Summary Regional Medical Programs have made an impressive beginning. But it is only a beginning. Much is yet 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. SECTION ONE Summary In October 1965 President Johnson signed Public Law 89-239, the Heart Disease, Cancer and Stroke Amend- ments to the Public Health Service Act, authorizing grants to help es- tablish Regional Medical Programs to combat heart disease, cancer, stroke, and related diseases. This program had its origin in the recommendations of the President’s Commission on Heart Disease, Can- 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. To accomplish this purpose, Public Law 89-239 proposes the establish- ment 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 seeks to unite the health resources of the Nation, region by region, in close working relationships which will speed 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 total about $20 million, and 10 second year awards about $4 mil- lion. (Exhibit III) 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 IV) Additional applications for grants to support planning covering 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 mechanisms 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 the country. In each 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 staff. 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 are clearly indi- cated: [] 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 purposes 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 set aside during the con- sideration of the bill in the Congress. This modification should be carefully designed, in amount and administra- tion, to meet 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 community 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 use 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 deliver medical care in the local communities of the country. To accomplish these purposes, the Law authorizes the award of grants for the planning and then for the operation of regional arrangements, designed to stimulate new patterns of cooperative action among physi- cians, hospitals, university medical centers, public and voluntary health agencies. Each regional arrangement should help to create a coordinated program encompassing research, training and continuing education, patient care demonstrations and re- lated activities. Its goal is to advance the accessibility and the quality of health services available throughout the region for heart disease, cancer, stroke and related diseases. The emphasis in this program, re- flecting 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 each Region, including those of the con- sumers of service, is required by law as an essential step in the develop- 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 variety 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, uncertainties 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. Still others emerge from certain broad changes which are inherent in the further development of these programs. Significant among these questions are the following: (] 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 meas- urably modified? [] Are the regional administrative entities developed for these programs viable and durable over a long period of time? (] Gan voluntary professional and institutional compliance be obtained in the efficient disposition and use of critical manpower, facilities and 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? [] What long-term _ relationships should be established to assure that Regional Medical Programs comple- ment other Federal health programs, particularly the Comprehensive Health Planning Program initiated under Public Law 89-749? (J How can local programs over- come lack of space to carry ‘out cer- 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 limited 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 either 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 to 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 sci- entific medicine.” Excerpt from the Report of the Senate Committee on Labor and Public Welfare on S. 596 (P.L. 89- 239). SECTION TWO The Essential Nature BACKGROUND The Report of the President’s Com- mission on Heart Disease, Cancer and Stroke in 1964 was the imme- diate stimulus for the legislation that became Public Law 89-239. That report, issued in December of 1964, made a series of recommendations aimed at 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- tients 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- ety, 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. This advance has greatly strengthened the 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 threatens the heavily burdened physician with rapid obsolescence of knowledge. This threat in turn raises new prob- lems in communication and educa- tion. New patterns of relationships, systems of service, and mechanisms are critically needed in medicine, as 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 set 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 diseases, and other social progress. In addi- tion, national concern has focused on the special problems of disadvantaged groups and areas not sharing fully in the overall progress. Efforts to meet these demands for services have been complicated by manpower and fa- cility shortages and increases in costs of medical care. More efficient and effective use of health services has been 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 years 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- 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 general they reflect the difficulties of inducing common action among sep- arate and independent components of the health enterprise, and the lack of financial resources in sufficient amounts and duration to assure con- tinuing stability. The present day circumstances of the practice of medicine and the de- livery of health services may provide more suitable conditions for the 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 Disease, 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 base 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- ease, cancer, stroke and related dis- eases ta be available to all. The scope of the program is nationwide, encom- passing the great cities, suburbia, and rural areas. The program design inherent in Public Law 89-239 derives from a series of basic concepts: C] The best in modern diagnostic and treatment methods is not readily accessible to many Americans suffer- ing from or threatened by heart dis- ease, cancer, stroke, and related diseases. [] There is need for increasing inter- action between the diagnostic and therapeutic capability in the major medical centers, where an effective interplay between research, teaching, and patient care can bring rapid and effective application of new medical knowledge, and the medical capabil- ity in many community settings. C1 The progress of science will con- tinue to increase the complexity of making available to all the potential benefits of modern medicine. (] The complete realization of these potential benefits requires the co- operative involvement of the full range of each region’s medical and related resources. (] The diversity of local health needs and resources calls for the as- sumption of responsibility by each region for the design of a pattern of collaborative action best suited to its own special circumstances. The role of the Public Health Serv- ice in developing this broad program design is defined in the Congressional declaration of purpose: “Through grants, to encourage and assist in the establishment of regional cooperative arrangements among medical schools, research institutions, and hospitals for research and train- ing (including continuing educa- tion) and for related demonstrations of patient care in the fields of heart disease, cancer, stroke, and related diseases .. 2” Thus, Public Law 89-239 repre- sents a Federal investment in regional initiative. It invites and supports the creation of new patterns of coopera- tive action among physicians, allied health workers, hospitals, medical centers, universities and research in- stitutions, public and voluntary health agencies, and the consumers of health services. THE CONDITIONS AND QUALITIES EMPHASIZED Regional Medical Programs put into practice the principle that essential responsibility and power for the im- provement of health services should be 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 each program has been provided. The achievement 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 effective patient care. The Law does not allow support of isolated projects, however meritorious, whether they be in continuing education, research, patient care demonstrations, cooper- ative arrangements or training. Thus the success of a Regional Program will depend upon how 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 efforts. 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 geographic and social circum- stances that 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 largely private character of our med- ical care process. The 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 structure 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 efficient 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, they will help to assure every individual, wherever he lives, that: C] His physician has readily avail- able the knowledge, skills and techni- cal support that permit early diag- nosis of these diseases and prompt initiation and appropriate follow through for the most effective known preventive or curative action. (J 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 full strength of modern medical science available to him through the cooperative efforts of the medical and related resources of the region in which he lives. These are the goals to which Regional Medical Programs are dedicated. Activities and Progress “|. the Surgeon General . . . shall submit . . . a report of the activities ... together with (1) a statement of the relationship between Federal fi- nancing and financing from other sources. . . (2) an appraisal of the activities assisted . . . in the light of their effectiveness. . . .” Public Law 89-239 Section 908 SECTION THREE Activities and Progress 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 III, TV) These programs received awards of about $24 million for planning and $6.7 million 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 early fall of 1967 Regional Medical Programs covering the entire country will be either 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 in 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. How 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 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 Programs, 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. In early 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 areas 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 recommended for approval by the National Advisory Council. At the Council meeting 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- erate in this new framework. The in- terest and enthusiasm generated 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. TABLE 1 AWARDS FOR PLANNING AND OPERATIONS OF REGIONAL MEDICAL PROGRAMS, Planning Awards........----..-5++5 For Ist Year Activities............ For 2d Year Activities... .......... Operational Awards.............--- For Ist Year Activities............ About one hundred consultants aided the new Division by providing advice and counsel 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- Others their thinking to the development of view groups. contributed 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 ee 61 $30, 946, 907 ee 57 $24, 277, 174 Ooovesereee 47 19, 822, 153 eens 10 4, 455, 021 Oceeeeees 4 $6, 669, 733 “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 members of Regional Advisory Groups. Membership in these groups 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 MEMBERSHIP OF ADVISORY GROUPS FOR REGIONAL MepicAL Pro- GRaMs, JUNE 30, 1967! Num- _ Per- Category ber _—_cent- age TOTAL. ........ 1634 100 Cians............. 356 22 Medical Center Officials.......... 281 17 Members of Public.. 260 16 Voluntary Health Agency Represent- atives............ 196 12 Hospital Admin- istrators.......... 170 10 Other Health Workers.......--- 142 9 Public Health Officials.......... 122 7 Other............. 107 7 1 Includes 51 Regions, of which 47 had received planning grants and 4 had applications under review. 1 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 societies, 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 Hospitals. Community Councils, planning councils, Blue Cross and similar groups are also being involved in many instances. Representatives of Veterans Administration and Public Health Service Hospitals are also frequent participants. Regional Organizations Several kinds of institutions have assumed responsibilities as coordi- nating headquarters for Regional Medical Programs. Since the legisla- 12 tion does not designate these agencies, 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, 28 university medi- cal schools have assumed _ responsi- bilities 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 multi-institutional agencies. One State and one inter- state agency have also undertaken this task. (Table 3) Program Coordinators and Staff 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 university 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 VIIT) TABLE 3 CoorDINATING HEADQUARTERS AND GRANTEES FOR REGIONAL MEDICAL ProcraMs, JUNE 30, 1967 Coordi- nating head- Grant- Type of Agency quarters ees! TOTAL...... 47 47 Universities. ... 28 33 State....... 23 25 Private..... 3 8 Nonprofit Agencies. ... 17 12 Medical Societies. . 5 6 Newly Organized Agencies. . 10 3 Other Agencies. . 2 3 State and Interstate Agencies. ... 2 2 1 The grantee differs from the coordinat- ing headquarters when the Region re- quested this arrangement or the latter agency did not have the capability to assume formal fiscal responsibility. These coordinators are building staffs with a wide range of com- petencies. As of June 30, 1967, there were some 600 staff people working in these programs. These include over 300 professional workers with train- ing in medicine, hospital administra- tion, and other health disciplines as well as in related fields 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 process and by operating experience. The individual Regions ranged in population from 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- have cern, have not materialized in the initial planning proposals. TABLE 4 NuMBER OF PERSONS IN PRELIMINARY PLANNING REGIONS FOR REGIONAL MEDICAL PROGRAMS Regions! Population range ~TOTAL.........0.0005- 51 Less than 1,000,000......... 4 1,000,000-2,000,000........ 10 2,000,000-3,000,000........ 14 3,000,000-4,000,000........ 5 4,000,000-5,000,000........ 8 More than 5,000,000....... 10 1 Includes 51 Regions, of which 47 had received planning grants and 4 had appli- cations under review. 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 and in 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 each 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: (1 Organization and staffing for planning and coordination ( Strengthening relationships and liaison among institutions and indi- viduals throughout the Region (1 Development of planning data C1 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 needs 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- ceiving 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 studies aimed at assessing the workability and utility of particular program 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 allied 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 forces 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 to explain and discuss the purposes and nature of the prospective Regional Program. Working together in planning and imitiating planning and _ feasibility studies has been found to be one of the most effective methods of estab- lishing and implementing common objectives. Although each Regional Medical Program is in many ways unique, some flavor of what Public Law 89- 239 means in action is revealed by reports of certain programs that are 1 As reported by individual Regional Medi- cal Programs. 13 TABLE 5 Major PLANNING StupiEsS UNDER Way or PROJECTED BY 44 REGION- AL MenicaL ProcRaMs, MARCH i, 1967 Subject Under Study Regions Patient care OO Specialized Clinical Facili- ties... 2. eee eee 30 Disease Patterns............ 28 Patient Referral Patterns 28 Patterns of Services......... 25 Laboratory Services... ..., 25 Transportation Patterns. .... 21 Manpower Physician Manpower....... 30 Nursing Manpower......... 29 Dental Manpower.......... 25 Other Allied Health Man- POWE.... eee 26 Training and education Continuing Education Pro- grams................--. 28 Training Resources......... 28 Medical Library Resources. . 26 Communications Patterns and Resources........... 26 14 presented as a supplement to this Re- port. What is happening in six Re- gions is discussed against a back- ground of previous activities. In addi- tion, excerpts from the first annual 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. In these places sufficient planning had already been accomplished so that operational activities could be initi- ated early. In the beginning stages these oper- ational programs will encompass four principal types of activities: L] Application of the latest knowl- edge and technology to improve capabilities for diagnosis and treat- ment. C] Specialized training and continu- ing education to enable health prac- titioners to use these capabilities most effectively in treating patients. [J Use of modern communication technology. L) 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. In 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 programs: () 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 cen- ter and other specialized personnel. C] Continuing education programs for medical practitioners and allied health workers, at both local facilities and medical centers including the development of learning centers at community hospitals and communi- cation systems joining medical cen- ters and community hospitals. L] 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. Expansion 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 physi- cians and hospitals. CL] 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 es- tablished subcommittees 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 itself 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 ex- 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 each 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 A conference 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 field. 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 schools 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 Gom- 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 TABLE 6 | EstimMATED AMOUNT OF Funps From Non-FEDERAL SOURCES FOR PLANNING REGIONAL MEDICAL PRoGRaMs, THROUGH Marcu I, 1967! Region Total Cash Services Region Total Cash Services } TOTAL................... $1, 497, 300 | $287,800 | $1,209,500 |} Missouri...................0.0.. $48, 900 $3, 900 $45, 000 Mountain States................. 15, 000 13, 700 1, 300 Alabama..................0005. 21, 200 3, 800 17,400 |} Nebraska-South Dakota........... 9, 000 1, 400 7, 600 | Albany, N.Y................... 96, 800 24, 500 72,300 || New Jersey.................00.. 17, 800 12, 000 5, 800 | AviZona.... 0 ee eee 2, 800 100 2,700 || New Mexico.................-.. 25, 200 5, 700 19, 500 Arkansas... 0.0.0.2... eee 5, 100 600 4,500 || New York Metropolitan Area...... 11, 000 1, 000 10, 000 Bi-State.. 020... eee eee 13, 200 1, 500 11,700 || North Carolina.................. 38, 100 |.......... 38, 100 California. ......0.00.0000 000.0 chee ee een ees en North Dakota... .........000..00)ee eee ee en eee en Central New York............... 12, 000 6, 000 6, 000 Northern New England........... 134, 200 10, 000 124, 200 Colorado-Wyoming.............. fcc. cece eee Northlands..................2--- 30, 900 5, 400 25, 500 Connecticut............ 0.000000 33, 800 {.......... 33, 800 || Ohio State. .................... 37, 200 6, 600 30, 600 Florida... 0.0.0.0... eee eee 7,500 |.......... 7,500 |} Ohio Valley...................6. 10, 600 2, 100 8, 500 Georgia... ....2.-..0..02..2.-5. 2, 300 900 1,400 || Oklahoma.... ................. 50, 000 |.......... 50, 000 Greater Delaware Valley.......... 174, 500 70, 100 104, 400 Oregon.... 00.0... 0 2. ee eee ee 18, 000 6, 000 12, 000 Hawaii... 0.0.0... eee 6,900 j.......... 6, 906 Rochester, N.Y..............--5- 33, 500 40, 900 12, 600 Illinois... 22.0.0... eee eee 48, 000 3, 000 45, 000 South Carolina.............e00: 3, 000 1, 500 1, 500 © Indiana... sete eter e ee eee 76, 900 4, 500 72,400 || Susequehanna Valley............. 6, 000 |.......... 6, 000 Intermountain. ................. 53,500 | —_5, 000 48,500 | Tennessee-Mid South............. 20,400} 3, 400 17, 000 POW as ee eee ee 19, 500) 11, 100 8,400 |) Texas. oo... ccc ce cece cece eees 82, 000 | 10, 000 72, 000 Kansas... 0... cece eee 125, 000 |.......... 125, 000 : 2 Louisiana... 0.000.000 ccc cc eee deen eee e eens C2) fev cse eee eee 2ueState ese rs eee scene espe @) frrvrsrrsees Maine..............-.. eee eee 16, 200 1, 500 14, 700 Virginia Lecce eee ene e eens 25, 000 |.......... 25, 000 Maryland..........0.e00cceseees 7,000 |.......... 7,000 || Washington-Alaska............... 4,000 |.......... 4, 000 Memphis...................200- 20, 000 9, 700 10,300 || West Virginia................... 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...............2..-005. 4,500 |.......... 4,500 || Western Pennsylvania............ 7, 000 1, 000 6, 000 Mississippi. ......--0. 0.0.00 eee 15, 000 9, 000 6, 000 Wisconsin.... 0.0.2.0 ..00 0 cee eee 37, 500 8, 500 29, 000 1 As reported by individual Regional Medical Programs. 2 Not reported. development of Regional Medical Programs from non-Federal sources. A listing of these amounts, by Region, is set forth in Table 6. Procedures are being developed and implemented in the Regions so that these cooperative programs are financed from a variety of sources. In some areas, total responsibility for the support of the activities will be assumed by local funds after an ini- tial period of study, testing and dem- onstration. In many Regions, volun- tary agencies and foundation funds are being enlisted. At this stage in the development of Regional Medical Programs, it is not possible to ascertain the longer term relationships of Federal and non- Federal funding of the activities un- der this program or to assess the nature of their impact upon medical service costs. If this program is suc- cessful in developing needed addi- tional elements in the community health scene that are parts of im- proved services, the extent to which these can be financed through regular cost and payment processes or other local funding mechanisms and the extent to which permanent or temporary Federal assistance will be required are issues that will call for critical examination services as 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 needs 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. Progress 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 generally being established as part of the planning process so that essential baseline data will be accumulated and capabilities 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 easily, however. The full fruition 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. Issues And Problems SECTION F OUR Issues And Problems The initial experience with Public Law 89-239 has raised a number of issues and problems which face the Regional Medical Programs as they seek 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 issues 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 issues and problems are derived from the particular char- acteristics of the health care activity 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 general 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 extent to which these programs may contribute to 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, each 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 meet 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. Indeed 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 spe- cial significance to the progress already achieved in establishing what the Law calls “regional cooperative arrangements.” Evidence of this progress is con- siderable. However, 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 variety 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 enough 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 due 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 each Regional Medical Pro- gram with a formidable task in es- tablishing regional cooperative ar- rangements and carrying out operating programs. As a conse- quence planning will involve the establishment of priorities of action and careful phasing in the develop- ment of the program. Selectivity 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 are relevant to the Regional Medical Programs in several ways. First, they place a constraint on the rate of implemen- tation of some program activities. 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- ties 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- ties 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 manpower; 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 Prograras 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- ease, cancer, 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 areas of activity, the Regional Medical Programs will have to de- velop and modify techniques as the programs are 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 general 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 and systems analysis being used by some Regional Medical Programs can be helpful in making these assessments. The major determinants of medi- cal care costs seem to be beyond the scope of Regional Medical Programs. Nonetheless, Regional Medical Pro- grams can contribute to the efficiency of program implementation and toa greater awareness of the cost impli- cations of improved medical care. They can provide (1) definitions of needs, resources, and program activi- ties through a planning process which includes all major elements of the health-care system; (2) develop- ment of cooperative decision-making frameworks that may speed accept- ance of efficient means of delivering care; (3) opportunities to explore and evaluate the usefulness of new technologies and new types of health personnel which will contribute to the more efficient improvement of the quality of patient care. The Regional Medical Programs will need to make cost analysis an integral part of pro- gram planning and evaluation. Regional Diversity The diversity of this Nation is re- flected not only in the health problems and resources but also in the patterns of medical care in the various Re- gions. The problems and appropriate responses in a sparsely settled rural area with difficulties in attracting physicians and transporting patients over long distances are very different from those in the crowded metro- politan areas with both great con- centrations of medical resources and pressing needs, particularly in the core city slums. Perhaps because of the relative simplicity of the medical resources, Regional Medical Programs seem to be developing more rapidly in pre- dominantly rural areas and smaller cities. Paradoxically, it has been particularly difficult to develop the initial steps toward effective Regional Medical Programs in the metropol- itan areas where the greatest con- centration of medical talents and facilities is to be found. Their added complexities begin with the large populations to be served. They. in- clude also high concentrations of disadvantaged groups. These com- plications are multiplied by the large numbers of institutions, including medical schools, hospitals, and other health agencies and their long-stand- ing habits of autonomy and even rivalry. Added to these difficulties are the multiple social, economic, and political complexities that charac- terize 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- erates real tensions. The mechanisms which evolve for the metropolitan areas may prove to be quite different from the more simple models appro- priate for less 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 develop- 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 early stages in the development of the pro- gram, it seems too early 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. ISSUES ASSOCIATED 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 a 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 24 Programs. Speeches, articles, and the Program Guidelines issued 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 either 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- lated 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 ef- 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 must be based on broad 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 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 are 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 general 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 disease, cancer, stroke and related diseases, it can also be useful 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 of support for this work. Definition of the Region Public Law 89-239 provides consid- erable latitude for the definition of “regions . . . appropriate for carry- ing out the purposes” of the Act. However, the Surgeon General has the responsibility for insuring that all parts of the country are served and that inappropriate overlap is avoided. An early policy decision was to place initial responsibility for delin- eating the “Regions” upon local groups developing the planning appli- cations. It was foreseen that many considerations would need to be 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- ties 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 from the Re- gions indicate that programs and proposals are now being discussed with members of health professions, institutions, and members of the pub- lic at large through workshops, meet- 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 reaching many interested health practitioners and other local groups. In some areas 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 also 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 meet 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 groups as mechanisms for both achieving and monitoring the effec- tiveness of regional cooperative ar-