ne REPORT ON REGIONAL MEDICAL PROGRAMS June, 1967 JIN Duh Wins ON REGIONAL MEDICAL PROGRAMS TO THE PRESIDENT AND THE CONGRESS Submitted by William H. Stewart, M D. Surgeon General Public Health Service U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE June 1967 CONTENTS Page FOREWORD SECTION ONE Summary... 60-000 eee ees I SECTION TWO The Essential Nature............--5 5 SECTION THREE Activities and Progress. ..........-. 9 SECTION FOUR Issues and Problems...........----: 19 SECTION FIVE Conclusions and Recommendations. . 31 SUPPLEMENT: Regional Medical Programs in Action. .. . EXHIBITS I II iil IV VI Steps in Preparation of the Surgeon Gencral’s Report on Regional Medical Programs to the President and the Congress... 60. eee eter e ern es Surgeon General’s Special Ad Hoc Advisory Committee to Develop the Report on Regional Medical Programs to the President and the Congress.......... seer eee eee Planning Grants for Regional Medical Programs..........- Operational Grants for Regional Medical Programs........ National Advisory Council on Regional Medical Programs. . Regional Medical Programs Review Committee. .......--- Page 37 60 61 62 74 76 Vil Vl IX XI XII XII XIV Consultants to the Division of Regional Medical Programs. . Program Coordinators for Regional Medical Programs... . . Procedures for Review and Approval of Operational Grants. . Principal Staff of the Division of Regional Medical Prograins. Complementary Relationships between the Comprchensive Health Planning and Public Health Service Amendments of 1966 and the Heart Disease, Cancer and Stroke Amendments Of 1965. occ cee ete eee ener eee Public Law 89-239 (Heart Disease, Cancer and Stroke Amendments of 1965)........ 02.0 c eee tee ee tenes Regulations Governing Grants for Regional Medical Programs... 06-020 scenes eet e nen ees Selected Bibliography... ...---.-. 0s eee e teeters ta mn 1 HEART DISEASE, CANCER AND STROKE AMENDMENTS OF 1965 On or before June 30, 1967, the Sur- geon General, after consultation with the Council, shall submit to the Scerctary for transmission to the President and then to the Congress, a report of the activities under this tile together with (1) a statement of the relationship between Federal fi- nancing and financing from other sources of the activities undertaken pursuant to this title, (2) an apprais- al of the activities assisted under this title in the light of their effectiveness in carrying out the purposes of this title, and (3) recommendations with respect to extension or modification of this title in the light thereof. Public Law 89-239 Section 908 This Report on Regional Medical Programs is required by Section 908 of Public Law 89-239, the Heart Dis- case, Cancer and Stroke Amend- ments of 1965. The significance of this requirement was highlighted by the Senate Conumittee on Labor and Public Welfare in its Report on the Heart Disease, Cancer, and Stroke Amendments of 1965: The Committee views this require- ment for accomplishments and recommendations for further devel- opment as an important and integral part of this lepislation. This program provides the opportunities for major innovations ... The impressive cn- dorsements of the concept of the program give a hasis for launching the program as soon as possible, but the final form in all its particulars ts not, and cannot be clear at this tune. Therefore, the need for careful and continuous reevaluation assumes a special importance for this program. This Committee urges that the pro- gram be administered at all times with a view loward the identification of productive modifteations for sub- mission to the Congress when the ex- tension ts considered in Ure future. For the most part, this Report describes progress and experiences during the 20 months that have clapsed since the enactment of this legislation. ‘This period encompassed the time-consuming process of ini- tiating organizations at both the na- tional and regional levels, assembling key operating staff, and developing program guidelines. These tasks have been accom- plished with dispatch. However, the period of actual operations has been so limited that firm conclusions can- not yet be drawn concerning some of the issues emphasized in the Con- gressional directive. On the other hand, the general shape and direction of program de- velopment has clearly emerged dur- ing this period. ‘The quick and enthusiastic response it has received indicates that it can fill an impor- tant national need. ‘Phe great op- portunities this innovative program presents, and the critical issues with which it is confronted, have been brought into sharper focus. To be certain that full considera- tion was given to all aspects of this initial Regional Medical Programs experience and to assist in forging the conclusions and recormmenda- tions in this Report, we sought views and advice of a wide range of in- dividuals expert in medicine, health, and public alfairs (lxhibit I). Last fall, I appointed a Special Ad Hoe Subcommittee of the National Ad- visory Council on Regional Medical Programs to help in the development of the Report (Exhibit TI). A na- tional conference of some 650 per- sons, representing a broad spectrum of health and related groups through- out the Nation, was held in January 1967 to discuss and exchange views on the development of this program. This conference provided the back- ground for the initial drafting of the Report; the Proceedings: Conference on Regional Medical Programs have been published (PHS Publication No. 1682). ‘The essence of this Report, I am pleased to note, is that Regional Medical Programs have made a sub- stantial and impressive beginning. But it is only the beginning. The task ahead is to bring to fruition a truly unique and promising venture de- signed to advance the effectiveness and quality of medical care available to those who suffer from cancer, heart ‘disease, stroke and related diseases. Critical issues remain, and cffec- tive regional programs are not yet completely realized. But as we enter the period of full: operation, the prospects for success appear highly favorable. Looking to the future, the single inost Important condition for further progress is to sustain the enthusiasm, vigor and cooperative spirit of the many individuals who have volun- tarily undertaken this pioncering cf- fort in the Regions throughout the country. "Fo do this the national commitment to this program must be clear. If these conditions are met and the potential of the program is realized, health resources of the Na- tion will move forward, region by region, in building new patterns of collaboration, and people suffering from these diseases will receive the care they need, more promptly and more efficiently. William H. Stewart, M.D. Surgeon. General Public Health Service U.S. Department of Health, Education, and Welfare Summary Regional Medical Programs have inade an impressive beginning. But it is only a beginning. Much is yct to be done. Many problems and is- sues are yet to be resolved. How- ever, if the future is marked by the same enthusiasm and cooperation and our national commitment is sus- tained, a major change may well be wrought in the workings of Ameri- can medicine. This change will benefit the health professions and bring great benefits to the American people. SE CT J ON ONE Summary In October 1965 President Johnson signed Public Law 89-239, the Heart Disease, Ganeer and Stroke Amend- ments to the Public Health Service Act, authorizing grants to help cs- tablish Regional Medical Programs to combat heart disease, cancer, stroke, and related discases. ‘Chis program had its origin in the recommendations of the President’s Commission on Eleart Disease, Gan- cer and Stroke, presented in Decem- ber 1964. Its ultimate goal, like that of the Commission itself, is to help make the best in modern medical sci- ence readily available to all people who suffer or are threatened by these major diseases. ‘Lo accomplish this purpose, Public Law 89-239 proposes the establish- iment of direct and continuous link- ages between the patient, his physi- cian, his community hospital, and the Nation’s centers of scientific and academic medicine. It secks to unite the health resources of the Nation, region by region, in close working relationships which will specd the transmission of scientific knowledge and methods to the people whose lives depend upon them. “The first stages in the development of the Regional Medical Programs - are now well underway. As of June 30, 1967, planning is moving forward in 47 Regions with the support of planning grants; the 47 first. year awards tolal about $20 million, and 10 second year awards about $4 mil- lion. (Exhibit TED) The geographic Regions encompassed in these awards contain about 90 percent of the Na- tion’s population. The beginning stages of program operations have be- gun in 4 Regions with the support of grants totaling $6.7 million. (Exhibit 1V) Additional grants to support planning covering applications for the remainder of the country are now under review or development. On this record, progress in the development of Regional Medical Programs is substantial. It is partic- ularly impressive when viewed in the context of the initial tasks that had to be performed. These included) the creation within the Public Health Service of a new administering orga- nization and the assembling of staff. Program guidelines had to be devel- oped and promulgated ; criteria and inechanisms for review of grant ap- plications had to be established. The many issues and problems presented by this new departure in Federal health action were widely and in- tensively ' discussed with individuals from all parts of tlie country. In cach Region, initial tasks included working out the bases for developing regional cooperation among major health in- terests, designing the planning pro- gram, appointing and convening the Regional Advisory Group, and re- cruiting stalf. "The initial experience described in this Report demonstrates the pro- gram’s potential for improving the ‘health of the American people. To fulfill this potential, the following recommendations arc clearly indi- cated: (J The program should be estab- lished on a continuing basis. There is every indication that the approach authorized by Public Law 89-239 is valid and promising. Extension of the program, building upon the initial planning and pilot projects, will lead to realization of its potential and will contribute significantly to the attack on these major diseases. [1] Adequate means should be found to meet the needs for construction of such facilities as are essential to the purposes of Regional Medical Pro- grams. A limited amount of new con- struction has been found to be es- sential to achieve the purposcs of the Programs; priority needs are educa- tional facilities, particularly in com- munity hospitals. Authority to assist the construction of new facilities, which was requested in the initial bill in 1965, was sct aside during the con- sideration of the bill in the Congress. ‘This modification should be carefully designed, in amount and administra- ET tion, to mect the special requirements of Regional Medical Programs and to enhance cooperation with related programs. [) An effective mechanism should be found to assist interregional and other supporting activities necessary to the development of Regional Medical Programs. This assistance will facili- tate the work and implementation of individual Regional Medical Pro- grams. (] Patients referred by practicing dentists should be included in the re- search, training and demonstration activities carried out as necessary parts of Regional Medical Programs. ( Federal hospitals should be con- sidered and assisted in the same way as communily hospitals in planning and carrying out Regional Medical Programs. Underlying this program and the recommendation for its extension is the broad national concern over the extent to which new ‘medical knowl- edge and technology is brought rap- idly and effectively into usc in health services and medical care throughout the Nation. The legislation proposes regional frameworks for accelerating this transfer. It envisions two-way flows of useful science and technology between academic and scientific cen- ters and agencies and individuals who ‘ver medical care in the local nmunities of the country. [o accomplish these purposes, the w authorizes the award of grants the planning and then for the eration of regional arrangements, signed to stimulate new patterns cooperative action among physi- ins, hospitals, university medical nters, public and voluntary health rencies. Each regional arrangement iould help to create a coordinated rogram encompassing ‘aining and continuing education, atient care demonstrations and re- uted activities. Its goal is to advance he accessibility and the quality of realth services available throughout he region for heart disease, cancer, troke and related diseases. The emphasis in this program, Te- lecting the legislative background from which it emerged,’ is on local initiative and local planning. This approach is intended to sustain the essentially private and voluntary character of American medicine. At the same time, it permits the use of Federal funds to stimulate and sup- port innovative approaches to com- mon problems under local leadership. An advisory group, representing the regional health interests in cach Region, including those of the con- sumers of service, is required by law as an essential step in the develop- research, ment of a Regional Program. Thus the character of the individual pro- grams will vary as they reflect the differing needs, resources, and pat- terns of relationships. The experience gained in the year since the first grant was made has provided considerable evidence that new cooperative arrangements can be developed among institutions and in- dividuals involved in health and medical affairs. Regional groups rep- resenting a wide varicty of interests and functions have come together in an unprecedented fashion to plan and work cooperatively on common needs and goals. Over 1,600 individ- uals, including physicians, medical educators, hospital administrators, public health officials and members of the general public are serving on Regional Advisory Groups. They are performing an important role in the planning and development of the in- dividual Regional Medical Program. It seems reasonable to anticipate that workable mechanisms for accomplish- ing the goals of the Heart Disease, Cancer and Stroke Amendments of 1965 will progressively emerge based on these initial cooperative efforts. There are, however, uncertaintics and problems still to be resolved in the further evolution of this program. In part these questions arise out of the diversity and complexity of forces that characterize the American health scene. Some of the questions are generated by the particular terms of the legislation under which the program operates. Stull others emerge from certain broad changes which are inherent in the further development of these programs. Significant among these questions are the following: LJ Can the character, quality and availability of health and medical care services in the area of heart disease, cancer, stroke and related diseases be significantly and micas- urably modified? O) Are the regional administrative entities developed for these programs viable and durable over a long period of time? C Can voluntary professional and institutional compliance be obtained in the efficient disposition and use of facilities and critical manpower, other resources on a regional basis? C) How will the activities generated under Regional Medical Programs af- fect medical care costs and influence the extent to which such costs can be met by normal financing methods versus direct support through Re- gional Medical Programs? CL] What should he established to assare that long-term relationships Go Regional Medical Programs comple- ment other Federal health programs, particularly the Comprehensive Health Planning Program initiated: under Public Law 89-749? (] How can local programs over- come lack of space to carry out ccT- tain of the activities and functions being engendered by Regional Med- ical Programs, particularly space for training and continuing education? In addition, it has been difficult thus far to obtain more than a tenta- tive commitment from many insti- tutions and individuals because of un- certainties over the national intention and the limitetl duration of authoriza- tion for grants for Regional Medical Programs. Assurances of longer sup- port are essential to maintaining the vigor and achieving the objectives of this program. Many of these issues and prob- lems will be resolved in the future conduct of the program. Others will require cither executive or legislative action. Regional Medical Programs have made an impressive beginning. But it is only a beginning. Much is yet to be done. The Essential Nature “The objective of this legislation is to build from strength and te pro- vide those mechanisms which can link the source of strength with the needs of the community .. . We would hope that the proposed new program could have its greatest in- novative effect... as a significant new extension of the capability of existing programs in bringing: to bear on patient needs the benefits of sei- entific medicine,” Excerpt from the Report of the Senate Gommittee on Labor cand Public Welfare on 8. 596 (PL. 89.- 249). DEC LION “DV ©) the Essential Nature SACKGROUND ‘The Report of the President's Com- mission on) Tleart: Disease, Cancer and Stroke in) 1964 was the inime- diate stimulus for the legislation (hat became Public Law 89-239. That report, issued in December of £964, inade a series of recommendations aimed al the development across the nation of regional complexes of med- ical facilities and resources. ‘These would function as coordinated sys- tems to provide specialized services for the benefits of physicians and pa- licnts in the several geographic areas. In the longer perspective, however, the Regional Medical Program con- cept is the result of many ideas and trends that have evolved over a pe- riod of years. These include some of the social, economic, and scientific changes affecting all of modern soci- ely, as well as developments in the de- livery of medical and health services. The progress of science has exerted a powerful force for change. Since World War II great strides have been made in extending the frontier of medical knowledge and capability through research, Vhis advance has. greatly strenethened (he armamen- tarium of medicine available to con- tend with the problems of health and disease. It is providing a fundamen- tal impetus for progress in health, stimulating intensified efforts to bring the benefits of science to all the people. Along with great: benefits, these advances have brought: new prob- lems. Increasing specialization has be- come necessary for mastery of rapidly advancing knowledge and = technol- ogy. While specialization has raised levels of expertise, it has also increased the fragmentation of services, thereby complicating the process of delivering medical care. At the same time the advance of science burdened = physician with rapid obsolescence of knowledge. ‘This threat in turn raises new prob- Jems in communication and educa- tion. New patterns of relationships, systems of service, and mechanisms are crilically needed in medicine, as threatens the heavily in other fields, to cope with and ex- ploit advances of science for the well- being of the people of the Nation. Other important forces have also contributed to the conditions and needs which sct the stage for Regional Medical Programs. Many factors have raised the public’s expectation for health: the rising economic capa- bility of the Nation, the higher gen- eral level of education of the public, the record of success in the control of the major communicable discases, and other social progress. In addi- tion, national concern has focused on the special problems of disadvantaged groups and arcas not sharing fully in the overall progress. Efforts to meet these demands for services have been complicated by manpower and fa- cilily shortages and increases in costs of medical care. More efficient and effective use of health sought through regionalization for many years. It has also been viewed as a means to broaden the availability of high quality health services. In 1932, the Committee on the Costs of Medi- cal Care focused attention on this approach. In the same year, the Bingham Associates Program of the ‘Tufts University-New England Medi- cal Center initiated the first compre- hensive regional medical effort in the United States. About 15 ycars later, similar ideas were included in the Report of the Commission on Hospi- tal Care and were, in turn, reflected in the Hospital Survey and Construc- tion Act of 1946 (Hill-Burton Pro- gram). While other regionalization plans have been advocated and at- services has been tempted from time to time, these ef- forts were largely isolated and limited. Efforts to achieve regional organi- zation of private and voluntary health services have not been notably suc- cessful. The reasons vary, but in gencral they reflect the difficulties of inducing common action among sep- arate and independent components of the health enterprise, and the lack of sufficient amounts and duration to assure con- linuing stability. The present day circumstances of the practice of medicine and the de- livery of health services may provide more suitable conditions for the financial resources in growth of the regional approach. The physician is the part of a com- plex system involving closely related facilities and ancillary services. The hospital has become the central in- stitution in the community medical scene. Prepayment plans and group health programs contribute to coordi- nation and common action. Federal programs committed to social prog- ress provide a pervasive force for action. ‘Thus the regional concept emerged again in a new form, in the major recommendations of the President’s Commission on Heart Discase, Can- cer and Stroke which proposed the development and support of “region- al medical complexes”. This proposal called for substantial and sustained Federal support as an essential con- dition of success. THE ESSENTIAL, NATURE President Johnson, at the signing of Public Law 89-239 on October 26, 1965, said, “Our goal is simple: to speed miracles of medical research from the laboratory to the bedside.” The bill he signed into Law on that occasion, the Heart Disease, Cancer and Stroke Amendments of 1965, stated the same goal in slightly differ- ent terms: “. .. to afford to the medical profession and the medical institutions of the Nation .. . the opportunity of making available to their patients the latest advances in the diagnosis and treatment of [heart disease, cancer, stroke and related diseases]... .” To accomplish these goals, P.L. 89-239 authorized a 3-year, $340 mil- lion program of grants for the plan- ning and establishment of Regional Medical Programs. These grants pro- vide support for cooperative ar- rangements which would link major medical centers—usually consisting of a medical school and affiliated! teaching hospitals—with clinical re- search centers, local community hos- pitals, and practicing physicians of the Nation. Grants are authorized for planning and feasibility studies, as well as pilot projects, to demonstrate the value of these cooperative re- gional arrangements and to provide a hase of experience for further devel- opment of the program. The objectives of the legislation are to be carried out by, and in co- operation with, practicing physicians, medical center officials, hospital ad- ministrators and other health work- ers, representatives from appropriate voluntary health agencies and mem- bers of the public. The law specifies that there shall be no interference with patterns or the methods of fi- nancing of patient care, or profes- sional practice, or with the adminis- tration of hospitals. Because this broad range of co- operation is the central concept of Regional Medical Programs, each program is required to establish an advisory group representing the vari- ous health resources of the region and including consumer participation. This group has the important func- tion of assuring full collaboration and advising all the participating insti- tutions in planning and carrying out the program. The ultimate objective of Regional Medical Programs is clear and un- equivocal. The focus is on the patient. The object is to influence the present arrangements for health services in a manner that will permit the best in modern medical care for heart dis- case, cancer, stroke and related dis- cases ta he available to all. The scope of the program is nationwide, encom- passing the ereat cities, suburbia, and rural areas, The program design inherent in Public Law 89-239 derives frome a series of basic concepts: [C1 The best in modern diagnostic and treatment methods is not readily accessible to many Americans suffer- ing from or threatened by heart dis- stroke, and related case, cancer, diseases, ] There is need for increasing mter- action betecen the diagnostic and therapeutic capability in the major medical centers, where an effective interplay between rescarch, teaching, and patient care can bring rapid and effective application of new medical knowledae, and the medical capabil- ity in many community settings, CO The progress of science will con- tinue to inerease the complexity of making available to all the potential benefits of modern medicine, The complete realization of these potential benefits requires the co- operative tnvalrement of the full range of cach region’s medical and related resources. C] The diversity of local health needs and resources calls for the as- sumption of responsibility by cach region for the design of a pattern of collaborative action best suited to tts own spectal circumstances, The role of the Public Wealth Serv- ice in developing this broad program design is defined in the Congressional declaration of purpose: “Through wrants, to encourage and assist in the establishment of regional cooperative medical schools, research institutions, and hospitals for research and train- ing (including continuing cduca- arrangements among tion) and for relaicd demonstrations of patient care in the fields of heart disease, cancer, stroke, and related diseases ” Thus, Public Law 89-239 repre- sents a Federal investment in regional initiative. It invites and supports the creation of new patterns of coopera- live action among physicians, allied health workers, hospitals, meclical centers, universities and research in- stitutions, public and voluntary health agencies, and the consumers of health services. THEE GCONDEPIONS AND OUALLPUES EMPTASIZED Regional Medical Programs put into practice the principle that essential responsibility and power for the tm- provement of health services should he exercised locally. ‘The basic policy of the program is designed to en- courage innovation, adaptation and action at the regional level. Freedom and flexibility to do those things necessary to achieve the goals of cach program has heen provided. The achteveanent of any one objective of a Region may require a combina- tion of activities, such as research, specialized training of allied health personnel, continuing education of physicians, experimentation to find the best methods to achieve desired results, and demonstration of the most elective patient care. ‘Vhe Law does not allow support of isolated projects, however meritorious, whether they be in continuing cducation, research, patient care demonstrations, cooper- alive arrangements or training. “Uhius the success of a Regional Program will depend upon bow effectively the Re- gion brings to bear its unique combi- nation of institutions, agencies and organizations to define and meet its own needs and opportunities, Critical to future progress is the willingness of members of the medi- cal profession to accept their full share of leadership in this effort. Equally important is the willingness of university schools of medicine to become involved in cooperative ef- forts to apply the fruits of research elforts. Similar challenges and new responsibilities are presented to hos- pital administrators, health officers, voluntary health agencies, schools of public health, and the allied health professions, New systems are being sought amid diverse peorraphic and social cireum- stances Chat will make available to all the people medical services for heart disease, cancer and stroke and related diseases that are excellent in quality and adequate in quantity, while preserving the diversity and Jargely private character of our med- ical care process. “Vhe responsibility of achieving these desirable ends does not devolve upon Regional Medical Programs alone. “They must operate in conjunction with other programs having related objectives. But Re- gional Medical Programs, properly developed, can serve as a keystone of a structive which will permit the de- livery of the type of medical care serv- ices desired by all. In accomplishing this goal, it is essential to find ways to harmonize the values of personal and scien- tific freedom with the deraands for eMficient use of resources and nation- wide availability of services. Re- gional Medical Programs offer the private and public institutions and the health professions of the country opportunities to demonstrate that, on a voluntary cooperative basis, given adequate resources and flexibility to use them, it is possible to work out effective regional and local systems to bring the benefits of scientific prog- ress to all. When the Regional Medical Pro- grams are fully developed across the nation, Chey will help to assure every individual, wherever he lives, that: (J is physician has readily avail- able the knowledge, skills and techni- cal support that permit carly diag- nosis of these diseases and prompt mitiation and appropriate follow through for the most effective known preventive or curative action. [] His community hospital is equip- ped and staffed to provide the full range of services his condition re- quires, or is part of a system which makes this range of services available to him, In short, every person whose life and well-being may be in jeopardy from one of these diseases should have the fill strength of modern medical science available to him through the cooperative clTorts of the medical and related resources of the region in which he lives. These are the goals to which Regional Medical Programs are dedicated. Activitics and Progress. uc ... the Surgeon General... shall submit... a report of the activities J. together with (1) astatement of the relationship between Federal fi- nancing and financing from other sources... (2) an appraisal of the activities assisted... in the light of m” their effectiveness. . 2. Public Law 89-239 Section 908 Wht A ALLY REPORT OF ACTIVITIES During the 21 months from the time Public Law 89--239 came into being until June 30, 1967, 47 Regions re- ceived grant funds to aid their plan- ning activities and 4 of these Regions also initiated the operational phase of their Regional Medical Programs. (Exhibits ILI, IV) These programs received awards of about $24 million for planning and $6.7 imillion for operations. (‘Table 1) ‘The regional areas to which the awards for plan- ning relate contain about 90 percent of the Nation’s population. Additional applications for grants to support the planning of Regional Medical Programs covering the re- mainder of the country are under review or development. Overall, a total of about 54 Regional Medical Programs are anticipated. It is likely that by the late summer or carly fall of 1967 Regional Medical Programs covering the entire country will be cither in the initial planning or initial operational stages. Progress in the development of Regional Medical Programs thus far must be measured against the tasks involved. in launching a, new and innovative venture dependent to a very high degree upon local enter- prise. The establishment of many new relationships and activities has been required. Moreover, this devel- opment has taken place in a time of widespread manpower shortages and im conjunction with parallel demands from many other health programs, such as Medicare and Medicaid. In this context the progress reflected by the present state of activity represents a considerable achievement in a rela- tively short time. Tow this was ac- complished provides a gauge of the direction and potential for the future. The Initiating Actions Shortly after the Law was. signed by President Johnson on October 6, 1965, the Division of Regional Medi- cal Programs was established at the National Institutes of Health. To direct its activities, Dr. Robert Q. Marston accepted the invitation to leave his post as Dean of Medicine and Vice Chancellor of the Univer- sity of Mississippi and become Asso- ciate Director of the National Insti- tutes of Health. Prior to the arrival of Dr. Marston, Dr. Stuart Sessoms, Deputy Director of the National In- stitutes of Health, was responsible for the development of plans and policies for the new program. The Supplemental Appropriation Act of 1966 provided initial funding for the program, making available $24 million for grants and $1 million A AALAN DUIS Activities and Progress for the Division for fiscal year 1966. The Department of Health, Educa- tion, and Welfare Appropriation Act of 1967 provided $43 million for grants and $2 million for the Division for fiscal year 1967. The National Advisory Council on Regional Medical Prograins, estab- lished by the Law, was named from outstanding experts in heart disease, cancer and stroke, plus top leadership in medical practice, hospital and health care administration and pub- lic affairs. (Exhibits V, VI) It met for the first time in December 1965 to advise on plans and policies. [n carly February 1966, the Council met again to review and approve the prelimi- nary issue of the Program Guidelines. Quickly printed, this publication was given its initial distribution in March. During the spring of 1966, about 20 applications for planning grants were received and reviewed by the initial review groups and the Na- tional Advisory Council. By July 1, 10 grants were recommended for ap- proval and awarded. Between July and December 1966, approximately 40 applications were reviewed. Many were returned for revision or addi- tional information. Twenty-four were approved and funded. As a result, 1966 ended with a total of 34 Re- gional Medical Programs receiving awards for planning: programs, rep- resenting arcas that included some 60 percent of the population of the country. The first applications for operational grants had also been submitted. Subsequently, in February 1967, the first four operational and 10 ad- ditional planning applications were reconnnended for approval by the National Advisory Council. At the Council mecting in May, five addi- tional planning applications were recommended for approval. In June, continuation grants were awarded to 10 Regions for the second year of planning. Broad Participation in Planning The promptness and manner with which program proposals were de- veloped reflect the interest this new program has generated in the nation- al health scene and give heartening evidence of the willingness of diverse interests in the health field to coop- crate in this new framework. The in- terest and venerated throughout the country is the result of a number of factors, not the least of which was widespread participation of many individuals and groups, both in the formulation of policies at the national level and in setting up and planning their own Regional Medical Programs. enthusiasm TABLE 1 Awarps FoR PLANNING AND OPERATIONS OF RecionaL Menicar PROGRAMS, TOTAL... 2... eee eee Planning Awards......--. 25-2500 00> For Ist Year Activities. ......-.5-- Yor 2d Year Activities. .....------ Operational Awards......--+-+++++> For [st Year Activities. .....-..--- About one hundred consultants aided the new Division by providing advice and counscl on various as- pects of the Program during the ini- tial period. These advisors repre- sented a broad cross-section of the leaders in American medicine and health fields. They devoted intensive efforts to the review of Program pro- posals and grant applications. Some of these people sat on technical re- view groups. : Others contributed their thinking to the development of such specialized activities as continu- ing education, community health planning, systems analysis, data col- lection, communications, evaluation, and the preparation of this Report. (Exhibit VIT) June 30, 1967 Number Amount cov eeeeeeees 61 $30, 946, 907 re 37 «$24, 277, 174 Lo eee cesses 47 19, 822, 153 Doce neeeees 10 4, 455, 021 coe ecebeeees 4 $6, 669, 733 Lovet ee eenes 4 6, 669, 733 Activities in the Region Similarly, in the Regions, the wide- spread participation of concerned in- dividuals as members of Regional Ad- visory Groups and as Coordinators and staff is infusing the Programs with vitality and character. Over 1600 individuals are participating as Regional Advisory Groups. Membership in these groups members of ranges from 12 to 111, averaging 32. "The members include a variety of pro- fessional backgrounds and representa- tion of a broad cross-section of insti- tutions and organizations. (Table 2.) In fulfillment of the intent of the program, the major health agencies of the regions have been involved in TABLE 2 Memnersmip or Anvisory Grours ror Rectonar Mepicar PRo- crams, June 30, 1967 ! Num- Per- Category ber cent- age TOTAL. ....---: 1634 100 Practicing Physi- cians.........-... 356 22 Medical Genter Officials.......... 281 17 Members of Public.. 260 16 Voluntary Health Agency Represent- ACTIVES. 2. eee 196 12 Hospital Admin- istrators......-.-- 170 10 Other Health Workers.......--- 142 9 Public Health Officials... ....--- 122 7 Other.....-.5---55 107 7 1 Includes 51 Regions, of which 47 had received planning grants and 4 had applications under review. the development of these Regional Medical Programs. All of the Na- tion’s existing medical schools and their affiliated hospitals and most of the schools under development have participated. In virtually every pro- gram, representatives of State medi- cal societies, health departments, can- cer societics, heart associations, hos- pital associations or hospital planning agencies have taken part. In addition, many programs have already developed links with univer- sity resources outside the medical schools and with other State and local private and public agencies having related interests. Examples of these are Schools of Dentistry, Nursing, Social Work, Business Administra- tion, Education and Public Health and Departments of Vocational Re- habilitation, Welfare, Education, and Councils, planning councils, Blue Cross and Hospitals. Community similar groups are also being involved in many instances. Representatives of Veterans Administration and Public Health Service Tlospitals are also frequent participants. Regional Organizations Several kinds of institutions have assumed responsibilities ‘as coordi- nating headquarters for Regional Medical Programs. Since the legisla- EE __—-— —— tion does not designate these aencics, they must be decided upon by the various institutions and interests par- ticipating in the development of the Programs. The agency so selected acts for all involved in these cooperative programs. Among the 47 Regions receiving planning grants, 2% university mnedi- cal schools have assumed responsi- Iiilities as coordinating headquarters. Seventeen are private nonprofit agen- cies, 10 of which were newly orga- nized for this purpose, 5 are medical societies, and 2 are mmulti-institutional agencies. One State and one inter- state agency have also undertaken this task. (‘Table 3) Program and Staff Coordinators The Program Coordinators and Directors holding key leadership po- sitions in the administration of the Regional Medical Programs come from a variety of backgrounds. About half previously held important posi- tions in medical education, such as universily vice-presidents, medical school deans and professors. Others have come from. private practice of medicine and from positions of administrative leadership in hospitals. The rest previously held key roles in voluntary health and governmental agencies. (Exhibit V1 IL) TABLE 3 CoorbiINATING JIEADQUARTERS AND GRANTEES FOR REGIONAL MEpbICAL ProcRaMs, JUNE 30, 1967 Coordi- nating head- Grant- ‘Lype of Agency quarters ces 1 TOTAL. 00... 47 47 Universities... 28 33 State. ...--- 23 25 Private... .- 5 8 Nonprofit Agencies... \7 12 Medical Socictics. . 5 6 Newly Organized Agencies. . 10 3 Other Agencies. . 2 3 State and Interstate Agencics...- 2 2 ee a 1 The grantee differs from the coordinat- ing headquarters when the Region re- quested this arrangement oF the latter agency did not have the capability to assume formal fiscal responsibilily. These coordinators are building staffs with a wide range of com- petencics. As of June 30, 1967, there were some 600 staff people working in these programs. T hese include over 300 professional workers with train- ing in medicine, hospital administra- tion, and other health disciplines as well as in related ficlds such as sta- tistics, economics, sociology, systems analysis, education, communications and public relations. Special coordi- nators or consultants for heart dis- ease, cancer and stroke are commonly included. Nature of Preliminary Planning Regions ‘The applications for Regional Medi- cal Programs planning grants have defined — the geographic areas in which the initial planning efforts will be focused. It has been recognized that these definitions are preliminary and will be refined during the plan- ning and by operating experience. The individual Regions ranged in population {rom less than 1 million to over 18 million. (‘Table 4) ‘The median is 2.6 million persons. Collectively, the preliminary plan- ning regions encompassed in pro- grams now in being or proposed cover the entire country. Gaps in geographi- cal coverage, which was an early con- process have cern, have not materialized in the initial planning proposals. ee a TABLE 4 NuMBER OF PERSONS IN PRELIMINARY PLANNING REGIONS FOR REGIONAL MrpicaL PROGRAMS eee eee veneer ee ee at Regions! Population range... POTAL...cceeerettt 51 Less than 1,000,000..-.-.-++ 4 1 ,000,000-2,000,000 Lenses 10 2,000,000-3,000,000 a 14 3,000,000-4,000,000 Li aeeeee 5 4,000,000-5,000,000 ee More than 5,000,000...-.-- 10 ——— ' Includes 51 Regtons, of which 47 had received planning grants and 4 had appli- cations under review. ven TT In 30 cases, the preliminary plan- ning regions approximate State lines, due principally to the existing respon- sibilities of many of the key groups participating in the preparation of the initial planning grant application. Inasmuch as none of the Regions is bound by State lines, many of these preliminary definitions are likely to be modified on the basis of criteria more specific to health needs. In 11 Regions, the initial Region includes parts of 2 or more States TTT andin 10 it is part of a single State. Some regions primarily cover urban metropolitan areas. Others follow lines previously established for plan- ning health facilities. Planning Activities The planning activities of cach Re- gional Medical Program are directed at the design of operating programs and the steps for their establishment. Initial planning activities have gen- erally been of four major types: {] Organization and staffing for planning and coordination (0 Strengthening relationships and liaison among institutions and indi- viduals throughout the Region () Development of planning data (] Preparation of designs for pilot operational programs A principal effort in the planning of Regional Medical Programs is the careful study and analysis of many relevant factors: demographic and biostatistical characteristics of the Region, the manpower and facilities resources, the adequacy of and necds for specialized clinical facilities and problems of manpower supply and distribution. Surveys of training and library resources, on-going con- 268-649 O-—67-—— 2 tinuing education programs and un- met educational needs are also re- éeiving widespread attention. The patterns of occurrence of heart disease, cancer, stroke and re- lated diseases are also being studied by many regions. Most are analyzing patient referral patterns and existing methods of providing diagnostic, treatment and laboratory services. Present and possible communication and transportation patterns relating to these services are also receiving widespread attention, ‘These planning studies have, in most instances, been based on previous data collection ef- forts and have, in turn, contributed to the development of cooperative arrangements among the partici- pating organizations. About one-half of the planning ap- plications proposed the undertaking of specific feasibility stuclies aimed at assessing the workability and utility of particular programy elements. Many are exploring better ways of advanc- ing educational and training activi- ties. Particular attention is being given to improvements in continuing education programs for both practic- ing physicians and alfied health per- sonnel. The effectiveness of | tele- phone, radio and television networks in linking community hospitals to uni- versity medical centers is being in- vestigated under differing local con- ditions. Methods of carrying out demonstrations of patient care and applying evaluation procedures are also being tested. In addition to analytical activity, planning for Regional Medical Pro- grams involves major efforts directed toward the strengthening of the rela- tionships and communications among health and related agencies within the Region, Various approaches are being used to further these coopera- tive relationships. ‘The establishment of working task forees and commit- tees, the conduct of conferences and workshops, and the employment of liaison personnel are common, Nu- merous programs are scheduling con- ferences at community hospitals and with other local groups te explain and discuss the purposes and nature of the prospective Regional Program, Working together in) planning ard initiating planning and feasibility studies has been found to be one of the most effeedive methods of estab- lishing and implementing common objectives. Although each Regional Medical Prograny is ino many ways unique, some flaver af what Public Law 89 - 239 means in action is revealed by reports of certain programs that are Yate reported by individual Regional Mfedi- cal Programs. TABLE 5 Mayor PLANNING Srupms Unper Way or PROJECTED BY HE REGION- AL Mrnrean Programs, Marci 1, 1967 Subject Under Study Regions Patient care Specialized Clinical Faei- HES. eee eee 30 Disease Patterns............ 28 Patient Referral Patterns 28 -atterns of Services... 0.0... - 25 Laboratory Services... ..... 25 Transportation Patterns... . 21 Muanpotwer Physician Manpower... 2... 30 Nursing Manpower... 0.02. 29 Dental Manpower. ......... 25 Other Allied Health Man- POWER. oe 2b ‘Training and education Continuing Education Pro- QYAINS. ee 28 Training Resources... 0.0... 28 Medical Library Resources. . 26 Communications Patterns and Resources... 00... ee 26 iE presented as a supplement to this Re- port, What is happening in six Re- gions is discussed against a back- round of previous activities. In addi- tion, excerpts from the first anuual reports submitted by ten Regions that received grants as of July 1, 1966 are also presented, Operational Activities The four grants that have been made for operational programs are based largely on planning activities started prior to the passage of Public Law 89-239 (Exhibit IV). During the consideration of the legislation, it was recognized that there were several areas of the country where consid- erable effort had already been di- rected toward improved regional rela- tionships among health resources. En these places sufficient planning had already been accomplished so. that operational activities could be initi- ated carly. In the beginning stages these oper- ational programs will encompass four principal types of activilics: C] Application of the latest Anoicl- cdue and technology to improve capabilities for diagnosis and treal- ment, [] Specialized training and continu- ing education Lo enable health prac- lilioners to use these capabilities most effectively in treating patients, Cy) Use of modern communication technology. { Research on and exploratory de- velopment of new methods for the organization and delivery of high quality services for patients with heart disease, cancer, stroke and related diseases. Each Region will have differing requirements and approaches toward upgrading its capabilities for the diagnosis and treatment of heart disease, cancer, stroke and related diseases. [iv general, the designs of the initial Regional Medical Pro- grams provide for the following spe- cific kinds of activities as examples of the basic ingredients of comprehen- sive operating progyarus: ( The exchange of personnel be- tween medical centers and commu- nity hospitals and the provision of consultation and other assistance to practicing physicians by medical ecn- ter and other specialized personnel, (] Continuing education programs for medical practitioners and allicd health workers, at both local facilities and medical centers including the development of learning centers at community hospitals and communt- cation systems joining medical cen- ters and community hospitals, (0 The development and demonstra- tion of improved methods and ar- rangements for providing detection, diagnostic, treatment and rehabilita- tion services including such activities as: Demonstrations of coronary care in teaching and community hospitals. Iixpansion of cerebral vascular diag- nostic resources. Demonstrations of improved methods of utilizing computers in monitoring physiologic data and in providing data for the use of practicing plvyst- cians and hospitals. (] Development of information pro- grams to further communications, understanding, and cooperation among the institutions, organizations and individuals of the Region. The Review Process ‘The review of applications for opera- tional grants has been designed to en- sure careful consideration of the strategy and soundness of the pro- posal for a Regional Program. Many Regional Advisory Groups have cs- tablished subcommittces to analyze the validity and significance of pro- posals prior to their review and rec- ommendation; these committees draw upon both community and academic resources. In line with the specifica- tions of the Law, the Regional Ad- visory Group itsclf must approve all applications for-operational funds. The review process at the National Institutes of Health involves technical review by both expert nonfederal con- sultants and the staff of the Division and other offices with relevant cx- pertise prior to action by the National Advisory Council. This process is focused on evaluating the organiza- tion and conceptual strategy of the Regional Programs and making avail- able the benefits of expert professional analysis of project proposals. It seeks to preserve for cach Region a large measure of the responsibilities and opportunities for deciding on prior- ities for action. A detailed statement of the review process is contained in Exhibit IX. SUPPORTING ACTIVITIES OF THE DIVISION OF REGIONAL MEDICAL PROGRAMS As support for Regional Programs, a number of activities have been under. , taken by the Division of Regional’ Medical Programs to develop needed information and resources which can, facilitate regional program develop! ment. (Exhibit X) Continuing Education Aconference in September 1966 of 16 leaders in the continuing education of physicians and allied health person- nel identified needs critical to the de- velopment of more effective activ- ities ‘in this ficld, The meeting documented a national shortage of professional health workers capable of. conducting and evaluating pro- grams in continuing education. To help meet this need, a contract was developed with the Center for the Study of Medical Education at the College of Medicine of the University of Illinois to study the feasibility of expanding graduate programs lead- ing to a degree of Master of Educa- tion and also short term training pro- grams in the area of continuing education. In addition, other univer- sity groups have submitted proposals for assistance to extend their pro- grams in these fields. In January and May 1967 representatives from six universities, including staff from tchools of medicine and education, Met to examine possibilities of ex- panding programs to train educa- tional manpower. : The Division staff has also worked closely with national organizations to broaden resources in continuing edu- cation, They include committees of the American Medical Association, the National Board of Medical Ex- aminers, the Association of American Medical Colleges, American Public Health Association, American Physi- cal Therapy Association, Association of Hospital Directors of Medical Ed- ucation, Inter-University Communi- cations Council (EDUCOM) and other professional and public groups. Systems Analysis The use of systems analysis has been encouraged in Regional Medical Program activities as an integral component of program development. Exploratory efforts have been under- taken to make broader use of systems analysis skills in studying specific problems of improving medical serv- ice. As part of this effort, the Divi- sion has entered into a contract with the Department of Industrial En- gineering of the University of Michi- gan to study how to apply operations research and systems analysis meth- ods to problems of regional medicine. Data Collection Conferences of specialists met in March and May of 1967 to identify and discuss data available for plan- ning and evaluation of Regional Medical Programs and problems of data collection. By taking advantage of available data, Programs can avoid duplication of effort and there- by concentrate on studies of coopera- tive arrangements and other issues and needs unique to Regional Programs. Listing Facilities Section 908 of Public Law 89-239 re- quires the Division to “. . . estab- lish and maintain a list or lists of facilities . . . equipped and _ staffed to provide the most advanced meth- ods and techniques in the diagnosis and treatment of heart disease, can- cer or stroke... .” As a first step to fulfill this requirement, the Divi- sion has contracted with the Ameri- can College of Surgeons for its Com- mission on Cancer to undertake a study of appropriate standards to provide the highest level of diagnosis and treatment of cancer patients. Such standards may then be useful as measures by which medical care in- _ stitutions of the country can evaluate their own capabilities, and by which the individual Regional Medical Pro- grams can estimate where additional support may be needed. Disseminating Information A device for sending periodic reports to the Regions has been established to disseminate to Program Coordina- tors and other interested persons in- 15 formation and data affecting the development of Regional Programs. This medium will also help speed the exchange of reports of significant progress and problems among the Regions. FINANCING FROM OTHER SOURCES Substantial contributions have been made to the development of Regional Medical Programs by hundreds of individuals and institutions through- out the country. Leading officials of medical schools, hospitals, research institutions, voluntary health agencies and members of the public have de- voted effort and resources to plan for these new programs. In many areas, local funds have been made available specifically to aid in the initial plan- ning. For example, in Vermont, the State legislature appropriated $10,- 000 to help defray planning expenses. In Oregon the University Medical School, the State Medical Associa- tion, and the members of the Re- gional Advisory Group donated $6,000. The Mountain States Re- gional Medical Program received a grant of $13,700 from a_ private foundation. Altogether, it is estimated that through March 1, 1967, more than $1.5 million in cash and services has been contributed to the planning 16 Estimatep Amount or Funps F TABLE 6 rom Non-FEDERAL SOURCES FOR PLANNING RE GIONAL MepIcat Procrams, THroucn Marci 1, 19673 Region otal Cash Services Region Total Cash Services TOTAL. ..0..0...0 0000 ee $1, 497, 300 | $287, 800 | $1, 209, 500 Missouri... . 000 ee cee cece etree $48, 900 $3, 900 $45, 000 Mountain States.........255 05005 15, 000 13, 700 1, 300 Alabama........-0.000 eee eee 21, 200 3, 800 17,400 |; Nebraska-South Dakota........--- 9, 000 1, 400 7, 600 Albany, N.Y... .--6 02.052 eee 96, 800 24, 500 72,300 || New Jersey... ..--+-e reer e rene 17, 800 12, 000 5, 800 AYVIZONA.. occ eee 2, 800 100 2,700 || New Mexico. ......-.+-esee rere 25, 200 5, 700 19, 500 Arkansas... 0.000 eee 5, 100 600 4, 500 New York Metropolitan Arca...... 11, 000 1, 00G 10, 000 Bi-State. 20... eee ee ees 13, 200 1. 500 11, 700 North Carolina. ........-25-0000? 38, 100 |.......--- 38, 100 California...... 0000 eee pe teens a North Dakota. ....... 00: e ener efor ere teens Oe ee Central New York... 0.06602 00055 12, 000 6, OOO G6, O00 Northern New England.........+- 134, 200 10, 000 124, 200 Colorado-Wyoming.....--.0 02+ feet centers Northlands.........00 00 eee eee eee 30, 900 5, 400 25, 500 Connecticut.......0-- 06ers 33, 800 j....--.--- 33, 800 Ohio State. 2.0... cee eee ene 37, 200 6, 600 30, 600 Florida... ccc cece eee eens 7,500 |.......--- 7, 500 Ohio Valley........062 see ee eres 10, 600 2, 100 8, 500 Georgia... 62: e eee eres 2, 300 900 1, 400 Oklahoma... . cee eee ee eens 50, 000 |......---- 50, 000 Greater Delaware Valley.......-.- 174, 500 70, 100 104, 400 Oregon... 6.2 e eee eens 18, 000 6, 000 12, 000 Hawali.. oc. ccc eee 6,900 j.......--- 6, 906 Rochester, N.Y.....-00000 ee ree 53, 500 40, 900 12, 600 [linois.. 0... eee 48, 000 3, 000 45, 000 South Carolina........000 20ers 3, 000 1, 500 1, 500 Indiana... peer se rss ers s cesses 76, 900 4, 500 72,400 || Susequehanna Valley......----+-- 6,000 |.....-.--- 6, 000 Entermountale Pete eee nates es eres 3 a Mm M00 . 400 Tennessee-Mid South........+0+5- 20,400 | 3, 400 17, 000 OWDs ce ccc cece eet eens ,5 ’ , Weaisns..... 2c. seeeesee eee 125,000 |......-66- 125,000 || ox 82, 000 | 10,000 72, 000 Louisiana... ccc cee ee eee re epee ere ee eee C7) [ewe cece ee eee Tri-State Perens rene rene re eee e Pesce et es tte OC) fererersteees Maine. ....:.cscsceveeeetenseees 16, 200 1, 500 14, 700 Virginia Decne eee eee en been eenee 25,000 |.......--- 25, 000 Maryland........0-00000000e eee 7,000 |.......05 7,000 || Washington-Alaska...-.----- +--+: 4,000 |....-.-++- 4, 000 Memphis. .......-.000200e2 000 20, 000 9, 700 10, 300 || West Virginia. ...------s2-s0r ee 11, 000 1, 000 10, 000 Metropolitan Washington, D.C.... 2, 000 300 1, 700 Western New York.....-------++> 38, 300 2, 100 36, 200 Michigan........--0000 seer eeee 4,500 |.....-.0-- 4,500 || Western Pennsylvania. ......----- 7, 000 1, 000 6, 000 Mississippi. ....-.-- +2022 errr eee 15, 000 9, 000 6,000 || Wisconsin......--..-+sse reer 37, 500 8, 500 29, 000 2 Not reported. t As reported by individual Regional Medical Programs. velopment of Regional Medical ograms from non-Federal sources. listing of these amounts, by Region, set forth in Table 6. Procedures are being developed d implemented in the Regions so at these cooperative programs are anced from a variety of sources. _some areas, total responsibility for e support of the activities will be sumed by local funds after an ini- ul period of study, testing and dem- istration, In many Regions, volun- ry agencies and foundation funds ¢ being enlisted. At this stage in the development of egional Medical Programs, it is not yssible to ascertain the longer term lationships of Federal and non- :deral funding of the activities un- ‘y this program or to assess the iture of their impact upon medical rvice costs. If this program is suc- sssful in developing needed addi- onal clements in the community ealth scene that are parts of im- roved services, the extent to which nese. services ¢an be _ financed irough regular cost and payment rocesses or other local funding iechanisms and the extent to which ermanent or temporary Federal ssistance will be required are issues nat will call for critical examination s the program progresses. AN APPRAISAL OF ‘THE ACTIVITIES ASSISTED IN THE LIGHT OF THEIR EFFECTIVENESS Only a tentative appraisal of the effectiveness of Regional Medical Programs in carrying out any of the established objectives is possible this soon after enactment of the legisla- tion. On the basis of this limited period of observation there seems to be clear evidence that overall prog- ress has been substantial. The pros- pects for the future are positive and auspicious. The first objective of the Regional Medical Programs is “the establish- ment of regional cooperative arrange- ments.” Accomplishment in respect to this objective has been outstand- ing. As noted above, the health in- terests of the Regions as well as re- lated agencies and members of the public have come together in an un- precedented fashion to consider the most appropriate local ways of meet- ing identified necds under this pro- gram. Maintaining the continued commitment of these groups with di- verse goals and interests to continue to work together in establishing and implementing Regional Medical Pro- grams will be crucial. The second purpose ‘of Regional Medical Programs specified in the legislation is “to afford the medical profession and the medical institu- tions of the Nation, through such cooperative arrangements, the op- portunity of making available to their patients the latest advances in the diagnosis and treatment of — these diseases.’ Much of the planning effort is focused on identifying the types of “opportunities” that are most appropriate and practical to provide and strengthen) capabilities. As re- ported above, a broad spectrum of potential approaches to this objec- tive are being explored in planning, feasibility studies and pilot projects. Provress to date indicates that the basic concept of looking to regional groups for ideas and initiative is well founded. — The third purpose specified in the Law is “to improve generally the health manpower and facilities avail- able to the Nation. . . .” Regional planning holds the potentiality of ac- complishing this objective also. Better ways of utilizing and training health manpower, including many types of allied personnel, are also being ex- plored. More efficient methods of extending the effectiveness of exist- ing and new facilities, through shar- ing and cooperation, are being initiated. Most importantly, Regional Medi- cal Programs themselves are develop- ing resources and procedures for 17 continuing evaluation. A principal strength of these programs is the op- portunity to build up resources for continuous evaluation; this is par- ticularly appropriate and necessary in light of the concentration on in- novation and experimentation, Eval- uation mechanisms are gencrally heing established as part of the planning process so that essential baseline data will be accumulated and capahilitices developed to assess continuing progress and problems. In this way, the Regional Programs will be better able to modify their direc- tion and speed, on the basis of actual experience, and progressively im- prove their effectiveness. ‘The long-term effectiveness of Re- gional Medical Programs will be demonstrated by evidence of ad- vancement in the quality of services for these diseases, by extensions in periods of productive life, and by re- duction in mortality and morbidity. Initial progress has established a promising foundation for such gains. These goals will not be accomplished quickly or casily, however. The full friition will depend, in largest part, upon the continuing commitment of regional health resources, the succes- ful recruitment of high quality per- sonnel, and the sound support of op- erating programs. v4 ae : . ? - ‘ . : : te ee Se mt ‘ . . PRU LLIN CVU SL Issucs And Frobicms The initial experience with Public Law 89-239 has raised a number of issucs and problems which face the Regional Medical Programs as they seck to achieve the ultimate purposes of the Law. The prospects for prog- ress toward the objectives of the legis- lation and the rate of that progress can only be realistically assessed when they are measured against the magni- tude of the challenges. Thus a clear understanding of the issucs and prob- lems encountered thus far is essential to evaluating the initial progress de- scribed in the report. This under- standing also provides the setting for the conclusions drawn and recom- mendations made. Some of these issucs and problems are derived from the particular char- acteristics of the health care activily in this country and the dynamics of its growth and change. Other issues derive more specifically from partic- ular provisions of Public Law 89-239. These latter problems have special relevance to the policies already de- veloped and bear directly on the rec- ommendations for its extension and modification. Many of these issues and problems are interrelated in a complex manner. They reflect the gencral problem of reconciling na- tional needs and objectives with the values, patterns of action and the diverse interests that exist in the com- munity health setting. Regional Medical Programs and the General Problems of the National Health Scene The fundamental principles and processes of health activities in this Nation have generated immediate issues for the conduct of Regional Medical Programs. ‘These conditions have imposed certain constraints. ‘They have affected and will continue to affect the manner and cxtent to which these programs may contribute io better health. Voluntary Health System Health activities in this country are predominantly private and voluntary in nature. With some exceptions, such as treatment of the mentally ill, the medical program of the Veterans Ad- ministration, and the care of indi- gents, most medical care in the United States is not a direct govern- mental responsibility. Recent years have seen a rapid rise in the provi- sion of public funds for a broad range of health activities; however, the terms and conditions under which these funds are provided have sought to preserve the voluntary and private nature of United States health care. Specific provisions of Public Law 89-239 and its legislative history re- flect this prevailing pattern by stress- ing the voluntary, cooperative nature of the Regional Medical Programs. These programs, therefore, face the challenge of influencing the quality of services without exercising admin- istrative control over current health activities. To achieve its objectives, cach Regional Medical Program will have to undertake many activities which require the active involvement of a variety of medical institutions, personnel, and organizations. Such activities include reaching a con- sensus on the distribution of special- ized facilities and manpower required to mect the needs of heart, cancer and stroke patients at the most rea- sonable cost; determining the char- acter and conduct of continuing edu- cation programs that utilize the resources of both university medical centers and community hospitals; and applying technological innovations such as techniques for diagnosis and patient monitoring using centralized computer facilities. Such decisions must be made within the regional setting. Indecd they are already being made by many of the Regional Medical Programs. To do so in the context of the voluntary medical system, the Regional Medical Programs must establish and main- tain a sufficient consensus of the major medical interests concerning the means being used to achieve the objectives of the program. The im- portance of this consensus gives spc- cial significance ‘to the progress already achieved in establishing what the Law calls “regional cooperative arrangements.” Evidence of this progress is con- siderable. Llowever, it is still too early to assess the effectiveness and stability of these mechanisms when they are faced with difficult decisions. The first steps cannot be considered defin- itive, but it is reasonable to assume that the goals of the Regional Medical Programs could not be achieved in a voluntary medical system without the progress toward the necessary con- sensus that is now underway. Leadership is obviously of vital im- portance in achieving voluntary co- operation. The Law does not specify the source of leadership for the Re- gional Medical Programs. This has permitted leadership to develop in a varicty of ways. Flexibility in the choice of the leadership focus has been cited by several regions as a key to achieving the necessary consensus of the major health interests. This flexibility, however, carries with it the risk that decision-making mechanisms may develop which are not strong cnough to deal with important prob- lems and issues. For this reason the review of grant applications is con- cerned not only with the development of workable cooperative arrange- ments but also with the effectiveness of decision-making mechanisms and leadership. Magnitude and Complexity of Our Total Health Resources Another characteristic of health ac- tivities in this country which compli- cates the development of any new health program is the magnitude and complexity of the health resources. Such gross statistics as 288,000 active physicians, over 600,000 nurses, 7,000 hospitals, 100 schools of medicine and osteopathy, and a total annual health expenditure of approximately $43 billion give some indication of the magnitude of the total health endeavor. The ultimate goal of Re- gional Medical Programs is to have an impact on the health of patients threatened or afflicted with these diseases. Its accomplishment will eventually involve ‘a staggering num- ber and variety of health resources. To the magnitudes of this universe must be added the complexity of in- creasing specialization of personnel | and facilities, acceleration of change in the nature of medical practice duc to the advances of science, social and economic changes, and the vari- ety of patterns of medical care. A program concerned with the wider availability of advances in heart disease, cancer, stroke, and related diseases will inevitably encounter the full range of this complexity. Thus the facts of this size and complexity raise many problems for the devel- opment of the Regional Medical Programs. The diversity of health resources, together with the relative lack of organized relationships among them, presents cach Regional Medical Pro- gram with a formidable task in es- tablishing regional cooperative ar- rangements and carrying out operating programs. As a consc- quence planning will involve the establishment of priorities of action and careful phasing in the develop- ment of the program. Sclectivity and phasing are made necessary by limits on resources, other institutional com- mitments, the need to gain accept- ance by health personnel, and the importance of careful testing of new mechanisms. This necessity for phas- ing, however, will place strains on the arrangements for the voluntary co- operation necessary for the Regional Medical Program. Unless partici- pants in the program accept the necessity for selective action and phased development, it seems un- likely that the regional cooperative arrangements will survive in a vol- untary form. On the one hand both patients and health resources will need to recognize that the Regional Medical Programs cannot solve all the prob- lems in these disease fields. Neither can they become a mechanism for paying for each medical institution’s priority needs identified on an iso- lated basis. On the other hand each Regional Medical Program will need to de- velop a plan which illustrates both to the potential participants and to their patients, the rationale for selection of priorities and phasing of program. It will need to generate confidence in the fairness and capability of the de- cision-making process for making the necessary program determinations, and the relevance of program plans and activities to the needs of the people in the entire Region. It is still too soon to say that all the Regional Medical Programs being planned and established will meet these tests. There is early evidence, however, that initial steps are being taken which will enable the Regional Medical Programs to do the job. Manpower Limitations The Regional Medical Programs are being planned and carried out during 21 a period characterized by shortages of health manpower necessary to provide high quality health care to an expanding population. The Pub- lic Health Service has assumed a major role in assisting in the expan- sion of the supply of trained health manpower. This is being done through many programs including construction of training facilities, scholarships, training grants, and other forms of training support. However, most of these programs have been implemented in the last several years. Their impact in terms of increased training capacity is only begining to be felt. Meanwhile the needs continue to increase and are accelerated by the implementation of large scale programs of health care financing such as Titles XVIII and XIX of the Social Security Act. Manpower shortages arc relevant to the Regional Medical Programs in several ways. First, they place a constraint on the rate of implemen- tation of some program activitics. This is already being reflected in the difficulties some regions are experi- encing in acquiring the initial plan- ning staff. There is keen competition for manpower with planning and leadership capabilities. The man- power constraint also applies to the setting of priorities and the rate of progress of operating activities. This 22 constraint has been cited by some of the Regional Medical Programs as a major factor in establishing priorities for action. Manpower limitations also affect Regional Medical, Programs by in- creasing the relative emphasis given to training activities in both the plan- ning and operational phases of the Regional Medical Programs. Man- power shortages are real, and high priorities are being assigned to train- ing activities to help meet these shortages. It seems likely therefore that the emphasis on training activi- tics will be greater in the initial stages than in later periods. This likelihood could create the false impression that the Regional Medical Programs are primarily training programs. A third relevant aspect of man- power limitations could be the as- signment of higher priority to activi- tics which increase the efficiency of manpower utilization. These would include: (1) the development of new techniques for diagnosis and treat- ment that increase the productivity of existing manpower; (2) the devel- opment of new types of manpowcr; and (3) the more efficient division of labor among different levels of man- power and among the several parts of the regional framework. The use of operations research and systems analysis in the development of Re- gional Medical Programs may con- tribute to development of new ways to use health manpower. Applications of these analytical and management tools are already under development in a number of regions. The Regional Medical Programs may create an en- vironment and a mechanism for ex- ploring many approaches to the efficient use of health manpower, as well as the opportunity to evaluate those new approaches under many different conditions. The future evaluation of the effectiveness of Regional Medical Programs should take into account their contributions to the solution of these manpower problems. Data Gathering and Evaluation The lack of objective data and meth- ods for using data may hamper the launching of programs which require planning, selection of target objec- tives, priority setting, and evaluation of effectiveness in terms of the ulti- mate objective of better health for persons threatened with heart dis- case, stroke and related diseases. ‘Techniques are not highly developed for acquiring and analyz- ing data which provide the basis for measuring cause and effect in terms of improved patient care. As in many other arcas of activity, the Regional cancer, Medical Programs will have to de- velop and modify techniques as the programs arc initiated. They will not be able to rely entirely upon estab- lished data-gathering and analytical mechanisms. Initially, the assessment of needs and the choice of program strategies will depend heavily upon informed judgment. Regional Medi- cal Programs will need to strike the difficult balance between the initia- tion of activities on the basis of in- formed judgment about effects on patient care, on the one hand, and the continued refinement of the data base which will essentially permit re- direction of effort based on objective analysis of experience. Increasing Cost of Medical Care The gencral public is deeply con- cerned about the rapid and continu- ous rise in the cost of medical care. The Secretary of Health, Education and Welfare has indicated the importance of due attention to moderating the price of medical care in developing Regional Medical Pro- grams, The measuring of cost against benefits is very difficult in health care. Inadequate knowledge of the effects of changes in alternative methods of diagnosis and treatment render an accurate cost- benefit as- sessment practically impossible with current data and techniques. How. ever, useful approximations can be developed in some areas. The tech. niques of operations research anc systems analysis being used by som Regional Medical Programs can bi helpful in making these assessments The major determinants of medi cal care costs seem to be beyond th scope of Regional Medical Program: Nonetheless, Regional Medical Pre grams can contribute to the efficienc of program implementation and to greater awareness of the cost impl cations of improved medical car They can provide (1) definitions « needs, resources, and program activ tics through a planning process whic includes all major elements of tl health-care system; (2) develo ment of cooperative decision-maki: frameworks that may speed acce} ance of efficient means of deliveri care; (3) opportunities to explc and evaluate the usefulness of ni technologies and new types of hea! personnel which will contribute tot more efficient improvement of t quality of patient care. The Regior Medical Programs will need to ma cost analysis an integral part of p gram planning and evaluation. Regional Diversity The diversity of this Nation is flected not only in the health proble esources but also in the patterns edical care in the various Re- . The problems and appropriate mses in a sparsely settled ruraJ with difficulties in attracting cians and transporting patients long distances are very different those in the crowded metro- an areas with both great con- ‘ations of medical resources and ing needs, particularly in the city slums. ‘thaps because of the relative icity of the medical resources, ional Medical Programs seem to leveloping more rapidly in pre- inantly rural areas and smaller s. Paradoxically, it has heen jeularly difficult to develop the al steps toward effective Regional jical Programs in the metropol- _ areas where the greatest con- tration of medical talents and lities is to be found. Their added aplexities begin with the large yulations to be served. They. in- de also high concentrations of advantaged groups. These com- tations are multiplied by the large mbers of institutions, including dical schools, hospitals, and other ilth agencies and their long-stand- t habits of autonomy and even alry. Added to these difficulties are + multiple social, economic, and litical complexities that charac- ze modern urban life. Consequently, the development of effective cooperative arrangements has been especially difficult in the largest cities. It has proved more difficult’ to develop a meaningful focus of leadership which can pro- vide the basis for cooperative action. The juxtaposition of great resources and great needs not only creates sig- nificant opportunities but also gen- crates real tensions. The mechanisms which evolve for the metropolitan areas may prove to be quite different ’ from the more simple models appro- priate for Iess complex Regions. Vol- untary cooperation in such an urban environment will be put to a stern test. Planning for Regional Medical Programs is now underway in all these areas, however, and the new patterns of relationships and respon- sibilities are being explored to over- come these special metropolitan problems. The Regions are now facing the challenge of creating under these diverse circumstances an administra- tive framework which not only serves the objective of regional cooperation but also provides sufficient focus of administrative responsibility to per- mit effective decision-making and program operation. This framework must provide sufficient authority and responsibility for good management by the full time program staff with day to day operating responsibilities. At the same time it must preserve a meaningful and continuing policy role for the Regional Advisory Group with its broadly representative base. The multiple administrative patterns which are emerging in the regions would seem to be an appropriate re- sponse to diverse situations. The effectiveness of the various patterns remains to be tested. How the various Regions manage to cope with their diverse situations will probably bring about a different rate of development of Regional Medical Programs and will lead to wider variations in the approaches developed by the various regions than would be appropriate if the patterns of medical care were more uniform throughout the Nation. This diversity, and the devclop- ment of appropriate strategies in re- sponse to diversity, make more difficult the communication of a gen- eralized concept of a Regional Medi- cal Program, They complicate the development of responses to needs perceived at the national level. They hamper the widespread use of new techniques and approaches devel- oped in one set of circumstances. On the other hand this diversity is one of the strong arguments for the flexibility in the provisions of the authorizing legislation. Given the facts of this diversity in the carly stages in the development of the pro- irram, it scems too carly to reassess the 23 appropriateness of this flexible ap- proach. Comparative evaluations of specific program accomplishments over a period of years offer the op- portunity to refine techniques and approaches. ISSURS ASSOCTATED WITH THE LAW Understanding Program Purposes From the time the legislation to au- thorize these grants was first intro- duced in January 1965, there has been some misunderstanding about the nature and purposes of the pro- gram, This misconception was based largely upon the mistaken idea that the objective of the law was to build 2 national network of Federal centers to give care to heart disease, cancer, and stroke patients. To help clear up this misunderstanding, the Congress made changes in the legislation to further emphasize local initiative and involvement of practicing physicians, community hospital administrators, and the many other relevant interests including the public. In spite of these efforts to clarify understanding of the purposes and mechanisms of the Regional Medical Programs, fears and misun- derstandings were a major impedi- ment to be overcome in initiating the Programs. Speeches, articles, and the Program Guidelines issucd by Divi- sion of Regional Medical Programs emphasized the utilization of exist- ing institutions and manpower re- sources, the participation of prac- ticing physicians, the necessity for planning and implementation ‘at the regional level, the cooperation of all major health interests and the ulti- mate common focus of all activities on improving the care of patients. Progress in understanding has been made. However, tendencies toward fragmentation and insularity of health activities in this country have made it more difficult to overcome apprehension and suspicion. Clearly, the initial achievement of trust and its reinforcement through action is an essential ingredient of success. The steps taken thus far can be judged successful in the context of the difficulty of the task. It would be misleading cither to underestimate this difficulty or to assume that the programs can be carried out without a significant level of common under- standing. It is expected that under- standing will grow through experi-- ence in working together. Categorical Nature of the Program Public Law 89-239 is directed at “heart disease, cancer, stroke, and re- Jated diseases.” These disease prob- lems, which cause more than 70 per- cent of all deaths in the United States and afflict millions more, constitute an appropriate nucleus for the devel- opment of effective broadly based regional cooperative arrangements. Because of the tremendous scope of these disease problems, they have a major impact upon the total range of personal health services. ‘To plan cf- fectively for heart disease, cancer, and stroke, and related diseases, it is often necessary to consider the entire spectrum of resources available for personal health services. For example, effective programs of continuing edu- cation based on analyses of the capabilities and inter- ests and attitudes of medical and allied practitioners toward all types of continuing education activities; only in this way can the particular role and place of programs concerned must be broad with specific categorical diseases be determined. ‘The criteria governing the award of a Regional Medical Program grant are whether or not the activities in the program arc necessary for achiev- ing the established statutory objec- tives and whether they reflect a coherent whole centered upon ad- vancing the quality and availability of services in the areas of heart disease, cancer, stroke and related diseases. The approach is practical— are the activities to be undertaken an integral and essential part of a coordinated effort to advance the attack on heart disease, cancer and stroke and related diseases? Review procedures, including the Regional Advisory Groups and the National Advisory Council on Regional Medi- cal Programs and related technical committees, evaluate applications against this standard. Regional reports indicate many activities supported under and essential to the development of Re- gional Programs will contribute to other health goals. It would not be possible to achieve the legisla- tive objectives efficiently if attempts were made to sort out the frac- tions of indirect effect. In some instances, activities which have a more gencral impact extending be- yond the specific problems of heart, cancer, stroke and related diseases may need to be supported because they are essential to the achieve- ment of the purposes of Regional Medical Programs. Without the full support of these basic” activities by Regional Medical Programs, im- portant underpinnings of the attack on heart disease, cancer, and stroke and related diseases would be missing. An example of this situation is the financing of personnel and equipment needed for educational purposes which are basic to specific educa- tional programs for heart disease, cancer, stroke and related diseases. Moreover, the cooperative arrange- ments and relationships initiated through Regional Medical Programs provide mechanisms that should be useful in dealing with other health problems. If regional cooperation is effective in meeting problems of heart discase, cancer, stroke and related diseases, it can also be uscful in accomplishing other health ends. A number of Regional Medical Pro- grams have already indicated an in- terest in working on other health problems, enlisting other sources o! support for this work. Definition of the Region Public Law 89-239 provides consid erable latitude for the definition o “regions . . . appropriate for carry ing out the purposes” of the Ac’ However, the Surgeon General hz the responsibility for insuring that a parts of the country are served an that inappropriate overlap is avoidet An carly policy decision was t place initial responsibility for delir eating the “Regions” upon loc: groups developing the planning appl cations. It was forescen that mar considerations would need to t taken into account in arriving at these decisions, and that their rela- tive weight would vary in different areas, The Program Guidelines pro- vided that the Regions should be: “an economically and socially cohe- sive area taking into consideration such factors as present and future population trends and patterns of growth; location and extent of trans- portation and communication facili- lies and systems; and presence and distribution of educational and health facilities and programs. The region should be functionally coherent; it should follow appropriate existing relationships among institutions and existing patterns of patient referral and continuing education; it should encompass a sufficient population base for effective planning and use of expensive and complex diagnostic and treatment techniques.” , It was recognized that original defini- tions would necessarily be prelimi- nary and might be modified by findings from planning studies, re- finements in criteria and changing conditions. Therefore, one principal objective of the initial planning is a more precise definition of the preliminary planning Regions. The award of the planning grant has been the begin- ning of the effort to determine the most appropriate current interrela- tionships. It seems likely that a num- ber of Regions will be modified. No single definition of a Region can serve all of the program’s purposes with equal effectiveness. Therefore, determination of any Region is a judgmental balancing of benefits and liabilities. Consultation among neighboring Regions, as between Mis- souri and Kansas, helps to identify the most effective division of re- sponsibilities. In some areas it may be best for individual hospitals and groups to participate in different as- pects of several programs. In addi- tion, continuing arrangements for in- terregional cooperation will help to serve the. effectiveness of individual Regions. Achieving Widespread Participation Public Law 89-239 and its legisla- tive history emphasize involvement of medical centers and practicing physicians in Regional Medical Pro- grams. This emphasis has stimulated the active participation of the medi- cal schools and the leadership of physician organizations. The statu- tory requirements for membership on the regional advisory groups has ex- tended participation ‘to leaders of other major health organizations and agencies. In the development of many of the applications for planning grant funds, participation was largely con- centrated in this limited group of leaders because of the necessity to work out the initial acceptance of regional cooperative arrangements among representatives of the major health interests. However, the award of planning grants has provided the funds and staff time to mount con- certed efforts to extend the scope of participation. Reports froin the Re- gions indicate that programs and proposals are now heing discussed with members of health professions, institutions, and members of the pub- lie at large through workshops, mect-_ ings at community hospitals, confer- ences with other local groups and medical societies, and through State conventions of health organizations. However, in many Regions there still remains the substantial job of health practitioners and other local groups. reaching many __ interested In some arcas limitations of man- power and time have not yet per- mitted sufficient investment in the complex and time-consuming activity of developing new mechanisms for cooperation. The pace of progress is slowed by the frequent lack of expe- rience in working together on the part of organizations and institutions 25 which have been accustomed to a considerable degree of autonomy. Achieving wider participation and communication alsa requires in some cases the modifying of attitudes based on prior experiences, misunderstand- ings of the purposes of the program, and fears of domination and control by the large medical centers. In some regions the split between “town” and “gown,” frequently the source of past tensions, has to be overcome. The progress reports, however, present encouraging evidence that the pro- gram is, in fact, bringing the neces- sary groups together, Region by Re- gion. True collaboration will gener- ally involve stress, trial and error for each Region to arrive at the most suitable procedures and mechanisms to mect its needs. Role of the Regional Advisory Groups The composition and role of the Regional Advisory Groups has re- ceived considerable attention both within the Regions and in the review of grant applications. This concern is justified by the attention given in the Law and the legislative history, which stressed the importance of these for both achieving and monitoring the effec- groups as mechanisms tiveness of regional cooperative ar- 26 rangements in mecting the necds of the people in the Region, The Law requires that these groups be broad- ly representative of the major health resources of the Region. It also insists that members of the public familiar with health needs be included. ‘The Law makes their approval of applica- tions for operational grants a condi- tion of Federal grant support. To carry out the full intent of the Law, the Program Guidelines and the National Advisory Council have stressed the importance of the con- tinuing role for the Regional Advisory Group and the necessity for independ- encc of its functions, As evidence that the advisory group is performing its role and is not a pro forma or sub- servient group, an annual report is required from the Advisory Group itself giving its evaluation of the cf- fectiveness of regional cooperative arrangements. The importance and composition of these Advisory Groups have been. given further attention in a recent policy statement of the Secretary of the Department of Health, Educa- tion, and Welfare on “Medical Care Prices.” This policy calls for special emphasis to be given to adequate and effective consumer representation in the administration of Regional Medi- cal Programs. The Regional Advisory Groups are a logical locus for that representation. Continuing Education for Patient Care Continuing education is an essential component of Regional Medical Pro- grams. It contributes in a most dircct way to the primary purposes of the Regional Medical Programs. Im- provements in patient care require the primary participation of prac- _ ticing physicians and other members of the health team in their daily prac- tice. Therefore, if the advances of biomedical research are to be made available to patients, the means must be provided continuously to update the performance of all health profcs- sionals and supporting personnel. However, Regional Medical Pro- grains are not exclusively nor even primarily a continuing education ef- fort. Continuing education is one of a number of means of working to- ward their total objectives. Continu- ing education projects, no matter how meritorious, are supported from Re- gional Medical Program grant funds only when they are part of integrated, comprehensive approaches of cn- hancing regional capability for the diagnosis and treatment of heart disease, cancer, stroke, and _ related discases. The accelerating rate of advance in the biomedical sciences and re- lated technology makes the problem of keeping current increasingly diffi- cult for all involved in health care. Regional Medical Programs are pro- viding new opportunities to develop the essential linkages between cduca- tion and practice, as an important means of diminishing professional ob- solescence which is the inevitable consequence of rapid scientific ad- vance. Studies of better ways of pro- viding health services, demonstra- tions of patient care, and educational and training for all types of health personnel are joined together in a unified effort. In continuing educa- tion, as in other components of the program, attention is focused directly on the question, “Will this effort change behavior and will this change result, in fact, in the patient receiv- ing the benefits of advances in heart disease, cancer, and stroke?” Progress reports show Regional Medical Programs are proving to be a strong catalyst to the entire field of continuing education and training of the health professions. They are providing mechanisms for the coop- erative relationships that can make continuing education more effective in improving patient care. Latest Advances in Diagnosis and Treatment Section 900(b) of Public Law 89- 239 states that the Regional Medical Programs are to help the medical pro- fession and the medical institutions of the Nation make available to their patients “the latest advances in the diagnosis and treatment” of heart disease, cancer, stroke and related diseases. A narrow and rigid interpre- tation of this section would seriously hamper the effective accomplish- ment of the purposes of the program. Improved health for patients threat- ened or afflicted with these diseases requires emphasis on prevention and rehabilitation as part of diagnos- tic and treatment processes. It re- quires dissemination and widespread use of all relevant knowledge in order to achieve the benefits of the ‘Jatest advances.” The Public Health Service has encouraged the Regions to consider health functions as a continuum and not a set of isolated functions. This continuum involves the environment of research and teaching, where the latest advances in diagnosis and treatment are most readily intro- _ duced, as well as the other institution: and groups involved in preventing and caring for victims of thes« diseases, To overcome existing gaps it is necessary to overcome problem of organization, distribution, man power, cost, attitudes of the public o the health professions and evaluatior of the effectiveness of activities i ranging the health status of the opulation. imitations on Institutional nd Personal Commitments and serious commitments of institu- tions and personnel. Relationships to Other Programs . practical issue is raised by the iitial authorization of the program n a 3-year exploratory basis. If the rogram is to succeed, institutions nd organizations must commit them- elves to participation in regional co- iperative arrangements which may nvolve some lessening of their inde- yendence of function. Many of these nstitutions are under continuous jnancial pressures. Full commitments ‘0 new patterns of relationships in- yolve changes in attitudes. For these reasons it is very difficult to obtain this full commitment on the basis of a limited authorization of the pro- gram. Similar problems apply in recruit- ing talented manpower. High caliber people are reluctant to make career changes when the permanency of the program is under question. The de- gree of commitment already achieved in the initial phases of the program is the basis of hopeful expectations. However, it will be difficult to obtain a valid trial on which to base judg- ments of the ultimate effectiveness if the nature of the program authoriza- tion does not encourage voluntary The great trends of accelerating sci- entific advances and rising public expectations in health have gener- ated many new activities and pro- grams to stimulate and support con- certed action for health across the Nation. Regional Medical Programs are part of the response to these forces, Other major actions relate to financing the costs of medical care, education for the health professions, delivery of mental health services in the community, strengthening public health services and planning and con- struction of hospitals and other facilities. In the preamble to the most recent of the major Federal enactments, the Comprehensive Health Planning and Public Health Services Amendments of 1966 (Public Law 89-749), the Congress made the following state- ment of national health purpose: “The Congress declares that fulfill- ment of our national purpose depends on promoting and assuring the high- est level of health:attainable for every person, in an environment which con- tributes positively to healthful indi- vidual and family living; “that attainment of this goal depends onan effective partnership, involving close. intergovernmental collabora- tion, official and voluntary efforts, and participation of individuals and organizations; “that Federal financial assistance must be directed to support the mar- shalling of all health resources—na- tional, State, and local—to assure comprehensive health services of high quality for every person, but without interference with existing patterns of private professional practice of med- icine, dentistry and related healing arts.” The many and diverse health pro- grams, both nationally and in the Re- gions, States and communities, all contribute to these goals. However various thrusts must be interrelated to achieve maximum impact and cf- fectiveness. Utilizing resources wisely in the many promising avenucs of health activity calls for planning and cooperation at many levels and the recognition of the preponderance of nonfederal financing for the total health function. ‘Two fundamental principles, both implicit in the Congressional declara- tion of purpose just cited, govern the Federal participation in health pro- grams. The first is a commitment to local, broadly based initiative and plan- 27 ning. A diversity of patterns and priorities, determined by the people of a Region, State, or community can help to match programs to particular needs. No master plan imposed by a central authority can be sensitive or responsive to the multiplicity of local conditions and requirements. Planning is to aid foresight and ra- tional action, not dictate solutions. The second is that decisions in- volving health involve the whole of society, not just a few public or pri- vate agencies. Rather all those af- feeted by these programs—providers and consumers, public and private groups, educators and practitioncrs— must participate actively in decision inaking. Division and fragmentation impair progress and effectiveness. These two principles are demon- strated with special clarity in two major new Federal programs designed to pull together a number of efforts whose impact has been diffused in the past: the Regional Medical Pro- grams, and the Comprehensive Health Planning Program authorized by Public Law 89-749. The first seeks to stimulate the development of co- operative arrangements for programs directed toward enlarging the avail- ability and enhancing the quality of care provided for major disease prob- lems on a regional basis; the second sceks to stimulate effective planning for the use of all existing resources and the sound further development of health resources by the States, metropolitan areas and local com- munities. The two programs are in concept complementary and mutually supportive. A policy statement has been issued concerning these two programs which outlines general areas of relationship and support. (Exhibit XT) Practical operating methods under these con- cepts are now being refined. Dis- cussions are taking place through- out the country, at the levels where the coordination must be put into practice. These are the most critical decisions of all, for, as Secretary Gardner has pointed out: “We are beginning to understand that much of the problem of coordination must be solved at the local level. If the Federal Government tried to coordi- nate all its programs at the Washing- ton level, it would end up imposing a pattern on State and local govern- ment. More important, only State and local leadership has the knowledge of local needs and resources that will enable them to put all the programs together in a way that makes sense.” Arrangements are being made to insure close coordination between Regional Medical Programs and other Federal activities. Continuing linison is maintained with the Na- tional Heart Institute, the National Cancer Institute, National Institute of Neurological Diseases and Blind- ness, National Institute of General Medical Sciences, National Library of Medicine, National Center for Chronic Disease Control and the National Center for Health Statistics. Working relationships are being de- veloped with the new Bureau of Health Manpower and plans are be- ing made for collaboration with the proposed National Center for Health Services Research and Development. Similar cooperation is being devel- oped with agencies outside the Pub- lic Health Service, such as the Voca- tional Rehabilitation Administration, the Veterans Administration and the Department of Housing and Urban Development. This partial listing of the programs whose missions relate io that of the Regional Medical Pro- grams is an indication of the magni- tude of the coordinating task. The need for and responsibilitics of Regional Medical Programs to identify the most effective ways of linking programs at the regional level are emphasized in the Program Reg- ulations and Guidelines. These indi- cate, that in awarding grants, the Surgeon General will take into con- sideration “the extent to which the applicant or the participants in the program plan to coordinate or have coordinated the regional medical program with other activities sup- ported pursuant to the authority con- tained in the Public Health Service Act and other Acts of Congress in- cluding those relating to planning and use of facilities, personnel, and equipment, and training of man- power.” Relationship Between Federal and Nonfederal Financing eee nope ee nee ee Regional Medical Programs can serve as an integrating force to bring to bear all the resources required to reduce the tell from heart disease, cancer, stroke and related diseases. Grant funds under Public Law 89~ 939 will necessarily provide only a very small fraction of the total funds necessary to mect all the identified needs. The costs of these diseases constitute a large portion of the Na- tion’s $43 billion health care expendi- tures. The full application of medical scientific advances in the diagnosis and treatment of heart disease, can- cer, stroke and related diseases will require additional support from many public and private sources. Regional Medical Programs will in fact provide only a minor share of financing for the full range of activities relevant to accomplishing the purposes of the Law, even though formal matching requirements are limited to construc- tion aspects of the programs. Federal grant funds, while they can provide only partial support, must be adequate to stimulate the continuing technological and social innovations to translate the latest scientific advances into the daily practice of medicine at the commu- nity level. The “venture capital” for such innovative cfforts must, in large measure, be supplied initially from public funds. The potential return i: high and will accrue to individual: throughout the Nation. A relativel small amount of new money, wisel’ and flexibly applied and fully coordi nated with related efforts, can hel] assure that benefits from the “cuttin edge of science” are realized bot now and in the future. As noted previously the impac of this program on medical ca) costs has yet to be ascertained. | the benefits of this program do resu in warrantable additions to heal services costs, the extent to whit such costs can be met by norm financing methods versus direct Fe eral support through Regional Mec cal Programs will require carel examination. The Role of University Medical Centers Public Law 89-239 does not spec the role of the university medical c ters in the development of Regio lical Programs. Yet the nature of functions to be carried out by the ional Medical le- the university medical centers a | resource in most areas for ac- plishing the objectives of the 7, In many Regions the university lical centers have played leader- | roles in initiating the develop- it of the Regional Medical grams. ome medical leaders have seri- y questioned whether the uni- ‘ity is an appropriate focus for leadership of these cooperative ts. These doubts are raised from sral points of view: (1) Some Jical school faculty members and ainistrators have concerns that tional Medical Program respon- lities might divert medical school _ yurces from carrying out their ching and research functions. (2) ier health representatives have ex- ssed concern that medical school Jership will result in domination absorption of other health re- rees by the medical schools to ve their educational and research srests. (3) Questions have been ied from many sources about the yacity of university medical centers expand their meworks to encompass the plan- administrative ig and administrative implementa- n of a major effort involving the 268-049 O-—67—3 Programs has- total health resources of the Region with an ultimate focus on improving the quality of patient care. Since university medical centers have played prominent leadership roles in the initial development of most of the Regional Medical Pro- grams, these concerns about diver- sion, dominance, and administrative capacity deserve careful attention. Solutions to these problems require new forms of relationships between the university medical centers and the other health resources of the Regions. Coordination and Leadership Various mechanisms are being tested for administering and coordi- nating regional efforts: (1) the de- velopment of new administrative frameworks within the university and formalized administrative relation- ships with the other primary health resources; (2) the use of executive coordinating committees representa- tive of major health interests which can serve as decision-making bodies closely related to day-to-day operat- ing problems, reserving for the large Regional Advisory Groups a more general advisory and policy-making function; (3) the utilization of exist- ing nonprofit corporations as frame- works for administration of the cooperative program; (4) the estab- lishment of new nonprofit corpora- tions with boards of directors rep- the major health interests and having as their major responsibility the planning and ad- ministration of the Regional Medical Program. The creation of new administra- resentative of tive structures outside of the univer- sity medical center framework, as de- veloped in a number of Regions, seem to offer a most attractive solution to the problems noted. These new en- tities, however, create other problems related to the provision of sufficient status and stability to attract the high caliber personnel required for the planning and administration of the Region Medical Programs. TH these innovative approaches to the admin- istration of cooperative health activi- lies prove effective, they may be a useful mechanism for broader health purposes. They may, in fact, provide a useful prototype for relating the re- sources of the university to broader social needs without undue diversion of the university's attention from functions of teaching and research. Regional Medical Programs will continue to contend with this array of problems listed, as they continue their development. The resolution of most of these matters will derive 29 from the increasing sophistication and experience gained in the course of full program operations. Others will require further evolution of national health policies and attitudes. Certain are dependent upon clear exccutive or legislative action and form the basis of the recommendations con- tained in the following section. mendations weet wae ty. He “ ox ET tha}, 4 sie gd aN ae = at. ne val SE CT ION FIVE Conclusions and Recommendations On the basis of the initial experience in the implementation of Public Law 89-239 certain conclusions and rec- ommendations are indicated. CONCLUSIONS 1 An effective beginning has been made in the creation of cooperative arrangements among the health re- sources on a regional basis for im- plementing the purposes of the Law. ( The regional cooperative arrange- ments being established and the plans being developed and implemented show great promise for providing the benefits of the advances of medical science to persons threatened or al- flicted with heart disease, cancer, stroke, and related diseases. (J The Regional Medical Programs will be secking to accomplish their ‘ mission during a time when many major problems beset our health pro- fessions and institutions. The Re- gional Medical Programs scem_ to provide a relevant and useful tool in the search for better solutions to these health problems. [] The extension of this program and the indication of substantial _ further national support are needed, to sustain and nurture the individual and institutional commitments as well as the enthusiasm which give vigor and substance to the regional co- operative arrangements. These initial efforts require an environment of stability and status in which per- manent effective cooperation can flourish. (1 The initial progress provides solid evidence for continuing the program without modification of its essential nature and purposes. [] A more effective means for meet- ing the special space necds generated by this program is requisite to the full achievement of the purposes of the legislation. RECOMMENDATIONS Extension of the Act As discussed in the earlier sections of the Report, the sum of experiences in the development of Regional Mcedi- cal Programs throughout the country demonstrates the validity and poten- tial of these new cooperative ar- rangements in both planning and action. The needs are pressing and the opportunitics promising for mak- ing available the benefits of medical research advances. The establishment of the Regional Medical Programs as continuing instruments in the health field will contribute significantly to the fulfillment of these opportunities. Many groups and individuals initi- ally expressed uncertainty and doubt about the Regional Medical Program concept. Most have been reassured on the value of this approach as major regional interests have come together to determine locally the most appro- priate and effective ways of moving the program forward in their Regions. Groups throughout the Nation are coming to recognize that through Re- gional Medical Programs, local plan- ning, decision-making, initiative, and capabilities to meet the necds of patients with heart disease, cancer, stroke and related diseases can be enhanced significantly. Individuals undertaking regional planning have reported that uncer- tainty about the program’s future isa serious obstacle in recruiting well qualified persons for leadership and key staff positions. Some institutions and agencies have been reluctant to embark upon a course of action, what- ever its promise and potential, with- out reasonable assurance that the program will be continued. There- fore, extension of the program will prevent a loss of momentum and enthusiasm already achieved and will provide a firm basis for strengthening and building upon the beginning efforts. The importance of this momentum and enthusiasm for the success of a voluntary cooperative endeavor should not be underesti- mated. A 5-year extension should attract the long-term commitment of the kind and quality of people, and the full participation of all affected institutions which are essential to the program’s success. This requirement calls for an authorization that, in both its duration and its level of funding, will indicate a national intent to maintain this effort until the job is done. Funds for Regional Medical Pro- grams can be a critical factor, even though they are only a small fraction of the total national expenditures for heart disease, cancer, stroke, and re- lated diseases. For these funds, effec- ‘tively used, can be a fulcrum in rais- ing the quality of care generally throughout the country as well as in significantly enhancing the diagnosis and treatment of these diseases. Experience gained thus far indi- cates that the annual cost of operation for each Regional Medical Program may be as much as $10 million or more. There are several bases for this estimate. The initial operational grants and the plans being developed around the Nation indicate that there are myriad opportunities for improv- ing the diagnosis and treatment of heart disease, cancer, stroke, and re- lated diseases by bringing the latest advances into the daily practice of medicine in all parts of the Nation. The number of potential partici- pants—institutions, groups, agencies, and health personnel—is very great. All must contribute if the benefits of the programs are to be widely avail- able to the population of the Nation. Frequently, sophisticated and ex- pensive equipment is required be- cause of the high order of technologi- cal innovation entailed by many recent medical and related advances. This equipment will advance clinical, communication and computing serv- ices, Many technological innovations should be rapidly introduced to bring to patients the benefits of the ad- vances, This will require effective re- gional planning with the cooperative involvement of full-range medical resources. It will also require sources of funding to be spent on the basis of regional priorities which do not have to compete with pressing needs of the individual institutions. It is recommended that the pro- gram be established on a continuing basis. New Construction of Essential Facilities The original Administration proposal to the Congress in 1965 requesting legislative authority for Regional Medical Programs included grant as- sistance for construction of new as well as the renovation of existing facilities. It thus identified the need for facilitating construction in the successful development of Regional Medical Programs. In enacting Public Law 89-239, however, Congress amended that pro- vision to limit construction authority to “alteration, major repair, remodel- ing and renovation of existing build- ings” during the initial period of authorization. In so doing, the Report of the House Committee on Inter- state and Foreign Commerce stated: “The lack of this authority for new construction should create no serious problems during the three years au- thorized in this legislation and when a request is made for extension of this legislation in the future, the com- mittee will review this question again.” The lack of authority to assist new construction has not presented serious obstacles to the initial planning and development of Regional Medical Programs. Thus, the early judgments of the Congress have been confirmed. Experience, however, has identified several areas in which authority to assist new construction will be essen- tial to the full development of Re- gional Medical Programs. Specific construction needs essen- tial to the work of Regional Medical Programs have been more clearly de- fined and documented during the initial planning phase. Information obtained from Regional Medical Pro- gram Coordinators and key staff, Re- gional Advisory Group Members, and others involved with these programs at the regional level indicates that there are major needs in a number of areas. These inadequacies will ham- - per activities within the next several years as Regional Medical Programs move into the operational phase and their range of activities increases. The likelihood of significant limita- tions on Regional Medical Program activities from increased by the overwhelming de- mand for new health facilities gen- erally in the years immediately ahead. The demands of an expanded population and its desires for high quality medical care, the expansion of medical education facilities, and the backlog of demand for health research facilities all indicate very great competition for funds to finance the necessary facility expansion. The types of construction needs described below, defined according to regional priorities, will have great dif- ficulty in competing successfully with the immediate and overwhelming construction needs to house ade- quately the basic functions of the par- ticipating institutions. Construction space shortages is of facilities needed for the purposes of the Regional Medical Program is likely to be delayed until these urgent institutional needs are met. Since the 33 lage between identifying a need for construction and the availability of the facility is so great, this competi- tive position might seriously delay the implementation of the Regional Med- ical Program. It is also important that the types of needs cited below be given adequate consideration during the general ex- pansion of health facilities of the Nation. Only then will the activities represented by them become an integral part of the functions of the medical institutions of the Regions: [] Space for continuing education programs and training purposes ts urgently needed, including class- rooms and conference room space, learning center facilities, and medical reference and audiovisual facilities. This is the need most frequently cited by Regional Programs and other groups, such as the Association of Hospital Directors of Medical Edu- cation.. It is particularly acute in community hospitals. In the past there has been a paucity of operational support in both com- munity hospitals and medical centers for continuing education activities. The same situation has been true with respect to capital expenditures. Most of the Nation's 7,000 hospitals, especially the smaller ones, simply do not have existing space that can be converted or renovated for educa- tional purposes. The same holds true for most medical schools, most of which cannot significantly expand their present postgraduate ecuca- tion programs without additional space and facilities. In the past, as documented by the 1962 survey of the Amcrican Medical Association Council of Medical Education, con- tinuing education programs have not been a major responsibility and in- terest of most medical schools; ac- cordingly, the development of appro- priate resources (including related facilities and spacc) neglected. was usually In both community hospitals and medical schools, the pressures of ris- ing expenditures for direct patient care have made it impossible to allocate sufficient funds to the con- tinuing education activities that are essential to high quality care. ‘Thus, the potential impact of continuing education and training programs in heart disease, cancer, stroke, and re- lated diseases will be seriously ham- pered unless essential facilitics are _ constructed. ( There is a critical need for addi- tional space and facilities for patient care demonstration and training pur- poses. Intensive care units, radium therapy facilities, and specialized sur- gical suites are, for example, often necessary in order to provide facilities to demonstrate to practicing physi- cians, nurses, and allied personnel the use of these and similar advanced tools and techniques for diagnosis and treatment. Only if physicians and the other mem- bers of the health care team Iearn how to utilize these advances “by doing,” and have the required facilities avail- able to them at the community level, will they be able to fully exploit the continuing education and_ training afforded them, and bring to their patients the full benefit of their learning. Most community hospitals do not now have such facilities. In the case of older hospitals, adequate provision was not made for the inclusion of such specialized facilities because the underlying advances which make continuing education a ‘necessity today had not yet been made; newer hospitals often were unable to in- clude sufficient space for these pur- poses because of limited funds (pub- lic and private) available for initial construction. Developing these facili- tics on the basis of regional planning will permit great educational impact at minimal cost. (1 Some community hospitals have need for additional space for new or expanded diagnostic laboratory facili- ties. Both the introduction of new diagnostic tests and procedures, and the fuller use by practitioners of exist- ing tests, depend upon adequate hos- pital laboratory facilitics. Such facili- tics will serve as teaching laboratories for medical technologists and other supporting personnel. C] The establishment of integrated data banks and communications sys- tems for the storage and rapid trans- mission of diagnostic information, patient records, etc., requires space to house the computer and communi- cations facilities. Similarly, television and radio transmission of continuing education programs will require new space and facilities. Most Regional Medical Programs are undertaking inventories of exist ing facilities for both educational and specialized clinical care activities re- lating to heart disease, cancer, stroke and related activities. These planning efforts are being closely coordinated with State and area-wide hospital planning agencies. Experience in ad- ministration by the Public Health Service of other recent programs, such as the construction of commu- nity mental health centers and mental retardation facilities, has developed patterns and procedures that can help assure necessary coordination of effort. ‘The construction of new facilities for Regional Medical Programs must be limited to facilities that are essen- tial, carefully selected, and designed to meet regional necds. Each such request will need to be approved by the Regional Advisory Group which represents the major health interests of the Region. This review and ap- proval process will ensure that an excessive amount of attention and funds are not devoted to construc- tion, and that no construction is undertaken exclusively or primarily for the benefit of any single institu- tion or group in the Region. Most community hospitals, medi- cal schools, and other institutions would have serious or insurmountable difficulties in raising matching funds for construction of facilities needed for continuing education and demon- stration essential to mect regional needs, The regional nature of the program may make it especially diffi cult for any individual agency to ob tain substantial funds for this pur pose. The current matching require ment of 10 percent applicable to ren ovation and alteration of facilities, re quires a local commitment withou impeding progress. A larger matchin: requirement at this time in the devel opment of this pioneering new prc gram could be self-defeating. It is recommended, therefore, the adequate means be found to meet th needs for construction of such facili- fies as are essential to carry out the purposes of Regional Medical Pro- grams. Priority should be given to facilities required for continuing edu- cation, training, and related demon- strations of patient care, particularly in community hospitals. In meeting these needs, the follow- ing considerations should be taken into account: 1. Construction undertaken for Regional Medical Programs should be directly supportive of the operational programs and should be broadly distributed for maximum impact. This might be done by (1) limiting the amount available for con- struction to no more than 15 percent of the total appropria- tion for operational activities; and (2) restricting grants for such construction to no more than $500,000 for any single project. 2. The special space needs of the program, can be met either through additional authority to aid new construction as part of grants for Regional Medical Programs under Title IX of the Public Health Service Act or through other mechanisms, such as amendments to Title VI and Title VII of the Public Health Service Act (Hospital and Med- ical Facilities and Health Pro- fessions Educational Facilities Construction Programs). Support of Interregional and Other Supporting Activities The present Act authorizes grants for the planning and operation of indt- vidual Regional Medical Programs. No consideration was given during the development of the legislation to support for other activities which might contribute to the implementa- tion of the Regional’ Medical Pro- grams. These activities include both cooperative efforts among several Re- gions and other activities supported centrally which make available to all or several Regions specialized skills and resources which are not generally distributed throughout the Regions. The desirability for extensive co- operation among Regional Programs was foreseen. However, the extent of and rapidity with which cooperative arrangements among Regions would develop was not fully anticipated. Nor, in turn, was the corollary need for additional funding for this pur- pose apparent, During the first year of the pro- gram, individual Regional Medical Programs devoted considerable at- tention to coordinating their efforts with other Regions. Interregional co- operative efforts involving several Regions have already evolved in a number of areas throughout — the country. In some instances, these arrangements are still informal; in others, interregional agencies are he- ing established. These interregional activities have arisen in response to real needs. Re- gions have identified a number of objectives that can be best served and activities carried out in this way. Among the principal potential bene- fits are the following: (J To. facilitate among Regions, including exchange of information on approaches to and problems in planning and program development. communications CI To help in defining responsibili- ties and coordinating efforts in “in- terface” areas between Regions. (Q To foster consistency in ap- proaches to the conduct of planning studies. (] To achieve comparability in data collection and program evaluation. [] To develop and apply better and more comprehensive methods of pro- ‘gram evaluation. [] To utilize more effectively skilled manpower, specialized facilities and resources. 35 (1) ‘Yo help achieve compatibility in communication networks and com- puter systems. [] To plan and conduct joint cpi- demiological and research studies. - (1 To develop jointly common edu- cational programs and materials. (J To orient and train staff person- nel. A somewhat similar situation has been identified with respect to cer- tain specialized needs common to all or anumber of Regions. ‘The support of a limited number of facilities and programs is needed to develop tech- niques and prepare personnel to facilitate the work of individual Re- gional Medical Programs. The sup- port of such activities in agencies that can serve a number or all of the Regions will avoid unnecessary delay and duplication of effort and make the best use of specialized facilities. Central support for these activities will enable the Division of Regional Medical Programs to make avail- able to some regions skills and re- sources which are not available with- in the Region. This assistance at a crucial time in the development of a regional program could improve the quality and accelerate the pace of the region’s activities. / For example, continuing educatio and training programs will require significant numbers of specialized professional personnel (c.g., educa- tion specialists, communication and information specialists). Many of these categories of personnel are in scarce supply and the facilities in which they can be trained are limited. There are also numerous studics and demonstrations that need to be carried out in such areas as motiva- tion, learning theory and evaluation affecting both continuing education and other aspects of Regional Med- ical Programs. In many instances, these studies will call for resources in one Region to study these issues in a number of Regions. “Vhese interre- gional efforts, too, will substantially assist and expedite work of the indi- vidual Regional Medical Programns. It is recommended that an effective mechanism be found for the support of interregional activities necessary to the development of Regional Med- ical Programs. This assistance will facilitate the work and implementa- tion of individual Regional Medical Programs. Referrals by Practicing Dentists Section 901(c) of the Act provides that “no patient shall be furnished hospital, medical, or other care at any facility incident to research, training. or demonstration activities carricd out with funds appropriated pursuant to this title, unless he has been referred to such facility by a practicing phy- sician.” In certain instances, in carrying out the programs authorized by the legis- lation, a dental practitioner may as- sume responsibility for the referral of a patient. For example, a patient with oral cancer may be diagnosed by a dentist and referred by him for treat- ment and rehabilitation. It is desir- able to clarify the Lay to cover this type of situation. It is recommended that patients referred by practicing dentists be in- cluded in’ research, training and demonstration activities carried out as necessary parts of Regional Medi- cal Programs. This modification is in line with the original intent of the legislation in this regard and would correct the original oversight. Funding of Activities In Federal Hospitals Veterans Administration and Public Health Service Hospitals in many areas have been involved in the plan- ning of Regional’ Medical Programs. The participation of these institu- tions has been particularly helpful and desirable in light of their significant role in providing diagnosis and treat- ment services to many residents of the Region. The effectiveness of the pro- grams operated by Federal hospitals can be enhanced by close cooperation and sharing of effort and resources with other health facilities in neigh- boring communities. The Congress recognized and en- dorsed this principle in enacting the Veterans Hospitalization and Medi- cal Services Amendments of 1966, Public Law 89-785, enacted Novem- ber 7, 1966. Among other provisions, this legislation authorized the Vet- erans Administration to enter into cooperative agreements for the shar- ing, of medical facilities, equipment and information with mcdical schools, hospitals, research centers and others. The Law required that, to the maxi- mum extent practicable, such pro- grams should be coordinated with Regional Medical Programs. A some- what similar provision is included for Public Health Service Hospitals in legislation now pending before the Congress. While the staffs of Federal hospitals may now participate directly in plan- ning Regional Medical Programs, those institutions are not eligible to receive funds from the grants author- ized by Public Law 89-239. Thus, a technical modification is necessary to authorize Federal hospitals to receive such funds on the same basis as other hospitals. In this way, programs can be developed in these facilities when such an approach is identified as the most desirable way to strengthen the total Regional Medical Program. As in the case of all other projects pro- posed for support as part of Regional Medical Programs, such requests must be part of the overall regional program and will need to be approved by the Regional Advisory Group and the National Advisory Council on Re- gional Medical Programs. It is recommended the Federal hos- pitals be considered and assisted in the same ways as community hospi- tals in planning and carrying out Re- gional Medical Programs. This modi- fication will, in effect, increase the flexibility, discretion and capabilities of Regional Programs. opie, aa : . "ganizations of. smediéal services, found’ ‘i ~ a nee we “ SUPPLEM aia Regional Medical Prograins are best defined by the particular actions and activities being undertaken across the country. In this Chapter, outlines of a number of individual Programs are presented. {([] Four reports summarize what has happened in the planning of the ’ Jowa, North Carolina, Washington- Alaska, and Western New York Re- gional Medical Programs. They sum- marize salicnt developinents in the preliminary and initial planning phases and the interaction among various institutions and groups that has occurred. -] Two reports indicate the nature of the initial operational activitics of the Intermountain and Missouri Re- gional Medical Programs. ‘They high- light how these activilics will benefit the practicing physician and_ his paticnts. (0 In addition, excerpts are pre-_ sented from the annual progress re- ports of the 10 Regional Medical Pro- grams for which the first grants were effective July 1, 1966—Albany (New York}, Connecticut, Hawaii, Inter- mountain, Kansas, Missouri, North Carolina, Northern New England, Tennessee Mid-South, and Texas. These excerpts provide further in- sights into specific aspects of the Ke- gional Programs. wank ENT Regional Mcdical Programs in Action Nastia! ww Collectively these reports reveal, in some detail, the accomplishments and problems of individual Regional Medical Programs. It is through these individual efforts and actions that Regional Medical Programs will be more precisely defined and ulti- mately will serve the needs of the Na- tion’s medical professions, institutions and patients. PLANNING GRANTS Towa Regional Medical Program The Towa Regional Medical Pro- gram, like a number of others, is built on a significant base of past re- gional activities. Extensive interrela- tionsltips between hospitals and prac- titioners have developed over, the last 50 years. By an interchange of pa- throughout the State have become, in effect, inte- grated with the activities of the stalf of the University of Iowa Medical Center. Continuing education pro- tients, physicians grams have been developed over the last 30 years and include courses at the Medical Center, programs at community hospitals, and closed cir- cuit television educational programs between the Center and a number of these hospitals. As a result, it has been possible to move forward in a num- ber of directions since the receipt of a planning grant in December 1966. Even with this previous experience of cooperative arrangements, how- ever, there was need to plan for an Towa Regional Medical Program. This preliminary planning involved cooperation between the Medical Center and three other major health planning groups—the Health Plan- ning Council of Iowa, a voluntary agency organized to coordinate state- wide health care planning; the Coun- cil on Social Agencics of Des Moines; and the Des Moines Health Planning Council. Other localities are also or- ganizing planning groups that will be related to the Regional Medical Program. The Regional Advisory Group, designated to guide the expanded ef- fort now being embarked upon, is broadly representative of all of the Region’s health professions and agencies. It includes the Dean of the College of Medicine, the Commis- sioner of Health, Past Presidents of the Iowa State Medical Socicty, Heart Association, Cancer Society and League for Nursing; also in- cluded are representatives of the Iowa Hospital Society of Osteopathic Physicians and Surgeons, Dental Associations, Nursing Home Association, Nurses Association, State Department of Social Welfare, re- Associatian, habilitative groups, and members of the public. This Group has met seven times through March—or almost monthly since its creation in mid- 1966. The goals which the Iowa Re- gional Medical Program has set for itself, with the advice of the Regional Advisory Group, are to: (1) aug- ment present education and training capabilities; (2) improve continuing education programs; (3) expand re- search programs; (4) broaden re- gional communication to promote dissemination and interchanges of knowledge and techniques; (5) de- velop programs for public education; and (6) develop demonstration units and systems. To accomplish these goals, the Pro- gram has been organized into four sub-areas: an Education Program, a Research Program, a Comprehensive Patient Care Program, and a Com- munications Program. Within the Education Program, for example, studies have been initiated to develop basic 2-year curricula for post-graduate education on heart disease, cancer and stroke. These curricula, once developed and tested, will be taught through a coordinated program of the College of Medicine and regional hospitals, utilizing live conferences and video-taped mate- rials. Extension of this endeavor to e community Jevel for individuals ‘small groups of physicians using mescope presentations is also sntemplated. Other planning activities or proj- cts in the other program sub-arcas ave also been initiated. These in- ‘olve a number of different agencies w groups. For example: 7] The Towa State Department of Health is planning program elements which concern public health gener- ally, professional and public com- munications, disease entity report- ing and health manpower. C] The University of Yowa Depart- ment of Economics is involved in re- search on the economic structure and performance of the medical care in- dustry in Iowa. One of its first proj- ects is the delineation of the Towa Medical Care Region, considering economic and demographic factors, traditional service areas, and political boundaries. ( The Iowa Central Tumor Regis- try is providing planning information and analysis guidance concerning disease registries. At the same time, the participation of the Colleges of Dentistry, Nursing and Pharmacy of the University and other health care and educational in- ctitutions is being developed. North Carolina Regional Medical Program In North Carolina, as in many other states and regions in the country, planning for regionalized medical and health programs has been underway for over twenty years. However, limited resources and other local factors have resulted in incom- plete implementation of these plans. Passage of the Regional Medi- cal Program legislation provided an opportunity for North Carolina to move ahead quickly and build upon its past experiences in developing a Regional Medical Program. The Program was established with the award of one of the first plan- ning grants effective on July 1, 1966. Even before the legislation was signed into Law, the deans of the three medical schools in the State met with the President of the Mcedi- cal Society to form an Executive Committee to make preliminary plans. The Executive Council of the Medical Society approved the plans for cooperation from which emerged a new, non-profit organization to carry out the purposes of the Pro- gram. The Association for the North Carolina Regional Medical Program was officially established in August 1966, and is made up of the three public and private medical schools in the State, the University of North Carolina School of Public Wealth and the Medical Society of North Carolina. It has adopted Articles of Association, and established a Board of Directors which has been actively working with the Program Coordi- nator and Advisory Council. To provide jeadership and overall direction to its Program, North Caro- lina sclected as Program Coordinator, Dr. Marc J. Musser, a physician with extensive experience in medical edu- cation, medical research and adminis- tration. His prior position as Deputy Chief Medical Director of the Vet- erans Adininistration and his previ- ous 25 years as Professor of Medicine at the University of Wisconsin School of Medicine provided background and stature invaluable to the Program. A 25 member Advisory Council, representing the major relevant health interests in the State, was organized to provide overall advice and guidance to the Program. Its Chairman is past president of the State Medical Society and its mem- bership includes the Director of the State Board of Health, the Directors of the North Carolina Public Health Association, Heart Association, and Cancer Society, other voluntary as- sociations, the current President of the State Medical Society, the State ro) oD dental, nursing, pharmaceutical, and other allied health professional as- sociations, practicing physicians, the North Carolina Health Council, the deans of the three medical schools, a leading hospital administrator, and members of the public. They have met monthly since August 1966, and have conducted intensive reviews of project applications. Subcommittees of the Council have also been organized to focus on and provide expertise in specific problem areas, such as heart disease, cancer, stroke and dentistry. Represented on these subcommittees are all the lead- ing organizations and experts in the respective fields in North Carolina. For example, the Subcommittee on Cancer is composed of representatives: from the Cancer Socicty, all the offi- cial relevant State agencies, practic- ing physicians, the experts from the North Carolina Division of the American College of Surgeons, the medical schools, and the State Medi- cal Socicty. Their discussions im- mediately revealed the need for a state cancer registry which would augment, coordinate, and make more effective usc of the several on-going independent cancer registries in the State. This led to recommendations of a project proposal which was sub- mitted to the Advisory Council, cou- pling the resources of the Regional 4u Medical Program with the on-going cancer registry activities of the other health agencies. Financial contribu- tions from many of the participating agencies werc also anticipated as part of the Program. In the field of heart disease a sini- ilar process took place which resulted in a feasibility study now underway to develop a regional plan for pro- viding on-going educational services to coronary care units. Other pro- grams underway in North Carolina include planning for a statewide dia- betic consultation service; planning for education and research in com- inunity medical care; studics and sur- veys of education program needs and resources; surveys of relevant health professions needs and resources; and studies of patterns of illness and care. The impact of the Regional Mcd- ical Program is already being felt in the health affairs of the State. With the State Medical Socicty taking an early leadership role in developing the program with the medical schools, practicing physicians are actively involved in the planning phase. The channels of communica- tions which have opened up at all Jevels and among all health groups are quickly leading to fruitful discus- sions on a multitude of problems. i ‘The Dean of Duke University School of Medicine described the phenome- non when he said: “Channels for co- operation for many endcavors have now been opencd. Although we have talked together a great deal before, we now have available more effec- live channels of communications and financial resources to implement such programs, not only with other medi- cal schools but also with all other health agencics.” As the North Caro- lina program moves ahead, it will be a program conceived, designed and implemented by and for the people of the State. As one Icading official of a voluntary health agency put it: “We hope to weave it so that it won’t be your program, or my program, but our program.” Washington-Alaska Regional Medical Program Although — the Washington-Alaska Region previously had little regional health activity, Alaska, which has no large medical center, is naturally related to Washington by transpor- tation, communication, economic and social tics and traditional pat- terns of medical referral and consulta- tion. The joint Washington-Alaska Regional Medical Program is being developed on this basis. Here, as in many other regions, there was widespread participation in’ the preliminary planning and preparation of an application. An initial conference, held only onc month after Public Law 89-239 had been enacted, included some 35 members of the University of Wash- ington Medical School faculty, ap- proximately 50 practicing physicians, and representatives of the Washing- ton Hospital Association, State De- partment of Health, and the Seattle- King County Department of Health. ‘Though the planning proposal that eventually resulted was formally sub- mitted by the University of Washing- ton Medical School, it had the ap- proval of the Governors of both Washington and Alaska, the Presi- dent of the University of Washing- ton; the Washington and Alaska State Medical Associations, -Dental Asso- ciations, Nurses Associations, and Heart Associations; the Washington and Alaska Divisions of the American Cancer Society; the Washington Health Department, Alaska Depart- ment of Health and Welfare and the Divisions of Vocational Rehabilita- tion in both States. Many of the health institutions in the region are being involved in the Regional Medical Program. Repre- sentatives from virtually all of the 130 hospitals in the region have been con- my tacted. Interest has been expressed by the Heart Associations and the Cancer Socicties of both Washington and Alaska; their programs of re- scarch, professional and public edu- cation, community. service, traince- ships and direct patient services will be coordinated in a joint effort. The Program Coordinator for the Washington-Alaska Regional Medi- cal Program, Dr. Donal Sparkman, assumed his position on March 1, 1966, six months prior to the begin- ning of the planning grant. Thus, the Program has had the benefit of over- all administrative direction since its preliminary planning phase. Dr. Sparkman has had extensive expe- rjence in the practice of internal medicine, in teaching at the Uni- versity’s School of Medicine and with the State Department of Vocational Rehabilitation. Other key staff, including a ¢& ordinator for Alaska, an associate director, a cardiologist, a hospital ad- ministrator, and a systems analyst, have been recruited since the Re- gion’s planning grant was awarded, effective September 1, 1966. In addition, a wide variety of consul- tants, including epidemiologists statisticians, economists and com munications specialists, are bein utilized. a votes aa eet - The Program strategy of the Wash- ington-Alaska Region is to concen- , trate first on the following: ' L] Assess the existing disease problem in the region. ( Delineate resources and needs in patient care, education, training and research. (1 Investigate the effectiveness of current programs and how they can be improved by regional planning and cooperative efforts. Initial planning studics now un- derway are focused on identifying needs of physicians, particularly needs for continuing education and the best use of- medical consultants visiting smaller communities. Partic- ular attention is being given to phy- sician manpower needs in Alaska as well as transportation and communi- cation patterns in that part of the region. Planning studies relating to the coordination of coronary care facili- ties and services, a post-graduate pre- ceptorship program, and the estab- lishment of a regional medical library system have also been inaugurated. Other planning studies soon to be initiated will concern methods of pooling data from cancer registries, a feasibility study of open channel tele- vision, a survey of physician and nurse participation and interests in con- tinuing education, and the early de- tection and care of coronary disease. Western New York Regional Medical Program Western New York is a comparatively small and compact but heavily popu- lated Region. It is essentially urban and dominated by metropolitan Buffalo. There had been relatively little regional and cooperative ac- tivity among the health resources and interests in this area in the past. Sub- stantial and rapid progress has been made in creating a regional health organization and framework for de- cision-making since the enactment of Public Law 89-239. The development and creation of a Western New York Regional Medi- cal Program has been characterized from the very beginning by the wide- spread participation by nearly all of the major health institutions, groups, and agencies in the eight-county re- gion covered by it (Allegheny, Cat- taraugus, Chautauqua, Erie, Genesee, Niagara, and Wyoming Counties in New York, and Erie County in Penn- sylvania). The Regional Medical Program has been received by the practitioners, with unexpected en- thusiasm following the well-publi- cized interest of the State University of New York at Buffalo (SUNYAB), Roswell Park Memorial Institute and other major hospitals in the area to build on and strengthen the existing good relationships. In November 1965, following pas- sage of Public Law 89-239, an Interim Coordinating Committee composed of key people concerned with health and health care was formed to study the bill and “to promote as rapidly as possible re- gional interest in the establishment of a regional program” for heart dis- ease, cancer, and stroke. The com- mittee, as initially constituted, in chided the Dean of the Medical School, Director of Roswell Park, the Executive Director of the Western New York Hospital Review and Planning Council, the Past President of the Erie County (N.Y.) Medical Society, Erie County Health Com- missioner, and the Regional Officer for Western New York of the State Health Department. In January 1966 this committee called together representatives from the medical, hospital, and other health-related professions, practicing physicians and voluntary health agen- cies, From each of the eight counties came the health and hospital commis- sioners, the medical society repre- sentatives, chairmen of the Boards of Supervisors, the hospital administra- tors, and the American Cancer Society and Heart Association Chair- men. Individuals from social welfare 41 agencies, public health and nursing representatives, as well as education personnel were also present. A total of 78 persons representing 70 organi- zations, institutions, and groups at- tended. This group, originally invited to participate in the formation of the program, evolved into the Regional Advisory Group. This was no simple task. For the first time in the history of Western New York, an assemblage from the above groups met with a common objective. In an atmosphere paralleling that of a town mecting, each force presented its particular point of view. As the day wore on, a unique spirit of understanding and cooperation evolved. It was unani- mously agreed that it ts the patient who must benefit from the Law. Wholechearted support was expressed for a Western New York Regional Medical Program. Several meetings were held by the group during the spring of 1966. The outcome of these meetings was the formation of a new nonprofit organi- zation called Health Organization of Western New York, Inc. (HOWNY) and the designation of its 111 mem- ber representatives as the advisory body. Their initial grant application, looking toward the development of a sound and workable proposal, in- corporated a six-point planning program. [] A coronary care unit feasibility study (J The feasibility of multiphasic screening in Western New York (] Health care team planning (] A medical communications study (J A planning survey for a local con- sultation program (0 A health care manpower survey By the time a planning grant was awarded in December 1966, some other important and parallel devel- opments had also taken place. (J New channels of communication had been opened among the many diverse health institutions and groups in the region. CA parallel organizational frame- work was established at the com- munity level. Through these local ad- visory committees, broadly represent- ative of the health interests in the communities and including public members, the intent and aims of Re- gional Medical Programs were more fully and accurately conveyed to the practicing physicians and others at the community level. In addition, communities had been prompted to examine their own necds. () Perhaps most significant was the decided change in the attitude of the practicing physicians in the re- gion. Initially they had been quite wary and somewhat suspicious of the inedical centers and the “cooperative arrangements” approach embodied by Regional Medical Programs. This view has altered with their increasing involvement in and better under- standing of the program, so that now, in the judgment of many, including the Regional Advisory Group Chair- man, who is himself a private prac- litioner, a majority of them support it. Since the award of its planning grant, the Western New York Re- gional Medical Program has obtained a full-time Program Director, Dr. John R. F. Ingall, formerly an associ- ate cancer rescarch surgeon at Ros- well Park. The Director has begun visits to all the medical communities, large and small, to explain the re- gional concept of the program and to stress the necd for coordination, He aims personally to discuss with physi- cians and the health service agencies the aim of the Regional Medical Program to support all involved in giving medical care; the patient is most important and his needs can only be met by action in concert. The patient in turn, as consumer, is being informed by radio and television of the objectives of the Program. The health care manpower and coronary care unit feasibility studies had al- ready been launched prior to his ap- pointment; the remainder of their proposed planning activities have got- ten underway since then. The HOWNY Board of Directors, with members from each of the par- ticipating countics—one representing the county medical society, the other usually from a health related field— as well as SUNYAB, Roswell Park, the Western New York Hospital Asso- ciation, the area-wide hospital plan- ning group, and official public health agencies, has already sct up proce- dures for reviewing proposed pilot projects. These include, in addition to a number of tentative proposals generated by local communities, pro- posals for the establishment of a regional hematology reference labora- tory and a regional blood bank com- munication system. OPERATIONAL GRANTS Intermountain Regional Medical Program The initial operational activities of the Intermountain Regional Medical Program will provide the following opportunities to a medical practi- tioner in this Region (which encom- passes Utah and parts of Colorado, Idaho, Montana, Nevada and Wyom- ing) to improve the care of his patients: (1 He will have available at his com- munity hospital a communication network, including radio and tele- vision facilities, which will provide education programs and opportu- nities for interchange and discussion with consultants at the medical center. (1 He will have available at his com- munity hospital for himself, nurses and other personnel, a training pro- gram in the resuscitation of patients with heart disease, and the necessary equipment to makc it possible to carry out these techniques. He will also have on call a medical consultant who has been specially trained to head hospital cardiopulmonary arrest alert programs. ( He may have tested at his hospital the feasibility of a system that trans- mits, in a 24-hour day operation, physiological information on heart disease patients to a computer facility in Salt Lake City and transmits promptly back to stations within his hospital information for diagnosis and treatment. C] He will be able to attend training courses in the intensive care of heart patients and will have available for consultation medical and nursing spe- cialists who have completed such training. (J He may participate in seminars led by local, regional and national ex- perts in order to better understand trends which are influencing medical care practices as well as new methods of maintaining ‘and extending his medical skills. (] He will have available at his hos- pital both continuous 24-hour con- sultation by telephone and visits by special consultants knowledgeable in the latest information in the diag- nosis and treatment of cancer. (] Through the use of a computer- ized tumor registry, lhe will be able to analyze and compare his own cancer patients with local, regional and na- tional standards. O Consultants will visit his hospital (if it is in a community with less than 10,000 persons) periodically, to as- sist him in the diagnosis and care of heart disease patients by working at the bedside of his patients. (] He may apply for a special clini- cal traineeship in cardiology that will involve specialized training at 5 co- operating medical institutions in pro- grams designed to meet the individual interests ancl problems of the par- ticipating physicians. (J He will have available a com- munication and information ex- change service that will provide in- formation on the prevention and con- trol of these diseases to public groups as well as to professional and allied health workers. C He, along with other health work- ers and members of the public, will have oppertunities through a formal feedback system to communicate with the planners and Jeaders of the Re- gional Program to indicate his reac- tions, needs and recommendations for developing new program activities. _ Missouri Regional Medical Program The initial operational endeavors of this Program are “oriented toward maximizing the amount of diagnosis and care which can be delivered in the ©... community by the physician and the local medical resources while maintaining and improving the qual- ity of medical effort... .” As the program is implemented in the fu- ture, a medical practitioner in the Missouri Region may have the fol- lowing opportunities available to as- sist in the care of his patients: C1 He will benefit from the develop- ment and demonstration of a compre- hensive health care system that is being tested in Smithville, a subur- ban-rural community north of Kansas City, with a view to eventual replica- tion throughout the Region. This project is exploring the benefits to practicing physicians of having avail- able automated clinical laboratory testing for multiphasic screening and a computer fact bank displaying the results to him audio-visually; an au- tomated patient history system pro- viding him with a patient’s complete medical history before seeing the pa- tient; an automated EKG service connected with the University Medi- cal Center for rapid, accurate trans- mission, receipt and interpretation of clectrocardiograms; specialists con- sultation from the medical center by telephone; and an integrated con- tinuing education program at his hos- pital for himself and the allied health personnel supporting him. He may, through the connection of his community hospital with the Medical Center’s Department of Radiology and computer facility, ob- tain computer aided radiologic diag- nosis that will help improve the ac- curacy and reliability of his diagnosis of bone tumors, gastric ulcers, and congenital heart disease. (} He may, after a period of pilot testing and validation, have at his disposal an automated patient history acquisition system through which he can obtain a complete medical his- tory of a patient before seeing him. Presently this requires an amount of 43 time not normally available to the busy practitioner. CI He will, if the result of experi- ments being initiated are successful, have direct access by means of com- puter terminals in his office to a Com- puter Fact Bank providing the best and latest information concerning the diagnosis and care of stroke patients. This information will not only be available for application to individual patients while in the physician’s office but will make possible discourse with the computer so that the experience constitutes an integral part of his con- linuing education. (J We will have the use of a multi- phasic screening center to he estab- lished to provide him and his patients with If blood chemistry tests, com- plete blood count, urinalysis, stool guaias, and Pap smear, [] We and his colleagues in the Ozark area will have available at St. John’s Hospital in Springfield, and later at other small hospitals, a re- fined and more comprehensive car- diovascular care unit that will demon- strate the feasibility of an intensive care program without house staff. (] He and others will have available to them as a result of the establish- ment and sampling of population study groups, more current and ac- curate information about the true rates of disease incidence and preva- lence in the Region. (J He and his patients will benefit from an operations research and sys-. tems design project aimed at (1) improving carly detection of heart disease, cancer and stroke and (2) optimizing the utilization of the re- sources committed to these diseases in terms of the effectivencss of the medical services provided. (0 He and his patients will benefit {rom improvements in bioengineering techniques utilizing sensor-trans- ducers for carly detection of heart discase, cancer and stroke. (] He and his patients similarly will stand to benefit from studies of the Program Evaluation Center, a mul- tidisciplinary research unit of the Missouri Medical School, dealing with the problems of the distribution of health services and medical facili- tics. Priority will be given to develop- ing instruments for evaluating the quality of care and Jevel of health, both individual and community-wide. ( His patients will be the ultimate beneficiaries of a communications re- scarch project aimed at better under- standing public attitudes, opinions, and knowledge about heart disease, cancer, and stroke, in order to en- hance prevention and early detec- tion. ( He and the community service agencies and others will be provided with a directory of the names, services and addresses of all medical and paramedical services in the State to facilitate the referral of patients between agencies and the full use of available resources. EXCERPTS FROM ANNUAL PROGRESS REPORTS Albany Regional M edical Program “In our Operational Grant Apphi- cation it was mentioned that ‘there is no question but what the develop- ment of the Albany Regional Medi- cal Program has produced very im- portant effects, both in the surround- ing medical communities and at the Medical Center. The predominant attitude is one of interest, enthusiasm and cooperation. Relative to need the program is ideally timed. An early addition of operational support should allow us to take full advan- tage of the momentum of our rapid initial progress... - “T'g this statement should be add- ed the fact that the April 1, 1967, approval of our operational grant request allows us to intensify the continuous planning activity as the conduct of our Pilot Projects reveals additional ‘planning opportunities. We believe the most effective plan- ning will result as we relate the plan- ning to the conduct of our operational program. .. - “EJowever, since the initial proj- ects of our operational program are not intended to result in a complete program, it will obviously be neces- sary to continue planning supple- mental projects which will further increase the capability for diagnosis and treatment of heart disease, can- cer and stroke. In particular, we con- template extensive planning of con- tinuing education and training for medical and allied health professions. “The purpose of the Albany Re- gional Medical Program is to utilize education, training and demonstration care in an organized research, cooperative and effective approach to the prevention, detection and management of heart disease, cancer and stroke. Although leadership and the dissemination of scientific infor- mation are among the important re- sponsibilities of the Medical College, the intent is to promote interrelation- ships among all relevant institutions, agencies and individuals in a man- ner which will produce a sustained effort by the citizens of each local community. The intent is to strengthen community medicine and thus improve patient care. . - - “The Albany Medical College was involved in a great deal of advanced planning in anticipation of its in- volvement in Regional Medical Pro- grams. This resulted in extensive ac- tivities prior to the planning grant award... - “Five mature experienced physi- cians were contacted relative to their interest in becoming full-time mem- bers of the Department of Post- graduate Medicine, which has the responsibility for the dircction of the primary administrative Program. . - - “The needed nonprofessional ad- ininistrative personnel were sought and excellent individuals were ac- quired. One of these is now our Di- rector of Community Information Coordinators. He has three coordina- tors working with him. These men are experienced former pharmaceutical house representatives who have proven their ability to relate well to physicians and be successful in their contacts with physicians. . - - “Regional Medical Program staff have met with the administrators and staff of many of the hospitals in the Region. To date, 58 hospitals have ————==—SEEr—e————C—FT en contacted ; and formal presenta- ins on the Albany Regional Medical ogram have been made to the adical staffs and/or boards of trust- s of 25 of these. All of the latter ve indicated, by vote; their desire participate in the Program. . . . “In general all of the hospital ad- inistrators, staff physicians, and ard members have indicated their mpathetic agreement with the con- pts of Regional Medical Programs. 1 some instances there were mis- nceptions about the Program based on the Report of the President’s ommission on Fleart Disease, Can- r and Stroke; these were quickly id easily dispelled. The administra- rs and staff of many of the hospitals pressed the desire, long felt, for a oser working relationship with the Ibany Medical College and Center, pecially with respect to patient con- Itations with specialists; increased yportunities for continuing educa- on in the physician’s home com- lunity; assistance in updating their 1owledge and ability to diagnosc eart disease, cancer, stroke and ‘lated diseases; guidance and aid 1 the training of more nurses and ther allicd health personnel; and vice as to whether or not to engage 1 research activities as well as the ature thereof... . 268-649 O—67-—_—_+1 Procress REPoRT ON SELECTED PLANNING PROJECTS Project to Improve and Expand Cancer Detection and Therapy “A major project preparation has been prepared, involving the efforts of physicians and administration at Vassar Brothers Hospital at Pough- keepsie, New York. The study is di- rected towards the objective of en- abling more effective carly diagnosis and treatment of cancer in the Poughkeepsie area... . Vaginal Cytology Screening Program “This project proposes to develop a model for cytological screening of all female patients in a given com- munity for cervical cancer. Continu- ing study is underway to establish the most effective coordinated approach to the objective, combining the ca- pabilities of the Regional Medical Programs with the which other State and Federal efforts opportunities provide. ... Multiple Hospital Prospective Cancer Investigation Program “This project proposes to establish a sub-regional and eventually a re- gional approach to a prospective cancer investigative program which would result in major dividends with regard to research, with regard to diagnostic and therapeutic proce- dures and with regard to general cancer education. .. . Cardiopulmonary Laboratory Development “It is proposed to establish a car- diopulmonary physiology and diag- nostic laboratory at the Pittsfield Af- filiated Hospitals, Pittsfield, Massa- chusetts. Such a laboratory would provide accurate diagnostic facilities in heart disease, diseases of the blood vessels and pulmonary discase. In ad- dition, its’ establishment will lead to improved local physician continuing education in this field. Cardiac Care Unit at Herkimer Memorial Hospital “This project proposes the estab- lishment of a finnly based Cardiac Care Unit building upon the hospi- tals existing embryonic ‘homemade’ one. Such a unit will permit nurse training in intensive coronary care in this locality.” Connecticut Regional Medical Program ‘During the ‘tooling up’ phase, when the program objectives were 45 being set and the action program was being formulated, the primary work involved the RMP. staff, the Plan- ning Committee and the Regional Advisory Board. Good communica- tions were maintained by frequent mectings, which were well attended, and by circulating full follow-up minutes... . “The Planning Design, as finally adopted, is concerned with such fundamental elements as health per- sonnel, facilities, and finanees—and their effective blend into a coordi- nated regional medical program serv- ing all the people of Connecticut. . . . “Tt involved the creation of nine Task Forces to study specific compo- nents of the Connecticut health care system, to determine deficiencies, to chart action programs and ulti- mately to work for their implementa- tion. A serious effort was made to _ have various segments of the health community represented on each Task Force, as well as to obtain a reason- able geographic distribution. Each includes representatives of various points of view appropriate to the topic under consideration, drawn from private practice, education, vol- untary agencies, governmental service and the public at large... . “These ‘Task Forces are concerned with the (1) supply and distribution of physicians and dentists; (2) re- cruitment, training, distribution and continuing education of nurses and other allicd health professionals; (3) continuing education of physi- cians and dentists; (4) extended care facilities and programs; (5) univer- sity-hospital relationships; (6) the or- ganization of special services within hospitals; (7) implementation of a state-wide library system; (8) financ- ing of medical care; and (9) defini- tion of the Connecticut region and its subregions. . . - “The RMP staff is responsible for assembling the complete information on the health resources in Connccti- cut needed by cach Task Force in its subject field in order to go about its work. To date, preliminary steps have been taken to ascertain what data is available through a number of estab- lished health organizations. Fortu- nately, the assembly of health infor- mation by such organizations as the State Health Department, the Con- necticut Hospital Association, the Connecticut Hospital Planning Com- mission and others will provide much of the information needed. It re- mains, however, for the RMP staff to carry out some special studies and, ultimately, to compile much of the health resources data in a central profile. “There have been many opportuni- ties to discuss the Planning Design with boards of directors of health or- ganizauions, with hospital staffs and with many interested individuals, both from the medical and lay ranks. Thus, the potential of Regional Med- ical Programs is becoming known in a widening circle; and communica- tions among various segments of the Connecticut health community are improving. . - - “rhe Regional Advisory Board has assumed responsibility for the pivotal decisions relating to the de- velopment of the Program, c.g. the approval of the planning grant re- quest, the appointment of the Plan- ning |)irector, the adoption of the Planning Design and the appoint- ment of the ‘Task Force meinber- ship... + “Tt is noteworthy that Regional Ad- visory Board members are now serv- ing as Chairmen of cight of the nine ‘Task Forces and that every Board member has a position on one of them. ‘This means that Board mem- bers will be deeply involved in plan- ning activities, that they will be in good positions to weigh proposals for the operating program one and two years hence, and that they will have the background knowledge needed to push their implementation. . - - “The most difficult problems en- countered to date are the following: (a) the complexity of the subject fields under study; (b) the weakness of communication links between scg- ments of the health system; (c) the shortage of experienced health plan- ners and researchers in the delivery of health care; (d) the overlapping and uncertain jurisdiction of related health planning organizations ; and (c) the shortness of time available to achieve measurable results. “With regard to the complexity of the subject fields under study, it is pertinent that the Connecticut Re- gional Medical Program is probing questions which have perplexed lead- ers from the ficlds of medical edu- cation and medical care alike in re- cent and past years. There are no ready answers, for example, on how to provide family medical care to all citizens in the years ahead, or how to recruit and educate the necessary nurses and other supporting health personnel and make them a part of a true health team, or how to imple- ment effective programs of continu- ing education for all health practi- tioners, etc. It is even difficult to structure planning studies to lead to the best solutions to these important issues. Yet, the Program has chosen to concern itself with those very is- sues in the health field which are of greatest concern to the people of Connecticut. .-- “It is pertinent that in Connecti- cut, as elsewhere, there has been rela- tively little contact in the past between the medical and: social sci- ences in the universities. These need to work together to chart overall social progress in the health field. There has been a considerable ‘town and gown’ rivalry between clinicians in the university and community set- tings. There has been too little con- tinuing contact in the past between health spokesmen from the educa- tional and voluntary segments, on the one hand, and from local and state government, on the other. The plan- ning efforts of the Connecticut Re gional Medical Program depend it great measure on full collaboratior between representatives of the healt! establishment drawn from education from the voluntary community aq {rom government. Some of the neec ed communications links are havin to be forged as a part of the Cor necticut Regional Medical Progra planning process itself. . . “Despite the major problems ¢ countered and the enormity of t task...asound organizational frarr work for planning has been cstz lished; broad consensus has be reached on the program’s planni design; and a large number of ! leaders from the Connecticut hea scene have become involved in planning process. ————— Tawaii Regional Medical Program “The assessment of the overall situ- ition, and the establishment of com- nunication with the participating wencies have been the major items f activity since November 1966, vhen a full-time Deputy Program irector (General W. TD. Graham, VD.) arrived in TMawaii. Informal ‘onferences with members of the Re- tional Advisory Group and their rep- sented agencies and with other varticipants have been held, and the tatus of the public, private, and roluntary programs in the health field rave been studied. “Local assessment, and the detailed consideration of the content and concepts of programs under way in xther regions, lead to the conclusion hat tangible progress in the program 1ere is contingent upon projects in continuing education. There is at sresent no fully-staffed, on-going icademic clinical teaching center in Hawaii. Those highly qualified per- sonnel currently engaged in the train- ing programs of the teaching hospital are engaged to full capacity, and are augmented by ‘visiting professors’. By locating full-time teaching specialists in teaching hospitals, significant ad- ditional support for postgraduate training programs will result and will bring these specialists in close touch with private practitioners... . “Additional programs of particular interest are the Stroke Registry and the Facilities Studies. On March 1, 1967, exploration of the feasibility of the establishment of a Stroke Reg- istry was begun. Consultations with physicians and with medical record librarians have progressed most satis- factorily. Field testing of method- ology will commence about May 1, 1967, in selected hospitals. . . . “The project for stroke rehabilita- tion education involves a plan to sct up a training program for various categories of rehabilitation personnel at the Rehabilitation Center of Hawaii in Honolulu, at outlying hos- pitals on Oahu and on the neighbor islands, in order to augment stroke rehabilitation capabilities, which are at present at the full capacity of the Center staff. “The goal of a facilities study by the Hawaii Heart Association is to determine equipment status in facili- ties which provide diagnosis and . treatment to patients with heart disease. A questionnaire has been directed to hospitals and clinics and the returns will be preliminarily evaluated, using volunteer services. Collation, analysis, and subsequent development of the information will require RMP support, and will begin about June 1, 1967... . “Planning is under way for a pro- gram directed toward the hematolog- ic aspects of the care of heart, cancer and stroke patients. This will also have components of continuing edu- cation, consultative service and lab- oratory and investigational activity directed toward assisting physicians in diagnosis and patient care. Intermountain Regional Medical Program “Organized efforts to develop a Re- gional Medical Program for this Region began in the fall of 1965. Efforts were made early to enlist the interest and support of organized medicine. . . “In October 1965, Dean Castleton and Dr. Castle of the University of Utah School of Medicine met with the Utah State Medical Association Executive Committee to gain their interest and support for a regional program. Subsequent meetings were held with representatives of the Utah, Idaho and Nevada State Medical As- sociations, and county medical soci- etics in Reno and Las Vegas, Nevada; Grand Junction, Colorado; Tdaho Falls, Pocatello, Twin Falls and Boise, Idaho; and Butte, Great Falls and Billings, Montana. Meetings also were held with members of the hos- pital stalT in all the major hospitals in the region... . “On February 26, 1966, a regional workshop was held at the University of Utah Medical Center in Salt Lake City, which was attended by repre- sentatives fron all six states involved in the proposed region and all profes- sions, organizations and institutions concermed about heart disease, cancer and stroke. The purpose of the mect- ing was to begin to define a Region which could work together as a unit and to obtain ideas as to regional resources and needs, and how a pro- gram should develop. Ideas expressed at this meeting served as a foundation for the planning grant application submitted in May 1966 and awarded eTective July 1, 1966... . “Since July 1966, the major efforts in planning have been in recruiting a planning staff, establishing lines of communication with all within the region and with other re- elements gional programs in the country and developing systems for sustaining active among these groups, explaining the purpose of the program to professional and lay com- interaction munities, developing methods for collecting data relative to heart dis- ease, cancer and stroke, identifying needs which can be met by Regional Medical Program legislation, and formulation of proper procedures for construction of pilot projects and methods for their review and ap- proval by reacting panels and the Regional Advisory Group. . . . “Progress has been made toward meeting all objectives outlined in the planning grant application, but none have been completed and will require an intensity of planning similar to what has been established within the last {ew months for at least another year, One major obstacle to more rapid progress within the region has been the slow process inherent in ob- taining outstanding people to serve in key positions on the planning staff. Although the Intermountain Re- gional Medical Program has been particularly fortunate in obtaining an outstanding, dedicated, hardworking staff, the process of bringing them into a new program, allowing them time to understand the program and to define their role, has taken much longer than anticipated at the outsct. In licu of people with background and experience in developing the type of program outlined under Pub- lic Law 89-239, it has been necessary to recruit personnel with a variety of career commitments and ask them to make major changes in their careers in pursuing this new national pro- gram... . “To meet some of the most pressing necds in initiating a Regional Medical Program, specific projects to provide training for personnel and to involve i & , & ‘a . certain institutions, organizations and individuals in an active way were identified carly in planning. .. . “The community profiles devel- oped by the Intermountain Regional Medical Program are being used by the Mountain States Regional Medi- cal Program and the community com- mittees to be formed in Nevada, Wy- oming, Idaho, and Montana, will serve as liaison to both programs over- lapping these areas.” Kansas Regional Medical Program “By the first of the year the posi- tion of Regional Medical Programs with relation to Public Law 89-749 and other efforts of the medical school had become somewhat clari- fied. Dr. Charles Lewis, professor and chairman of the Department of Preventive Medicine and Commu- nity Health, who had been active in both the planning grant body and in preparing the operational grant ap- plication, agreed to take full-time responsibility as director of the Kan- sas Regional Medical Program. He assuined this role on March 15, 1967. Since this time considerable progress has been made with regard to a prin- cipal staff and development of a for- mal organizational structure. . . . “In addition, a Regional Medical Program office has been established Log ‘ii i mo - in the Wichita area. This was done since this metropolitan area contains 15.75 percent of the population of the state of Kansas as well as 357 physicans and 1,825 nurses. Mr. Dallas Whaley, the previous execu- tive-sccretary of the medical society in Sedgwick County (Wichita) was approached and hired... . “In addition to the Regional Ad- visory Council, two additional groups have been appointed to serve as stall advisory committees. One of these is the Professional and Scientific Re- view Committce. This is made up of individuals nominated from various organizations and groups, such as the Heart Association, the Cancer So- ciety, the state Medical Society, those from certain sections of the School of Medicine, etc... . “The second group appointed is a physicians’ panel. This is composed of a group of physicians sclected by stratified random sampling with re- gard to geographic area, type of practice, and age. This panel of names will be submitted to the presi- dent of the Kansas Medical So- ciety... . “The Regional Advisory Council was recently enlarged with the addi- tion of eight new members. This en- largement was accomplished in or- der to gain further representation of other non-health-related groups within the state and also to increase representation from the Wichita area... “Considerable discussion has taken place with the Missouri Regional Medical Program regarding coopera- tive planning efforts, particularly with regard to data pooling and evalua- tion. Special attention and coopera- tive planning have been directed ta the complex Kansas City metropoli- tan area which crosscs the Missouri- Kansas State boundary and six county boundaries. .. . “A special Metropolitan Kansas City Coordinating Committee has been established to advise and assist with the planning for this area. This committee, which is made up of rep- resentatives of both the Missouri and Kansas Regional Medical Programs, will consider all proposals of either Region which would have an impact in the greater Kansas City area. . . “An interregional conference on health manpower data recording and evaluation was held May 22-23, 1967, at the University of Kansas Medical Center. Representatives of the Oklahoma, Missouri, and Kansas Regional Medical Programs partici- pated with outside experts. The pur- poses of this conference were (1) to define basic core information which must be recorded on all professionals (having decided what disciplines will ye covered) and to develop a com- non data base for the three Regions ‘or the transmission and comparison of manpower data, and (2) to em- phasize the importance of proper evaluation rather than developing ar- tificial indices which mean nothing in terms of health delivery systems. . . . “It should be noted that feasibility studies will soon be under way in the Wichita regional area. A group representing the hospitals and physi- cians of that area is now making plans to develop a non-profit corpora- tion in order to seek non-federal fi- nancing from private industry to sup- plement funds from Regional Medi- cal Program resources. . . . “It is hoped by the first of Septem- ber that manpower data recording for the state of Kansas will be al- most complete. It is also projected that during the summer of 1967— several field investigations will be carried out on consumer and health professionals’ attitudes toward cur- rent systems of health care. A proba- bility sample of consumers will be interviewed, comparing their atti- tudes-‘toward medical care. In addi- tion, physicians, nurses, hospital ad- ministrators, etc., will be similarly consulted. The purpose of this is to describe the system in as many ways as possible and to correlate this with other information regarding param- eters of health care, i.c.. morbidity and mortality data, utilization of beds, number of office visits, costs, etc. By comparing two or three different types of medical care systems in different parts of the state, we will have a better idea of the means by which we can evaluate changes and variations on the original theme of delivering health care to patients and improving the quality of care for those with heart discase, cancer, and stroke... . “Another development which will be completed before the end of this planning year is the attempt to de- velop a health data bank. To this end the University of Kansas Medical Center, the Kansas Regional Medli- cal Program, the Kansas State Board of Health, Kansas Blue Cross-Blue Shield, and Kansas Health Facilities Information Service, Inc., have all agreed to pool data on manpowcr, postgraduate training, resources for health care, facilities, utilization, morbidity, mortality, vital statistics, economic development, outpatient utilization of office visits, etc.” Missouri Regional Medical Program “Under the leadership, guidance and direction of the Regional Ad- visory Council, planning for the Missouri Regional Medical Program and development of pilot projects for implementation have simultaneously during the year. The Advisory its Scientific Review and ‘Liaison Subcommittees and the Metropolitan Kansas City Coordinating Commit- tec, serves as the governing body, de- proceeded ‘council, with advice from termines policies, and approves (or disapproves) and sets _ priorities among proposals for pilot projects. The Scientific Review Subcommittee advises the Council relative to sci- entific problems, including the merit of pilot project proposals. “The Liaison Subcommittee serves as a two- way medium of communication be- tween the member organizations and the Missouri Regional Medical Pro- gram. The Kansas City Metropolitan Coordinating Committee reports to the Advisory Councils of the Kansas Regional Medical Program and the Missouri Regional Medical Program and works to encourage cooperation and avoid duplication of pilot project proposals among institutions, hospi- tals and other agencies of Metropoli- tan Kansas City. All the orpaniza- tions and institutions represented on these Committees have an active role in planning, and two have submitted pilot projects now under considera- tion and three are preparing pilot project proposals. . . . “The Advisory Council made an carly and crucial decision to place primary emphasis on maximum use 49 and refinement of present resources. This means learning more about the necds of practicing physicians and other health professions, the con- sumer, and State and local health resources. Missouri Regional Medi- cal Program aims to assist the prac- ticing physician in providing optimum patient care as close to the patient as possible, with equal access to any needed national resource. According- ly, Missouri Regional Medical Pro- gram stresses prevention and carly detection, continuing education, pub- lic education and information, and appropriate demonstrations of patient care... . “The Missouri Regional Medical Program staff is confident that the splendid interest, concern and con- tributions of the Advisory Council are, in important part, related to its decision-making authority. (There appears to be evidence that the con- tributions of Regional Advisory Groups to a certain extent parallel their responsibility for decisions.) . . . “Since July 1, 1966, the staff have taken steps to strengthen inter-agency cooperation and communications. The Program Coordinator and staff have made specches at socicty mect- ings, meetings of other health profes- sion organizations and lay groups. The staff has also conducted seven site visits with reference to pilot projects proposed by various communitics; has been in communication with six other communities relative to possible pilot projects; has consulted with nu- merous official health agencies and other organizations and individuals; has discussed plans, projects and ac- tivities with numerous visitors... . “Thus far all agencies, institutions, organizations, and individuals asked to cooperate have responded favor- ably... . “However, some practicing physi- cians necd to be informed that Mis- souri Regional Medical Program is primarily patient oriented and not Medical Center oriented, and that Public Law 89-239 emphasizes co- operative arrangements, continuing education, and demonstrations of pa- tient care within the present system of medical practice... . “Missouri Regional Mcdical Pro- gram may face problems when agen- cies present pilot projects for fund- ing and a choice must be made. How- ever, we are developing Guidelines on which funding decisions will be based and explained to interested agencies. . . “The Missouri Regional Medical Program emphasizes the importance of evaluation of results. The Program Evaluation Center for the University of Missouri School of Medicine is be- ing used to develop whatever meas- urement devices are required and to apply them to the results achieved by various funded programs. The staff's activitics have been spent in attempt- ing to conceptualize comprehensive coordinated community health serv- ices in terms of ‘schemes of action’ rather than ‘schemes of arrange- ment. Thus, the model will be de- fined in such terms as access, com- munications, and end points... . “Pilot projects proposed by Mis- souri Regional Medical Program in- clude built-in nisms... . evaluative mecha- “A study is being conducted in a rural Missouri community, Glasgow, approximately 40 miles from Colum- bia, to examine some of the decisions made and the systems used by mem- bers of this community in secking medical care... . “In keeping with the ‘scheme of action’ concept, this one has looked at (1) routes of access to care which have been used; (2) critical coordi- nation and comunication points in the systems used; and (3) endpoints or reference points in the health service system. “Missouri Regional Medical Pro- gram will continue to coordinate its planning and pilot projects with other health and related programs. This applies especially to Public Law 89-749 and a new State law relating to State and regional comprehensive planning and community develop- ment (including health). A new OF- fice of State and Regional Planning and Community Development has been designated by Governor Hearnes for administration of these two laws in Missouri. In order to effect proper coordination between Missouri Re- gional Medica! Program and the Of- fice of State and Regional Planning and Community Development, a new senior staff position (Liaison Officer) has been established. .. . “Up to this writing, Missouri Re- gional Medical Program has consid- cred approximately 40 pilot project proposals. Of these, 27 were for- warded to the Division of Regional Medical Programs in the form of three operational grant applications. If current negotiations are confirmed, 15 of these will be initiated during April 1967, as follows: Smithville Project Communication Research Unit Multiphasic Testing Mass Screening—Radiology Automated Patient History Data Evaluation and Com puter Sim- ulation Computer Fact Bank Operations Research and Systems Design Population Study Group Survey Automated Hospital Patient Survey Program Evaluation Center Bioengineering Project Central Administration — Comprehensive Cardiovascular Can Unit (Springfield) Manual of Services “Staffing arrangements for thes projects are underway and are ex pected to be completed in major paz within the month.” North Carolina Regional Medical Program ‘Very early in the consideration : the North Carolina Regional Pr gram it became clear that in order ' fully implement the provisions Public Law 89-239, it was necessa to develop a core concept whi would make possible the coordinatic and augmentation of an already lar number of existing health activitic interests, and institutions and in tl process enhance the ultimate effe tiveness of each component eleme! This unifying conceptual strate called for the mobilization, throu comprehensive planning and coopt ative enterprise, of all health ca knowledge and resources for a cc certed attack upon the problems heart disease, cancer, stroke a related diseases. . . . “The program has the unique ¢ portunity of being in a position bring together the talents of t hitherto widely diffused leaderst by exercising its own leadership to mount as concentrated and effective an assault upon heart disease, cancer and stroke as may be possible in terms of the resources of the State of North Carolina. On the basis of these prem- ises the Regional Medical Program of North Carolina has evolved a de- tision-making mechanism which is both responsible and rational, and which will maximize the effectivencss of the wealth of leadership which is available. . . . “Participating Organizations: The North Carolina Regional Medical Program has received the enthusiastic support of the participating organi- zations. ‘Particularly outstanding have been the contributions of the North Carolina Heart Association and the North Carolina Division of the American Cancer Society. “The staff of the Association for the North Carolina Regional Medi- cal Program has devoted much time and energy to the orientation of health interests throughout the region in terms of the nature and objectives of the Regional Medical Program, and as it has been possible to identify appropriate functional roles, an in- creasing number of them have he- come active participants. This effort will continue to be a dominant feature of the Program since to a large ex- tent its success will depend upon the degree to which the skills and man- power represented by these interests can be mobilized... . “The Planning Division has made good progress in assembling survey data essential for program planning and to provide overall! bascline data against which future impacts may be gauged. “One study which has been com- pleted has explored the dimensions of an affiliation between the Memorial Mission Hospital at Asheville and the Bowman Gray School of Medicine. In addition to collecting data perti- nent to this situation, this experience will serve to teach us how to organize and communicate the data needed to provide linkages beween Medical Schools and community hospitals. Surveys have been made of practic- ing physicians in Buncombe County and of other staff members of the Asheville Hospital aimed at securing their ideas of the general utility of such an affiliation and their specific recommendations of what such an affiliation should strive to provide, especially in the way of continuing education. “A report on this study was devel- oped by the Planning Staff for the Association for the Regional Medi- cal Program with the assistance and guidance of Memorial Mission Tos- pital, Bowman Gray School of Medi- cine, the Buncombe County Medi- cal Society and the State Medical Society. It includes a description of the characteristics of its patients and staff. Also included are ideas of key hospital personnel as to the desira- bility of developing the affiliation with the Bowman Gray School of Medicine, suggestions as to programs of continuing education, and sugges- tions as to what other clements might be included in an affiliation between the two facilities. It also includes the viewpoints of the county’s physicians toward affiliation, continuing educa- tion, diagnostic resources and needs, and paramedical personnel needs through an analysis of questionnaires that were distributed to all Bun- combe County physicians in Febru- ary and March, 1967. Diabetic Consultation and Education Service “This study was begun January |, 1967 and participants include rep- resentatives of Bowman Gray and Duke Medical Schools, the Univer- sity of North Carolina School of Public Health, the State Board of Health, Community Board of Health, practicing physicians, and public health nurses, The feasibility of a regional consulta- tive service and an educational pro- 51 gram for diabetic patients is being tested. Scheduled clinics in commu- nity hospital or similar settings and also at the university medical centers are included. These activities will be supported by a home nursing service to assure proper follow up and sus- tained patient contact. The educa- tional program will be directed to community groups of diabetic pa- tients and will be coordinated with community health organizations. . . . Continuing Education “Data on the number and types of continuing education programs for professional and ancillary personnel, their geographical outreach and the numbers and characteristics of indi- viduals attending is being collected through a monitoring system involv- ing obtaining of registration forms from program chairmen. When this monitoring process was first initiated, the researchers attempted to gather data only from those organizational meetings with program content re- lated to the categorical diseases. How- ever, it was often difficult to draw a line between those mectings that either did or did not fall within this provision. As a result an attempt has and will continue to be made to moni- tor all of the major medical meetings unless the program content clearly AL indicates no relevance to the RMP. In a statewide study of this nature an analysis of any part of the continuing education process becomes an analy- sis of the total on-going system. Con- sequently, the findings will be more relevant and meaningful if the widest possible representation of the education system is obtained.” Northern New England Regional Medical Program “The Northern New England Regional Medical Program and core stafT have been organized along functional lines—medical cconomics, education, information systems, dis- case prevention, and patient care. services. All planning and program efforts, in turn, are organized ac- cording to a systems approach which provides continuous feedback of information and assessment of progress... . “We have made good progress in determining the scope of participa- tion of various health related groups in Regional Medical Programs. Irom the beginning we have made every effort to include representatives from all interested groups in our planning effort... . “A number of steps have been taken to develop cooperative work- ing relationships with health profes- sions groups, hospitals, health agencies, and other organizations concerned with health and welfare throughout the Region. ... “Determining the planning ap- proach has been complex because we have attempted to shape our program in response to the requirements of the systems approach to planning. This approach provides for the appli- cation of advanced mathematical and computcr techniques in analyzing alternative solutions to problems. It also includes cost-benefit studies. Some cost estimates of the training of allied health personnel and coronary care training for nurses have been made, Since there are no precedents, some experimentation has been nec- essary... . “The development of a Model of Patient Care is the major initial planning effort. ‘To develop the edu- cational aspects of the Model, an Education Committee has been ap- pointed which will be concerned with lay health education, continuing education for all health professionals, and basic education in the allied health professions. . . . “A meeting held in February 1967 with representatives of some 25 or- ganizations which operate a variety of health education programs was a first step in coordinating the existing health education programs with Re- gional Medical lies. 2. Program — activi- “Since continuing _ professional education is an integral aspect of Regional Medical Programs, an ad hoe committee has been appointed for continuing education of allied health professionals with representa- tives from the Vermont Division of the American Cancer Society, the American Red Cross, the State Health Department, the Department of Physical Medicine and Rehabilita- tion of the College of Medicine, the Vermont Heart Association, the Ver- mont Pharmaceutical Association, the State Mental Health Depart- ment, the Office of Continuing Edu- cation of the College of Medicine and the Regional Medical Program’s staff. This group has defined specific objectives for continuing education and is gathering information on exist- ing activitics and personnel needs for carrying on these activities. . . . “The potential use of various modes of communication and trans- portation to augment continuing education programs is being ex- plored. Two-way television connec- tions between the Medical Center Hospital and community hospitals in the Region and the use of the Uni- versity’s airplane are two possibilities for future education program sup- port... “Assessing basic education needs in the allied health professions has been a prime concern; and surveys have been made to determine the number and types of such personnel in the Region. . .. “Health education for the public has cmerged as a top priority objec: tive, and recruitment of a full-time information specialist to be respon- sible for this aspect of the Program is currently underway... . | “Dissemination of recently ac: quired medical information to the practicing physician has also been a concern of the Northern New Eng- land Regional Medical Program and our proposed Pilot Project in Coro- nary Carc is an illustration of how we intend to accomplish this task. Through cooperative arrangements between health personnel at the Cen- ter and their counterparts in the re- gion which are described in out proposal, we intend to promote ap- plication of the latest techniques in progressive coronary care at the local level... . “The proposed Pilot Project in Progressive Coronary Care involves research related to the regional as- pects of the management of coronary disease. One such study will be a determination of modifications in equipment and personnel require- ments necessary to provide intensive coronary care in small community hospitals. Using the data collected through the Heart Inventory, which the Northern New England Regional Medical Program is developing, it will be possible to identify other potential research projects related to various aspects of the incidence and treatment of heart disease... . “Our planning efforts must neces- sarily take into account how trans- portation affects the delivery of health care. Thus, we currently are conducting with the State Medical Society a survey to determine which towns have emergency ambulance service, how it provided, and how effective it is.” Tennessee Mid-South Regional Medical Program “Understanding of what the fun- damental concept of a Regional Medical Program is and how to best develop and establish it in this region has proceeded steadily from the earliest discussions which led to the application for a planning grant. In- evitably, such understanding has de- veloped in an evolutionary fashion since it is, in fact, a reflection of a growing awareness of the medical faculties of ways in which they can serve as resource agencies for im- proved medical care, and of practic- ing physicians that the primary aim of the program is to help them in the care of patients in their own lo- cal area. Similarly, the role of exist- ing health agencies, public and volun- tary, and of the wide spectrum of health personnel on which good health care depends so heavily has gradually come into focus like a pic- ture on a screen as steps have been taken to promote discussion and planning for specific action to deal with real problems. “This first progress report of the Tennessee Mid-South Regional Med- ical Program attempts to chronicle the widespread growth of under- standing about its purposes and methods that has taken place in the past year. The basis for most of the achievements to date is the willing- ness of many persons, acting on their own behalf or that of their institu- tions and organizations, to study new approaches and to undertake new re- sponsibilities to assure the continued improvement of medical care in the fields of heart disease, cancer and stroke. .. . “In developing the strategy to be followed, the Director of the Ten- nessee Mid-South Regional Medical Program has sought consultation from Dean Batson (Director, Medi- cal Affairs, Vanderbilt University), Mr. Kennedy, (Chairman of the Re- gional Advisory Group), and from Dr. Anderson (Chairman of the Faculty Group formulating policy for Meharry Medical College). It seemed desirable to explore with the faculties of the two medical schools their interest in the general areas ‘of continuing education, the training of affiliated health personnel, and vari- ous aspects of heart clisease, cancer and stroke. Visits were made to key communities in the region which had given evidence that they were ready to develop cooperative arrangements. In addition, it was deemed essential to establish communication with the various voluntary and public health agencies in Nashville and other areas of the region... . “On January 10, 1967, the Direc- tor met with a group of approxi- mately 12 hospital administrators from the Nashville area. The group was knowledgeable about the objec- tives and procedures to be followed in developing a Regional Medical Program. They were greatly inter- ested in finding out how the Regional Advisory Group would function and the basis for establishing prioritics for projects which might come from a variety of sources. Questions were raised about the establishment of coronary care units in hospitals and particular inquiry was made about the eligibility of hospitals for funds to conduct renovation for projects of this kind. A discussion was held about the importance of building into the 53 design of projects a mechanism for evaluating their results... . “On February 22, 1967, Dr. Faxon Payne, radiologist at the Jennic Stuart Memorial Hospital and Chair- man of the Medical Society Commit- tee for Regional Medical Programs for Heart Disease, Cancer and Stroke, arranged a meeting of the Director with the chiefs of medicine, surgery, pediatrics and pathology, with the Administrator of the hospital and several members of the Board of Trustees. It was apparent that the group was anxious to establish com- munication with the Regional Medi- cal Program and was particularly in- terested in the field of continuing education. The potential of televi- sion and other communications inedia was discussed. The staff indi- cated that it would be greatly inter- ested in having medical school faculty members come cither for lectures or for periods of one or two days at a time. They expressed interest also in the possibility that a full-time chief of medicine might be appointed in order to help organize an educational pro- gram of some substance which could serve not only the Hopkinsville group but the 8 or 10 smaller hospi- tals which are located within a 10 to 15 mile radius of Hopkinsville. . . . “A meeting was also held with the staff of the Erlanger Hospital in Chattanooga on March 8, £967. We discussed the problem created by the fact that Chattanooga scrves arcas not only in Tennessee but also in Northern Georgia. The Dircctor as- sured the staff that the Regional Medical Program would in no way interfere with the relationships with established groups. We then discussed ways in which the hospital could proceed to become actively engaged in an operational project. The follow- ing suggestions were made—that a committee be appointed within the hospital to coordinate suggestions made by the various services and to cooperate with the already appointed committec of the medical society. The individual chiefs should be cncour- aged to draw up a rough draft of pro- posals relating to their own depart- ment. The Director indicated that the Regional Medical Program staff would work with the various groups to help refine the proposals, make sure that mechanisms for evaluating the projects were incorporated and that specific budgets relating to per- sonnel, supplies, equipment, ctc., were properly drawn. It appears likely that the Regional Mcdical Pro- gram will work through this group to establish an educational sub-center in this area anticipating that the group at the hospital will reach out into the surrounding areas to establish closer contact for the training purposes. ... “Similar developments are taking place at two hospitals in Nashville, St. Thomas, and Mid-State Baptist and in Knoxville and the Tri-City area... . “In addition to visits with hospi- tals, the Director has met with many of the medical societies in the re- spective communities and they have now established liaison committees to consider ways and nicans of foster- ing activilics under the aegis of the Regional Medical Program for Heart Disease, Cancer and Stroke. In most instances, it was found that these conunittees while expressing interest, had been unable to focus their ef- forts on specific programms. It was only through discussion of possible opera- tional projects for which grant funds might be made available that the ac- tivities began to achieve some degree of substance. . . . “Dr. Frank Perry, Associate Pro- {fessor of Surgery, is coordinator for the Meharry faculty and will devote a major share of his time to explora- tion of continuing cducation pro- grams for Negro physicians. He plans to coordinate his activities with the parallel efforts being made in con- linuing cducation by the faculty at Vanderbilt University. . . . “Dr. Leslie Falk of the University of Pittsburgh School of Health, who is serving as chicf consultant for the planning of a Neighborhood Health e Center sponsored by Meharry and funded through the Office of Eco- nomic Opportunity, believes that the Regional Medical Program could be of considerable value in supplement- ing the services that Neighborhood Health Center would ordinarily make available. . . . “The demands made by the Re- gional Medical Program have focused the attention of the professors of medicine, surgery, and radiology at Vanderbilt University on the need to make a major revision in the facili- tics for diagnosis and _ treating patients with surgically correctible cardiovascular disorders. The evident strengths of the institution have not been used as effectively as they might, and the requirements for a pene- trating assessment of the problem has been a beneficial experience. “Planning is underway to deter- mine how best to develop a rehabili- tation facility to serve the needs of the region. A gift in the amount of $2,000,000 from a Nashville family has insured the funds for construc- tion. Intensive effort is needed, how- ever, to coordinate the project for maximum involvement of faculty, community agencies and state and regional agencies. It is expected that the institution will serve important educational and research purposes. This appears to be an excellent ve- hicle for achieving regional ob- jectives in an arca where existing fa cilitics and personnel are desperate! needed... . “Acquisition of information abou the health resources of the region i underway and will be continued an expanded during the year. Using th resources of the biostatistical divisio: of the Department of Preventiv Medicine and Public Health of Van derbilt University, data has been pu on computer tape regarding physi cians, nurses and the hospitals. Usin this basic information, a health re sources profile will be developed fo each county and later certain coun tics will be grouped into areas to de termine the characteristics of thes larger areas. Demographic data wi also be used as a basis for determinin the size of the population to be serve in the respective counties and area Valuable correlative data has als been obtained from the statistical d vision of the Tennessee Departmer of Health... . “In cooperation with the Tennesse Nurses Association and the Tennesse Leaguc for Nursing, we are making study leading to the preparation of state-wide plan for nursing educatior Cooperating in this endeavor will b Miss Anne Dillon, Head of the Stz tistical Division of the Tennessee De partment of Public Health. The tim seems ripe for just such a study t lp focus on the total problem of arsing.” ‘exas egional Medical Program “The Project Director in Area I has onducted meetings with various ducational health agencies. Mect- ngs were held to determine meth- idology and to enlist the help of ded- cated individuals interested in the roals of the Regional Medical Pro- srams, Outside the Medical School community, the Council of Medical Society Representatives appears to be the most significant body to reach community physicians. Two meetings of the Council of Medical Societies Representatives have been attended by 28 physicians and 12 hospital ad- ministrators from 16 of the 44 Coun- ty Medical Socicties of Area I. There was a favorable attitude expressed to- ward the Regional Medical Program and a desire expressed for the need of the early development of an In- tensive Care Unit Training Program for nurses and physicians. The in- volvement of hospital administrators, individually or through the Hospital Council, has been most worthwhile since the eventual improvement of health services must generate from the community hospitals. . . - “There. are many facts to be un- covered by making a survey of phy- sicians. We need to know the future . patterns of medical practice. The gradual shift of gencral practitioners into specialties and into population centers is leaving many areas without younger physicians. Several counties have no young men coming into their communities. In order to examine regional problems Area J has been divided into six divisions and studies are now underway to define the phy- sician’s role in cach community. . + - “Within the regular teaching pro- gram for medical students, resiclents, and interns at the University of Texas Southwestern Medical School and affiliated teaching hospitals there are conferences, seminars, lectures, and clinics that are maintained on a regular basis and are available for physicians interested in continuing postgraduate education. There are several institutional grants in both heart disease and cancer supported by Public Health Service grants. These programs are oriented to co- operate with the Regional Medical Programs. . . - “Stroke: Significant programs are being developed in the medical school community, especially the Presbyterian Hospital, to develop a significant demonstration unit involv- ing all of the disciplines of medicine necessary to bring this program into one cooperative effort. A total pa- tient care program, including re- habilitation, will have high priority in developing an operational program in the immediate future. . - - “Ty Area I, many physicians were skeptical, suspicions, or hostile to the Regional Medical Program on initial contact. ‘The hostile response, how- ever, was not uniform. Many physi- cians, and a majority of many of the district and county medical societics, looked faverably and hopefully upon the program. ‘They saw in it an op- portunity for continuing education for themselves, for training of allied health professionals, for supplemen- tary special medical care facilities, and other meastres that may alleviate a feeling of isolation... - - “Certain difficulties have encountered in Area II in commu- nicating with peripheral points at which health care services are dis- pensed. Full-time personnel are still being sought for the professional posi- tions now filled on a part-time Iasis. A full-time Assistant Planning Direc- tor will concentrate his efforts on hospitals and other health care cen- ters. It is obvious that the circuit- rider technique must be employed to effect an appropriate response at the been community level... - “The feasibility study for develop- ing a School of Allicd Ifealth Sei- ences has progressed very well, Jim- phasis will also be placed on studying relationships — that could mutual evolve from the collaborative efforts with the Galveston Community Col- lege... - “The planning staff became acute- ly aware that the health practitioner and the hospital at the community level had little knowledge of the exist- ence, the intent or the potential of Regional Medical Programs. Efforts to establish written communication proved less than satisfactory; there- fore, a more direct approach was deemed essential. On February 25, 1967, the president of each county medical society in the Gulf Coast Area was invited to Galveston to en- ter into a dialogue on Regional Medical Programs. It was hoped that cach of these individuals would return to their respective communi- ties and would, in turn, create addi- tional dialogue at the local level. Rep- resentatives from seven county socic- ties, the “Texas Medical Association and planning staffs from cach of the several components of the Texas Re- gional Medical Program attended. While the physicians present repre- sented only a small part of the gco- graphic area, this mecting provided considerable information that verified the essentiality of a continuing inter- change between a planning office and the health practitioner. The meeting also demonstrated the difficult. task that lay ahead in establishing such a dialogue... - Intensive Care Unit “The planning director has collab- orated with the administration of the University of ‘Texas Medical Branch and the Medical Branch: Hospitals in developing a modern intensive care training unit which will contain four beds for postoperative care of patients with cardiovascular disorders. ‘The planning director is currently arrang- ing for partial funding through non- federal sources. ‘This unit will be de- veloped in such a manner that will permit the training of nurses and physicians to man intensive care units in other hospitals. . . . “Many interested individuals and groups are taking an active part in gathering information and are par- ticipating in studies, such as the Houston Area Hospital Personnel As- sociation and Houston Dietetic As- sociation. They have worked with the staff in designing questionnaires and gathering information. . . . “The program is serving as a cata- lyst in encouraging dialogue and co- operation between institutions, in- terest groups, associations and individuals, Progress in carrying out planning studies and surveys is being made. Misconceptions and erroncous conclusions about the purposes and goals of the program are being cor- rected. Resistance to the program is dissipating as further information is provided. . .. “In the carly phases of this pro- gram it is the primary objective of the Division of Continuing Education of the Graduate Medical School of Biomedical Sciences to determine how educational roles may be dis- charged within the framework of in- dividual needs and goals, while at the samme time providing practical and applicable information which will be both convenient and accessible to the physician and others who deliver health care, and which will ultimately result in better patient care... . “An attempt will be made to con- vey the concept that the medical school not only awards an M.D. de- gree, but provides annual opportuni- ties to appraise the practicing phy- sician of current attitudes and techniques, to support the physician in his need for lifelong learning. . . . Regional Training Program in Cardiovascular Disease “The initial study of personnel available within the Medical Center for postgraduate training programs in the area of cardiovascular disease has been. productive .. . initial con- siderations have led to plans for re- fresher courses lasting three to five days and providing for the participa- tion of practicing physicians and other health professionals in the con- ferences, clinics, and ward rounds of the Medical Center... “A study of the applicability of closed circuit television communica- tion with one or a few local com- munity hospitals is of considerable in- terest. ‘This institution will participate with others in the region to prepare formal postgraduate training pro- grams for television presentation. In addition, it is proposed to utilize this medium for individual consultations with patients who can then remain in a familiar environment with their own physicians. . . “A general planning study and sur- vey has been undertaken in the allied health professions education field to identify needs, trends, problems, and resources necessary to implement grant proposals and program goals in advancing, through education, train- ing and demonstrations, the care of heart-cancer-stroke patients. . . “In brief, findings indicate: a gen- eral awareness that a perilous short- age of allied health personnel exists in both numbers and quality... physicians want and necd to delegate more to allied health personnel to free themselves to serve more pa- tients . . . a closer liaison is evolv- ing between educational institutions and hospitals in the education and training of all levels of allied health personnel. .. . “At the Division of Allied Hea Science at South Texas Junior C lege (Houston, Texas) feasibi studies are in process in the devel ment of curricula in nursing, inha tion therapy, X-ray, medical recor physical and occupational therapy sistants, medical monitoring and el tronics, ophthalmic assistants and c tary supervision. . . . “At this writing, we have the pr pect of a cooperative feasibility stu for a multiphasic screening pilot pr ect in conjunction with the Bay University College of Medicine co puter science program and the I partment of Biomathematics of | University of Texas at Houston. T would involve a multiphasic auton tion and computer project in patir diagnosis. This would also bring ir focus projects for continuing edu tion of physicians in outlying hospit and allied health education and tra ing needs and programs. . . . “A major introductory activity volved recognition and visitation rehabilitation settings within 1 Texas Medical Center and Houston community agencies, P, grams in these institutions pertine to the development of the Progr: were explored and an attempt v made to build with these institutic appropriate collaboration. These « ganizations include: the Method Hospital, the Ben Taub General Hi pital, the Physical Medicine and Re- habilitation Service of the Veterans Administration Hospital, Houston, the Visiting Nurse Association of Houston, the American Cancer So- ciety, Harris County Unit, and Good- will Industries. The Texas Woman’s University, although relatively new, has a distinctive curriculum with early patient contact. The school is geared to agency collaboration and is constructively interested in Regional Medical Program participation. . . . “At the University of Texas Dental Branch restorative dentistry is con- cerned with a number of cancer pa- tients, and there is considerable expe- rience with restoration of the mouth, face, nose and ears. Prostheses includ- ing artificial eyes are fabricated. Closed circuit television has become a part of the teaching technique. . . “It is apparent that new methods and new techniques must be utilized to attract those who do not now par- ticipate in continuing education. . “Progress in the first year of plan- ning at the M. D.-Anderson Hospital and Tumor Institute has been handi- capped by lack of success in recruit- ing a full-time Physician Coordinator having the special combination of qualifications deemed essential to this important position. We have felt it expedient to evaluate the needed adjustments between the Texas Med- ical Association, the various county medical societies, specific practition- ers, hospital administrators and this cancer program which largely has been designed and planned through the University’s biomedical units. It has been considered essential that understanding and agreement be at- tained in an atmosphere of good will in order to project further progress. Therefore, time has been required to make this adjustment and to reach a consensus as to goals. In the case of some existing activities, such as the cancer registry, there have been on- going programs under diverse aus- pices. Before a statewide registry can be projected, all aspects of existing programs must be reviewed to fit into the larger effort in an harmonious and agreeable fashion.” 57 il TE IV XI NIL Preparation of Report Ad Foc Advisory Committee Planning Grants Operational Grants National Advisory Council Review Conunittee Consultants Program. Coordinators Review of Opcrational Grants Division Stal? Relationships of Public Laws 89-239 and 89-749 Public Law 89-239 NIP Reeulations XIV Seleeted Bibliography Saale y iy PSCTHITEBEES. Thad EXUIBYE J Steps in Preparation of the Surgeon Generals Report to Congress on Regional Medical Programs To assist in the preparation of the report required by Section 908 of Public Law 89-239, the Surgeon General appointed a Special Ad Hoc Commitice of non-federal consult- ants, ‘The nucleus of the committee was four members of the National Advisory Cowncil on Regional Medi- cal Programs. Eleven other persons with diverse backgrounds and inter- ests in health and public affairs also jeined the group. In addition, six other individuals with extensive ex- perience in medical education and governmental administration agreed to serve as consultants to the Ad Hoc. Committee. (‘The members of and consultants to the Committee are listed in Exhibit IT.) "The Committee net five times. At the initial meetings, on September 16 and October 7, 1966, issues pertain- ing to the development and admin- istration of Regional Medical Pro- grams were presented and discussed. From these deliberations came a serics of recommendations for the steps to be followed in preparing the Report. First, an outline of discussion items was prepared and reviewed at a meeting on November 7. From these, the key issues relating to the three areas specified for consideration in Section 908 of the Act and other as- pects of the program were identified and analyzed. Subsequently, a national forum was scheduled at which these issues were presented for consideration and reaction from health and related in- terests representing all sections of the country. This forum took the form of a Conference on Regional Medical Programs held in Washington (D.C.) on January 15-17, 1967. Nearly 850 medical, health and civic leaders were invited. This group in- cluded persons from both regions Where planning activities were al- ready underway and from other areas where proposals were still un- der development. In addition, many others with related interests received invitations. More than 650 persons attended the Four Issue Papers were prepared ronference. by the Division of Regional Medical Programs and distributed in advance. Seven papers were presented at ple- nary sessions and two pancl sessions were conducted. ‘These presentations provided background for the 26 dis- cussion groups of about 25 indi- viduals cach that met three times during the Conference, The results of this meeting are published in the Proceedings: Conference on Re- gional Medical Programs. The -wealth of information developed by the Conference was supplemented by letters and other ma- terial, voluntarily submitted by par- ticipants following the Conference. To gather additional information, the Division staff made a series of visits to on-going Regional Medical Pro- grams and held discussions with Pro- gram Coordinators and others en- gaged in the development of regional activities. A “14-point” survey form was also distributed to all Program Coordinators for their use in for- warding up-to-date data on the status of their activities and plans. All of this material was analyzed and used in the preparation of this Report. A preliminary draft of the Report was reviewed by the Ad Hoc Com- mittee on March 10, 1967. It was subsequently revised in accordance ‘with its recommendations and_ re- submitted to them on April 14. After consultation with the members of the National Advisory Council on Regional Medical Programs, the Re- port was submitted to the Secretary of Health, Education, and Welfare for transmission to the President and Congress. EXHIBIT II Surgeon General’s Special Ad Hoc Advisory Committee To Devclop the Report on Regional Mcdical Programs to the President and the Congress Ray E. Brown, L.H.D. Director Graduate Program in Hospital Administration Duke University Medical Center Durham, Nerth Carolina Michael E. DeBakey, M.D." Professor and Chairman Department of Surgery College of Medicine Baylor University Houston, Texas Bruce W. Everist, Jr.. M.D? Chief of Pediatrics Green Cline Ruston, Loutsiana James T. Howell, M.D." Executive Director . Henry Ford Hospital Detroit, Michigan George James, M.D. Dean Mount Sinat School of Medicine New York, New York *Member, National Advisory Council on Regional Medical Programs. 268-649 O—67. 5 Boisfeuillet Jones Director Emily and Ernest Woodruff Foundation Atlanta, Georgia Charles E. Odegaard, Ph. D, President University of Washington Seattle, Washington F.dmund D. Pellegrino, M.D." Director Medical Center State University of New York Stony Brook, New York Carl Henry William Ruhe, M.D. Assistant Secretary Couneil on Medical Education American Medical Association Chicago, Illinois Clark K. Sleeth, M.D. Dean School of Medicine West Virginia University Morgantown, West Virginia Ray E. Trussell, M.D. Director School of Public Health and Administrative Medicine Columbia University New York, New York Burton Weisbrod, Ph. D. Associate Professor Department of Economics University of Wisconsin Madison, Wisconsin Robert E. Westlake, M.D. Syracuse, New York Storm Whaley (Chairman) Vice President of Health Sciences University of Arkansas Medical Center Little Rock, Arkansas Paul N. Yivisaker, Ph. D. Commissioner New Jersey Department of Community Affairs Trenton, New Jersey Consultants to the Surgeon General's Special Ad Hoc Advtsory Committee To Develop the Report on Regional Medical Programs to the President: and the Congress Norman Beckman, Ph. D. Director Office of Intergovernmental Relations and Urban Program Coordination Department of Housing and Urban Development Washington, D.C. Ward Darley, M.D. Office of the Consultant to the Executive Director Association of American Medical Colleges University of Colorado Medical Center Denver, Colorado Kermit Gordon Vice President The Brookings Institution Washington, D.C. 61 Charles Kidd, Ph. D. Executive Secretary Federal Council for Science and Technology Office of Science and Technology Washington, D.C. Jack Masur, M.D. Associate Director for Clinical Care Administration Office of the Director National Institutes of Health Bethesda, Maryland Joseph S. Murtaugh Chief Office of Program Planning Office of the Director National Institutes of Health Bethesda, Maryland, EXHIBIT WT Planning Grants for Regional Medical Programs, fimie 30, 1967 REGIONAL DESIGNATION ALABAMA ALBANY, NEW YORK ARIZONA ARKANSAS PRELIMINARY Alabama Northeastern New York and Arizona Arkansas PLANNING REGION.! portions of Southern Vermont : and Western Massachusetts POPULATION ESTIMATE 3,500,000 * 1,900,000 1,635,000 1,960,000 1905.? COORDINATING ILEADQUARTERS. University of Alabama Medical Center Albany Medical College of Union University, Albany Medical Center. College of Medicine University of Arizona University of Arkansas Medical Center GRANTEES Sane. Same. Same. Same.® EFFECTIVE STARTING DATE. January 1, 1967 July f, 1966 April 1, 1967 April 1, 1967 PROGRAM PERIOD 2 3 2Y, ay, (YEARS), AWARD $318,046—Ist $373,254—Ist $119,045—Ist $360,174—Ist (AMOUNT AND YEAR). $384,244—2nd RECOMMENDED FUTURE. $286,750—2nd $252,486—3rd $287,000—2nd $421,682—2nd SUPPORT (AMOUNT! AND YEAR). 1 Preliminary regions for planning purposes as delineated in the original applications, State designations do not indicate they are coterminous with State lines, ‘These preliminary regions may be modified on the basis of planning and experience. 2 Population estimates include overlap between regions. As preliminary regional boundaries are evaluated $143,375—3rd $67,750—3rd $97,300—~3rd 4 Direct costs only. and clarified during the planning process, inappropriate overlap will be eliminated. 3 The Grantee differs from the Coordinating Headquarters when the Region requested this arranger or the latter agency did not have the capability to assume formal fiscal responsibility. 5 Indicates the Grantee Agency and the Coordinating Headquarters are the same organtzation. REGIONAL DESIGNATION BI-STATE CALIFORNIA CENTRAL NEW YORK COLORADO-WYOMING PRELIMINARY Eastern Missouri and California Syracuse, N.Y., and 15 Colorado and Wyoming PLANNING REGION.! Southern Illinois centered surrounding counties around St. Louis POPULATION FSTIMATE 4,700,000 18,600,000 1,800,000 2,300,000 1965,? University of Colorado COORDINATING Washington University School California Committee on Upstate Medical Center, HEADQUARTERS. of Medicine Regional Medical Programs State University of Medical Center New York at Syracuse GRANTEE.? Same.5 California Medical Education Research Foundation of State Same.® and Research Foundation’ University of New York EFFECTIVE STARTING DATE. April 1, 1967 November 1, 1966 January 1, 1967 January 1, 1967 PROGRAM PERIOD 2% 234 2 2% (YEARS). AWARD $603,965—Ist $1,511,381—Ist $299,522—Ist $361,984—Ist (AMOUNT AND YEAR). $547,989—2nd $2,198,452—2nd $211,206—2nd $326,114—2nd RECOMMENDED FUTURE SUPPORT , (AMOUNT! AND YEAR). $135,993—3rd $961 ,982—~3rd $170,662—3rd ' Preliminary regions for planning purposes as delineated in the original applications. State designations do not indicate they ore coterminous with State lines. These preliminary regions may be modified on the basis of planning and experience. 2 Population estimates include overlap between regions. As preliminary regional boundaries are evaluated § Direct costs only. and clarified during the planning process, inappropriate overlap will be eliminated. 3 The Grantee differs from the Coordinating Headquarters when the Region requested this arrangement or the latter agency did not have the capability to assume formal fiscal responsibility. 8 Indicates the Grantee Agency and the Coordinating Headquarters are the same organization. REGIONAL DESIGNATION CONNECTICUT GEORGIA GREATER HAWAII DELAWARE VALLEY PRELIMINARY Connecticut Gcorgia Eastern Pennsylvania and Hawaii PLANNING REGION. ! portions of Delaware and New Jerscy ‘POPULATION ESTIMATE 2,800,000 4,400,000 8,800,000 800,000 1965.7 Yale University Medical Medical Association of Georgia University City University of Hawaii College COORDINATING HEADQUARTERS. School and University Science Center of Health Sciences of Connccticut School of Medicine GRANTEE? Yale University School of Same. Same.’ Same.5 Medicine EFFECLIVE STARTING DATE. July 1, 1966 January 1, 1967 April 1, 1967 July I, 1966 PROGRAM PERIOD 3 2h 1 2 (YEARS). AWARD $406,622—Ist $240,098— Ist $1,531,494—Ist $108,006—Ist (AMOUNT AND YEAR). $338,513—2nd $119,122—2nd RECOMMENDED FUTURE SUPPORT (AMOUNT AND YEAR). $312,761—3rd $203,207—2nd $104,749—3rd 3 The Grantee differs from the Coordinating Headquarters when the Region requested this arran or the latter agency did not have the capability fo assume formal fiscal responsibilily. 4 Direct costs only. 5 Indicates the Grantee Agency and the Coordinating Headquarters are the same organizatia? ‘Preliminary regions for planning purposes as delineated in the original applications. State designations do not indicate they are coterminous with State lines. These preliminary regions may be modified on the basis of planning and experience. 2 Population estimates include overlap between regions. As preliminary regional boundaries are evaluated and clarified during the planning’ process, inappropriate overlap will be eliminated. 65 REGIONAL DESIGNATION ILLINOIS INDIANA INTERMOUNTAIN IOWA PRELIMINARY Illinois Indiana Utah and portions of Colorado, Towa PLANNING. REGION.' Idaho, Montana, Nevada, and Wyoming POPULATION ESTIMATE 10,700,000 4,900,000 2,200,000 2.800,000 1965.* COORDINATING HEADQUARTERS, Coordinating Committee of Medical Schools and Teaching Hospitals of Mlinois Indiana University School of Medicine University of Utah School of Medicine University of Towa College of Medicine GRANTEES University of Chicago Indiana University Foundation Same.4 Same? EFFECTIVE STARTING DATE, July 1, 1967 January 1, 1967 July 1, 1966 December 3, 1966 PROGRAM PERIOD 2 21% 7 2 (YEARS). AWARD $336,366—I1st $384,.750—Ist $456 ,415—Ist $291 ,348— Ist (AMOUNT AND YEAR). $363,524—2nd RECOMMENDED FUTURE SUPPORT (AMOUNT ‘ AND YEAR). $244,175—2nd $373,710—2nd $152,295—3rd ' Preliminary regions for planning purposes as delineated in the original applications. State designations do not indicate they are coterminous with State lines. These preliminary regions may be modified on the basis of planning and experience. ? Population estimates include overlap between regions. As preliminary regional boundaries are evaluated and clarified during the planning process, inappropriate overlap will be eliminated. $230,218—2nd 3 The Grantee differs from the Coordinating Headquarters when the Region requested this arrangement or the latter agency did not have the capability to assume formal fiscal responsibility. 4 Direct costs only. 3 Indicates the Grantee Agency and the Coordinating Headquarters are the same organization, OD 66 REGIONAL DESIGNATION KANSAS LOUISIANA MAINE MARYLAND PRELIMINARY Kansas Louisiana Maine Maryland PLANNING REGION.! POPULATION ESTIMATE 2,200,000 3,500,000 1,000,000 3,520,000 1965.” COORDINATING IEADOUARTERS, University of Kansas Mcdical Center Louisiana State Department of Hospitals. Medical Care Development, Inc. Steering Committee of the Regional Medical Programs for Maryland. GRANTEES Same.5 Same.5 Same.§ The Johns Hopkins University EFFECTIVE STARTING July 1, 1966 January I, 1967 May 1, 1967 January 1, 1967 DATE, PROGRAM PERIOD 2 2 2 2 (VEARS). AWARD $197,945-—Ist $490,448—Ist $193,909-—Ist $518,443—Ist (AMOUNT AND YEAR). $293,080—-2nd RECOMMENDED FUTURE $514,251—2nd $204,709——2nd $431,821—2nd SUPPORT (AMOUNT * AND YEAR). 1 Preliminary regions for planning purposes as delineated in the original applications. State designations do not indicate they are coterminous with State lines. These preliminary regions may be modified on the basis of planning and experience. 2 Population estimates include overlap between regions. As preliminary regional boundaries are evaluated and clarified during the planning process, inappropriate overlap will be eliminated. 3 The Grantee differs from the Coordinating Headquarters when the Region requested this arran or the latter agency did not have the capability to assume formal fiscal responsibility. 4 Direct costs only. & Indicates the Grantee Agency and the Coordinating Headquarters are the same organizatio: 67 REGIONAL DESIGNATION MEMPHIS METROPOLITAN MICHIGAN MISSISSIPPI WASHINGTON, D.C. PRELIMINARY Western Tennessee, Northern District of Columbia and Michigan Mississippi PLANNING REGION.! Mississippi, and portions 2 contiguous counties in of Arkansas, Kentucky, Maryland, 2 in Virginia, and Missouri and 2 independent cities in Virginia. POPULATION ESTIMATE 2,400,000 2,050,000 8,220,000 2,320,000 1965.7 COORDINATING Mid-South Medical Council District of Columbia Michigan Association University of Mississippi NEADQUARTERS. for Comprehensive Medical Society for Regional Medical Medical Center Health Planning, Inc. Programs, Ine. GRANTEE.’ University of Tennessee Same.® Saine.} Same.* College of Medicine EFFECTIVE STARTING DATE. April 1, 1967 January 1, 1967 June 1, 1967 July 1, 1967 PROGRAM PERIOD M4 mM, 1 2 (YEARS). AWARD $173,119—Ist $203,790—Ist $1 ,294,449—Ist $322,845—Ist (AMOUNT AND YEAR). RECOMMENDED FUTURE $140,000—2nd $169,658—2nd $295,825—2nd SUPPORT $54,825—3rd $84,829—3rd (AMOUNT ! AND YEAR). ' Preliminary regions for planning purposes as delineated in the original applications. State designations do not indicate they are coterminous with State lines. These preliminary regions may be modified on the basis of planning and experience. 2 Population estimates include overlap between regions. As preliminary regional boundaries are evaluated 4 The Grantee differs from the Coordinating Headquarters when the Region requested this arrangement or the latter agency did not have the capability to assume formal fiscat responsibility. § Direct costs only, . 5 Indicates the Grantee Agency and the Coordinating Headquarters are the same organization. and clarified during the planning process, inappropriate overlap will be eliminated. 68 ne REGIONAL DESIGNATION MISSOURI MOUNTAIN STATES NEBRASKA- NEW MEXICO SOUTH DAKOTA PRELIMINARY Missouri Idaho, Montana, Nevada Nebraska and South Dakota New Mexico PLANNING REGION.' and Wyoming POPULATION ESTIMATE 4,500,000 2,200,000 2,200,000 1,000,000 1965." COORDINATING HIKADQUARTERS. “University of Missouri School of Medicine Western Interstate Commission for Higher Education Nebraska State Medical Association University of New Mexico School of Medicine GRAN TERS Same. BEFECTIVE STARTING DATE. July 1, 1966 Same} November 1, 1966 Same. January 1, 1967 University of New Mexico October 1, 1966 PROGRAM PERIOD 3 2. 2 2% (YEARS). AWARD $398,556—Ist $876,855—Ist $350,339—Ist $449,736—Ist (AMOUNT AND YEAR). $324,254—2nd RECOMMENDED FUTURE $368, 125—3rd $761,983—2nd $281 ,450—2nd $729,285—2nd SUPPORT (AMOUNT ? AND YEAR). ' Preliminary regions for planning purposes a do not indicate they are coterminous with State lines. the basis of planning and experience. 2 Population estimates include overlap between regions. As preliminary regional boundaries are evaluated and clarified during the planning process, s delineated in the original applications. State designations These preliminary regions may be modified on $545,491—3rd 4 The Grantee diffe or the latter agency did not ha 4 Direct costs only. inappropriate overlap will be eliminated. 5 Indicates the.Grantee Agency an d the Coordinating Headquarters are the same organt rs from the Coordinating Headquarters when the Region requested this arrang ve the capability to assume formal fiscal responsibility. zation. 69 REGIONAL DESIGNATION NEW YORK NORTH CAROLINA NORTHERN NEW ENGLAND NORTHLANDS METROPOLITAN AREA PRELIMINARY New York City, and Nassau, North Carolina Vermont and 3 counties in Minnesota PLANNING REGION.! Suffolk and Westchester Northeastern New York. Counties. POPULATION ESTIMATE 11,400,000 4,900,000 550,000 3,600,000 1965.3 COORDINATING Associated Medical Schools Association for the North Carolina | University of Vermont Minnesota State Medical HEADQUARTERS, of Greater New York. Regional Medical Program. College of Medicine. Association Foundation GRANTEYF.? Same.5 Duke University Same.’ Same.5 EFFECTIVE. STARTING DATE. June 1, 1967 July 1, 1966 July 1, 1966 January 1, 1967 PROGRAM PERIOD 2 2 (YEARS). AWARD $967,010—Ist $435,851—Ist (AMOUNT AND YEAR). $600,944—2nd RECOMMENDED FUTURE SUPPORT (AMOUNT + AND YEAR). ' Preliminary regions for planning purposes as delineated in the original applications. State designations do not inditate they are coterminous with State lines. These preliminary regions may he modified on the basis of planning and experience. ; 2 Population estimates include overlap between regions. As preliminary regional boundaries are evaluated $961,957—2nd and clarified during the planning process, inappropriate overlap will be eliminated. $316, 186-—Ist $377, 701--2ne $234, H72- 3rd $370,004-—Ist $469,080—2nd $234, 700—3rd 3 The Grantee differs from the Goordinating Headquarters when the Region requested this arrangement or the latter agency didnot have the capability to assume formal fiscal responsibility. { Direct costs only. 5 Indicates the Grantee Agency and the Coordinating Headquarters are the same organization. REGIONAL DESIGNATION OHIO STATE OO VALLEY OKLAHOMA OREGON PRELIMINARY Central and Southern 35 of Greater part of Kentucky and Oklahoma Oregon PLANNING REGTON.! Ohio (61 counties excluding contiguous parts of Ohio, Metropolitan Cincinnati Indiana, and West Virginia. area). POPULATION ESTIMATE 4,500,000 5,900,000 2,500,000 1,900,000 1965.7 COORDINATING Ohio State University Ohio Valley Regional University of Oklahoma University of Oregon TIUADQUARTERS. College of Medicine. Medical Program. Mcdical Center. Medical School. GRANTEES Same.* University of Kentucky Same.5 . Same.5 Research Foundation AFEECTIVE STARTING April 1, 1967 January 1, 1967 , September 1, 1966 April 1, 1967 DATE. PROGRAM PERIOD i 2° 2 2% (YEARS). AWARD $109,417—Ist $346,760—Ist $177,963—Ist $219,163—Ist (AMOUNT AND YEAR). RECOMMENDED FUTURE $232,397 1—2nd $136,16B—2nd $171,998—2nd SUPPORT $44,078—3rd (AMOUNT 4 AND YEAR). 1 Preliminary regions for planning purposes as delineated in the original applications. State designations 3 The Grantee differs from the Coordinating Headquarters when the Region requested this arrangi do not indicate they are coterminous with State lines. ‘These preliminary regions may be modified on or the latter agency did not have the capability to assume formal fiscal responsibility. the basis of planning and experience, 4 Direct costs only. 2 Population estimates include overlap betreeen regions, As preliminary regional boundaries are evaluated 8 Indicates the Grantee Agency and the Coordinating Headquarters are the same organization, and clarified during the planning process, inappropriate overlap will be eliminated. 71 REGIONAL NESIGNA TION ROCHESTER, NEW YORK SOUTH CAROLINA SUSQUEHANNA VALLEY, PENNSYLVANIA TENNESSEE MID-SOUTH PRELIMINARY PLANNING REGION,! - Rochester, N.Y., and 11 surrounding counties. South Carolina 24 counties centered around Uarrisburg and Hershey. Eastern and Central Tennessee and contiguous parts of Southern Kentucky and Northern Alabama. POPULATION ES'TIMA'TE 1965.? 1,200,000 2,500,000 2,100,000 2,600,000 COORDINATING HEADQUARTERS. University of Rochester School of Medicine and Dentistry. Medical College of South Carolina. Pennsylvania Medical Society. Vanderbilt University School of Medicine and Meharry College of Medicine. GRANTEES Samce.5 Same.® Same.5 Vanderbilt University. EFFECTIVE STARTING DATE. October J, 1966 January !, 1967 June 1, 1967 July 1, 1966 PROGRAM PERIOD 234 2 2 (YEARS). AWARD $306,985—Ist $65,906——Ist $263,530—Ist $265,941—Ist (AMOUNT AND YEAR). $393,458—2nd RECOMMENDED FUTURE $329,364—2nd $249,550—2nd SUPPORT $259,900—3rd (AMOUNT ! AND YEAR). ! Preliminary regions for planning purposes as delineated in the original applications. State designations do not indicate they are coterminous with State lines. These preliminary regions may be modified on the basis of planning and experience. , 2 Population estimates include overlap betneen regions. As preliminary regional boundaries are evaluated and clarified during the planning process, inappropriate overlap will be eliminated. 3 The Grantee differs from the Coordinating Headquarters when the Region requested this arrangement or the latter agency did not have the capability to assume formal fiscal responstbility. § Direct costs only, 8 Indicates the Grantee Agency and the Coordinating Headquarters are the same arganization. i RR I I A een REGIONAL DESIGNATION TEXAS VIRGINIA WASHINGTON-ALASKA WEST VIRGINIA PRELIMINARY Texas Virginia Alaska and Washington West Virginia PLANNING REGION.! POPULATION ESTIMATE 10,500,000 4,500,000 3,200,000 1,800,000 1965.7 COORDINATING University of ‘Texas Mcdical College of Virginia and University of Washington West Virginia University HEADQUARTERS. University of Virginia School School of Medicine. Medical Center. of Medicine. GRANTEE? Same.® University of Virginia School of Same. Same. Medicine. EFFECPrIVE STARTING July 1, 1966 January 1, 1967 September 1, 1966 January 1, 1967 DATE. PROGRAM PERIOD 3 2 256 25 (YEARS). AWARD $1,271,013—I1st $291 ,454—Ist $266,248—Ist $150,798—Ist (AMOUNT AND YEAR). - $1,260, 181—2nd . RECOMMENDED FUTURE $133,987—3rd $254,000-—2nd $230,934—2nd $175,250—2nd SUPPORT $241,795—3rd $91,250—3rd (AMOUNT ‘ AND YEAR). 1 Preliminary regions for planning purpos do not indicate they are coterminous with State lines. These preliminary 1: the basis of planning and experience. 2 Population estimates include overlap between reg’ +s as delineated in the original applications. State designations egions may be modified on ions. As preliminary regional boundaries are evaluated and clarified during the planning process, inappropriate overlap will be eliminated 3 The Grantee differs from the Coordinating Headquarters when the Region requested thts arrang. or the latter agency did not have the capability to assui 4 Direct costs only. 8 Indicates the Grantee Agency me formal fiscal responsibility. and the Coordinating Headquarters are the same organization. 73 REGIONAL DESIGNATION WESTERN NEW YORK WESTERN PENNSYLVANIA WISCONSIN PRELIMINARY Buffalo, N.Y., and 7 surrounding Pittsburgh, Pa., and 28 Wisconsin PLANNING REGION.! counties. surrounding counties. POPULATION ESTIMATE 1,900,000 4,200,000 4,100,000 1965.7 COORDINATING School of Medicine, State University !fealth Center Wisconsin Regional HEADQUARTERS. University of New York at of Pittsburgh. Medical Program, Inc. Buffalo in cooperation with the Health Organization of Western New York. GRANTEE. The Research Foundation of Same.! Same.§ State University of New York EFFECTIVE STARTING December 1, 1966 January 1, 1967 September 1, 1966 DATE, PROGRAM PERIOD 2 QV, 2 (YEARS). AWARD $149,241—Ist $340,556—Ist $344,418—Ist (AMOUNT AND YEAR). RECOMMENDED FUTURE SUPPORT (AMOUNT ! AND YEAR). $117,626—2nd ' Preliminary regions for planning frurposes as delineated in the original applications. State designations do not indicate they are coterminous with State lines. These preliminary regions may be modified on the basis of planning and experience. 2 Pesulation estimates include overlap between regions. As preliminary regional boundaries are evaluated and clarified during the planning process, inappropriate overlap will be eliminated. $260,484—2nd $127,618—3rd $341 ,000—2nd 1 The Grantee differs from the C Joordinatiny Headquarters when the Rewion requested this arrangement or the latter agency did not have the capability to assume formal fiscal responsibility. 4 Direct costs only. 5 Indicates the Grantee Agency and the Coordinating Headquarters are the same organization. EXTIUBET TV Operational Coants for Reesonal Medical Programs, fume 30, 1967 REGIONAL DESIGNATION ALBANY, NEW YORK INTERMOUNTAIN KANSAS MISSOURI REGION, Northeastern New York and Utah and portions of Colorado, © | Kansas Missouri, exclusive of portions of Southern Verniont Idaho, Montana, Nevada, Metropolitan St. Louis. and Western Massachusetts. and Wyoming. POPULATION ESTIMATE 1,900,000 2,200,000 2,200,000 2,400,000 196%, COORDINATING Albany Medical College of University of Utah School University of Kansas University of Missouri HEADOUARTERS, Union University, Albany of Medicine. Medical Center. School of Medicine. Medical Center. GRANTEE, Same.! Saine.! Same.! Same.! LEPECEIVE SPAR EING DATE, April t, 1967 April 1, 1967 June 1, 1967 April 1, 1967 PROGRAM PERIOD IVEARS), JS SN FIRST-YEAR AWARD. $914,627—Ist $1,790,603—1] st $1,076,600—Ist $2,887,903—Ist RECOMMENDED FUTURE SUPPORT CAMOUNTE " ANTY YEARL ' Indicates that the Grantee Agency and the Coordinating Headquarters are the same organtzation. $750,000—2nd $1,162,049—2nd $1,036,378—3rd $1,000,000—2nd $2,625,00U—2nd 2 Direct costs only, EXHIBIT V National Advisory Council on Regional Medical Programs Leonidas IH. Berry, M.D. Professor Cook County Graduate School of Medi- cine Senior Attending Physician Michael Reese Hospital Chicago, Illinots Mary I. Bunting, Ph. D.* President Radcliffe College Cambridge, Massachusetts Gordon R. Cumming? Administrator Sacramento County Hospital Sacramento, California Michael E. DeBakey, M.D. Professor and Chairman Department of Surgery School of Medicine Baylor University Houston, Texas Bruce W. Everist, Jr., M.D. Chief of Pediatrics Green Clinic Ruston, Louisiana Charles J. Hitch Vice President for Administration University of California Berkeley, California John R. Hogness, M.D. Dean School of Medicine University of Washington Seattle, Washington James T. Howell, M.D. Executive Director Henry Ford Hospital Detroit, Michigan J. Willis Hurst, M.D.” Professor and Chairman Department of Medicine School of Medicine Emory University Atlanta, Georgia Clark H. Millikan, M.D. Consultant in Neurology Mayo Clinic Rochester, Minnesota George FE. Moore, M.D. Director Roswell Park Memorial Institute Buffalo, New York William J. Peeples, M.D.* Commissioner Maryland State Department of Health Baltimore, Maryland Edmund D. Pellegrino, M.D. Director Medical Center State University of New York Stony Brook, New York Alfred M. Popma, M.D. Regional Director Mountain States Regional Medical Program Boise, Idaho Mack J. Shanholtz, M.D. State Health Commissioner State Department of, Health Richmond, Virginia Robert J. Slater, M.D.” Dean College of Medicine University of Vermont Burlington, Vermont Cornelius Hf. Traeger, M.D. New York, New York en officta William Hf. Stewart, M.D. (Chairman) Surgeon General Public Health Service Bethesda, Maryland Liaison Members to the National Advisory Comune on Reoional Medica! Prorranns Liaivon ALomber for National Adoisory Cancer Cannell Sidney Farber, M.D. Director of Research Children’s Cancer Research Foundation Boston, Massachusetts Murray M. Copeland, M.D. Associate Director M.D, Anderson Medical Hospital and Tumor Institute Texas Medical Center Houston, Texas Tiaison Member for National Adaisory General Medical Sciences Council Edward W. Dempsey, Ph. D. Chairman Department of Anatomy Colleve of Physictans and Surgeons Columbia University New York, New York 75 Liaison Alember far Nattonal cldetvory Neurological Discases dnd Blindness Council A. B. Baker, M.D. Professor and Director Division of Neurology University of Minnesota Minneapolis, Minnesota A, Earl Walker, M.D. Professor of Neurological Surgery Johns Hopkins University Baltimore, Maryland Liaison Member for National Adetvaory Heart Council John B. Hickam, M.D. Professor and Chairman Department of Medicine Indiana University Medical Center Indianapolis, Indiana Liaison Member for the Veterans sldininistration Benjamin B, Wells, M.D. Assistant Chief Medical Director for Research and Education in Medicine Department of Medicine and Surgery Veterans Administration Washington, D.C. ' Resigned January 1967. * Membership terminated November 1966. 4 Appointment expired September 1966. 70 EXTER VI Reeional Medical Program Review Committee Mark Berke Director Mount Zion Hospital and Medical Center San Francisco, California Kevin P, Bunnell, Ph. D. Associate Director Western Interstate Commission for Higher Education Boulder, Colorado Sidney B. Cohen? Management Consultant Silver Spring, Maryland Edwin L. Crosby, M.D. Director American Hospital Association Chicago, Illinois George James, M.D. (Chairman) Dean Mount Sinat School of Medicine New York, New York toward W. Kenncy, M.D. Medical Director John A, Andrew Memorial Hospital Tuskegee Institute Tuskegee, Alabama Edward J. Kowalewski, M.D. Chairman Committee of Environmental Medicine Academy of General Practice Akron, Pennsylvania ' Deceased, April 1967. George E. Miller, M.D. Director Center for Medical Education College of Medicine University of Illinois Chicago, Illinois Anne Pascasio, Ph. D. Associate Research Professor Nursing School University of Piltsburgh Pittsburgh, Pennsylvania Samuel If. Proger, M.D. Professor and Chairman Department of Medicine Tufts University School of Medicine President Bingham Assoctates fund Boston, Massachusetts David KE. Rogers, M.D. Professor and Chairman Department of Medicine School of Medicine Vanderbilt Untuersity Nashville, Tennessee Carl Henry William Ruhe, M.D. Assistant Secretary - Council on Medical Education American Medical Association Chicago, Illinois Robert J. Slater, M.D. Executive Director The Association for the Aid of Crippled Children New York, New York John D. Thompson Director, Program in Hospital Administration Professor of Public Health School of Public Health Yale University New Haven, Connecticut Kerr L. White, M.D. Director Division of Medical Care and Hospitals School of Hygiene and Public Health Johns Hopkins University Baltimore, Maryland EXHIBIT VII Consultants to the Division of Regional Medical Programs Stephen Abrahamson, M.D. Director Office of Research in Medical Education University of Southern California Los Angeles, California Roy Acheson, M.D. Epidemiologist School of Medicine Yale University New Ifaven, Connecticut Alexander Anderson, M.D. Director Training Programs for Center of Medical Education College of Medicine University of Tlinois Chicago, Illinois William Anlyan, M.D. Dean Medical Center Duke University Durham, North Carolina Norman T, J. Bailey, Ph. D. Professor’ : Biomathematics Department Cornell: University Medical School and Sloan-Kettering Institute for Cancer Research New York, New York A.B. Baker, M.D. Professor and Director Division of Neurology University of Minnesota Minneapolis, Minnesota 268-4 O—67-——ti Norman Beckman, Ph. D. Director Office of Intergovernmental Relattons and Urban Program Coardination Department of Housing and Urban De- velopment Washington, D.C. A. E. Bennett, M.D. Department of Clinical Epidemiology and Social Medicine St. Thomas’ Hospital Medical School London, S.E. 1, England Robert Berg, M.D. Professor and Chairman Department of Preventive Medicine and Community Health University of Rochester Rochester, New York Donald Bergstrom Assistant to State Health Gomuntissioner Vermont Department of ITealth Burlington, Vermont Mark Berke Director Mount Zion Hospital and Medical Center San Francisco, California Leonidas HH. Berry, M.D. Professor . Cook County Graduate School of Medi- cine Senior Attending Physician Michael Reese Hospital Chicago, Hlinois Mark S. Blumberg, Ph. D. Special Assistant to the Vice President for Business and Finance University of California Berkeley, California Nemat ©. Borhani, M.D. Head, Heart Disease Control Program Bureau of Chronic Diseases California Department of Public Health Berkeley, Galifornta Paul Brading Director of Research in Medical Education Albany Medical Colleve Albany, New York Kevin P, Bunnell, Ph. D. Associate Director Western Interstate Commission for Higher Education Boulder, Colorado Mary J. Bunting, Ph.D. President Radcliffe College Cambridue, Massachusetts Ray E. Brown, 08 2. Director Graduate Program in Hespital Administration Duke University Medical Center Durham, North Carolina ITugh Butt, M.D. Professor of Medicine Mayo Glinte Rochester, Minnesota Donald J. Gaseley, MLD. Associate Dean and Medical Director Colleve of Medicine Universities of Hlinois Chicauo, Mlinois Ililmon Castle, M.D. Associate Dean College of Medicine Untversity of Utah Salt Lake City, Utah a7 Leonard Chiazze, Jr. MLD. “Assistant Professor of Community and International Medicine Georgetown University Washington, D.C. Sidney B. Cohen Management Consultant Silver Spring, Maryland . John D, Colby Chief Research Training Branch Division of Research and Training Dissemination Office of Education Washington, D.C, Warren Ff. Cole, M.D. imeritus Professor and Head Department of Surzery University of Chicazo Chicago, Illinois Murray M. Gopeland, M.D. Associate Director Af, D. Anderson Medical Hospital and Tumor lustitute Texas Medical Genter Houston, Texas Edwin L. Crosby, M.D. Director American Hospital Association Chicavo, MMlinois Gordon R. Gunning sldministrator Sacramento Gounty Hospital Sacramento, California Anthony Curreri, M.D. Professor of Surgery Director Division of Clinical Oncology Cancer Research Ios pital CUniversity of Wisconsin Madison, Wisconsin Frederick Cyphert, Ph. D. Assistant Dean School of Education Ohio State University Columbus, Ohio Michael &. Deldakey, M.D. Professor and Chairman Departsnent of Surgery Baylor University Houston, Texas Fdward W. Dempscy, Ph. Dd. Chairman Department of Anatomy College of Physicians and Surgeons Columbia University New York, New York McCormack Detmer Assistant Director Division of Longterm Care American Hospital Association Chicago, Illinois f¥. Grey Dimond, M.D. Director Scripps Clinie and Research Foundation La Jolla, California Robert Dyar, M.D. Chief of Research California Department of Public Health Berkeley, California Paul M. Ellwood, Jr., M.D. Executive Director American Rehabilitation Foundation Minneapolis, Minnesota Bruce W. Everist, Jr., M.D. Chief of Pediatrics Green Clinic Ruston, Louisiana Sidney Farber, M.D. Director of Research Children's Cancer Research Center Boston, Massachusetts Charles D. Flagle, M.D. Professor "ublic Health Administration School of Hygiene and Public Health Johns Hopkins University Baltimore, Maryland John G. Freymann, M.D. Medical Director Boston Lying-in Hospital Boston, Massachusetts Herbert P. Galliher, Jr., Ph. D. Professor Department of Industrial Engineering University of Michigan Ann Arbor, Michigan Kermit Gordon Vice President The Brookings Institution Washington, D.C. Jack Haldeman, M.D. Executive Director Hospital Planning and Review Council for Southern New York New York, New York John Hammock, Ph. D. Professor Department of Educational Psychology University of Georgia Athens, Georgia A. McGehee Harvey, M.D. Chairman Department of Medicine School of Medicine Johns Hopkins University _ Baltimore, Maryland James 5. Heald, Ph. D. Director School for Aduanced Studies in Educa- tion Michigan State University East Lansing, Michigan John 3. Hickam, M.D. Professor and Chairman Department of Medicine Indiana Uniuersity Medical Center Indianapolis, Indiana Chartes J. Hitch, Ph.D. Vice President for Administration University of California Berkeley, California Howard F. Hjelm Acting Director Flementary and Secondary Research Bureau of Research Office of Education Washington, D.C. John R. Hogness, M.D. Dean School of Medicine University of Washington Seattle, Washington James T. Howell, M.D. Executive Director Henry Ford Hospital Detroit, Michigan J. Willis Hurst, M.D. Professor and Chairman Department of Medicine School of Medicine Emory University Atlanta, Georgia Ralph Ingersoll, M.D. Director of Research in Medical Educa- tion School of Medicine Ohio State University Columbus, Ohio George James, M.D. Dean Mount Sinai School of Medicine New York, New York Hilliard Jason, M.D. Chairman Department of Medical Education, Research, and Development College of Human Medicine Michigan State University East Lansing, Michigan Boisfeuillet Jones Director Emily and Ernest Woodruff Foundatior Atlante, Georgia Richard D. Judge, M.D. Assistant Professor- Department of Internal Medicine University of Michigan Ann Arbor, Michigan Howard W. Kenney, M.D. Medical Director John A. Andrew Memorial Hospital Tuskegee Institute Tuskegee, Alabama Charles V. Kidd, Ph. D. Executive Secretary Federal Council for Science and Technology Office of Science and Technology Washington, D.C. Charles E. Kossman, M.D. Professor Department of Medicine New York University Medical Center New York, New York Edward J. Kowalewski, M.D. Chairman Board of Directors Academy of General Practice Akron, Pennsylvania Peter Lee, M.D. Assistant Professor Department of Pharmacology School of Medicine University of Southern California Los Angeles, California Jack Lein, M.D. Assistant Dean and Director for Continuing Education School of Medicine University of Washington Seattle, Washington £. James Lieberman, M.D. Director Audiovisual Facility Communicable Disease Center Public Health Service Atlanta, Georgia Abraham Lilienfeld, M.D. Professor and Chairman Department of Chronic Diseases School of Hygiene and Public Health Johns Hopkins University Baltimore, Maryland Robert Lindee Assistant Dean for- Administration Medical School Stanford University | Palo Alto, California Samuel Martin, M.D. Provost College of Medicine University of Florida Ganesville, Florida Manson Meads, M.D. Dean Bowman Gray School of Medicine Wake Forest College Winston Salem, North Carolina Richard L. Meiling, M.D. Dean College of Medicine Ohio State University Columbus, Ohio C. Arden Miller, M.D. Vice Chancellor for Health Sciences University of North Carolina Chapel Hill, North Carolina George E. Miller, M.D. Director Center for Medical Education College of Medicine University of Illinois Chicago, Illinois Clark H. Millikan, M.D. Consultant in Neurology Mayo Clinic Rochester, Minnesota George E. Moore, M.D. Director Roswell Park Memorial Institute Buffalo, New York William D. Nelligan Executive Director American Institute of Cardiology - Bethesda, Maryland Charles E. Odegaard, Ph. D. President University of Washington Seattle, Washington Stanley W. Olson, M.D. Program Coordinator Tennessee Mid-South Regional Medical Program Nashuille, Tennessee John Parks, M.D. Dean School of Medicine George Washington University Washington, D.C. Anne Pascasio, Ph. D. Associate Research Professor Nursing School University of Pittsburgh Pittsburgh, Pennsylvania Joye Patterson, Ph. D, Publications Director Medical Center University of Missourt Columbia, Missourt William J. Peeples, M.D. Commissioner State Department of Health Baltimore, Maryland Edmund J). Pellegrino, M.D. Director Medical Center State University of New York Stony Brook, New York Alfred M. Popma, M.D. Chief of Radiology St. Luke’s Hospital and School of Nursing Botse, Idaho Samuel Proger, M.D. President Bingham Associates Fund Boston, Massachusetts Fred M. Remley Chief Engineer Television Center University of Michigan Ann Arbor, Michigan David LE. Rogers, M.D. Professor and Chairman Department of Medicine School of Medicine Vanderbilt University Nashville, Tennessee 79 John Rosenbach, Ph. D. Director State University of New York at Albany Albany, New York Carl Henry William Ruhe, M.D. Assistant Secretary Council on Medical Education American Medical Association Chicago, Illinois Paul Sanazaro, M.D. Director Division of Education Association of American Medical Colleges Evanston, Hlinots. Raymond Seltser, M.D. Professor of Medicine School of Hygiene and Public Health Johns Hopkins University Baltimore, Maryland Mack I. Shanholtz, M.D. State Health Commissioner State Department of Health Richmond, Virginia Cecil G. Sheps, M.D. General Director Beth Israel Medical Center New York, New York Arthur A, Siebens, M.D. Director Rehabilitation Center University of Wisconsin Hospital Madison, Wisconsin Robert W. Sigmond Executive Director Hospital Planning Council of Allegheny County Pittsburgh, Pennsylvania Robert J. Slater, M.D. Executive Director The Association for the Aid of Crippled Children New York, New York Vergil N. Slee, M.D. Director Committee on Professional Hospital Ac- tivities First National Building Ann Arbor, Michigan Clark 1D. Steeth, M.D. Dean School of Medicine West Virginia University Morgantown, West Virginia John M. Stacy Director Medical Center University of Virginia Charlotisnille, Virginia Robert E. Stake, Ph. D. Assistant Director Center for Instruction, Research, and Carriculum Evaluation College of Education University of Illinois Urbana, Illinois Jacinto Steinhardt, Ph. D. Scientific Advisory to the President and Professor af Chemistry Georgetown University Washington, D.C. Patrick B. Storey, M.D. Professor of Community Medicine Hahnemann Medical College Philadelphia, Pennsylvania Emmanuel Suter, M.D. Dean College of Medicine University of Florida Gainesville, Florida Adrian ‘Terlouw Educational Consultant Sales Service Division Eastman Kodak Company Rochester, New York John D. Thompson Professor of Public Health Director Program in Hospital Administration School of Public Health Yale University New Haven, Connecticut Cornelius (L. Tracger, MoD. New York, New York Ray FE. Frussell, M.D. Director School of Publte Health and Administra- tive Medicine Columbia University New York, New York A, Earl Walker, M.D. Professor of Neurological Surgery Johns Hopkins University Baltimore, Maryland James V. Warren, M.D. Chairman Department of Medicine College of Medicine Ohio State University Columbus, Ohio Max IL. Weil, M.D. Associate Professor of Medicine School of Medicine University of Southern California Los Angeles, California Burton Weisbrod, Ph. D. Associate Professor Department of Economics University of Wisconsin Madison, Wisconsin Benjamin B. Wells, M.D. Assistant Chief Medical Director for Re- search and Education in Medicine Department of Medicine and Surgery Veterans Administration Washington, D.C. Kelly West, M.D. Chairman Department of Continuing Education University of Oklahoma Medical Center Oklahoma City, Oklahoma Robert i. Westlake, M.D. Syracuse, New York Storm Whaley Vice President Health Sciences University of Arkansas Medical Center Little Rock, Arkansas Kerr L. White, M.D. Director Division of Medical Care and Hospitals School of Hygiene and Public Health Johns Hopkins Untuersity Baltimore, Maryland Kimball Wiles, Ph. D. Dean School of Education University of Florida Gainesville, Florida Loren Williams, M.D. Director Research in Medical Education Medical College of Georgia Augusta, Georgia George A. Wolf, M.D. Provost and Dean School of Medicine University of Kansas Kansas City, Kansas Richard M. Wolf, Ph. D. Assistant Professor of Education School of Education University of Southern California Los Angeles, California Alonzo S. Yerby, M.D. Head Department of Health Services Administration School of Public Health Harvard University Cambridge, Massachusetts Paul N. Yivisaker, Ph. D. Director Public Affairs Program Ford Foundation New York, New York Lawrence E. Young, M.D. Chairman Department of Medicine School of Medicine University of Rochester Rochester, New York 81 EXHIBIT VIII Program Coordinators for Regional Medical Programs, June 30, 1967 Regional Designation Preliminary Planning Program Coordinator Regional Designation Preliminary Planning Progrant Coordinator Region Region ALABAMA. Alabama. Benjamin B. Wells, M.D. CALIFORNIA, California. Paul D. Ward University of Alabama Medical Executive Director Center California Committee on Re- 1919 Seventh Avenuc, South gional Medical Programs Birmingham, Alabama 32533 Room 302 _ 655 Sutter Street San Francisco, California 94102 ALBANY, N.Y. Northeastern New York, | Frank M. Woolsey, Jr., M.D. Morn and portions of Associate Dean cece ete ue wnns wentventens | ee sau ceiee nec ia coeneenen stn ene Southern Vermont Albany Medical College of . . . and Western Union University CENTRAL NEW Syracuse, New York, pichard If. Lyons, M.D. Massachusetts. 47 New Scotland Avenuc YORK. and 15 surrounding Professor and Chairman Albany, New York 12208 countics. Department of Medicine State University of New York anne Upstate Medical Center ARIZONA. Arizona. Merlin K. DuVal, M.D. 766 Irving Avenuc Acting Dean Syracuse, New York 13210 University of Arizona College of Medicine . Tucson, Arizona 85721 COLOR ADO- Colorado and Wyoming, | C. Wesley Eisele, M.D, cee WYOMING. Associate Dean for Postgraduate . K. Sh Medical Education ARKANSAS. Arkansas. Winston <. Shorey, M.D. University of Colorado Dean, University of Arkansas . | of Medici Medical Center Sot “ reine 4200 East Ninth Avenue 30 est Markham Strect Denver, Colorado 80220 Little Rock, Arkansas 72201 BI-STATE. Fastern Missouri William IY. Danforth, M.D. CONNECTICUT. Connecticut, Henry ‘P. Clark, fr.. M.D. and Southern Tllinois centered around St. Louis. Vice Chanccllor for Medical Affairs Washington University 660 South Fuclid Avenue St. Louis, Missouri 63110 Program Coordinator Connecticut Regional Medical Program 272 George Strect New Haven Connecticut 06510 Kepional Designation Preliminary Phooanine Pewton Proprag Coordinator Regional Designation Preliminary Planning Region Program Coordinator FLORIDA. GEORGIA. Florida. Georgia. GREATER DELAWARE VALLEY. Eastern Pennsylvania and portions of Delaware and New Jerscy, HAWAILE,. Hawaii. ILLINOIS, Tilinois, Samucl P, Martin, M.D. Provost J. Hillis Miller Medical Center University of Florida Gainesville, Florida 32601 J. W. Chambers, M.D. Medical Association of Georgia 938 Peachtree Strect N.E. Atlanta, Georgia 30309 William C, Spring, Jr., M.D. Greater Delaware Vallcy Regional Medical Program 301 City Line Avenue Kala-Cynwyd, Pennsylvania 19004 Windsor C. Cutting, M.D. School of Medicine University of Hawaii 2538 The Mall Honolulu, [Tawaii 96822 Leon O. Jacobson, M.D. Dean, University of Chicago School of Medicine Chairman, Coordinating Com- mittee of Mcdical Schools and Teaching Hospitals of Ilinois 950 East 59th Street Chicago, Hlinois 60637 INDIANA, Indiana. George T. Lukemeyer, M.D. Associate Dean Indiana University School of Medicine Indiana University Medical Center 1100 West Michigan Street Indianapolis, Indiana 46207 INTERMOUNTAIN. Utah and portions of Colorado, Idaho, Montana, Nevada, and Wyoming, C. Hilmon Castle, M.D. Associate Dean and Chairman Department of Postgraduate Education University of Utah Salt Lake City, Utah 84112 IOWA. Towa, Willard Krehl, M.D., Ph. D. Director, Clinical Research Center Department of Internal Medicine University Hospital University of Iowa Iowa City, Iowa 52240 KANSAS. Kansas, Charles E. Lewis, M.D. Chairman, Department of Preventive Medicine University of Kansas Medical Center Kansas City, Kansas 66103 83 Regional Designation Preliminary Planning Program Coordinator Regional Designation Preliminary Planing Program Coordinator Region Rerion LOUISIANA. Louisiana. Joseph A. Sabatier, M.D. MICHIGAN. Michigan. 1). Eugene Sibery Louisiana Regional Medical Executive Director Program Greater Detroit Area Hospital Clairborne Towers Roof Council 119 South Clairborne Avenue 966 Penobscot Building New Orleans, Louisiana 70112 Netroit, Michigan 48226 MAINE. Maine. Manu Chatterjee, M.D. MISSISSIPPI, Mississippi. Guy D. Gampbell, M.D. Merrymeeting Medical Group University of Mississippi Medical Brunswick, Maine Center . 2500 North State Street Jackson, Mississippi 39216 MARYLAND. Maryland. Thomas B. Turner, M.D. Dean, The John Hopkins " ~ ~ Tee ~ University MISSOURI. Missouri. Vernon E. Wilson, M.D. School of Medicine Dean, School of Medicine 725 Wolfe Street University of Missouri Baltimore, Maryland 21205 Columbia, Missouri 65201 MEMPHIS. Western Tennessec, James W. Culbertson, M.D. MOUNTAIN STATES, | Idaho, Montana, Nevada, | Kevin P. Bunnell, Fd. D. Northern Mississippi, Professor and Cardiologist and Wyoming. Associate Director and portions of Department of Internal Medicine Western Interstate Commission Arkansas, Kentucky, University of Tennessec for Higher Education and Missouri. College of Medicine University East Campus Memphis, Tennessee 38103 30th Street Boulder, Colorado 80302 METROPOLITAN District of Columbia and | Thomas W. Mattingly, M.D. ~~ ie ~~ WASHINGTON, D.C. 2 contiguous counties in Maryland, 2 in Virginia and 2 independent cities in Virginia. Program Coordinator District of Columbia Medical Society 2007 Eye Strect N.W. Washington, D.C. 20006 ’ NEBRASKA-SOUTII DAKOTA. Nebraska and South Dakota. Harold Morgan, M.D. Nebraska State Medical Associa- tion 1408 Sharp Building Lincoln, Nebraska 68508 Regional Designation PeelHiminary Ulanoing Repion Progrant Coordinator Regional Designation Preliminary Planning Region Program Coordinator NEW JERSEY. New Jerscy. NEW MEXICO. New Mexico. NEW YORK METRO- POLITAN AREA. NORTH CAROLINA. New York City, and Nassau, Suffolk, and Westchester Counties. North Carolina. NORTH DAKOTA. North Dakota. Alvin A. Florin, M.D., M.P.FL. New Jerscy State Department of Health Health-Agriculture Building P.O. Box 1540, John-Fitch Plaza Trenton, New Jerscy 08625 Reginald I]. Fitz, M.D. Dean, University of New Mexico School of Medicine Albuquerque, New Mexico 87506 Vincent de Paul Larkin, M.D. New York Academy of Medicine 2 East 103d Strect | New York, New York 10029 Marc J. Musser, M.D. Executive Director North Carolina Regional Mcdi- cal Program ‘Teer House 4019 North Roxboro Road Durham, North Carolina 27704 ‘Iheodore I. Harwood, M.D. Dean, School of Medicine University of North Dakota Grand Forks, North Dakota 58202 - NORTHERN NEW ENGLAND. Vermont and three countics in John E. Wennberg, M.D. University of Vermont Northeastern College of Medicine New York. Burlington, Vermont 05401 NORTHLANDS. Minnesota. J. Minott Stickney, M.D. Minnesota State Medical As: ation 200 First Street, Southwest Rochester, Minnesota 55901 OHIO STATE. Central and Southern two-thirds of Ohio (61 counties, excluding Metropolitan Cincin- nati area). Richard L. Meiling, M.D. Dean, Ohio State University College of Medicine 410 West 10th Avenue Columbus, Ohio 43210 OHIO VALLEY. Greater part of Kentucky and contiguous parts of Ohio, Indiana, and West Virginia. William H. McBeath, M.D. Director, Ohio Valley Regional Medical Program 1718 Alexandria Drive Lexington, Kentucky 40504 OKLAHOMA. Oklahoma. “Kelly M. West, M.D. University of Oklahoma Mcdical Center 800 N.E. 13th Street Oklahoma City, Oklahoma 73104 85 Regional Designation Preliminary Planning Program Coordinator Revional Desinnition Preliminary Plinntur Propram Coordinator Region Repion SUSQUEHANNA Block of 24 counties Richard B. McKenzic OREGON, Oregon. me Rober's Grover, ey \ VALLEY. centered around Harris- | Executive Assistant irector, ontinuing, Medea burg and Hershey. Council on Scientific Advance- Education ment Croll Median Pennsylvania Medical Society bipihecelbeiateibahuiaainiahd ‘Taylor Bypass and Erford Road 3181 S.W. Sam Jackson Park Lemoyne, Pennsylvania 17043 Road : | EE ee Portland, Oregon 97201 aes TENNESSEE MID- Eastern and Central Stanley W. Olson, M.D. - - motes SOUTII. ‘Fennessee and contigu- | Professor of Medicine . ous parts of Southern Vanderbilt University ROCHESTER, NEW Rochester, New York and | Ralph C. Parker, Jr., M.D. Kentucky and North- Baker Building YORK. 11 surrounding Clinical Associate Professor of ern Alabama. 110 2Ist Avenue, South counties. Medicine Nashville, Tennessee 37203 University of Rochester School ete nieeeeneee dee eueetecetien ee me es cane ones ane oe TEXAS. ‘Texas. Charles A. LeMaistre, M.D. ochester, New ¥or Vice-Chancellor for Health Affairs University of ‘Texas SOUTH CAROLINA. | SouthCarolina. Charles P. Summerall, III, M.D. Main Building Associate in Medicine (Cardiol- Austin, ‘Texas 78712 ogy) cece ieee ee ee eee eae vee ee ee Department of Medicine TRI-STATE. Massachusetts, New Norman Stearns, M.D. Medical College Hospital 55 Doughty Strect Charleston, South Carolina 29403 Hampshire and Rhode Island. Medical Care and Educational Foundation 22 The Fenway Boston, Massachusetts 02115 Repional Desipnation TEOMA, Primary Phiunning Revion “Virponle Prormran Coordinator Voundeh Lieb, MAb Doran, Medical College of Virginia 200 East Broad Strect Richmond, Virginia 23219 WASHINGTON. ALASKA. WEST VIRGINIA, Alaska and Washington. West Virginia. Donal R. Sparkman, M.D. Associate Professor of Medicine University of Washington School of Medicine Seattle, Washington 98105 Regional Desienation Primary Planning Rerion Program Coordinator WITS NEY YORK. | Buffala, New York and 7 hurrounding Counties, Douglas M. Surgenor, M.D. Diean, School of Medicine State University of New York : Buffalo 101 Capen Hall Buffalo, New York 14214 WESTERN PENNSYL- VANIA. Pittsburgh, Pennsylvania and 28 surrounding Francis S. Cheever, M.D. Dean, School of Medicine Charles L. Wilbar, M.D. West Virginia University Medical Center Morgantown, West Virginia 26506 counties. University of Pittsburgh Flannery Building 3530 Forbers Avenue Pittsburgh, Pennsylvania 15213 WISCONSIN. Wisconsin. John S. Hirschboeck, M.D. Wisconsin Regional Medical Program, Inc. Room 1103 110 East Wisconsin Avenue Milwaukee, Wisconsin 53202 EXHIBIT TX Review and Approval of Operational Grants This exhibit outlines review and ap- proval procedures for use in review- ing grants for the establishment and operation of Regional Medical Pro- grams authorized by Section 904(a) of Title IX of the Public Health Service Act. Background These. procedures were developed after extensive consideration of: (1) the philosophy and purposes of Title IX; (2) the initial experience in re- viewing the planning grant applica- tions awarded under Scction 903; (3) consideration of the first opera- tional grant proposals, including site visits to the regions involving mem- bers of the National Advisory Council on Regional Medical Programs and the Regional Medical Programs Re- view Committee; (4) preliminary discussion of the issues involved in the review of operational applica- tions by the National Advisory Coun- cil on Regional Medical Programs at its November 1966 meeting; and (5) extensive discussion with hoth the Review Committee and the National Advisory Council concerning the cf- fectiveness of these procedures dur- ing the actual review of the first op- erational applications. As a result of these considerations, the resulting re- view and approval process is to the greatest possible extent keyed to the anticipated nature of operational grant requests and to the policy issues inherent in the Regional Medical Programs concept. Characteristics of Operational Grants In designing this review process, at- tention has been given to the follow- ing characteristics of applications for Regional Medical Program grants: (1) complexity of the proposals with many discrete but interrelated activi- tics involving diferent medical fields; (2) the diversity of grant proposals resulting from encouragement of initiative and determination at the regional level within the broad parameters ‘provided in the Law, Regulations, and Guidelines: (3) the many different attributes of the over- all operational proposals which need to be evaluated during the review process, including not only the merit of highly technical medical activities in the fields of heart,disease, cancer, stroke, and related diseases but also the effect of the proposal on improved organization and delivery of health services and the degree of effective cooperation and commitment of the major meclical resources: (4) the re- lationships of the proposals to the responsibilities of many other com- ponents of the Public Health Service and other Federal programs; (5) the characteristics of these initial pro- posals as the first steps in the more complete development of the Re- cional Medical Program, guided by a continuing planning process. Objectives of Review Process The objectives sought in the develop- ment of this review process are based on a careful assessment of the goals of the Regional Medical Programs and how the achievement of those goals can be most effectively furthered by the process used in making deci- sions on the award of grant funds. tonsideration of these basic policy issues led to delineation of the follow- ing objectives of the review process: {J The operational grant applica- tion must be viewed as a_ totality rather than as a collection of discrete and separate projects, [-]} The decision-making process for the review and approval of opera- tional grants must be developed. in a way that stimulates and preserves the essential goal setting, priority 87 determination, decision making and evaluation at the regional level. (] During the review process the stall of the Division of Regional Medical Programs and the review groups must be concerned with the probability of effective implementa- tion of the proposed atcivities in ad- dition to the inherent technical merit of the specific proposals. (J The review process must provide the opportunity for the reviewers to assure a basie level of quality and feasibility of the individual activities that will make an investment of grant funds worthwhile. [-] The review process must have sufficient Mexibility to cope with the variety of operational proposals sub- mitted, allowing for the tailoring of the review to the needs of the par- ticular proposal. [7] ‘The review process should en- able the staff and reviewers to view a Regional Medical Program as a con- tinuing activity, rather than a dis- crete project with time limits. There- fore, the review process should have continuity during the grant activity and should provide the opportunity to judge the development of Regional Medical Programs on the basis of rests and evaluation of progress, in addition to the evaluation of the prob- able effectiveness of initial proposals. Criteria The basic criteria for the review of Revional Medical Program graat re- quests are set forth in the Regulations as follows: “Upon recommendation of the Na- tional Advisory Council on Regional Medical Programs, and within the limits of available funds, the Surgeon General shall award a prant to those applicants whose approved programs will in his judginent best promote the purposes of “Vide EX. Tn awarding grants, the Surgeon General shall take into consideration, among other re- levant factors the following: “(a) Generally, the extent to which the proposed program will carry out, through regional cooperation, the purposes of “Tithe EX, within a geo- graphic area, “(b) ‘Phe capacity of the institutions or agencies within the program, in- dividually and collectively, for re- search, training, and demonstration activities with respect to Title UX. “Ce) The extent to which the appli- cant or the participants in the pro- gram plan to coordinate or have co- ordinated the Regional Medical Pro- gram with other activities supported pursuant to the authority contained in the Public lealth Service Act and other Acts of Congress including those relating to planning aud use of facilites, personnel, equipment, and training of manpower. “(d) ‘The population to be served by the Regional Medical Program and relationships lo adjacent or other Re- sional Medical Programs. “(e) Phe extent to which all the health resources of the region have heen taken into consideration in. the planing and/or establishment of the Program, “(f) ‘The extent to which the par- I licipating institutions will wulize existing: resources and will continue to seek additional nonfederal re- sources for carrying out the objectives of the Regional Medical Program, “(ry ‘The geoeraphic distibution of grants throughout the Nation.” In utilizing these criteria in’ the review process, iL was determined that the sequence of consideration of the various attributes of the proposal would be importint if the objectives of the review process: listed above were to be achieved. The review proc- ess, therefore, must focus on three general characteristics of the total proposal which separately and yet collectively determine its nature as a comprehensive and potentially cf- fective Regional Medical Program: (J The first focus must be on those elements of the proposal which iden- tify it as truly representing the con- cept of a regional medical program. The review groups have determined thatit is not fruitful to consider spe- cific aspects of the proposal unless this first essential determination con- cerning the core of the program is positive. In making this determina- tion, considerations include such questions as: “Ts there a unifying con- ceptual strategy which will be the hasis for initial priorities of action, evaluation, and future decision mak- ing?” “Is there an administrative and coordinating mechanisin involv- ing the health resources of the regions which can make effective decisions, relate those decisions to regional needs, and stimulate the essential co- operative effort among the major health interests?” “Will the key lead- ership of the overall Regional Medi- cal Program provide the necessary guidance and coordination for the de- velopment of the program?” “What is the relationship of the planning al- ready undertaken and the ongoing planning process to the initial opera- tional proposal!” (J After having made a positive de- termination about this core activity, the next step widens the focus to in- clude both the nature and the el fectiveness of the proposed cooper« tive arrangements. In evaluating th effectiveness of these arrangement attention is given to the degree of ir volvement and commitment of th major health resources, the role « the Regional Advisory Group, an the effectiveness of the proposed ai tivitics in strengthening cooperatio: Only after the determination hz been madc that the proposal reflec a regional medical program conce] and that it will stimulate an strengthen cooperative efforts will more detailed evaluation of the sp: cific operational activities be made. (1 If both of the two previous éva uations are favorable, the operatior al activities can then be reviewe individually and collectively. Eac activity is judged for its own intrii sic merit, for its contribution to tl cooperative arrangements, and fi the degree to which it includes tl core concept of the Regional Medic Prograins. It should also fit as an i tegral part of the total operation activities, and contribute to the ove all objectives of the Regional Mee cal Programs. Review Procedures Below is a chart which describ the various steps in the review proce which will be applied to initial oper- ational grant proposals from each region. The first four operational grant proposals were subject to the various steps of this process. Those steps were not carried out in precisely the order and sequence provided in this chart since the first four ap- plications were used as a test situa- tion for the development of this op- erational procedure. It is also likely that further experience will lead to appropriate modification of these procedures. The following comments may help to explain this review proc- ess, which has been agreed to by the Regional Medical Programs Review Committee and the National Advis- ory Council on Regional Medical Programs. The complexity of these grant requests and the steps in the review process which seems appro- priate for their review will require as much as G6 months for the completion of the total review process in most cases. (J Initial Consideration by Review Committee—The first steps of the re- view process involve preparation for the site visit which will be conducted for cach operational grant applica- tion, The first consideration of the application by the Review Commit- tee will be for the purposes of pro- viding information and comments for the guidance of the site visit team, utilizing staff analyses of the plan- ning grant experience, considerations of gross technical validity, policy is- sues raised by the particular applica- tion, and initial input on relation- ships to other Federal programs. (0 Site Visit—T nitial experience has indicated that a site visit by mem- bers of the Review Committee and the National Advisory Council is es- sential for the assessment of the over- all concept and strategy used by the Regional Medical Program in’ de- veloping the operational proposal and for assigning priorities to specific proj- ects included in the proposal. Tt also provides the opportunity to assess the probable effectiveness of cooperative arrangements and degree of commit- ment of the many clements which will be essential to the success of a Regional Medical Program. As the discussion above points aut, favor- able conclusions on these aspects of the Regional Medical Program must be reached before it is justifiable to begin the major investment of the time of the Division staff, technical reviewers in other parts of the Pub- lic Wealth Service, technical consul- tants, and the Division of Regional Medical Program review groups, which is required for the assessment of the various components of the ap- plication. ‘The site visit is not a sub- stitute for the investment of this effort but provides the opportunity to evalu- ate the cooperative framework of the Regional Medical Program and ‘the overall probability of the success of the proposed program. [] Intensive Analysis and ‘Technical Reviews -Tf the site visit report jus- tifies the investment of additional ef- fort in the review of the application, the Division staff proceeds with an intensive analysis of the specifies of the application. ‘This analysis pro- vides the framework for obtaining specific connnents from other com- ponents of the Public Health Service and other Federal health agencies with related programs, detailed com- ments from the various components of the Division of Regional Medical Programs staff, technical site visits on specific projects within the overall application when considered neces- sary, and for the assimilation of ad- ditional information from the appl- cant asa result of the site visit. ‘The technical review of specific projects should not only evaluate the intrinsic inerit of the project but should help to identify specific problems on any project which might: prevent that ov project from making a meaningful contribution to the objectives of the Regional Medical Program. Techni- cal reviews also consider the justifica- tion for the particular project budget as presented. ‘This aspect of the re- view process presents the opportunity to consider possible overlaps and duplications with other Public Health Service programs which can be a factor in determining how much sup- port should be provided for the par- ticular activity from the Regional Medical Program grant. ‘The oppor- tinity to raise these questions is not limited to Division of Regional Medi- cal Programs stall initiative since copies of all applications are distril- uted to the interested National In- stitutes of Health, to all Bureaus of the Public Health Service, and to the National Library of Medicine at the time of receipt. Representatives from all these organizations are invited to incetings of the Review Conunittec.- [7] Second Review by Review Com- mittee and Recommendation for Ac- tion -The Review Conimiittee con- siders all of the information available concerning the application. In addi- tion to the application itself and) the site visit, report, a summary of all available information is presented to the Committee in a staff presenta- Initial Staff Information re: a. Planning grant experience b, Gross technical validity c. Policy issucs d. Relationship to other Federal programs Review Committee Guidance (Prepared 2d day by site team) Flow Chart Operational Grant Review and Approval Process OPERATIONAL GRANT APPLICATION RECEIVED _ REVIEW COMMITTEE . MEMBERS ns ce weer epee ae renee pain STAFF REVIEW COMMITTEE MEETING . FOR INF ORMATION ¢ AND COMMENT. ? a SITE-VISIT.. (8 “(Two days) Guidance for Site Visit Team Judgments re: 1. Concept of Regional Medical Programs 2. Cooperative Arrangements 3. Relationship of projects, one to another and to the total 4. Approximate magnitude of support warranted 5. Quality of projects where appropriate Jn addition to application and site visit report: 1. Additional information from applicant from outside Division of Regional Medical Programs, where indicated, including comments from other com- ponents of the Public Health Service; may have necessitated technical site visit on specific project(s) 3. Further Staff information 4, Discussion by site visitor(s) of additional information obtained subsequent to site visit Tn addition to above: 1, Review Committee recom- mendations _ 2, Further Staff information per Committee instructions Provided to Applicant: 1. Recommendation and comments of Council; if overall approval proceed to 2 2. Recommend overall budget ceiling for grant 3. Summation of all comments derived from the review process about particular activities contained in application Staff review of revised proposal ee __> _—— be, at . elas us _ : / . REVIEW, COMMITTEE MEETING | tr ‘ ' FOR. CONSIDERATION AND ACTION ce ened eta ee ei ea ee OF Binet teed we ae oat NATIONAL COUNCIL MEETING’ ; : FOR CONSIDERATION AND ACTION , So ema e dll toe Ree Panel aR ee amen tl ne tee we a oe ee ete ie i Sena Ley MEETING BETWEEN DIVISION 2° STAFF AND’ APPLICANT | : le. REPRESENTATIVES © '" cpntnead mith fete nahh atime ete ete ae FINAL AWARD DECISION —— TO Actions: 1. Recommendations a. Approval b. Approval with conditions c. Deferral d, Return for revision e. Disapproval . Instructions to Staff 3. Recommendation of an overall grant amount based on discussion of specifics of the application tre Actions: 1. Recommendations a. Approval b. Approval with conditions c. Deferral d. Return for revision ec. Disapproval . Instructions to Staff . Recommendation of an overall grant amount Lo} Applicant action: Submission of revised proposal within recommended overall budget ceiling utilizing the comments and criticism resulting from the review process Action: a. Award of Grant or b. Further negotiation with applicant 91 tion. The Review Committee then makes its recommendation concern- ing the application. Because of the complex nature of the applications, the Review Committce can divide its recommendation into several parts re- lating to different parts of the appli- cation. If there is an overall favor- able recommendation on the readi- ness of the Regional Medical Program to begin the operational program, the Review Committee recommends an overall grant amount based on a dis- cussion of the specifics of the applica- tion. This amount takes into consid- cration problems raised by technical reviewers, overlap with other pro- grams, {easibility of the proposals, and other relevant considerations raised during the review process. While the overall amount recon mended is based on discussion of the specific components of the total ap- plication, the recommendation docs nol in most cases include specific ap- proval or disapproval of individual projects except when a project is judged to be infeasible, to be outside the scope of Regional Medical Pro- grams, to be an undesirable duplica- tion of ongoing efforts, or to lack es- sential technical soundness. (J Review by National Advisory Council on Regional Medical Pro- grams—The- National Advisory Council considers the Review Com- inittee recommendations. It has avail- able to it the full array of material presented to the Review Committec and a staff summary of that material. Further information obtained by the staff on the instructions of the Re- view Committee may also be pre- sented. The National Advisory Coun- cil makes the required legal recom- mendation concerning approval of the application, including recommcn- dations on the amount of the grant. ‘The Council may delegate to the staff the authority to negotiate the final grant amount within set limits. A recommendation of approval applics to all projects except when indicated by the Council, even though the grant amount recommended may .be less than the amount requested because of the judgments applicd during the review of the application or because of overall limitations of funds. (CO Mecting with Representatives of the Applicant—Following the Na- tional Advisory Council meeting, the staf of the Division mects with rep- resentatives of the applicant and presents to them the recommendation and comments of the Council. If the recommendation is {avorable and the Division intends to award a grant, the staff also presents the recommended overall budget ceiling for the grant along with a summation of all the comments derived from the review process concerning particular activi- ties contained within the application, including criticisms of specific proj- ects and comments about the budgct levels proposed for specific projects. The staff also indicates if any proj- ects included in the application are not 10 be included in a grant award because of Council recommendation or Division decision based on nega- tive factors as discussed above. {J Submission of Revised Propos- al—On the basis of this mecting, the applicant submits a revised pro- posal within the recommended over- all budget ceiling, utilizing in the re- vision the comments and criticisms and technical advice resulting from the revicw process. This step of the process requires the applicant to reconsider their priorities within the recommended budget Ievel and to assume the basic responsibility for making the final decisions as to which activities will be included in the operational program. Unless a project has been specifically excluded from the approval action, the appli- cant may choose to undertake an activity even if doubts about the activity were raised during the re- view process. The applicant includes such an activity with the under- standing that the progress of the activity will be followed with special interest by the review groups and will be judged in the future on the basis of results. ( Final Award Decision—Follow- ing staff review of the revised pro- posal, the final decision on the award is made by the Division Director. Additional negotiations with the ap: plicant may also take place. June 196. a EXHIBIT X Principal Staff of the Division of Regional Medical Programs, June 30, 1967 The Office of the Director provides pro- gram leadership and direction. Robert Q. Marston, M.D. Director Karl D. Yordy Assistant Director for Program Policy William D. Mayer, M.D. Associate Director for Continuing Education Charles Hilsenroth Executive Officer Maurice E. Odoroff Assistant to Director for Systems and Statistics Edward M. Friedlander Assistant to Director for Communications and Public Information The Continuing Education and Training Branch provides assistance for the quality development of such activities in Regional Medical Programs. William Mayer, M.D. Chief Cecilia Conrath Assistant to Chief Frank L. Husted, Ph. D. Uead, Evaluation Research Group 208-19 O—7——-T The Development and Assistance Branch serves as the focus for two-way communi- cation between the Division and the in- dividual Regional Medical Programs. Margaret II. Sloan, M.D. Chief : Jan Mitchell, M.D. Associate for Regional Development The Grants Management Branch inter- prets grants management policies and re- views budget requests and expenditure reports. James Beattie Chief The Grants Review Branch handles the professional and scientific review of appli- cations and progress reports. Martha Phillips Acting Chief The Planning and Evaluation Branch ap- praises and reports on overall program goals, progress and trends and provided staff work for the Surgeon Gencral’s Re- port to the President and the Congress. Stephen J. Ackerman Chief Daniel I. Zwick Assistant Chief Roland L, Peterson Head, Planning Section Rhoda Abrams Acting Head, Evaluation Section EXHIBIT XI Complementary Relationships Between the Comprehensive Health Planning and Public Health Service Amendments of 1966 and — _ the Heart Disease, Cancer, and Stroke Amendments of 1965 A Fact Sheet from the Office of the Surgeon Gencral, Public Health Service, March, 1967 Public Law 89-749, the Comprelicn- sive Health Planning and Public Health Services Amendments of 1966, establishes mechanisms for compre- hensive areawide and State-wide health planning, training of planners,’ and evaluation and development ef- forts to improve the planning art. Public Law 89-239, the Heart Dis- case, Cancer, and Stroke Amend- ments of 1965, authorized grants to assist in the planning, establishment, and operation of regional medical prograins to facilitate the wider avail- ability of the latest advances in care of patients aMicted with heart disease, cancer, stroke, and related diseases. Public Law 89-239 has been in op- cration for about a year. Public Law 89-749 is yet to be implemented. The purposes of PL. 89-749, de- scribed in Section 2(b) are: to estab- lish “comprehensive planning for health services, health manpower, and health facilities’ essential “at every level of government’; to strengthen “the leadership and ca- pacities of State health agencies” ; and to broaden and make more flexible Federal “support of health services provided people in their communi- ties.” P.L. 89-749 asserts that these objec- tives will be attained through “an effective partnership, involving close -intergovernmental collaboration, of- ficial and voluntary efforts, and par- ticipation of individuals and organi- “Phe Act establishes a new relate varied planning and health programms to each other and to other efforts in achievement of a total health pur- 7alions., .. mechanisnr to pose. ‘The law has five major sections: [] Formula grants to the States for comprehensive health planning at the State level through a designated State agency ; (0 Grants for comprehensive health planning at the areawide level; (J Grants for training health plan- ners; (] Formula grants to States for pub- lic health services; (0 Project grants for health services development The purpose of P.L. 89-239, as sct forth in Section 900(b) of the Pub- lic Health Service Act, is “To afford to the medical profession and the medical institutions of the Nation, through . . . cooperative arrange- ments, the opportunity of making available to their patients the latest advances in the diagnosis and treat- ment of (heart disease, cancer, stroke, and related) diseases. . . .” The process for achieving this pur- pose is to establish regional coopera- tive arrangements among. science, education, and service resources for health care...” for research and training (including continuing educa- tion) and for related demonstrations of patient care in the fields of heart disease, cancer, stroke, and related diseases... .” (Section (a) ) This law focuses on the cooperative involvement of university medical centers, hospitals, practicing physi- cians, other health professions, and voluntary and official health agencics in secking ways to build effective link- ages between the development of new heowiedee aad its application to the rproblenis of patients. The law: pro- vides flexible mechanisms which em- — = phasize the exercise of initiative and responsibility at the regional level in identifying problems and opportuni- tics in sccking these objectives and ir developing ‘specific action steps tc overcome the problems and exploi' the opportunities. The Public Health Service sees P.L 89-239 and P.L. 89-749 as servin, the common goal of improved healt] care for the American people alon; with other Public Health Service ani non-Public Health Service grant pro grams such as community ment: health centers, migrant health pre grams, air pollution control, prograrr for the training of health manpowe: the neighborhood health centers ur der the Office of Economic Oppo: tunity, the medical programs of th Children’s Bureau, and State an local health programs. In the State and communitics, P.L. 89-749 wi provide a vehicle for effective inte action among these programs, reco nizing as it does that the diversity « the various States and arcas of th Nation is considerable, and that tt specific relationships between ar among programs will have to | worked out at these levels rather the through a specific Federal mandate The planning resources created at th State and local level under Publ Law 89-749 are expected to affor valuable assistance in the achiev ment.of the objectives of Public Law 99-239, other programs of the Public Health Service, and other health en- deavors in cach of the States. Public Law 89-749 provides, however_no_ authority for these planning resources to impose their conclusions or recom- ‘mendations on any other programs, Federal or non-Federal, except for activities carried out under Section (d) and parts of Section (e) of the Law which must be in accordance with the comprehensive State health plan developed by the State compre- hensive health planning agency. The Public Health Service intends to stimulate effective interaction among these programs, recognizing that the diversity of the various States and areas of the Nation is considerable. Both P.L. 89-239 and P.L. 89-749 provide flexible instruments for cs- tablishing productive relationships between these and other programs. The maintenance of this flexibility in the administration of the grant pro- grams will permit cach State and re- gion to design and develop a relation- ship that is appropriate for its par- ticular circumstances, Both programs call for a close private-public part- nership. Both programs must place dependence on imaginative, reason- able local approaches to cooperation Both recognize that they can only achieve and coordination. programs their full potential by the close and complete involvement of other com- ponents of the health endeavor, A vital partnership must be developed between the Federal government, the universitics, local and State govern- ment, the voluntary health interests and individuals and organizations de- signed to develop creative action for health. The Congress recognized the rela- tionship of comprehensive health planning to other planning activities. The Report of the Senate Committce on Labor and Public Welfare (No. 1655, September 29, 1966) stated: “The comprehensive planning of the State health planning agency with the’ ” advice of the council would comple- ment and build on such specialized planning as that of the regional medi- THll-Burton replace eal program and the but would not ” program, them. 2... “The State health planning agency provides the mechanism through which individual specialized plan- ning efforts can be coordinated and related to each other. The agency will also serve as the focal point within the State for relating comprehensive health plans to planning in areas out- side the field of health, such as urban redevelopment, public housing, and so forth.” Characteristics of Phese Two Important Acts The complementary relationship of the programs established by P.1.. 89 - 239 and PLL. 89-719 to foster de- velopment. of a “Partnership for Health” is illustrated by the follow- ing outline of some of their major elements. Scope PT. 89-239: ‘The Regional Medical Program. ‘To identify regional needs and resources relating to heart dis- ease, cancer, stroke, and related diseases and to develop a regional inedical program which wtlizes re- gional cooperative arrangements to apply and. strengthen resources lo meet the needs in making more widely available the latest advances in diagnosis and treatment of these cliseases. PL. 89-759: ‘Phe Comprehensive Health Planning: Programs. Vo estih- lish a phoning, process to achieve comprehensive health planing von a Statewide basis which identifies health problems within the State, sets health objectives directed toward tm proving the availability of health services, identifies existing resources Le O85 and resource needs, relates the activi- ties of other planning and health programs te the meeting of these health objectives, and provides as- sistance to State and local officials, private voluntary health organiza- tions and institutions, and other pro- erams supported. by PHS grant funds in achieving the more effective al- location of resources in accomplishing the objectives. Participants P.L. 89-239: centers, hospitals, practicing physi- University medical cians, other health professions, vol- untary and public health agencics, and members of the public. A_ re- gional advisory group representing these interests and playing an active role in the development of dhe re- gional program must approve any application for operational activities of the regional medical program. PA. 89 710: State agency designated by the Governor does the pleming. State advisory conmneil advises ou the plamning process. Membership aitast than half consumer representation, Membership will also inelude more include voluntary groups, practition- ers, public agencies, reneral planning agencies, and UNIVETSTUCs. The Process P.L, 89-239: [] Establish ments among science, education, and service resources. cooperative arrange- 1] Assess needs and resources. [1] Develop pilot and demonstration projects, emphasizing flow of knowl- edge in uplifting the cooperative capabilities for diagnosis and care of patients. (J Relate research, training, and service activilics. [c] Develop effective continuing edu- cation programs in relation to other * operational activities. [7] Develop mechanisms for evalu- ating effectivencss of efforts in the provision of improved services to patients with heart disease, cancer, stroke and related discases. P.L. 89-749: (0 Establish State and areawide health goals. [J Define total health needs of all people and communities within area served for meeting health goals. [J Inventory and identify relation- ships among varied local, State, na- tional, governmental and voluntary programs; regional grams, mental health, health facili- ties, manpower, medicare — so that these programs can be assisted in mak- ing more effective impact with their resources. C1 Provide and recommendations analyses, which can information, serve as the basis for the Governor, other health programs and communi- tics to make more effective allocations of resources in meeting health goals. (0 Provide a focus for interrclating health planning with planning for education, welfare and community development. [0 Strengthen planning, evaluation, and service capacities of all partici- pants in the health endeavor. (1) Provide support for the initiation, integration, and development of pilot projects for better delivery of health services; develop plans for targeting flexible formula and project grants at probleins and gaps identified by the planning process. Specific Planning Relationships ( There are a varicty of ongoing health planning and community health organization activitics. Many are supported in part by the Public Ilealth Service, such as Regional Medical Programs (P.L. 89-239), medical pro- . community mental health centers, arcawide health facility planning, and the Hill-Burton programs. These activities arc stimulating the creation of new relationships between health resources and functions as well as as- sisting in the creation of additional resources in the stimulation of more effective performance of functions for the purpose of achieving more cf- fective attainment of identified health goals. Each of these programs re- quires participation not only by a broad range of health professionals but also by representatives of the con- sumers of health services. Each of these programs is dependent upon the interaction of the full range of relevant health interests, including those in the public sector and the private voluntary sector in achieving ‘the particular progam goals. Comprehensive health _ planning (P.L. 89-749) is designed to provide assistance in the development of more effective relationships among such health programs and to provide a better basis for relating these pro- grams to the accomplishment of over- all health objectives at the State and local level. Based on similar prin- ciples of broad participation, it calls for the stimulation of all parties to contribute to the goal of insuring the availability of comprehensive health services to all who need them. (C Both regional medical program and comprchensive health plannin are intended to strengthen creativ Federalism—more productive mect anisms for partnership and coope: ation between’ the national, Stat and local levels of government, tt public and voluntary private healt activities, and the academic. an health services environments. P.] 89-749 will create planning resourc at the State and local level. The i formation, analyses, and plans d veloped by these planning resourc can provide invaluable assistance State and local authorities, to volu tary health organizations and ins tutions, and to the other health pr grams involved in planning and ¢ veloping the organization of heal activities which are support through other Public Health Serv: grant funds. This planning resoui created under Section 314(a) v thus contribute to the more effect accomplishment of health objecti and the setting of priorities in achi ing those objectives through the tivities supported under the other s tions of this Law. In addition, resource will contribute to the det mination of priorities for action - only by those with public respo! bility and accountability for hez services but also by the many ot health organizations, institutions, : personnel which bear the direct re- sponsibility for the delivery of health services for most of the population. P.L. 89-749 recognizes that the ac- complishment of improvements in the quality and coverage in health serv- ices, hoth personal and environ- mental, depends upon the voluntary participation and energics of both the private and public sectors of the health endeavor. (] The planning, operational pro- grams, and organizational frame- works being created under the Regional Medical Programs, commu- nity mental health centers, and arca- wide health facility planning groups, including the advisory groups estab- lished for other programs such as the Regional Medical Programs, should serve as sources of strength and valuable assistance for the areawide and State-wide health planning coun- cils created under P.L. 89-749 and for the planning resources created under this Law. C] The broad range of health inter- ests represented in Regional Medical Program planning efforts, along with other appropriate health interests, will he essential participants and con- tributors to the State health planning council and to the activities of the health planning agency. When the activities of that ageney address theniselves to the problems of extend- health services which fully benefit from the ing high-quality | personal developments in new medical kiowl- edye, the cooperative involvement of these health interests in both the Re- gional Medical Program planning and development and in the planning and evaluation activities under PLL. 89-749 will make can essential con- tribution to productive relationship between these activities. (J The comprehensive health plan- ning activities will use data available from many sourees including that generated or analyzed by the Region- al Medical Programs, particularly on health status of populations. ef- fected, health resources, and health problems and needs. ‘The compre- hensive health planning activities can also benefit from the experience obtained under the Regional Medi- cal Programs which have represented an exploratory effort of considerable importance in developing an en- vironment for concerted planning by many clements of the health en- deavor and in the implementation, development and evalnation of new systems for the facilitation of the de- livery of the benefits of medical ad- vance in specific disease areas through more effective means of communica- lion, education, training, organiza- tion, and delivery of health services. Many of the planning and inple- mentition activities under the Re- sional Medieal Progains will have implications and applications to a broader range of health problenss than heart disease, cancer, stroke, and related diseases. The mechanisms created by the Regional Medical Pro- eran can be useful in achieving the broad goals of comprehensive health stated under PLL. 89-749. Training [lealth Planners Section Bl4(e) of PLL. 89-7490 an thorives grants to public or nonprofit organizations for “training, studies, and demonstrations,” in order to ad- vance the state of health planning art and increase the supply of competent health planners. For the first years, emphasis will be placed on increasing health planning (Until Public Vealth Service effort has been lin- manpower, now, ited to ad hoc short courses or in- service training.) “This new activity will help meet a eritieal shortage faced by regional wedieal programs, medical centers, operating health agencies, as well as) comprehensive health planning agencies about to be launched. 97 Operating Grants Section BEC) of PAL. 89 7-19 ane State health and mental health authorities health service. The Act brings together a thorivves formula grants. to for comprehensive — public group of previously compartmented or categorical Public Health Service grants. Grant awards will depend on a plan submitted by the health agency which reflects the way in which the State intends to use the funds as part of an effort to provide Public Health ‘This plan, in turn, must bein accord adequate Services, with the State’s comprehensive health planning. Section 314 (c), authorizing project grants for “health services develop- ment,” broadens and consolidates a serics of Public Tealth Service proj- ect grants, making: possible Federal support for new and innovative pro} ects, locally determined, to mect health needs of limited geographic scope or specialized regional or na- tional significance ; stimulating and initially supporting new programs of health studies, demonstrations, or training services, and undertaking designed to develop new or improved methods of providing health SCTVICES. The first two of these categories of health service development grant must conform to objectives, prioritics, and plans of comprehensive State health planning. With the exception of the statutory requirement that the programs sup- ported by these grants must conform to comprehensive State health plan- ning, P.L. 89-749 formula and proj- ect grants bear the same relation to the comprehensive health planning process as do, for example, the opera- tional grants under regional medical programs, air pollution control, or community mental health center staffing. The operational grants under P.L. 89-239 will support an interrelated program of activitics which utilize regional cooperative arrangements to accomplish the objectives of that law in the fields of heart disease, can- cer, stroke, and related discascs. The cooperative arrangements and the specific program elements are viewed by many regions as providing useful models for application to a wide spectrum of health problems which can be implemented through other means and which will have close relevance to the achievement of many of the activities supported under P.L. 89-749 and other health pro- grams. Converscly, the regional med- ical programs can benefit from the planning and operational activities of other health programs including those supported under P.L. 89-749. Other programs supported by Public Health Service funds such as mental health, migrant health, and air pollu- tion can have the same type of pro- ductive interrelationship with the comprehensive health planning pro- prams. The Public Health Service has a re- sponsibility to prevent waste of scarce resources through useless duplication. ‘To assure the most effective inter- relationship among these and other Public Health Service grant pro- grams, the Public Health Service is currently developing informational, and review systems to promote cffcc- tive coordination between all of its varied grant programs. a i EXHIBIT XII Public Law 89-239 89th Congress, 5. 596 October 6, 1965 An Act Heart Disease, Cancer, and Stroke Amend. ments of 1905. To amend the Public Henlth Service Act to nssist in combating heart disease, cancer, stroke, and related diseases. He it enacted by the Senate and Jfouac of Representatives pf the United Stater of America tn Congrean assembled, That this Act may be cited as the “Feart Disense, Cancer, and Stroke Amendments of 1005". Sie, 2. fhe Publie Health Services Act (42 US.C, ch. GA) Ix amended by adding at the end thereof the following new title: erepLE IX—KDUCATION, RESWARCIL, TRAINING, AND DEMONSSRATIONS IN THE RIELDS OF HEART DISKBASE, CANCER, STROKE, AND RELATED DISEASES “Purpoacr “gee, 000, The purposes of thia title 1re— “(n) Through grante, to encourage and assist In the establishment of regional co- operative arrangements «among medleal dehools, research institutions, and hospitals for researeh and training (including con- tinuing edueation) and for related demon- xtrationas of patient care in the fields of heart disease, enneer, stroke, and related digenges ; “(b) To afford to the medical profession and the medical Institutions of the Nation, through Buch cooperative arrangements, the opportunity of muting avaliable to thelr ya- (ienta the Infest advances tn the dlagnonls and treatment of thease diseases; and “(e) Ry these means, fo Smprove gene erally the health manpower and facilitles —- available to the Nation, and to accomplish these ends without Interfering with the pat- terns, or the methods of financing, of pa- tlent care or professional practice, or with the administration of hospitals, and In co- operation with practicing physiclans, med!- eal center offielals, hospital administrators, and representatives from appropriate volun- tary health agencies.’ “Authorization of Appropriations “gee, 901. (an) There are nuthorized to be appropriated $50,000,000 for the fiseal yenr ending June 30, 1966, $90,000,000 for the fisent year ending June 30, 1067, and $200,000,000, for the fixent yeur ending June 30, 1968, for grantr to assist public or non- profit private universities, medical schools, research institutions, and other public or nonprofit private inatitutions and agencies in planning, in conducting fenaibllity studies, and In operating pilot projects for the estab- Mahment of regionr] medical programs of rexeareh, training, and demonstration activ. Itles for carrying out the purposes of thia title, Suma appropriated under this rection for any fiscal year ahalt remain available for making such grants antil the end of the fiseal yenr following the fixenl year for which the appropriation Is made, “(b) A grant under this title ahall be for part or ali of the cost of the planning or other uctivities with respect to which the application is made, except that any such grant with respect to construction of, or provision of built-in (as determined in ae- cordance with regulations) equipment for, any faellity may not exceed 90 per eentimn of the cost of such construction or equipment. “(e) Funds appropriated pursuant to this title shall net be avaiinhle to pay the cort of hogpital, medical, or other care of patients except to the extent it ix, as determined In necordance with regulations, Incident to those research, training, or demonstration activities which are encompassed by the purposes of this title, No patient shall be furnished hospital, medical, or other care at any fnellity Incident to research, training, or demonstration aethvitler eneried owt with funda approprinted pureundt to thin tlfle, unleas he has been referred to auch facility by a practicing whyrichan, “Nefnitions “Src, 902, For the purposes of this title— “(a) The term ‘reglonal medical program’ means a cooperative nrrangement among a group of public or nonprofit private Institu- tions or agencies engaged in research, train- ing, dingnosis, and treatment relating to heart disease, cancer, or stroke, and, ut the option of the applicant, related disease or dsenses; but only it such group— “(1) Is situated within n geographic area, composed of any part or parts of any one or more States, which the Surgeon Gencral determines, In accordance with reguintions, to be approprinte for carry- ing ont the purposes of this title; "(2) consists of one or more medical centers, one or more clinical research cen- ters, and one or more hospitals; and “(3) has In effect cooperative arrange- ments among its component units which the Surgeon General finds will be adequate for effectively carrying ont (he purposes of this title. “(b) The term ‘medical center’ means a medten! school or other medical institution Involved {in postgraduate medical training and one or more hospitals affiliated there- with for tenching, research, and demon- stration purposes. “(c}) The term ‘clinical research center’ means nn Institution (or part of an tnstilu- tion) the primary functlon of which is re- search, training of speelalists, and demoen- strations and which, in connection therewith, provides speclalized, high-quality dingnostle and treatment services for Inpatients: and outpatients, “(ay ‘Phe term ‘hospital’ means a hospl- tal as defined in section 625(e) or other health facillly in which loeal capability for dingnosis and treatment is supported and augmented by the program established un- der this title, “(e) The term ‘nonprofit’ as applied to any institutfon or ageney means an Institu- Yen or agency which is owned and operated hy one of more nonprofit corporations or na- sociations no part of the net earnings of whieh inures, or may lawfully Inure, to the benefit of any private sharcholder or Individual, “(f) Phe term ‘construction’ Includes alteration, major repalr (to the extent per- mitted by regulations), remodeling and renovation of existing buildings (ineluding initial equipment thereof), and replacement of obsolete, built-in (as determined in’ ae- cordance with regulations) equipment of existing buildingy. “rants for Planning “Spo, 903. (an) The Surgeon General, upon the recommendation of the Natlonal Ad- visery Council on Regional Medteal Vro- grams catablished by section 905 (hereafter in this title referred to as the ‘Council), is authorized to make grants to pablle or non- profit private universities, medical schools, research instiftudfous, and other publie or nonprofit private agencies and institutions fo nsaiat them ino plauntiag the devetopment of regional medlenl programs, “(b) Grants under this section may be made only upon, application therefor ap- proved by the Surgeon General, Any such appiiention may be approved only if it cone tains or Is supported by-~- “(1) rensonable assurances that Fed- eral funds pald pursuant to any such grant will be used only for the purposes for which paid and fn aecordance with the applieable provisions of this title and the regulations thereunder ; (2) reasonable nssurances that the applicant will provide for such fiscal con- trot and Cand accounting procedirres as are required by the Surgeon General to assure proper disbursement of and accounting for sneh) Federal funds ; “(€3) reasonable assurances that the ap- mMicant will make such reports, ino sueh form and containing such information as the Surgeon General may from time to time reasonably require, and will Keep such records and afford such access there- to as the Surgeon General may find neces- sary to assure the correctness amd verifiea- tlon of such reports ; and (4) a sotinfultory showing that the appileant has designated an tuilvisory group, to advise the applicant (and the institutions and agencies partieipating in the resulding regtonal medieal program) in formulating and carrying out the plan for the establishment and operation of such regional medical program, whieh advisory group ineludes practicing physi- clans, medical center officials, hospital ad- ministrators, representatives from appro- priate medical societies, voluntary health agencies, and representatives of other organizations, fnastitutlens, and agencies concerned with acthvities of the kind to he earried on under the program and mem- bers of the publle familiar with (he need for the services peovided under the program, “rants for Establishment and Operation of Regional Medical Programa “Seo, OO4. (a) The Surgeon General, upon fhe recommendation of the Counc, fs au- thorized to make grants to publie er non: profi, private universities, medfeal schools, research fastitutlons, and other pubtle or nonprofie private agencies mid fosiitudens to assist in establishment and operation of regional medieal programs, including ean strietion and equipment of faciiitles In con- necUion therewith. "*(bb) ‘Grants under this: seetfon may be made only upen application therefor ap proved by the Surgeon General, Any such application may be approved only if it ts ree- ommended by (he advisory group deseribed In seetlon GOS) GF) and contados or is snp: ported by reasonaliwe assurances thirt C1) Federal funds pald pursunint te any such grant (A) Wi be used only for the purposes for whieh pald and in ae: cordance with the applieahle provisions of this tte and the regulations Chereander, and (2) with net supplant fonds that are otherwise avaliable for extablishinent or operation of the reglonal medleat program with respeet to whieh the grunt is made ; “(2) the appHeant will provide for such fiseal control and fund accounting proce- dures as are required by the Surgeon General to assure proper dishursement of aud accounting for such Federal fands 5 Reeordy. C3) the applileant with mate sueh re. ports, in sueh form and containing such information as the Surgeon General may from the te time rensonnbly require, and will keep sueh records and afford such neeess Unereto ns the Surgeon Generat may find necessary to assure the cor- reetness and vertfiention of such reports ; and “(4) any taborer or mechanic employed hy any contractor or subcontractor in the performance of work on any construction alded by payinents pursuant to any grant under this section will he pald wages at rites not Jess than those prevailing on similar construedon in) the loeallty as tletermined by the Sceretary of Labor in naeeordance with the Davis-Bacon Act, a4 amended (40 U.S.C, 276n—-2760-5) > and the Seeretary of Laber shall have, with respeet to the Inbor standards speelfled in this. paragraph, the authority and fune- tlons set forth In| Reorganization Plan Numbered f4 of 1950 (15 IR. 21765 5 U.S.C) 1822-15) and veetion 2 of the Act of Jine 18, 1834, as amended CHO U.S.C, 276e), “National Advisory Couneil on Regional Medical Programs Appointment of members. “See, 90%. Gt) The Surgeon General, with the approval of the Seerctary, may appoint, without regard to the chi) serviee Tnws, a National Advisory Couneil on Regional Medi- en) Programs, ‘The Caunctl shall consist of the Surgeon General, who shall be the ehair- man, and twelve members, not otherwise in the regular full-thine employ of the United States, whe are lenders In the flelds af the fundamental selenees, the medical sciences, or public affalrs. AC Teaxt two of the ape pointed members shall be practicing physi- clans, one shall be outstanding In (he study, diagnosis, or treatment of heart, disease, one shall be outstanding in the study, dlagnosts, or treatment of cancer, and one shall be ont- standing in the study, diaguosis, or ‘Creat. mont of stroke. Tera of oftiee, “(h) Bach appointed member of the Conn. cll shalt hota office for a terun of four years, copt that any member appointed te fill a vacaney prior toe (he esplration of the term for which his predecessor was appointed shalt be appointed for the remainder of sueh ferm, and except that the terms of aftier of (he members first taking office shalbexpire, as designated by the Surgeon General at the time of appolniinent, four ah the end of the first year, four at the end of the seconth yenr, nnd four at the end of the third year after the date of appointment. An nppotnted inem:- ber shall not be eligible to serve continuously for more than two terms, : Camponsation. “(e) Appointed members of the Comnell, white altending meetings or conferences thereof or otherwise serving on business of {he Council, shall be entitled to reeelye com- pensation at rates fixed by the Seeretary, but not exceeding $100 per day, including {ravellime, and white so serving away from thetr homes or regular places of business they nay be allowed travel expenses, ineluding per stem in Hew of subsistence, 18 nuthorized hy section 5 of the Administrative Expenses Act of 1946 (9 U.S.C. Tbe2) fer per- sons In the Government service employed intermittently. Applications for grants, recom- “mendations, “(a) ‘The Council shall advise and assist the Surgeon General tu the preparation of regulations for, ant as fo polley matters arising with respeet to, the administration of this tithe, fhe Council shall consider all applications for grants under this title and shall make recommendations to the Surgeon General with respect. to approval of applen- tluns for and the amounts of grants under this title. “Regulations “See, 906. The Surgeon General, after consultation with Che Council, shail pre- serthe general regulations coverng Che ferns and condiions for approving applications for grants under (his tite and the coordination of programs. assisted under this title with programs for training, research, sand demon- strations relating to the same diseases assisted or authorized under other titles of this Act or other Acts of Congress, “Tnformation on Speeiat Treatment and Praining Centers este, 907, The Surgeon General sliall es- tnblish, and maintain on a eurrent basis, 4 Hst or lists of faeliitdes In the United States equipped and staffed to provide the most nd- vaneed methods and feehniques fn Che albinge- nosis and treatment of heart disease, cancer, or stroke, together with such related infor- mation,’ ineluding fhe availablity of aa vanced specialty training In such facilities, ns ho deems useful, and shall make such list or lists and related Information readily available to Heensed practitioners and other persons requiring such information, ‘Fo the oul of making such list or lists and other information most useful, the Surgeon Gen- eral shall from time to thne consult with Ine terested national professional organizations, Report to President and Congress “gee, OUR, On or before June 30, 1067, the Surgeon General after consultation with the Connell, shall submit, to the Seerelary for transmission to the President and then to the Congress, a report of the activities under this title together will (1) a state- ment of the relationship between Federal financing and financing from other sources of the activities undertaken pursuant to this title, (2) an appraisal of the netivities 18- sisted under this titte in the light of (heir effectiveness in carrying out the purposes of this (ide, amd (2) recommendations with respect to extension or modification of this title in the light thereof, “Records and Audit “She, 900, (a) Each recipient of a grant nader this title shall keep such records as the Surgeon General may preseribe, Including records which fully diselose the amount and dispasitien by such recipient of the procecds of such grant, the fotal eost of the project or wndertaking In connection with which such grant is made or used, and the amount of (hat portion of the cost of the project or undertaking supplied by other sources, and such records as will facililate an effective audit. “(b) The Sceretary of Health, Kduention, and Welfare and the Comptroller General of the United States, or any of their duly au- thorized representatives, shall have access for the purpose of audit and exainination to ny books, documents, papers, and records of the recipient of any grant under this title whieh are pertinent to any such grant,” See. 3. (a) Section 1 of the Publie Health Service Aet Is nmended to read as follows “Snerion 1. UItles I to 1X, inclusive, of this Aet may be clted as the ‘Public Tealth Service Act.” (b) She Act of July 1, 1944 (5S Stat. 682), as amended, is further amended by re- numbering tille EX (1s in effect prior to the enactment of this Act) as title X, and by renumbering sections 901 through 914 (as in effect prior to the enactment of this Act), nnd references thereto, as sections 1001 through 1014, respectively. APPROVED OCTOBER 6, 1965, 10:15 AM. Legislative dlistory: Tlonse Report No, 96.3 aecompanying TLR. 8140 (Comm, on Interstate and Foreign Conmmeree). Senate Report No. S68 (Comm, on Labor and Public Welfare). Congressional Record, Vol. 111 (1965) : June 25: Considered In Senate, dune 28: Considered and passed Senate. Sept, 28: HL. 3140 considered in Mouse. Sept. 24: Considered and passed House, amended, in Hou of ILR. 3140. Sept. 20: Senate concurred in Tlouse munendments. EXHIBIT XIII Regulations Regional Medical Programs March 18, 1967 SUBPART E—GRANTS FOR REGIONAL MEDICAL. PROGRAMS (Added 1/18/67, 32 FR 571.) AuTuortry: The provisions of this Sul part 1) issued under see. 215, 58 Stat. GO Kec, 006, 79 Stat. 030; 42 U.S.C. 216, 299 Interpret or apply secs. 000, 901, 902, 90: 904, 905, 909, 79 Stare, 926, 927, 928, 92! 930, 42 U.S.C. 299, 299a, 299b, 299e, 2091 2990, 209i. DO 54.401 AVPLICABILITY. Yhe provisions of this subpart apply | grants for planning, establishment, a0 operation of regional medical programs 1 authorized by Title LX of the Public Meal Service Act, as amended by Yublic La $9239. O 54.402 DEFINITIONS. (a) All terms not defined herein sht have the meaning given them in the Act. (b) “Act means the Public Tealth Ser lee Act, ns amended, (ec) “Title IX” means Tithe IX of t Public Menalth Service Act as amended. (d) “Related disenses” means those d eases which can reasonably be considered bear a direet relationship to heart disea: cancer, or stroke. (ce) “Title IX diseases” means heart d case, cancer, stroke, and related diseases. (£) “Program” means the regional me eal program as defined In section 902(a) the Act. (g) "Practicing physician” means 2 physicinn licensed to practice medicine accordance with applicable State laws and currently engaged in the diagnosis or treat- ment of patients. (h) “Major repair’ includes resteration ofan existing building to a sound state. {i} “Built-in equipment’? ots equipment afixed fo the faellity and custeamarily tn. chrted in the construetion contract, (j) ‘Advisory group" means the group designated pursuant to seetion YOR Cb) (4) of the Act. (k) “Geographle area means any area that the Surgeon General determines forms an economie and socially related region, taking into consideration such factors as present and future population trends and patterns of growth; location and extent of transportation and communication facilities and systems; presence and distribution of educational, medical and health facilities and programs, and other netivities which in the opinion of the Surgeon General are ap- propriate for carrying out the purposes of ‘Title IX, O 4.103 ELIGUIBILTPY, In order ty be elfgihte for a grant, the applteant shalt: {#) Meet the requirements of section 900 or Of of the Act ; (bh) Be located ina State; (e) Be situated within a geographle area appropriate under the provisions of this sub- tuirt for carrying out the purposes of the Act, D1 f4.404 APPLICATION. {a) Forms, An application for a grant shall be submitted on such forms and in such nianner. as the Surgeon General may prescribe, (h> Ereention, The application shall be exeented by an indlfvidual authorized to net for the applicant asd do assume on behalf of the applicant all of the obligations specl- fied in he terms ail conditions of (re rant including those contained ino (hese regeala- tians, . {e) Deseription of program. Tn addition tecany ofher pertinent information that the Surgeon General may require, (he applicatt shalt submit a deseripfion of he program in sufficient aledail te clearly identify the nature, need, purpose, pluon, aad methods of the program, fhe nature amd funefions of the partietpating tnstilutions, the geographic area to be served, the cooperative arrange. ments In effeet, or intended to be mitde ef- feclive, witldn the group, the justifieation supported by a budget or other data, for the amount of the funds reqresteat, smd singnetal or other data demonsteating that grate fumes Will net supplant futds otherwise avaitebte for establishment or aperation of tee regional medica) program, (ad) Advisory group: establishment: ert. denec, An application for a grand tneder see. lion DOS of the Act shall contiali or be sup. ported by documentary evidence of the es- tablishment of an advisory group to provide advice in formulating and carrying out Clie ostaltishment and operation of a program, (e) Advisory qranp; membership; descrip- tion, The application or supporthig material shall deserthe the sclecUlon and membership of the designated advisory yroup, showing fhe extent: of inelusion imo suel group of practleing physicians, members oof offer hetith professions, medien) center offieials, hospital administrators, representatives: front appropritte omedtenl societies, voluntary agencies, representatives of ofher organiza- lions, institutions and agencies concerned with netivitles of Che kind to be earrient an moder the program, and members of the pub. Ne familiar with the need for the serviees provided tnder the program, (f) Construction; purposes, plans, ant speeifientions; narrative deacription, With respeeL to ain appiication for finds ta be used in whole or part for construction gs ade. fined in ‘file IX, the applieaut shall furnish ino sumMeiont detail plans and specifications as well asa narrative description, to imdiente the need, nature, and purepose of the pre. posed construction. (x) Advisory group: recommendation. An application Cor ao grant under seetion tot of the Aeto shalf contain or be supported by a copy of the written recommendation af ie advisory group. CO f4-6i TERMS, CONDITIONS, AND ASSURANCES. In addition to any other terms, conditians, ail assiennees required by baw ar iiapexed by the Surgeon General, cach grant shill Toe sabjeet fo the following ferms, conditions, aed assurances fo be furnished by the grantee, ‘The Surgeon General ney at any time approve exceptions where lie fires Uhnat such exceplions are nad ineensistent witht dhe Act aad Che purposes of the program, (ay tise of finds, Whe grantee will use yvrant funds solely for the pirrpoases for whieh the grant was inade, as set forth in the ap- Provedk application ane award statement. dn the event cuy puree ef Che ganennt povieta Kranfee ds found by the Surgeon General to fave been expended for purposes op by any tefheds comtrary fo the Act, Che resadatioas of this subpart, er contrary to any condition fo the award, Hien steel poametee, eqn being notified of sueh finding, and in aeddiiien te tay other requirement, shall pay a equal amount fo the Pnited Stites. Changes in Svan purposes aaty be made only ta necord- tnee with proceedures established by the Surgeon General, Oh) Obligation of funds. No funds iay be charged against! the grant for serviees per- formatoor uirterbel ar equipament detiver: Pursipe fea comfrach of wercenmecsit ¢ into by the apptieret prior fe the clfective tite af the grange. fe) fncentions or discarvries. Any graut navaned hereunder in whole or im part for re seareh ds subject to the regulations af the Pepartnerd of Tlealth, Edireation, amd Wel fareces set forth in Parts amet S of Title i, as ninended, Stel regulations shall apply te any program aelivity for whieh grant funds wre dn fitet used whether within the seope af the progeam as approved or otherwise, Appropritte measures shalt be tiken by the grantee and by (he Surgeon General fe assare that ne eontratelis, assignments, ar other ar raingements Ineansistent with the grant obli- vation are continued or enterecdl inte and that all persounel invelved in the supported vetiviiy are aware of and comply with sueli obligation. Laboratory notes, refitted tech wien) aketa, and information pertatodng (oo ine ventions or discoveries minke Chromsh aetivi ties supported day grramt Combs shat he weaidstiaead for pared) periods, aul ited with or otherwise ouade ayaihibte te the sa General oar these die nmiy adesisauite als “te \ fies saat Ge suelo maaner as tre iy defer thine necessary teccrrry out sel Departrient resaliel ious. (ay Repurts, ‘Vhe cerimtee sted aaeitie and fie wilh tle Surgeon Crete rab streda poraege ress, fiseat, aaed other repor including: reperts of meetings of Che gulvisers proup convened before and after award of oa grant 101 r nader section O0-£ of the Act, as the Surgean General may preseribe, (ce) Records retention, AW construction, fingnediel, and other records reheting to the tse of grink funds shall be retained until the grantee has reeeived written notice that the records Inve heen aiidited: unless a citer. ent period is permitted or recived in writing by the Surgeon General, (f) Respousibte oficial The officint designated in the application as respousibte for the coordination of (he program shall coulinne: to be responsible for the duration of the period for whieh grant funds are made available. The grantee shall! notify the Sur- geo General finmediately Ef such official te. eomes Unavailtble to discliurge this respon- sibility. Phe Surgeon General may terminate fhe grant whenever such offielal shall hecame (hos mirvrilable unless the grantee replices suede odttedal witte camether etthebad formed dae the Sereygean Ceenerat toe de qguath fied, C) St40G AWAID, Upon recommendation of the National Aed- visors Counell on Regional Medieat Pro- sramis, sinth owilhin the fimits of availuble famed, Clee Sauer, noGenerab shalb award a prank fe those applicants whase opproved programs Will in his judgment best promete the parposes of Tile IX. Do awarding grants, fhe Surgeon General shall take inte eon- sideration, among offer relevant faetors the following : Gay Generally, the extent toe whieh the proposed program WHE carry ont, Chrough regional cooporition, the purposes of ‘Title tN, wilthia a geographle area. cb) The capacity of the institutions or agencies within the program, individually aad collectively, Cor reseavel, Craining, and demonstration aetivities with respeet ta Title IX. ted The extent ta whieh the appileand or the qarticipants in dhe prayran phen fa coordinate ar hive coordinated (he regional tnedieal program with other wetivittes sup. ported: pursiant to the anthority: contained in the Puldie Heatth Servies: Act nial other Aets of Congress inelading Ghose rebrting fo plonning: and use of facitities, persenined, aml oqnipment, and Crating of manpower, (dd) The population to he served by the regional medien) program and relationships to adjacent or other regional medical programs. (e) The extent to which all the health resources of the region have been tnken into consideration in the planning and/or estab- Hshment of the progran. (f) The extent to which the participating Institutions wi uffllze existing resources amt will continue to seck additional non- federnt resources for carrying out the objec- tives of the regional medical program. (2) Tho geographic distribution of grants throughout the Nation. 0 54.407 TERMINATION. {a) Termination by the Surgeon General. Any grant award may be revoked or termi- nated by the Surgeon General in whole or In part at any time whenever he finds that in his judgment the grantee has fatled in a material respect to comply with requirements of Tithe IX and the regulations of this sub- part. The grantee shall be promptly notified of auch finding in writing and given the rensons therefor. (h) fermination by the grantee. aA grantee may at any timo terminate or eance] its conduct of an approved project hy notify- Ing the Surgeon General tn writing setting forth the reasons for such termination. (ce) Accounting. Upon any termination, the grantee shall account for all expenditures and obligations charged to grant funds: Provided, That to the extent the termination fy due in the Judgment of the Surgeon Gen- eral to no fault of the grantee, eredit shall be allowed for the amount required to settle at costs demonstrated by evidence satisfac- tory to the Surgeon General to be minimum settlement costs, any noncancellable obliga- tlons Incurred prior to receipt of notices of termination. 0 54.408 NONDISCRIMINATION. Section GU1 of Tithe VI of the Civil Rights Act of 1964, 42 U.S.C. 20000, provides that no person Jn the United States shall, on the ground of race, color, or national origin, be exeluded from participation In, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Fed- eral financial assistance. Regulations imple- menting the statute have been issued ns Part 80 of the Title 45, Code of Federal Regula- tions. The regional medical programs pre- vide Federal ftnanelal assistance subject to the Civ Rights Act and the regulations. Knech grant Is subject to the condition that the grantee shall comply with the require- ments of Executive Order 11246, 30 FR. 12310, and the appleable rules, regulations, and procedures preseribed pursuant thereto. O) 54.409 EXPENDITURES BY GRANTEE, (n) ANocation of coats, ‘The grantee shall allocate expenditures as between di- rect and indirect costa in accordance with generally accepted and established account- tng practices or ag otherwise preseribed by the Surgeon General. (b) Direct costs in general. Funds erunted for direct costs may be expended by the grantee for personal services, rental of space, materiats, and supplies, and other items of necessary cost as are required to earry out the purposes of the grant. The Surgeon General may issue rules, instruc- tions, Interpretations, or limitations sup- plementing the regulintions of this subpart and preseribing the extent to whieh partl- eular (ypes ef expenditures may be charged fo grant funds. (e) Direct costa; peraonal acrvices, The costs of personal serviees are payable from erent funds substantially in proportion to the thme or effort the Individunl devotes to carrying out the purpose of the grant. In such proportion, such costs may include all rect costs Incident to such servicer, such naa sntiary during vaentions and retirement and workmen's compensation charges, in ac- cordance with the policies and necounting practices consistently applied by the grantee to all its activities. (d) Direct costa; care of patients, The cost of hoapital, medical or other care of patients Is payable from grant funds only to the extent that such cnre is Incident fo the research, training, or demonstration activi- (les supported by a grant hereunder. Such care shall be incident to such activities only If reasonably associated wlth and required for the effective conduct of such activities, and no sueh care shall be charged to such funds unless the referral of the patient ts documented with respect to the name of the practleing physicfan making the referral, the name of the patient, the date of referral, and any other relevant information which . 1 ak sad” ( eh ] may be preseribed by the Surgeon General. Grant funds shall not be charged with the cost of — (1) Care for intercurrent conditions (ex- cept of an emergency nature where the inter- current condition results from the care for which the patient was admitted for treat- ment) that unduly Interrupt, postpone, or terminate the conduct of such activities. (2) Inpatient care if other care which would equally effectively further the pur- poses of the grant, could be provided at a amaller cost. . (3) Bed and bonrd for inpatients In excess of the cost of semiprivate accommodations unless required for the effective conduct of such activities, For the purpose of this paragraph, ‘semiprivate accommodations” means two-bed, three-bed, and four-bed aecommodations. 0 54.410 PAYMENTS. Tho Surgeon Gencral shall, from tlme to time, make payments to a grantee of all or n portion of any grant award, elther in ad- yanee or by way of relmbursement for ex- penses to be ineurred ov Jncurred to the extent he determines such payments neces- sary to carry out the purposes of the erant. 0 54.411. DIFFERENT USE OR TRANSF DR: GOOD CAUSE FOR OTHER USE. (n) Compliance by grantees. If, at any time, the Surgeon General determines that the eligibility requirements for n program are no longer met, or that any facility or equipment the construction or procurement of which was charged to grant funds is, dur- ing ils useful life, no longer being used for the purposes for which Jt was constructed or procured efther by the grantee or any transferee, the Government shall have the right to recover its proportionate share of the value of the facility or equipment from either the grantee or the transferee or any institutlon that {s using the facility or equipment. The Government's proportionate share shal! be the amount bearing the same ratlo to the then value of the facility or equipment, as determined by the Surgeon teneral, ag the amount the Federal particl- pation bore to the cost of construction or procurement. (b) Different uac or transfer; notification. The grantee shall promptly notify the Sur- geon General in writing if at any time during {ta useful life the facillty or equipment for construction or procurement of which grant funds were charged is no longer to be used for the purposes for which it was constructed or procured or is sold or otherwlse transferred. . (ce) Forgivencsa. The Surgeon General may for good cnuse release the granteo or other owner from the requirement of con- -tinued eligibility or from the obligation of continued use of the facility or equipment for the grant purposes. In determining whether good cause exists, the Surgeon Gea- eral shall take into consideration, among other factors, the extent to which— (1) The facility or equipment will be de- rvoted to rescarch, training, demonstrations, or other activities related to Tithe IX diseases. (2) The cireumstances calling for Aa change In the use of the facility were not known, or with reasonable diligence could not have been known to the applicant, at the t!me of the application, and are circum- stances reasonably beyond the contro! of the npplicant or other owner. (3) Lhere are reasonable assurances that other facilities not previously utilized for Title IX purposes will be so utilized and are substantially the equivalent In nature and extent for such purposes. O 54.412 PUBLICATIONS. Grantees may publish materials relating to their regional medical program without prior review provided that such publications carry a footnote acknowledging nealstance from the Public Health Service, and Indl- eating that findings and conclusions do not represent the views of the Service. 0) 54.418 COPYRIGHTS. Where the grant-supported activity results In copyrightable material, the author Is free to copyright, but the Public Health Service reserves n royalty-free, nonexclusive, irrevo- enble license for use of such material. 0 54.414 INTEREST. Interest or other income earned on psy: ments under this subpart shall be paid to the United States as such interest Ie recelved by the grantee. XHIBIT NTV dected Bibliography Selected [listorical Documents id National Reports itizens Commission on Graduate Medi- il Education; The Graduate Education | Physicians. Chicago, Illinois. Council n Medical Education, American Medical ssociation, 1966. ‘oggeshall, Lowell T., Planning for Medi- al Progress Through Education, Fivan- ton, Illinois. Association of American Acdical Colleges, 1965. ‘ommission on Hospital Care, Hospital “are in the United States. New York. Yommonwealth Fund, 1947. Yommittee on the Costs of Medical Care, Medical Gare For the American People: rhe Final Report (28). University of Shicago Press, 1932. : Consultative Council on Medical and Allied Services, Interim Report on Future Provisions on Medical and Allied Serv- ices. The Right Honorable Lord Dawson of Thames, Chairman. London, England, His Majesty’s Stationery OMice, 1920. Council on Medical F.ducation and Hos- pitals, Money and Medical Schools. Chicago, THinois. American Medical As- sociation, Undated. : Dryer, Bernard V., Study Director, Life- time Learning for Physicians: Principles, Practices, Proposals. Joint Study in Con- tinuing Medical Education, Journal of Medical Education, Vol. 37, No. 6, Part 2, June, 1962. Flexner, Abraham, Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Ad- vancement of ‘Teaching. New York, 1910. Kidd, C. V., American Universilies and Federal Research. Cambridge, Massa- chusetts. Belknap Press of Harvard Uni- versity Press, 1959. Mountin, Joseph W., Pennell, Eliot H., and Hoge, Vane M., Health Service Areas—Requirements for General Hospi- tal and Health Centers. Public Health Service Bulletin, No. 292. U.S. Govern- ment Printing Office, Washington, D.G., 1945, Mountin, Joseph W. and Greve, Clifford IL., Public Health Areas and Hospital Facilities. Public Health Service Bulletin No. 42, U.S. Government Printing Office, Washington, D.C., 1950. National Commission on Community Health Services, Health Is a Community Affair, Cambridge, Massachusetts, VTar- vard University Press, 1966. President's Commission on the Health of the Nation, Building America’s Iealth: A Report. U.S. Government Printing OF- fice, Washington, D.C., 1952. President's Commission on Heart Disease, Jancer and Stroke, Report to the Presi- dent: A National Program to Conquer Heart Disease, Cancer and Stroke. Vol. 1. U.S. Government Printing Office, Wash- ington, D.C., December, 1964. President's Commission on Heart Disease, Cancer and Stroke, Report to the Presi- dent: A National Program to Conquer Heart Disease, Cancer and Stroke, Vol. 2. U.S. Government Printing Office, Wash- ington, D.G., February, 1965. Pricc, D. K., Government and Science: Their Dynamic Relation in) American Democracy. New York, New York Uni- versity Press, 195-4. Price, D. K., The Scientific Estate. Gam- bridge, Massachusetts. Belknap Press of Larvard University Press, 1965. Sheps, C. G., Wolf, G. A., Jr, and Jacob- son, C., editors, Medical Education and Medical Care—Interactions and Pros- pects. Report to the Eighth Teaching Tn- stitute, Association of American Medical Colleges, Evanston, Tlinois, 1961. Somers, Terman M., and Somers, Anne R., Doctors, Patients and Health Insur- ance. Washington, D.C, The Brookings Institution, 1961. U.S. ‘Gongress, Senate Committee on Appropriations, Federal Support of Medi- cal Research, Report of the Committee of Consultants on Medical Research to the Subcommittee on dhe Depiartinents of Labor and Health, Education, and Wel- fare; 86th Government Printing Office, Washington, D.G., 1960, tongress, 2nd Session. US. US, Department of Health, Edueation and Welfare, The clduancement of Medi- cal Research and Education. (Bayne- Jones Report), U.S. Government Printing Office, Washington, D.C., 1958. U.S. Department of Health, Education, and Welfare, Surgeon General’s Consul- tant Group on Medical Education, Phy- sicians for a Growing America (Bane Report), Public Health Service Publica- tion No. 109, U.S. Government Printing Office, Washington, D.C, 1959. 103 IJ. Publications on Rezional Medical Programs Batley, Louis, T., “Georgia Regional Medical Program,” Journal of the Medi- cal Association of Georgia, Vol. 56, No. , dy. V4bt-142. April, 1967. Burgess, Alex M., Jr, Colton, Theodore, Peterson, Osler L., “Categorical Programs for Heart Disease, Cancer, and Stroke,” The New England Journal of Medicine, Vol, 273, No. 10. September 2, 1965. Callahan, -Barbara, ‘Those Regional Medical Programs: Where the Action Will Be,” Hospital Progress, Vol. ‘£7, p. 57-6 December, 1966, Callahan, Barbara, “Regional Medical Programs taking Giant Steps,” Hospital Progress, Vol. 48, No. 3,p. 78-83. March, 1967. , Castle, CG. Hilmon, “Regional Medical Programs,” Rocky Mountain Medical Journal, January, 1967. Clark, Henry T., Jr., “Shaping the Hos- pital for its Future Role,” Hospitals, Vol. 10, p. $9-53. February 1, 1966. Clark, Henry T., Jr, “The Challenge of the Regional Medical Programs Legisla- tion,” The Journal of Medical Education, Vol. HE. April, 1966. Clark, Henry T., Jr, “Regional Medical Programs,” Hospital Practice. March, 1967. “Conference on Regional Medical Pro- grams Examines Plans for Heart Disease, Cancer and Stroke,” The Modern Hos- pital, Vol. 198, No. 2, p. 79-80. February, 1967. “Continuing Medical Education: -Dors il Matter?” (Editorial), Journal of the American Medical Association, Vol. 197. No. 6, p. 505-506. August 8, 1966. Dempscy, Edward W., “The Case for Regional Medical Complexes,” Medical Opinion and Review. October, 1965. Dodge, Harold ‘T., “Regional Medical Program for Heart, Cancer and Stroke,” The Journal of the Medical Association of the State of Alabama, Vol. 36, No. 7. January, 1967. Wbbert, Arthur, Jr. “A Look at Public Law 89-239: ‘The Heart Disease, Gancer, and Stroke. Program,” Connecticut Med- icine, Vol. 30, No. 9, p. 8-16. June 21, 1965. “Evolution or Revolution in American Medicine,” Modern Medisine, p. 8-16. June 21, 1965. “Get Yogether If You Want a Regional Grant,” The Modern Hospital, Vol. 107, No. 2. August, 1966. Guidelines for Regional Medical Pro- grams, Division of Regional Medical Pro- grams, National Institutes of Health, U.S. Department of Health, Welfare. July 1, 1966. Education and Hill, Lister, “A Program to Combat Heart Disease, Cancer and Stroke,” The En- November. quirer. Boonville, Indiana. 1965. Hopness, John R., “Phe Northwest Hos- pital” Bulletin of the New York Aca- demy of Medicine, Vol. 43, No. 6, p. AQS-. 503. June, 1967. Hudson, Charles L., (P.-L, 89-2539) Re- inarks on Regional Medical Programs,” Journal of the Medical Association of Georgia, Vol. 56, No. dp. 154-155. April, 1967. ITusten, Phillips, “De We Need Those Regional Complexes?” Medical Econom- tes. June 28, 1965. “Synovative Plans for the Georgia Re- sional Medical Programs,” Journal of the Medical Association of Georgia, Vol. 56, No. 4, p. 149-151. April, 1967. James, George, “Tnplications of the Heart Disease, Cancer and Stroke Prograins, an Interpretation.” Afedical Opinion and Review. Ovtober, 1966, James, George, “Summation” Bulletin of the New York Academy of Medicine, Vol. 43, No. 6, p. 522-524. June, 1967. Jones, Frank W.. “Phe Medical Society and the Regional Medical Progra in - North Carolina” North Garolina Medi- cal Journal, Vol. 28, No. 5, p. 173-175, May, 1967. Kissick, William b.. “Regional Medical Programs”. Address delivered at the Pack Forest. Conference on Regional Medical Programs, La Grange, Washington, No- vember 6, 1965. Lyle, Garl B., “Pdueation and Research in Community Medical Care: University of North Carolina School of Medicine Ap- proach,” North Carolina Medical Journal, Vol. 28, No. 5, p. 102-194. May, 1967. Marston, Robert Q.. “Regional Medical Programs: A Review,” Bulletin of the New York Academy of Medicine, Vol. 13, No. 6, p. 490-491, June, 1967. Marston, Robert Q., “Regional Medical Provranis Begin Second Year.” U.S. Med- icine, Vol. 3, No. 25-27. January 1, 1967. Marston, Robert ()., and Mayer, William D., “The Interdependence of Regional Medical Programs and Continuing Edu- cation,” The Journal of Medical Educa- lion, Vol. 42, No. 2, p. 119-125, Febru- ary, 1967. = Marston, Robert Q., and Yordy, Karl, “A Nation Starts a Program: Regional Med- ical Programs, 1965-1966," The Journal of Medical Education, Vol. 42, No. 1, p. 17-27. January, 1967. Mattingly, ‘Thomas W., “The Regional Medical Program of Metropolitan Wash- ington,” Medical Annals of the District of Golumbia, Vol. 36, No, 3, 1. 186-188, March, 1967. Mayer, William D., “Regional Medical Programs--A Progress Report,” Journal of the Medical Association of Georgia, Vol. 56, No. 4, p. 143-147. April, 1967. McCormack, James E., “The New York City Story,” Bulletin of the New York Academy of. Medicine, Vol. 43, No. 6, p. 515-521. June, 1967. Morgan, Ralph $., “Development of a Regional Medical Program in Western North Carolina,” North Carolina Medical Journal, Vol. 28, No. 5, p. 195-197. May, 1967. Musser, Mare J., ‘North Carolina Re- tional Medical Program,” North Carolina Medical Journal, Vol. 28, No. 5, p. 176-- 182. May, 1967. “National Goals foe Regional Medicine,” Posturaduate Medicine, August, 1966. “A National Program to Conquer Heart Disease, Cancer and Stroke,” The Jour- nal of the American Medical Association, Vol, 192, No. 4. April 26, 1965. Page, Irvine H., The Gestation of Med- ical Complexes,’ Modern Medicine, p. #092, June 21, 1965. “Regional Complexcs Gain Momentum,” Medical World News. February 3, 1967. “Report of the President’s Commission,” The New England Journal of Medicine, Vol. 272, No. 18. May 6, 1965. Ross, Robert A., “The Regional Medical Program: An Opinion,” North Carolina Medical Journal, Vol. 28, No. 5, p. 125. May, 1967. Russell, John M., “New Federal Regional Medical Programs,” New England Jour- nal of Medicine, Vol. 275, p. 309-312. August 11, 1966. Schechter, Mal, “Planners Work Today on Medicine of Tomorrow,” Modern Medicine, p. 33-52. February 13, 1967. Schineck, Harold M., Jr., “National Gam- paign Against Disease to Begin with Four Regional Programs,” The New York Times. April 15, 1967. Shannon, James A., “The Advancement of Mcdical Research: A Twenty-Year View of the NIH Role,” Journal of Med- ical Education, Vol. 42, No. 2. February, 1967. Smith, Harvey L., “Data-Gathering Op- erations of the Regional Medical Pro- gram,” North Carolina Medical Journal, Vol. 28, No. 5, p. 190-191. May, 1967. Snyder, James D. and Enright, Michael J., “Regional Medical Programs: A Prog- ress Report,” Hospital Management, p. 36-38. April, 1967. atement of Policy on the Report of the sident’s Commission on Heart Disease, acer and Stroke,” Bulletin, American lege of Surgeons, Vol. 51, No. 2. rch—April, 1966. wart, William H., “Regional Medical rams,” Medical Tribune. July 6, 6. 3. Congress, House Committee on In- state and Foreign Commerce, Regional ‘dical Complexes for Heart Disease, neer, Stroke and Other Diseases; Ucar- s. 89th Coneress, Ist session, on FLR. 10, Ser. No. 89-20, U.S, Government nting Office, Washington, D.C., 1965. 3. Congress, House Committee on In- state and Forcign Commerce, [Jeart sease, Cancer and Stroke Amendments 1965; Report No. 963, 89th Congress, ; Session, U.S. Government Printing fice, Washington, D.C., September 8, 65. §. Congress, Senate Committee on bor and Public Welfare, Combating tart Disease, Cancer; Stroke, and her Major Diseases; Hearings Before e Subcommittee on Health, 89th Con- ess, ist session, S. 596. U.S. Govern- ent Printing Office, Washington, D.C., 165. 5S. Congress, Senate Committee on abor and Public Welfare, Heart Disease, ancer and Stroke Amendments of 1965; eport No. 368, 89th Congress, Ist scs- on, U.S. Government Printing Office, Vashington, D.C., June 24, 1965. Vakerlin, George E., “Missouri Regional Aedical Program,” Missouri Medicine Journal of the Missouri State Medical \ssociation), p. 90-94. February, 1967. Walker, Jack D., ‘Regional Medical Pro- grams for Heart Disease, Cancer, Stroke and Related Diseases for Kansas,” Journal of the Kansas Medical Society, Vol. 58, No. 4, p. 161-165. April, 1967. Weinerman, E. Richard, “Planning and Organization of the Connecticut Re- gional Medical Program,” Bulletin of the New York Academy of Medicine, Vol. 43, No. 6, p. 504-514. June, 1967. Williams, T. Franklin, “Diabetic Consul- tation and Educational Services: A Fea- sibility Study,” North Carolina Medical Journal, Vol. 28, No. 5, p. 187-190. May, 1967. Williams, W. Loren, “Evaluation and the Georgia Regional Medical Program,” Journal of the Medical Association of Georgia, Vol. 56, No. 4, p. 151-153. April, 1967. Woods, James W., “Intensive Coronary Care Units in Community ITospitals,” North Carolina Medical Journal, Vol. 28, No. 5, p. 185-187. May, 1967. U.S. GOVERNMENT PRINTING OFFICE: 1967 O---26B- 649 105 Por sale by the Superintendent of Documents, U.S, Government Printing OMec Washington, 9.C., 20102 - Priee $1 (paper cover)