concerns are more pressing,
and yet they have relevance to what might happen In the more distant
future. Each Region, In order to mount a visible operational program,
has begun caut lously by undertaking {Imtted feasibility studies or
pilot projects. In these early stages, visibtiity, solidification
of cooperative arrangements, and a beginning Impact upon the Improve-
ment of patient care have taken precedence over the amount of money
avaliable. Very soon though, the point Is roached where tosted
projects should be expended ,and an Increasing number of now project
proposals are submitted, roflecting to a large extent the success
of efforts to stimélate pert lclpation and planning. It becomes

Important et this stage for those responsible for decision making
to know how close to the belt they must operate, how restrictod a
priority range they must adopt to stand a reasonable chance of funding.
With limited avallabliity of funds, If becomes the tendency to support
the winners ------ to put one's money on the favorite. However,

Public Law 89-239 encourages Innovation --- and Innovation 1s the antested,
unproved -~ very often the long shot. Restricted funding at too early
a stage Is apt to discourage Innovation and thereby serlously | imit
the programs potential. Certainly there never will or should be un~
jimited funds, but It must be hoped that sufficient money will be
available to enable regions to adequately explore and evaluate new

and Innovative approaches and to determine how those that are success-
ful can be Incorporated into the health cere system.

Eventually, It will be possible to free up funds by terminating
unsuccessful projects and by devising measures by which good projects
can be self supporting. However, as exper lence Increases, project |
cesign and relevance to objectives should improve. This could
necessitate some very hard choices by Advisory Counciis, should
Limited avallablilty of funds force a choice between continued -
support of a good project or recommended support of a new one that
looks better. Some recourse might be provided by the avalilablilty
of other than Regtonal Medical Program funds. To a large extent,
this might depend upon how well federal health programs are coordinated
from now one

On a more simple level, e need has emerged for the clarifica-

tion of a mechanism for a large number of small, short term fiscal

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transactions. The orfgtinal gulde-tines Indicated that the Invol va-
ment of community hospitals should be accomp! Ished by a letter of
affiliation which would make the hospital a participant. Also, they
provided for participant faculty and staff Involvement on a part
“time salary basis, and not as consultants.

Becoming a participant requires conformance with certain
Bureau of the Budget regulations, It also makes indirect costs
available which In turn eliminates such Itoms as rental charges.
This Is fIne for the long term, permanent type of participation. Thus
far, however, most of the transactions with community hospitals have
been short term affairs Involving gmail sums of money -- for which
the letter of atflilation ts not practical. Fortunately, the new
guide-lines provide a mechanism to purchase necessary services in
much more acceptable manner.

In a similar veln, there ere some faculty members with long
term comnittments to the Program who can be employed part time.
However, the need Is Increasing tor/reimbursenent nvcnanism for
occastonal or limited services.

Concern has also been expressed over the moct practical and
realistic manner to deal with equipment that Is provided to coopera~ -
ting hospitals and other Inst Itutlons. Existing government reguls-
tions are directed to a large extent to the established situations
where equ I pment remains under the dlroct supervision of tho grantee.
Such will seldom be the case with Reglonal Medical Program oqul pment

for It must be placed In the fled where it will do the most good.

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